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From Network Solutions:

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From our anonymous insider…

We have four straight days of exams, covering clinical exam skills, biochemistry, anatomy and cellular biology. Exams begin at 8:00 am, but on two days we were finished by noon. Our first, and main exam is a practice NBME Step 1 using prior, retired questions. The biochemistry and metabolism questions are quite similar to the MCAT. A classmate sent a message our GroupMe after he finished the exam: “There goes my Derm practice out the door.” Anita, and some of the other more sensitive, nervous individuals, did not find this funny. (Dermatology, along with orthopedics and surgery, are some of the most competitive residencies, requiring high Step 1 scores to get matched.)

Anatomy was a sore subject for many. The exam required detailed knowledge of discrete muscle group innervations. There was grumbling afterwards: “I couldn’t read the poor quality images”; “Who cares what the fascial layer is called?” I am grateful our medical school still purchases cadavers for us to learn anatomy; numerous schools are replacing cadavers with electronic images for anatomy education. There is no substitute for the real thing.

After our last exam, we were invited to a cocktail party by a wealthy local sponsor of the medical school. It was pouring rain, but they had a valet service working in their front yard–I’m not sure it was a big night for valet tips given the medical students’ typical debt load. The mayor and board members of the local health system were there to welcome our class to the city. The city symphony director played a few original jazz compositions on the piano. The class stayed late drinking martinis at the open bar and smoking free cigars.

I learned about tension among some physicians who teach us. Most of them love it. However, some are frustrated by the pressure from the health system to teach yet still are expected to have the same patient load. Instead of spending less time with their overbooked patients, they usually just stay later.

The celebration continued at our classmate’s apartment complex. Our whole class was there, including the few married couples. The diversity of ages and lifestyles was illustrated by someone doing the college-favorite “slap the bag” of disgusting Franzia wine next to the 27-year-old father of two.

Statistics for the week… Study: 35 hours; Sleep: 7 hours/night (more than previous weeks due to going to bed earlier); Fun: 1 night out at cocktail party after exams.

The Whole Book: http://tinyurl.com/MedicalSchool2020

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A Facebook friend who was an ardent Obama and Hillary supporter posted the following comment over an article about Trump’s plans to deport up to three million illegal immigrants with criminal records:

The community I live in is 80% Hispanic and Latino. I can’t imagine what this is going to be like for undocumented family members. Neighbors, how can we help?

She didn’t appreciate the following suggestion:

Obama deported more than 2.5 million immigrants. So maybe you could go find some of those folks and help them return to the U.S.?

Folks: Now that the dust has settled on the election, what do we expect from the deportation bureaucracy?

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From our anonymous insider…

Exams begin next week. Type-A Anita is particularly nervous. Beginning last week she has refused to learn anything that is more in-depth than the NBME questions: “only high-yield.” She interrupts class once per day to complain when a professor gives more detail than the Step 1 exam books do. She also requests clarification about the number of questions per exam topic. She dropped her sweet Midwestern demeanor and submitted a formal complaint to the administration when an older physician said males have to work more to learn patient interviewing because women are more naturally caring.

Lectures focused on glycolysis and summarizing metabolic pathways. A rather plump gastroenterologist in his 50s gave an “energy” synopsis about different states of metabolism. These lectures were paired with our patient case, a young anorexic teenager. Anorexia fits with the metabolism unit because it forces the body to break down protein to use for gluconeogenesis. We heard from her doctor that the patient is on antidepressants and receiving psychotherapy, but didn’t get to meet the patient.

We finished dissecting the upper extremity with the elbow, forearm and the bewildering hand, whose muscles and vessels entail hours of dissection. I share my cadaver with three other students. Yet, with three hours of dissection time, we had explored only about 10 percent of the hand. Fortunately, the instructors convinced a chief surgery resident to spend his evenings dissecting a demo cadaver and then come in at 10:00 am to give us a guided tour of a perfectly dissected hand. We were doubly appreciative of his efforts after we heard about his 24-hour hospital shifts.

One of our most passionate and funny doctors spoke about using ultrasound to investigate the shoulder and upper arm. Ultrasound sends high frequency sound waves into the body and relies on differences in the ways that tissues reflect or absorb the sound. We broke up into groups of six, each provided with a donated battery-powered 10 lb. ultrasound machine. The expert (attending) arrived at each workstation to help us diagnose each other. We were able to see torn muscles, ligament damage, tendinitis, and bursitis. As with Week 6, a high percentage of our classmates were able to supply examples of musculoskeletal damage. I contributed a torn supraspinatous (rotator cuff) muscle torn in the college weight room.

In an after-workshop discussion, our professor described his frustration that the medical school accrediting body, Liaison Committee on Medical Education (LCME), limits the number of “formal instruction” hours. “I’m not exactly sure, but it is only about 25 hours per week,” he said. He recounted stories from his professors’ education in the 1920s. For example, a instructor asked a first year class if anyone was uncircumcised. Two students raised their hands. They were instructed to drop their trousers, and in the pursuit of education, were circumcised in front of the entire class, including the two female students. His own 1950s education did not include any in-class circumcisions, but they were at school for 12 hours each day, with some mandatory Saturday sessions. Anatomy lab dissection was 4 hours per day compared to our 4 hours per week. Our professor noted that passing the NBME exams requires more knowledge than for comparable tests in years past. Thus today’s medical student faces greater pressure to study independently.

Statistics for the week… Study: 35 hours (about 5 hours after class each weekday plus more on the Sunday); Sleep: 7 hours/night; Fun: 1 hiking excursion with Jane.

The Whole Book: http://tinyurl.com/MedicalSchool2020

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In response to “How was your weekend?” my neighbors here in Massachusetts are responding with “sad”. Why sad? They’re in mourning for Hillary Clinton’s loss, which they feel personally. Massachusetts residents were already down at #30 (out of 50) in this state-by-state happiness ranking. As the smartest people on the planet we tend to take it personally when we’re not consulted by those in power down in New York and D.C. I don’t see King Donald the First calling up Harvard professors to ask for advice. Thus it is going to be a dark and moody 4-8 years.

Why not move to a state that ranked higher to begin with and one where we don’t think Hillary’s loss will sadden people, either because (a) the majority of voters in that state supported Trump, or (b) voters in that state don’t expect to have substantial influence in a country of 325 million.

Number 1 on the list is Hawaii, which voted for Hillary but is so far from D.C. it is tough to imagine folks there feeling responsible for what the Trumpenfuhrer does.

Number 2 is Alaska, which voted for Trump and where global warming may not be feared. Bonus: no income tax. Double bonus: permanent fund dividend (more of which you’ll get to keep under Trump’s proposed lower federal income tax rates).

Number 3 is Montana, another Trump state. Colorado is #4 and the vote was narrowly divided. Perhaps stay away from Boulder and people will be in a good mood?

Wyoming has no state income tax, supported Trump, and was #5 in happiness prior to the election. Texas and Florida have no state income tax, rank #11 and #12, and voted for Trump.

What do folks think? If the post-election malaise will be prolonged for Hillary Clinton supporters, why not move away from it to a state that ranked higher in happiness to begin with? Why choose to live around the grumpy?

[Be sure to check Real World Divorce before moving! The alimony and child support plaintiff who gets $10 million in Massachusetts would be entitled to $400,000 in Texas. The custody plaintiff entitled to sole custody (“winner parent” status) in New York would be forced into shared 50/50 parenting in Alaska.]

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From our anonymous insider…

One week before exams; my classmates are nervous.

Lectures introduced the immune system, both the innate and the marvelous adaptive immune system. All of our immune cells start their lives as bone marrow stem cells. These stem cells undergo education, either in the thymus or bone, to ensure they do not attack healthy cells yet can potentially attack foreign antigens. I had always thought during an infection our adaptive immune system would create a new immune cell against this foreign structure. Instead, the diversity of potential antigens to which our body can respond is determined within the first few years of life by a process of “student” immune cells randomly self-mutating their antigen receptors (see VDJ recombination). Only about 1-2 percent of the total cells graduate from self-mutation school; the remainder kill themselves. The textbook says that our immune system ends up with roughly 1,000 billion cells that can recognize 10 million different antigens. When an unknown invader arrives, if it is among the 10 million antigens that we’ve prepared to fight since early childhood, we’re in great shape. Otherwise we will need antibiotics or a trip to the hospital.

A doctor from the world’s only hospital that does thymus transplantation came in. As mentioned above, the thymus is the schoolhouse of the immune system, educating immune cells to not attack self. Transplanting a donor thymus, typically obtained from a young child whose thymus got in the way of cardiac surgery, could theoretically eliminate the issue of organ transplant rejection. If a diabetic needed a new kidney, immunosuppressors would be used to destroy the patient’s immune system and then the donor kidney and a donor-matched thymus would be transplanted. The regenerating immune system would be educated to not attack the patient nor the matched donor organ — thymus education is additive! The challenge is to generate a comprehensive thymus donor database or even engineer a biosynthetic thymus.

We dissected the arm from the shoulder to the elbow joint. I was amazed by the vasculature (arteries and veins) as it branches from the major vessels in the thorax and the interweaving nerve structures (see brachial plexus). We saw the funny bone, a.k.a. the ulnar nerve, as it passes between the medial epicondyle of the humerus and the olecranon, or elbow bump, of the ulna. I also discovered my favorite joint: the radiohumeral joint with the annular ligament of the radius. The radial humeral joint allows rotation of the forearm (supination, palm up, and pronation, palm down). The radial head, a spherical protrusion at the proximal end of the radius, is encapsulated in a sheath that allows it to rotate around a fixed point. Listening to the PhD medical researchers who come in as lecturers, I am coming to appreciate the amazing opportunity of anatomy lab. The researchers are experts on test tube experiments, but haven’t had time to look at the circulatory system or liver anatomy, for example.

Statistics for the week… Study: 18 hours; Sleep: 6 hours/night; Fun: 2 nights out. Example Fun: Friday after-class soccer followed by a repeat of the Week 4 jam session. More than half the class showed up and most of them sang along, despite any lack of formal musical training.

The Whole Book: http://tinyurl.com/MedicalSchool2020

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We decided to escape our kids for one recent evening and ventured out into the adult world of restaurant dining and conversation. To take some of the load off the older generation without our household we brought in an 8th-grade babysitter whose job was to entertain a 3-year-old. When we returned home, still stunned from the novelty of a dinner without having once had to say “Alex, let go of her lips!” or “Don’t pull her tail”, the babushkas provided an unfavorable report: “She was on her phone the whole time and didn’t play games with Alex.” When the babysitter’s father showed up there was a discussion about said phone being at only 1 percent charge, thus lending credence to the babushkas’ tale.

Folks: Is there any hope for teenage babysitters in the smartphone age? If you hire one should you make sure to give the young kids their own devices so at least each person can have his or her own screen?

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Here’s why I still like Facebook. A friend shared a posting by Piaw Na, regarding the new MacBook laptop computers:

First they came for the optical drive, and I said nothing, because I didn’t need it. Then they came for the removable battery, upgradeable RAM, and upgradeable Mass Storage, and I said nothing, because work paid for my computer and they replaced it every 2 years anyway. Then they came for my ethernet port, and I said nothing, because I had great WiFi. When they finally came for my magsafe connector, USB-A port, and SD Card slot, there was no one to speak up for me, because only fashionistas were in my market segment. (With apologies to MARTIN NIEMÖLLER). (Note I’m not a Mac user, and don’t really care — Apple does not cater to me with ANY of their devices. I’m just watching the blow-back with mild interest, like a cyclist riding around a massive car crash that’s caused a massive backup for the car drivers stuck behind it)

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Folks:

Before the last election, a friend (white, but married to someone who identifies as “mixed race”) posted the following to Facebook:

The rise of The Donald has brought a lot of racists and haters out into the open, and he’s to squarely to blame. It baffles me that the good and generous people I know can support him. Even in NYC I see these hate crimes happening, and it puts my family and loved ones in danger. His racism, sexism, bullying, vengeful nature, illegal acts, etc. is not leadership for a UNITED States of America; he is tearing us apart. A vote for him is a direct assault on my family.

I tried to figure out whether there were any limits on this “direct assault.” I asked “What about a person who had been promised a lucrative, interesting, and rewarding job within the Trump Administration? What if she shared all of your political beliefs and was going to work to implement them within whatever department Trump was planning to park her? Could she vote for Trump in hopes of actually getting this job and yet not be directly assaulting your family?” The answer was a simple “no”.

Then I posed the following hypothetical: “What about a woman who was born in the U.S. but emigrated to Canada as a child? She was successful in business in Canada, accumulating a fortune of $50 million. All of the money was earned in Canada and she has no connection to the U.S. other than the childhood citizenship, which she never gave up. Upon her death, her children will get only about half of the $50 million because her estate will have to pay U.S. federal death taxes. Hillary wants to raise death taxes; Trump wants to eliminate them on the grounds that the income that led to the savings was already taxed. If this woman votes for Trump in hopes that Congress will agree with him to reduce death tax rates, is she directly assaulting your family?” The answer to that was “yes.” His female-named friends added some more:

Because heaven help those poor kids if they’re unable to make it on just 25M. In my world that’s a high class problem to have. I don’t think I know you Philip and I’m sure you’re a very nice man but I can’t believe you’re trivializing T’s thoughtful post of very valid concerns with dollar signs. Or perhaps your intent was sarcasm…?

Humanity is far more important than money, Philip.

A vote for Trump makes this land, our children, your hypothetical descendants in Canada, and ALL the other human beings on this rock far less safe.

Enough with the hypotheticals, it’s incredibly insulting to T’s original post. The issue that T raised is not hypothetical. It’s real and it’s serious and it should be of concern to everyone. I have a multitude of friends around the world who are of different ethnicities, genders, religions, & orientations and I fear for what could happen to them given the results of tomorrow’s election.

I probed a little more and it turned out that the answer was always the same. Anyone who disagreed with this group of Hillary supporters was “directly assaulting” them and/or their families.

As part of my researching the hypothetical Canadian I discovered that Canada has no death taxes, neither inheritance nor estate (TurboTax), though they do collect capital gains tax on any unrealized capital gains.

I’m wondering if this tips the balance and makes Canada a lower-tax environment for wealthy people than the U.S. (where total tax rates, for those who are working to accumulate assets for their children, are close to 90 percent). A lot of rich people own stock in corporations. Like other OECD countries, Canada has a much lower corporate tax rate than the U.S. (Tax Foundation). Personal income tax rates also seem to be lower (Canada Revenue Agency). Sales taxes are higher in Canada, of course, but a wealthy person who wants to save, invest, and pass down to future generations won’t be buying a lot of Teslas and other toys.

Canadian readers: What am I missing?

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In an earlier post I mentioned that the school superintendent here in a rich suburb of Boston had emailed about a meeting with a child psychologist regarding “How to talk with your children about the election and its aftermath”.

I went to the meeting!

First, what had kids actually learned at school?

• a first-grader heard that Trump would be rounding up women and then shooting them
• a second-grader thought that four of her classmates (children of legal immigrants, I believe, and one of them Muslim) would be deported by Trump
• a father overhead third-grade girls say “My mom said the President is a racist.” (children in Happy Valley cannot be dumped off at the curb; parents who are serious about parenting walk them into school and assist them with locker operations)
• a fifth-grade boy saw a plane overhead (probably a Gulfstream off KBED heading 250 bound for Teterboro with one rich bastard in the back) after school and wanted to go straight home out of fear that the plane would be dropping bombs

There was a broad spectrum of political opinion represented at the meeting: Trump’s victory ranged from being characterized as a “crisis” to a “catastrophe”. The therapist herself admitted to going on a long angry rant (to a friend) about Trump in front of her 7-year-old: “We’re scared and they know it.”

One challenge at the meeting was keeping the focus on children. Adults kept wanting to talk about their own grief and how could they be healed. When the discussion would circle back to the kids, the therapist recommended telling children “I’m really upset” or “I’m worried about this because it is not the way I want the country to go.” A father who is a member of the town School Committee said “My mood is down, but I don’t hide it from the kids [11 and 13]. I don’t believe in putting on a false face.” He then compared us to Germany in the 1930s (but without the high quality carpentry?).

A woman who had sued her husband talked about the challenge presented by the middle school boy learning (during occasional visits with the father) that the defendant had supported Trump. She presented her passionate support for Hillary and his vote for Trump as a vast moral gulf that the child was having trouble navigating. This prompted the therapist to remind the group that not all Trump voters were racists and sexists. Some people voted for Trump for “reasons that came out of their own pain” (i.e., the difference in voting behavior could not be explained by the fact that the person who is not subject to income tax (child support is tax-free) voted for a Democrat while the person who pays taxes voted for a Republican in hopes of facing lower tax rates).

I dumbfounded the group by asking “Would it make sense to try to point out some things that might be better for them under a Trump Administration compared to what they experienced in the last few years?” Jaws literally dropped.

The most practical-sounding advice from the therapist was to throw questions back at children. If a child says “X told me that Trump is a racist” then ask “What do you understand a racist to be?” This way the adult response is calibrated to what the child actually cares about.

The therapist noted that, although the walls of every school may be plastered with posters about tolerance, love, acceptance, etc., there remains aggression, a lot of which was let loose during the campaign. It is this aggression that is upsetting to children. She recommended reminding them repeatedly that they are safe (but see above for how she doesn’t truly believe it), kind of like the message to MIT undergraduates. “Model calm and confidence. Show them where is the strong place, the safe place.”

Bonus image of a non-deplorable’s car (taken the weekend following the election):

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