A posting every day; an interesting idea every three months…
An engineer posted the following on Facebook a couple of days ago:
They say women can’t show anger…
I predict those words will be recanted shortly.
Her woke friends all clicked “Like”.
My response:
There’s a fairly new play in which a woman shows a bit of anger: Medea.
Readers: Of the women who have been attacking Brett Kavanaugh, which one would be best cast in the role of Medea for an Amazon Prime revival in modern dress?
Full post, including commentsA friend who is a Cirrus SR22-G5 owner recently had the opportunity to fly the Icon A5.
He liked the flight characteristics and described the controls as “coordinated”. On the other hand, the plane was not more fun to yank and bank than the SR22.
He hated the instrumentation (photo). “The prominent altimeter in the cluster goes only to 1,000′ [reading out in height above the ground, I think]. If you want to know your actual altitude you have to redirect your attention to the Garmin GPS in the center.”
What about the angle of attack indicator, intended to keep customers safe even when the aircraft is over-gross (i.e., all the time given the likely buyers and their girth!)? “Useless. You put the nose down and the indicator won’t change for 2 or 3 seconds. There is a huge amount of lag.”
He did not like that the attitude indicator was the smallest instrument (but the thing isn’t legal to take into the clouds anyway).
“There was a lot of vibration,” he said. “It felt like being in a helicopter. Maybe it was buffeting from flying with the doors off.”
He would have bought it at $200,000 if it had conventional instruments. At $390,000 and/or the prices that they’re asking to buy into a partnership, he is not interested.
[He also felt that they had some options to upsell and therefore the real price was over $400,000. Due to his lack of interest in the plane, however, he didn’t get a formal quote.]
Related:
From our anonymous insider…
We are finished with classroom education and now begin our Step 1 study period. Eight weeks from now we begin clinical rotations, also known as clerkships. Students may take the Step 1 exam, which determines the rest of our careers, at any time within this period. Mine is scheduled for six weeks in.
Unlike after most block exams, there is no mass exodus to exotic travel destinations or to visit family. The library is packed with M2 classmates as the M1s go on break.
Study resources are standardized across medical schools and were made available to use at the beginning of our M2 year. The most future minded among us began cramming for Step 1 back in August when our school’s one-year group subscription to the Step 1 UWorld question bank began (the individual rate, with two practice tests, would have been $479). First Aid is the foundation and we also use Pathoma ($85) and SketchyMicro and SketchyPharm ($160 each). Several students have also been using Anki, a flashcard manager, to test themselves on First Aid information. We are told to focus on the four “High-Yield” subjects: neurology, cardiology, pulmonary, and gastrointestinal.
Mischievous Mary, driven by her desire to be a heart surgeon to extreme studying habits, gets up every morning at 5:30 am for a Orange Fitness class. “It’s my guilty pleasure. I know we have gym membership through our tuition, but paying $100 a month gives me motivation to actually work out. When I wake up I think, I can’t go back to sleep. I have to go, or I am wasting $100.”. People respect her corner table in the library, where she leaves her books, and she arrives there by 8:00 am for a 12-hour shift. I’ve asked her several times to get lunch with me. She explains, “I don’t really eat meals. I just snack.” She showed me her bag from the local health food store: kombucha, fruits, and nuts. The only chink in her discipline is Netflix on her Macbook’s screen, visible through a window from outside the library.
Sarcastic Samantha drafted a Step 1 studying schedule for Lanky Luke. Samantha had taken her PA boards in January. “She killed her boards,” said Luke. “She is smarter and frankly should be the doctor.” Samantha responds: “I am so thankful that I didn’t go to medical school.” She now makes $115,000 a year as an inpatient hospitalist at a competitor’s hospital. Luke took his exam three weeks in and has been relaxing all day while Samantha works 12-hour shifts, 7 days on/7 days off.
Gigolo Giorgio complains, “The stuff we’re learning now is not useful in practice. For me to get those extra ten points, I have to study so many trivial details.” He cited the different types of immune mediators (IL-6 versus IL-5), different RNA polymerases (Pol II synthesizes messenger RNA, whereas Pol I synthesizes ribosomal RNA), and preferred growth agar (media) for various bacteria (Chocolate agar versus Thayer Martin agar).
Jane scheduled her exam for four weeks into the period. Our typical day starts with the gym or a run, which should help Jane prepare for summer military boot camp, and we’re ready to study by 10:00 am. Jane purchased a paper calendar and color-coded days for each subject. She watches Pathoma videos in the morning, then does 80 UWorld questions before lunch. She watches Sketchymicro videos when she is burnt out from questions or from First Aid. We’re a little out of sync because I made the decision, later regretted, to spend two weeks shadowing a third-year Emergency Medicine (EM) resident and a ENT physician (see the next chapter).
Not everyone is as faithful to the library as Mischievous Mary. Gigolo Giorgio studies at Starbucks in the morning and expressed fear and anger regarding the company’s plans to shut down for a day of diversity training. I saw six classmates working individually at a nearby county library. Through the school library’s plate glass windows one can usually see two or three students taking a break on the patio. During my own breaks, the patio crowd would tend to gossip about study habits and travel plans after “Step”: “How many UWorld questions have you done?” or “Are you finished with Pathoma yet?” Mischievous Mary: “Why do we put ourselves through this again?” My response: “Don’t forget that we are paying three percent more tuition than last year, even though we are in school for twenty-five percent less time.”
After two weeks, classmates lose some of their intensity. Pinterest Penelope sighs deeply and mutters “God Dammit” when she misses a UWorld question. Although the entire library can hear her, people no longer lift their heads in surprise. I can’t resist checking Facebook or WSJ after finishing a Pathoma video or 10-question UWorld test.
Our school gives us vouchers for two practice tests and more can be purchased at $60 each. I take one about two weeks into studying and score 221: primary care. I take another 3 weeks before my exam and score 247: near-dermatology. Two days later, the Dean of Student Affairs stops me in the halls and says, “Good job on the practice test.” I didn’t realize that he had access to our our practice test scores.
Averaged over six weeks, I probably managed less than 8 hours per day of real study. I get to spend time with Jane. I’ve picked up some hobbies, such as gardening, woodwork, and biking. Lanky Luke, Sarcastic Samantha, Jane and I get together twice a week for our favorite burger-and-beers spot or for grilling at their new house. They just signed a two-year lease on a house as the apartment was not big enough for their adorable Great Pyrenees runt.
Jane’s best friend from childhood comes to stay with us. She works nights as a certified nurse assistant (CNA) at a large academic health system specializing in neurological disorders. One of her recent patients, a 60-year-old veteran suffers from cauda equina syndrome (“horse’s tail” syndrome, describing how the nerves of the lumbar and sacral region get pinched in the spine). The veteran had been going to the VA for several months complaining about leg numbness. “They just gave him lots of anti-inflammatories. When he came to our hospital, he was not able to walk. If he had been treated early on, he might still be able to walk.”
Jane’s friend described how her 25-year-old stepbrother has schizophrenia. “He needs to be committed. He is is starting to resist haloperidol injections. My father is concerned that if he is committed he will lose any future job opportunities when he gets better. My father and stepmother need to accept that he is not going to get better. Job opportunities should be the last thing on their mind. He could never hold a job in his present state. You should see some of the things he does. He goes off and buys hundreds of dollars of clothing, he moves around to new cities and lives homeless for several weeks at a time.”
We start talking about marijuana. Jane’s friend mentions that she noticed a lot of their high school friends who smoked pot early have mental illnesses. Jane, in full study mode, exclaims, “It’s in our First Aid! Smoking pot early on is associated with schizophrenia.” I add, “I do not understand why so little research funding is allocated to marijuana. States are legalizing. An entire generation is going to impacted with unknown complications.” I leave Jane and her friend to reminisce while I walk her beagle-mix dog, a joint shelter adoption with a boyfriend. The boyfriend is gone, but the dog and his neurological disorder, which had discouraged anyone else from adopting him, remains. The animal freaks out whenever there is an unexpected noise.
I attend a Planned Parenthood event hosted by the women in medicine student group. A 27-year-old led the discussion. She graduated college and began as volunteer medical assistant and was then hired as an educator. She runs workshops at local high schools and middle schools “advocating for women’s health and reproductive rights”. The Our OB/Gyn clerkship director arrived late for questions.
Why would someone go to Planned Parenthood, instead of a typical gynecologist? Our OB/Gyn director: “The main reason is animonity. For example, a 30-year-old mother of four who wants birth control, but is uncomfortable telling her husband she does not want more children. The husband would see this visit and prescription bill from the insurance company. Planned parenthood can guarantee a greater level of anonymity. This is a common situation in my experience for my Muslim or immigrant patients.”
A fourth-year student, interested in OB/Gyn: “How do residents get trained on performing abortions?” Clerkship director: “Great question. The ACGME requires that every Ob/Gyn residency program train their graduates to perform abortions. Most large health systems, such as training hospitals, will perform only medically-necessary abortions. For residents to get enough practice to meet the procedure requirements, each health system will have a connection with an abortion provider in the area for elective procedures.” (Why won’t big hospitals perform elective abortions? Our director attributed this to the complexity of ensuring that Federal funds weren’t used to pay for the procedures, but did not explain why this was more challenging that the rest of the administrative and bureaucratic operations of a big hospital.)
Catholic-run hospitals generally do not perform abortions, except in emergencies. What about Catholic would-be Ob/Gyns? There may be an opt-out policy during residency. Thus not every Ob/Gyn will have training or experience in performing abortions.
Classmates have been more active lately on Facebook, perhaps because students are on their computers most of the day. Type-A Anita enjoys sharing “Sassy Socialist Memes” on Facebook.
“When America regularly overthrows democratically elected governments but suddenly needs someone to overthrow its own government like come on CIA where u hiding all of a sudden isn’t this ur “thing”
“Someone should probably tell the rich that workers banding together to present formal address of grievances is the alternative we worked out a long time ago to breaking down the factory owner’s front door and beating him to death in front of his family? I fell [sic] like they forgot.”
Anita is hoping that her Step 1 scores will be sufficient to get her into an Ob/Gyn residency. If she completes her training she will be able to bash “the rich” on Facebook while earning a salary over $200,000 per year and closer to $1 million per year if she decides to specialize in fertility.
Anita is also passionate about immigrants:
Keeping families together is reproductive justice.
Where all my PRO-LIFE and ALL LIVES MATTER people at? I can’t hear y’all over the cries of immigrant children at the border…
These assholes who call parents “irresponsible” for trying to immigrate to America with their children to escape violence and create a better life for their families ARE THE SAME people who exult their own ancestors who “risked it all” to come to America on the Mayflower or some other shit … FUCK that racist bullshit
Pinterest Penelope:
Full post, including commentsIf you had time to wish your dad a happy Father’s Day you had time to (depending on how tech savvy you are) google what’s happening at our border, email your state representatives about refusing to cooperate with ICE, email your federal representatives to demand they work to end this barbaric practice, and/or consider if you are able /willing to attend a protest against this injustice near you.
“This week has brought another wave of tragic news that has left me beyond repulsed and outraged. Thank you, Facebook, for reminding me 100x that my birthday is coming up and I should start a *birthday fundraiser*. I’m no Chrissy Teigen/John Legend, but I’d like to raise at least $280 to support RAICES (The Refugee and Immigrant Center for Education and Legal Services), the largest immigration legal services provider in Texas. After researching how I can help the humanitarian
Part of Dr. Christine Blasey Ford’s story is that she needed to add a separate entrance to a portion of her Palo Alto home due to the trauma that she suffered as a rape victim. This would let her escape from the $3 million ($5 million) Eichler-style home via one additional door (the typical Eichler blueprint has at least three doors; see eichlersocal.com for floorplans). As it happens, she testified that the escape door is currently being used by a rent-paying Google employee, so she can escape through this door now only by stepping over cases of Red Bull and stacks of diversity and bias training materials.
(Testimony and news coverage on this subject is confusing. She wanted an escape door from her bedroom, but now that bedroom is the very one that is rented out for cash? Or the rent-paying Googlers enter and exit through Dr. Ford’s personal bedroom before proceeding to some other bedroom?)
Wealthy advocates of affordable housing tend to be passionate about preventing the construction of rentable apartments, with separate entrances, within neighborhoods zoned for single-family homes. But they’re even more passionate about helping female victims of sexual assault. Thus for any homeowner who identifies as female, maybe it is a winning strategy to “pull a Blasey Ford” and go in asking that a project be approved because it is necessary to reduce a victim’s PTSD symptoms following a never-reported rape?
Readers: What do you think? Has Dr. Ford shown a way to streamline Americans’ trip through the Permit Raj?
[My own experience with the Permit Raj began in Cambridge some years ago. A black couple came in asking for permission to add a cover over a side entrance to their house. PTSD following a 1980s rape was not mentioned, but rather a desire to be able to put down grocery bags protected from the rain, get out keys, and open the door. They had a simple drawing from a contractor. Their proposal was rejected. A white developer came in with a proposal to build a monstrosity of a condo building in violation of all of the zoning square footage rules. The white architect wowed the all-white volunteer committee with renderings and discussion of the crushed stone driveway. The committee members softly murmured “crushed stone driveway” and approved the out-of-scale eyesore.]
Related:
Full post, including commentsI’m not concerned about Brett Kavanaugh’s reputation because (a) I don’t know him, and (b) I don’t support his confirmation for the Supreme Court (see “How did Christine Blasey Ford make it back and forth to Hawaii?” for my reasons, which predate any allegations of sex crimes).
As a frequent pilot or instructor in a propeller-driven airplane, however, I was saddened when a reader forwarded me “Christine Blasey Ford ex-boyfriend says she helped friend prep for potential polygraph; Grassley sounds alarm” (Fox).
The letter says, in part, “While visiting Ford in Hawaii, we traveled around the Hawaiian islands including one time on a propeller plane. Dr. Ford never indicated a fear of flying.”
In other words, it should be obvious to the reader that propeller implies “death machine” and that boarding a prop-driven plane is a brave act. This was probably at least a turbine-powered Cessna Caravan, not a piston-driven four-seater. (Accidents do happen in Caravans, admittedly. See “Health director who approved Obama birth certificate dies in plane crash” (NBC) for a Hawaii crash in which everyone survived except the official who was involved with Obama’s birth certificate. Compressor turbine blades failed at 4,900 hours (NTSB).)
[Separately, the letter also says “I ended the relationship once I discovered that Dr. Ford was unfaithful while living in Hawaii. After the break up, I took her off the credit card we shared. But nearly 1 year later, I noticed Dr. Ford had been charging the card, and charged about $600 worth of merchandise.” Sex with new friends and unauthorized credit card charges… Tracey Richter-Roberts! See “What will people do for love?” for a discussion of her early amorous adventures and credit card sprees.]
Full post, including commentsElizabeth Warren says she will make the U.S. an affordable place to live despite (1) our incompetence at building physical infrastructure, such as housing, and (2) population growth of about 2 million people per year through immigration and the children of immigrants (Pew). Her plan is to grab hold of family via an increased estate tax and use it to build 3 million housing units over a 10-year-period (i.e., one for each of the 3 million refugees who’ve been granted U.S. residency/citizenship since 1980; compare also to the 7.2 million units of affordable housing of which the U.S. is currently short).
Today, however, the NYT has a big article on the conventional estate-tax avoidance strategies used by the Trump family to prevent more than half of their wealth from being taxed away. The effective estate tax was 5 percent rather than the headline 55 percent sought by the government. This was all illegal/immoral according to the Times, though the IRS and the various tax professionals involved at the time (nearly 20 years ago) thought that it was legal and proper.
[One thing that the article shows is that Trump’s sister has to be pretty darn rich and yet she has gone to work every day as a Federal appeals court judge (same job that folks think a proven rapist such as Brett Kavanaugh should keep!).]
Readers: Could Elizabeth Warren’s plan for 3 million housing units over 10 years make any difference? If the estate tax is cranked up, will wealthy families pay it or go back to their time-honored avoidance strategies?
[Also, doesn’t this article mostly falsify the Times‘s own reporting over the last few years? We were told by the Times that Trump was poor. He was heavily in debt to rich Russians and therefore they controlled him. Now this new article says he inherited at least $1.96 billion, adjusted for inflation and S&P 500 returns.
Which is it? Is he a rich guy with a personal Boeing 757 and another $2+ billion to keep it fueled and renew the gold-plating on the seatbelt hardware? Or is he broke and beholden to some rich person in Moscow?]
Related:
The latest California law establishes a quota for “female” corporate board directors (SB-826):
More women directors serving on boards of directors of publicly held corporations will boost the California economy, improve opportunities for women in the workplace, and protect California taxpayers, shareholders, and retirees, including retired California state employees and teachers whose pensions are managed by CalPERS and CalSTRS. Yet studies predict that it will take 40 or 50 years to achieve gender parity, if something is not done proactively.
Numerous independent studies have concluded that publicly held companies perform better when women serve on their boards of directors
I.e., companies are so desperate to underperform that they will wait 40 or 50 years before doing something that gives them a competitive advantage.
Why “female” in quotes? The way that the bill is structured, companies can comply in about 5 minutes, without bringing in anyone new to serve on a board:
“Female” means an individual who self-identifies her gender as a woman, without regard to the individual’s designated sex at birth.
Suppose that a company does want a new board member who (a) is a California resident, (b) has identified as a woman for a long period of time, (c) has a lot of experience with raising funds, and (d) has managed a company that is in the public spotlight? The obvious choice? Elizabeth Holmes! (additional reason: she is blond)
Maybe this new quota system is all about getting Elizabeth Holmes back to work?
[Separately, why is there a quota only for women? If there is no need to adhere to the Equal Protection Clause of the Constitution, why wouldn’t there be a quota for African-American, Hispanic, Native-American, Asian-American, etc. board members?
Will Sheryl Sandberg establish a prize and recognition ceremony for companies that replace men of color with white women?
Woke Silicon Valley men often preface their feminist statements with “Because I have daughters…” Will we see one of these loyal Hillarists say “As the father of white daughters, I support this because I want to see my girls grow up to enjoy paychecks from diversity token jobs, not find that their path to quota-based success is blocked by black or Hispanic men”?]
Full post, including commentsHumanities scholars these days make the news for only the following reasons:
The Celtic World, a 24-lecture class from The Great Courses, will restore your faith in this corner of the U.S. education industry. The lecturer is Jennifer Paxton, a professor at Catholic University, and she wears her expertise lightly. She uses modern idioms and plain language when appropriate and then drags out her Latiin or Gaelic as necessary.
One learns a lot about the Romans in this class as they were the big power in the region and the authors of most of the primary sources.
Highlly recommended for listening in the car (available on Audible).
Full post, including commentsI was down in Bethesda, Maryland over the weekend, technically home to Georgetown Prep (actually located, since 1919, in what we Native Bethesdans would have called “Rockville”) and its weekly official gang rape parties (organized by Brett Kavanaugh, according to Julie Swetnick). None of these parties were on the calendar for Saturday night at my parents’ retirement fortress, so we were able to enjoy a quiet family dinner (cooked and served by immigrants to the pro-immigration elderly Democrats (nearly all had retired from careers, e.g., civil service, medicine, or law, that depended on Big Government becoming Yet Bigger)).
A grandson who is a local high school junior joined. I asked “Are you partying like a Kavanaugh?”
I’m hoping that this can become a new meme to replace “Party like a Rock Star”.
[I posted this on Facebook. It was #NotFunny and #TooSoon. A woman who manages an anti-development non-profit org:
Really? You mean like, get drunk, assault women, black out, and don’t remember a thing the next day. You seriously think that’s funny?
to which I responded
All the more reason to ask!
A self-employed carpenter and contractor whom I know commented
I only hope he turns out that smart. Remember also “he, who is without sin, cast the first stone”
He’s 70 years old and, for 55 years, has been getting up at 5 am every morning, 6 days per week, to work. It is possible that he interpreted my post literally as he is not a close friend nor a close reader. A woman who went to an elite high school then two elite universities before settling into a cushy university desk job, resonded to him and men in general:
It sounds like you may have things on your conscience. That’s ok, we are not judging you (at least not until you run for a public office). Let me give you this advice. Just come clean and apologize. You will be forgiven.
If Jesus were alive today, he would be a liberal!
I can see the aggrieved male privilege getting up at arms about “politically correct” taking away the last bits of “boys will be boys” fun you were able to have (at our expense too!). Please pardon me if my heart is not breaking for you. I cannot feel guilty or bad that it is no longer ok to drink until you are liberated enough to force yourself on another human being. Please figure out how to bond with other guys and have fun some other way.
Is it reasonable for a woman with an elaborate list of educational credentials and a highly paid desk job that starts at 10:00 am (or later!) to say that a man who gets up at 0500 to work with his hands has “privilege” compared to her? (They both appear to be white, but their respective photos have not been evaluated by official government race-identifiers.) Could billionaire Sheryl Sandberg, for example, say that her immigrant landscapers are “privileged” if they happen to identify as male? If not, where is the line over which a female can cross into the land of “more privileged than a blue-collar guy”?]
For the record, though I was a high school student in Bethesda in the late 1970s, right in the middle of the Jimmy Carter Malaise and a core non-woke period of “rape culture”, I did not hear about any rapes at parties or otherwise (maybe Walt Whitman (public) High School kids were not cool enough for these?). Teenagers back then were terrible gossips and keeping secrets was more or less impossible. The most common sex-related scandal was a pregnancy (this, despite the extensive contraception education provided by Montgomery County officialdom). A few Catholic girls got married as a result of unintended pregnancies. The happy new couple would move into a walk-out basement belonging to one set of parents (our neighborhood was called “Mohican Hills” (maybe Elizabeth Warren lives there now?) and nearly all of the houses were on a slope). The new moms would take a couple of months off school and then hand the resulting baby to their 40-something parents. At the time, a 17-year-old giving birth was considered unfortunate. This was before the advent of child support guidelines (history) that made single motherhood a financially sensible lifestyle choice and every pregnant girl either married the father or had an abortion (legal since 1968 in Maryland).
(Teenage motherhood still seems to be something for people to condemn. I spoke with an anesthesiologist the other day. She remarked negatively on having recently assisted with a birth at which four generations were present: baby, mother, grandmother, and great-grandmother. “The oldest family member in the room was 39. Nobody had a male partner or a job.” (i.e., each child had been born to a 13-year-old mom) In her view, this fecundity was due to our welfare system. “What this country needs is more hunger. You don’t see people in China having babies so that they can then live in public housing.” She’s a frequent business traveler to China so this is based on first-hand knowledge. I was shocked by her statements because typical Boston-area academic physicians are just as liberal as you’d expect given that more than 50 percent of their income comes from the government (Medicare, Medicaid, etc.). It is odd that Americans want to condemn something that they also vote to fund and enable!)
Update: “Kavanaugh Was Questioned by Police After Bar Fight in 1985” (nytimes), which says “As an undergraduate student at Yale, Brett M. Kavanaugh was involved in an altercation at a local bar during which he was accused of throwing ice on another patron, according to a police report.” Compare to students in the 18th century (Daily Mail): “duelling with swords; getting loudly and raucously drunk and getting kicked out of taverns … Trapping a servant girl in their rooms and scaring her; … Getting drunk and arguing with a lecturer…”
Related:
From our anonymous insider…
Exam week: two one-hour clinical standardized patient (SP) encounters, a 4-hour NBME-style 200-question exam, a 2-hour case-based exam, and a 2-hour clinical multiple choice exam over four days.
My first SP is 50-year-old nonobese non-smoking female with a two-month history of radiating back pain. She describes pain beginning in her lower left back, traveling down her buttocks to her feet like a bolt of lightning. She denies urinary incontinence or retention, denies headaches or visual changes. She reports difficulty walking. Physical exam reveals weakness in plantar flexion of the right foot decrease in station over the lateral aspect of the foot. She is unable to walk on heels. She has 2+ pulses in distal extremity. Positive straight leg raise while supine. I diagnosed her with a disc herniation spinal stenosis causing a L5 or S1 radiculopathy. One mistake: I forgot to do sensation testing of the distal lower extremities (feet).
My second SP is a 40-year-old nonobese nonsmoking female presenting for right-side hearing loss and one-hour episodes of dizziness over the past several days. I conduct the Rinne test (tuning fork is placed next to the ear and then on the mastoid bone. If conduction loss, the patient can hear better when fork is placed on the bone) I then do the Weber test (tuning fork is placed on the midline skull, and localizes to the affected ear if conduction loss)
Good news: I have ruled out a problem with mechanical conduction and therefore her hearing issue is due to a sensorineural cause. Bad News: I did not read up on sensorineural hearing loss. Although we are not supposed to discuss the cases (others will see the same patients later in the week), Jane and I overhear the correct answer in the line at Starbucks: Ménière’s disease. Neither Jane nor I had ever heard of this, let alone how to diagnose or treat this disease.
The clinical multiple-choice exam tests ophthalmology, suture technique, lumbar puncture technique, and psychiatric cases. Several questions showed images where we had to identify the correct diagnosis: for example, a cherry red spot in the macula (pigmented area near the center of the retina) suggests a retinal artery occlusion or Tay-Sachs disease. How is it possible to test suture technique with multiple choices? Example: “What suture size and needle type should be used to close a face laceration? What technique is depicted with this diagram?”
Students led by Type-A Anita swarm the clinical director because one of the questions had the wrong units attached to an optic ultrasound measuring the optic sheath diameter. It had calipers measuring the optic nerve diameter at 3 mm distal to the retina. The multiple choice questions all were in cm instead of mm.
The case-based exam covers five patients, each starting with a two-paragraph description of a patient’s presentation. We are then asked open-ended questions about what tests we would order and other symptoms to ask about. The exam for this block covers neurological diagnoses, endocrine diagnostic workups, musculoskeletal fractures, dislocations and malignancies. Neurology questions asked what other symptoms is most likely in a description of a Huntington’s disease patient and localize the lesion for stroke symptoms (e.g,. right anterior cerebral artery for left-sided leg weakness). Endocrine questions dealt with determining if an endocrine pathology is primary (disorder of the endocrine gland itself) or secondary (exogenous or pathologic dysfunction of the pituitary). For example, a patient with low thyroxine hormone and high TSH suggests a primary thyroid disorder; a patient with low thyroxine hormone and low TSH suggests a secondary cause of hypothyroidism. Pinterest Penelope complained about a lifelong smoker with Cushing syndrome (excess cortisol) and high ACTH (adrenal corticotropin hormone, hormone released by the pituitary gland to stimulate the cortisol release from the adrenal cortex). We had to determine if this was a ACTH-secreting pituitary adenoma or paraneoplastic syndrome from an underlying small cell lung carcinoma. “How were we supposed to know what is more likely?”
Jane and I look at the sample question bank on UWorld the night before to prepare for our final NBME block exam. These will be retired Step 1 questions from the National Board of Medical Examiners. I ask Jane about drugs for the treatment of bipolar disorder. She responds, “First Aid says mood stabilizers. lithium and valproic acid.” I look at my own copy of this book: “On page 545, First Aid says you can also use antiepileptics like carbamazepine and lamotrigine.” Jane exclaims, “What!?! Those are sodium channel blockers for seizures.” I add, “I understand why doctors order psych consults and call it a day. We cannot go into psychiatry.”
The Thursday NBME block exam was our toughest so far. Type-A Anita claims to have “blacked out” for the last 15 minutes: “I do not remember anything.” Pinterest Penelope: “Where was the biochem, where was the actual neuro on the test? There was nothing of yield.” Mischievous Mary adds: “I am glad I do not go to lecture because I’ve heard not much was represented on the exam.”
The renal questions required differentiating different types of chronic renal disease. Some questions you could answer using the patient demographics, e.g., African Americans are more likely to get focal segmental glomerulosclerosis (FSGS), whereas whites and hepatitis B/C patients get membranous nephropathy. Others started with black-and-white scanning electron microscopy images and asked about the immune complex deposition pattern. Anita was not happy: “There is nothing to memorize. It’s like learning a new organ system every single question.” Her mood was not lifted by a genetics counseling question concerning the probability that a couple’s potential children will develop an autosomal recessive disorder. The husband has a sibling afflicted with the disease, which has a 1 in 40,000 prevalence in the general population. “I did not go to medical school to do math!” Anita exclaims. Answer: assuming Hardy-Weinberg equilibrium, 1 in 100 individuals are carriers of the disease. The husband’s parents must both be carriers for a sibling to have inherited two affected genes and therefore the spouse has a 2/3rds chance of being a carrier (he doesn’t have the disease so 1/4 of the sample space is removed). Thus the probability of an affected child is wife’s risk of being a carrier times husband’s risk times child’s risk of receiving two carrier genes: 1/100 * 2/3 * 1/4 (1 in 600).
[Editor: In most states, any child born during a marriage will entitle the parent who can obtain custody to child support, regardless of actual paternity. So the wife could have sex with a genetically-clean neighbor and in the event that the husband ever does find out, she can still count on child support profits for 18-23 years (depending on the state).]
After exams, Jane, our class VP, and I help Lanky Luke and Sarcastic Samantha move into their new house. Luke and I rent a U-Haul trailer for his F-150 pickup. While driving, Luke informed us that his uncle has autosomal recessive polycystic kidney disease. “I thought the question Anita was complaining about was a great question. My father is an engineer, but has no idea about medicine. He told us he debated having children out of fear his children would inherit the disease.” He continued, “Just like in that question, the doctor informed my parents it would be very unlikely.” We googled ARPKD — a prevalence of 1 in 20,000 puts the carrier frequency at about 1 in 70. Based on the uncle’s phenotype, there is a 0.24 percent chance of his children getting the disease. Luke continued: “People overestimate certain risks. That’s about the same likelihood as a typical couple having someone with Down syndrome. When you put it in that perspective, you wouldn’t change your whole plans based upon that risk.”
We drink some craft beer on their new porch overlooking a small creek as their dog and cat explore their new home. With exams over, campaigning for the six student admissions committee representatives (from M3 and M4) has begun. Geezer George sets off a firestorm by texting the class GroupMe:
Hey all, I know it’s a little early, but I’d like to throw my hat into the ring for the Medical school admissions committee. If you think I would be good for the job, and if one of your better friends isn’t running, I’d love your support!”
Buff Brad responds:
I would also like to throw my hat into the ring for a spot on the Medical School Admissions Committee. I have been working hard to promote the vision of our school to both incoming applicants and current undergrads. I believe that being elected as a committee member would allow me to really make an impact.
Type-A Anita grills the two men: “What are your strategies for getting more girls at our school?” Our class and M1 are both over 50 percent female, but nobody asks Anita to clarify her question with a target percentage. Instead, Fashionable Fiona announces her candidacy:
… Being a women (@Anita) I will ensure we will have equal representation of genders and as a minority I will ensure we have a diverse class. Let me know if you have any questions! I’d love your support!
Optho Annie, an aspiring opthamologist with a family heritage from the Indian subcontinent::
To piggyback off of Anita’s question, I’m also interested in being on the Admissions Committee and have thought about increasing both female enrollment and enrollment of people of color and minorities, something we severely lack. I think the answer comes down to increasing visibility and outreach through different endeavors to show we host an environment where every student can flourish and feel safe. Happy to talk to anyone in person about my ideas, and would appreciate your support if you think I’d be a fair and just committee member!
Our school was awarded a diversity award by the LCME. What was lacking from Annie’s point of view?
… In general, diversity to me means a community or group of people that are of different races, religions, cultures, which can all help expand their peers’ world views. However, that’s the more obvious form and not all of what diversity means to me. I also think people of different socioeconomic backgrounds, hailing from different geographic areas , and also people on different sides of the political spectrum can contribute to and enhance diversity. …
… our class is pretty diverse when it comes to a lot of things like socioeconomic background, geographic background, and even culture and religion. However, I do think we are lacking in minority enrollment as well as female enrollment. We historically have had very few black, Hispanic, and Native American students. Also, over 50% of medical school students are now women but our class percentages do not always reflect this.
It turns out that one of Annie’s prime motivations was hearing about a class several years ago that was 50/50 female/male rather than adhering to the national trend of majority female. Neither of the two closeted conservatives whom I know in our class offer to sit down with her and share their perspective from their Trump-tainted side of the political spectrum!
Adrenaline Andrew, an aspiring ED physician whose family is from Kurdistan:
I would also like to be considered! I think it’s important we present ourselves as inclusive and well-rounded. I really enjoy talking to future students and believe I can represent our school as such. I am huge advocate of diversity and ensuring minority students feel welcomed in our city (and increasing awareness within our school). This a very exciting position! I would love your support and welcome any advice you have for me.
After an extensive exchange of messages, it turns out that nobody wants to promote diversity of undergraduate majors, age, or any other characteristic other than gender and race ID. No white males come forward (Geezer George and Buff Brad can qualify as persons of color).
Sarcastic Samantha, who currently identifies as “white,” cracks up as
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