Medical School 2020, Year 4, Week 35 (Advanced Anatomy)

by philg

It is March 30, 2020. Our rotations are now “socially-distanced”: medical education (Zoom meetings with M1s and M2s), pathology (share a screen with a pathologist), and anatomy (handful of masked people in a large lab). The most popular choice is an additional two-week block of “study time” (i.e., vacation) for the Step 3 exam, a two-day multiple choice exam that costs $895 and duplicates material from Step 2. It is impossible to register for the exam until after we graduate, so nobody is actually studying. Jane and I have decided to learn anatomy from our favorite retired trauma surgeon for two weeks.

There are just two other students on our elective, including Buff Bri who matched into neurosurgery and a Canadian who matched into Internal Medicine. School administrators have decreed that everyone wear masks in the anatomy lab and that no more than two students at a time can be present in the thoroughly ventilated cavernous anatomy lab. Jane: “I’m surprised that our professor is teaching. She’s the ideal patient to actually be harmed by COVID-19.”  We will meet five times over two weeks, starting at 10:00 am and working until the early afternoon.

The first week we focus on trauma exposures. Jane and I start Monday on a cadaver with an untouched abdomen! Our attending first goes over how to make a midline incision. “A lot of residents do not extend the incision all the way to the xiphoid process. That few extra centimeters gives you a much better exposure.” We both take turns cutting, then suturing each fascial layer back together, and then cutting the sutures. Next we play the “Exposure Game”: she tells us an organ or structure, and we have to describe how to get to it once inside the peritoneal cavity. We perform the Kocher maneuver, medialization of the duodenum through incision of the inferior lateral border of duodenum, and the Cattell-Braasch, medializing the lateral edge of the ascending colon. A typical abdominal organ can be mobilized (or “medialized”) from its natural resting place by incising a thin layer of connective tissue (“peritoneum”) thereby releasing its long blood supply attachment (mesentery) to its full length. From this principle, you can bring the right colon or spleen out of the abdominal cavity while still attached to its blood supply. 

We quickly realize that the cadaver’s anatomy is way out of whack, which makes winning the game a lot more challenging. There is a seven-inch predominantly solid mass in her midline, which encircles the aorta and pushes her vena cava to the right. We cannot identify the abdominal aorta at all, but slowly dissect it out moving backwards from the bifurcated right and left iliac arteries. We also perform the Mattox maneuver in which the left colon and kidney are medialized to reveal the aorta.

We go in Wednesday and Thursday to continue to dissect the abdomen and remove the mass. During our dissection, we find that she had a ureteral stent placed in her left ureter due to obstruction from the mass. Our professor hands us a bucket to save the specimen for future classes. “Next year’s class wont have cadavers because authorities are requiring all cadavers be Covid-negative. There just won’t be any supply.”

We then perform a resuscitative thoracotomy (creating a hole in the chest). I make an oblique incision from below the nipple to the sternum, dissect down to the ribs, and place a rib expander (“Finochietto”) device in between the two ribs. Jane starts turning the crank to expand the ribs apart. We switch and Jane takes over to dissect out the heart and lungs. “Bedside thoracotomy is a procedure that is a last ditch effort to bring a trauma patient back from death,” our attending explains. “Imagine a 30 year old with multiple stab wounds is dropped off at the ED entrance. He is in extremis – he doesn’t open his eyes and is groaning only. His heart rate is 160, and the automatic BP cuff cannot get a reading. He has a pulse when he is transferred over to the trauma bay bed, but shortly thereafter, an astute medical student says that she cannot feel a pulse. What do you do?” A resuscitative thoracotomy is performed to try to bring this dead patient back to life. A large incision is made, the ribs are spread. The heart is delivered out of the chest. The aorta is clamped to decrease the circulating blood volume and divert blood flow to the brain. Frankly, attendings sometimes let residents do it to practice even though it doesn’t significantly improve patients’ outcomes.” She concludes, “The best evidence suggests performing resuscitative thoracotomy after traumatic arrest from penetrating injuries to the chest – maybe you can stitch a hole in the heart – or penetrating injuries to the abdomen where you can halt massive hemorrhage by clamping the aorta.”

On Friday, we perform a mastectomy, much to Jane’s disappointment after her two-week breast service rotation. “After a few mastectomies, it is boring. You’re just cutting into fat.” I make an oblique incision along the cadaver’s breast and find the pectoral fascia (connective tissue plane overlying the pectoral major muscle). I then dissect, mostly with my hands, to remove the breast tissue (all fat in this 86-year-old). We then perform the much more exciting axillary lymph node dissection! Jane begins it by reflecting the pectoral major to identify the clavipectoral (“clavipec”) fascia which runs up to the coracoid process (bony protuberance on the front of your shoulder). “The coracoid is the key to the axilla,” exclaims our attending. Jane and I have not studied this anatomy for awhile, having not been in the hospital since almost January, let alone on a surgery rotation. We pull out Netter’s Atlas of Human Anatomy, multiple copies of which are strewn around the lab, and turn to the axilla plates. We receive a ten-minute tangent about the most important books for surgeons to have: Netter’s Atlas of Human Anatomy,  Maingot’s Abdominal Operations, Skandalakis’ Surgical Anatomy, Netter’s Surgical Anatomy and Approaches.

We review the shoulder anatomy, and head back to our dissection. “In an axillary node dissection, you typically should not see the neurovascular bundle. You mostly have to watch out for what two nerves?” Jane responds, “The thoracodorsal (latissimus dorsi) and the long thoracic (serratus anterior).” Women are already self-conscious enough about losing a breast. It’s best not to also give her a winged scapula [injury to long thoracic nerve leading to impaired function of the serratus anterior].” 

Buff Bri comes in every day for several hours, defying social-distancing orders from the administration, but our elderly trauma surgeon doesn’t care (“the cadavers are far enough apart”). From the first two cadavers he removes the brain by removing the skull and cutting the brain stem from the spinal cord. On the third cadaver, however, he spends hours meticulously dissecting out each vertebral arch/lamina to have an undisturbed nervous system from the brain to the end of the spinal cord. When it was time for final removal, our attending hands him the scalpel. “You know what to do.” He shrieks, “No, no, I can’t! You do it!” After a few more shrieks, he begins cutting each of the spinal nerves to finally remove the entire central nervous system – the brain connected to the spinal cord. I am amazed how small it looks. “We’re saving this one,”  as she grabs a bucket. “Not a bad haul for two weeks. Two interesting specimen buckets!”

Type-A Anita is actively sharing “Sassy Socialist Memes” on Facebook. She adds her own gloss: “People, if we’re afraid that giving people $600 per week in unemployment benefits will stop them from working, that’s an argument for raising wages, not for refusing to bail out the people!” If any of her friends are turning to her posts in hopes of reassurance regarding coronavirus, they will be disappointed: “viruses can mutate into different strains. Look at how hard it is to guess which flu strain to account for in annual vaccines. We just don’t know enough about this virus to assume anyone is immune.”

During small group sessions, Anita frequently expressed her hatred of immunology (e.g., “Who cares about CAR-T cells and HLA types?”). A classmate who has specialized in immunology responds to Anita’s fear of lethal mutations: “The mutation rate of this virus is orders of magnitude less than either the flu or HIV, two viruses that have much more genetic diversity than SARS-CoV-2 due to extremely error-prone replication machinery. This bodes well for development of effective vaccines and possibly antibodies in comparison to circulating influenza viruses. Doesn’t change the fact that the duration of post-infection immunity is unknown, though!”

[Editor: Maybe they were both wrong, like most people who made predictions about COVID-19. SARS-CoV-2 never mutated into a virus capable of killing people with different characteristics than the early victims (i.e., the death rate kept falling because the virus killed those susceptible to death in the first year or two). But the immunology nerd was also wrong. We never developed a vaccine that reduced infection or transmission and maybe the vaccine had no effect on the death rate either. See “Where is the population-wide evidence that COVID vaccines reduce COVID-tagged death rates?” and “Did vaccines or any other intervention slow down COVID?”. Anita’s prediction that Americans would go back to work after long-term unemployment was at least partly wrong. Bureau of Labor Statistics data showed that the U.S. labor force participation rate remained lower in 2023 than it had been in 2019, though the most dramatic fall was from 2009 through 2015, after the 99 weeks of unemployment authorized by Congress during the first weeks of the Obama administration (“99 weeks of Xbox”).]

Statistics for the week… Study: 0 hours. Sleep: 9 hours/night; Fun: 2 nights. Jane and I continue packing up our house and training our two puppies. We go to the dog park every other day.. Pinterest Penelope ordered graduation-themed tee-shirt pullovers for each dog and arranged a class dog photoshoot. Wine night every night.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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International Day of Solidarity with the Palestinian People (and a poll result)

by philg

It’s the International Day of Solidarity with the Palestinian People, established by the United Nations. The most recent scientific poll of Palestinians in the West Bank and Gaza was conducted by Arab World for Research and Development (AWRAD), a West Bank-based organization. The English-language version of the tables of results disappeared from the AWRAD web site, but I managed to find an archive copy and am making it available from this server.

If we’re going to have solidarity with the Palestinians, we might want to look at what they want and how they’re feeling. Western media tends to portray the Palestinians as helpless victims. They lack agency, know that they’re defeated, are cowering in fear, and feel “humiliated”. Example from the New York Times:

The Palestinians interviewed just as bombs were falling and artillery shells were exploding, however, tell a different story. First, 73 percent expect to win the current round of battles (or maybe the entire war that Arabs declared in 1948):

What’s the long-term goal? “A Palestinian state from the river to the sea” (say 75 percent):

They are overwhelmingly supportive of what the pollsters refer to as “the military operation” of October 7 (let’s put aside whether raping, maiming, killing, and kidnapping civilian women and children is “military”) as progress toward the above goal of river-to-the-sea liberation:

How are the current leaders of Gaza government and society viewed? The Islamic Resistance Movement (“Hamas”) and Palestinian Islamic Jihad have 75-85% positive ratings among Palestinian civilians:

What do the United Nations folks who created this day of solidarity offer? Here’s a tweet from the top executive:

His way of expressing solidarity with Palestinians is to propose a two-state solution when that is supported by only 17 percent (see above) of the Palestinians (75 percent want river-to-the-sea).

Where can Palestinians who want true solidarity turn, then? California, of course! “Anti-Israel protesters defend Hamas as Oakland city council meeting descends into chaos over cease-fire resolution” (New York Post):

The city council in Oakland, California, unanimously passed a resolution Monday calling for a permanent cease-fire in the Israel-Hamas war — while spurning language that would have condemned the terrorist group for the Oct. 7 massacre following an uproar from anti-Israel protesters.

Councilman Dan Kalb’s amendment spotlighting Hamas’ role in the slaughter of an estimated 1,200 people across southern Israel was rejected 6-2.

The proposal was met by boos from demonstrators, who condemned the language as “anti-Arab” — with some going as far as to spread conspiracy theories that the Israel Defense Forces had slaughtered Jews to justify an invasion of Gaza.

“There have not been beheading of babies and rapings. Israel murdered their own people on Oct. 7,” one woman told the city council.

Another woman, who was eventually cut off from speaking, claimed: “The notion that this was a massacre of Jews is a fabricated narrative. Many of those killed on Oct. 7, including children, were killed by the IDF.”

“To hear [the Jews] complain about Hamas violence is like listening to a wife-beater complain when his wife finally stands up and fights back,” the man said.

UNRWA, which has provided the basics of life (food, health care, education, etc.) to Palestinians for 75 years (funded by US and EU taxpayers), thus enabling both one of the world’s highest rates of population growth and the ability by Palestinians to maintain a permanent wartime footing (up to 100 percent of GDP can be spent on military because UNRWA pays for the essentials) is also more supportive than the top UN guy: “It is a day to affirm our support for the full rights and national aspirations of Palestinians”. (“national aspirations”, as noted above, means river-to-the-sea for about 75 percent of Palestinians)

Feminists in India support the guys who broke through the fence on October 7 to interact with Israeli women and girls:

Readers: What are you doing today to follow the United Nations guidance for expressing solidarity with Palestinians?

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Shifting gears: Why Tesla’s previous failures in Full Self-Driving might not predict future failure

by philg

From Elon Musk, the book:

Almost every year, Musk would make another prediction that Full Self-Driving was just a year or two away. “When will someone be able to buy one of your cars and literally just take the hands off the wheel and go to sleep and wake up and find that they’ve arrived?” Chris Anderson asked him at a TED Talk in May 2017. “That’s about two years,” Musk replied. In an interview with Kara Swisher at a Code Conference at the end of 2018, he said Tesla was “on track to do it next year.” In early 2019, he doubled down. “I think we will be feature complete, Full Self-Driving, this year,” he declared on a podcast with ARK Invest. “I would say I am certain of that. That is not a question mark.”

So they’ll fail again in 2024? Maybe not.

For years, Tesla’s Autopilot system relied on a rules-based approach. It took visual data from a car’s cameras and identified such things as lane markings, pedestrians, vehicles, traffic signals, and anything else in range of the eight cameras. Then the software applied a set of rules, such as Stop when the light is red; Go when it’s green; Stay in the middle of the lane markers; Don’t cross double-yellow lines into incoming traffic; Proceed through an intersection only when there are no cars coming fast enough to hit you; and so on. Tesla’s engineers manually wrote and updated hundreds of thousands of lines of C++ code to apply these rules to complex situations.

C++?!?! Seriously?

According to the book, Tesla is shifting to a ChatGPT-style machine learning approach:

“Instead of determining the proper path of the car based only on rules,” Shroff says, “we determine the car’s proper path by also relying on a neural network that learns from millions of examples of what humans have done.” In other words, it’s human imitation. Faced with a situation, the neural network chooses a path based on what humans have done in thousands of similar situations. It’s like the way humans learn to speak and drive and play chess and eat spaghetti and do almost everything else; we might be given a set of rules to follow, but mainly we pick up the skills by observing how other people do them. It was the approach to machine learning envisioned by Alan Turing in his 1950 paper, “Computing Machinery and Intelligence.”

By early 2023, the neural network planner project had analyzed 10 million frames of video collected from the cars of Tesla customers. Does that mean it would merely be as good as the average of human drivers? “No, because we only use data from humans when they handled a situation well,” Shroff explains. Human labelers, many of them based in Buffalo, New York, assessed the videos and gave them grades. Musk told them to look for things “a five-star Uber driver would do,” and those were the videos used to train the computer.

During the discussion, Musk latched on to a key fact the team had discovered: the neural network did not work well until it had been trained on at least a million video clips, and it started getting really good after one-and-a-half million clips. This gave Tesla a huge advantage over other car and AI companies. It had a fleet of almost two million Teslas around the world collecting billions of video frames per day. “We are uniquely positioned to do this,” Elluswamy said at the meeting.

Despite grand claims by academics seeking funding, rules-based AI generally failed to do anything interesting or practical from 1970-2010 (see MYCIN and CADUCEUS, for example). Statistical approaches to AI, however, began to deliver useful systems, e.g., for speech recognition, starting around 2010.

How Tesla describes the future:

FSD would provide a huge lifestyle boost here in South Florida where there are a lot of 1- and 2-hour drives that lead to interesting places, such as parks, cultural events, theme parks, etc. The drives themselves, however, are boring: straight highways, a lot of traffic close to Miami and Orlando. FSD should work quite well. FSD would also be good for getting to/from international airports. There are a lot more flights from FLL and MIA than from PBI, which is closer to our house, but with a self-driving car it might become more sensible to fly out of farther-away airports.

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Science is a fundamental right for humans…

by philg

…. as long as they can afford $15,000 for a lifetime of access to Nature.

A tweet from the righteous:

Science is a right, which means it is something that anyone, regardless of wealth level, should be able to claim and, if denied, be able to enforce the claim.

Suppose that a person attempts to claim his/her/zir/their human right to science at the nature.com web site? He/she/ze/they quickly hits a pay wall:

My response via X:

Aren’t you the same people who say that nobody can have access to the science published in your journal unless they pay $200/year (that’s $15,000 during a human lifetime)? Science is then a “right” for anyone who can afford to pay you? If that’s the standard then we can say that owning a superyacht is a right as well because anyone with enough money can buy a 100-meter yacht. Here are some yachts that are available on the same terms as the science published by Nature:

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Immigrants can get U.S. passports in one day

by philg

For native-born U.S. citizens, it takes about three months, including mailing time, to get a passport if you pay extra for “expedited” service. From the State Department web page (retrieved end of October 2023):

As of October, they were saying that it would take 2 weeks to mail, then 5-7 weeks to “process”, then 2 more weeks to mail.

Friends who are immigrants have been reporting U.S. passport renewals in just a day or two. How do they do it? The U.S. government offers an emergency service. The immigrant uses Adobe Acrobat to create the required PDFs regarding the “life-threatening illness or injury” from which an immediate family member back in the old country is suffering. The American bureaucrats have no means of verifying these documents so entirely fictitious physician names and addresses work fine. The immigrant buys a fully refundable plane ticket back to the old country, makes an appointment, walks into a U.S. government passport agency.

Why can’t State Department clear the backlog, especially for simple renewals? What stops them from paying overtime to the existing staff to work nights and weekends until the processing time is back to something more reasonable? (or hiring Venezuelan asylees to assist? We are informed that 500,000+ Venezuelans who’ve joined us are eager to work and highly qualified) What’s “reasonable”? In 1971, when the U.S. population was 200 million, it typically took between 5 and 21 days to get a passport (New York Times) and when the backlog increased the government would add night shifts to clear it. In 1961 (US population 180 million), it took 3 days:

A native-born American might be able to work a similar process via the “urgent travel” channel. Buy a refundable ticket for travel within 14 days and then begin to work the phones and try to get an appointment and travel to a major city (a customer in Tallahassee, Florida would have to drive perhaps 6 hours to Miami or Atlanta or New Orleans).

Finally, why do we need to show passports when returning to the U.S.? The passport was already checked twice by airline personnel on the departure side. If the southern border is open to millions of new Americans who choose to walk in, why must we stand in line for a third check after an exhausting international flight?

Related:

  • “Airport travel delays after U.S. Customs computer outage” (NBC, 2019): International travelers were waiting in long entry lines at some of the nation’s busiest airports Friday … The outage affected New York’s John F. Kennedy Airport, Los Angeles International Airport and Chicago’s O’Hare International Airport, among others. Images on social media showed travelers jammed into terminals at JFK and O’Hare as they awaited admittance to the United States.
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Elon Musk at war in Ukraine

by philg

Can a private citizen change the outcome of a foreign war? The answer is “Yes” for Citizen Musk. From Elon Musk, the book:

An hour before Russia launched its invasion of Ukraine on February 24, 2022, it used a massive malware attack to disable the routers of the American satellite company Viasat that provided communications and internet to the country. The command system of the Ukrainian military was crippled, making it almost impossible to mount a defense. Top Ukrainian officials frantically appealed to Musk for help, and the vice prime minister, Mykhailo Fedorov, used Twitter to urge him to provide connectivity. “We ask you to provide Ukraine with Starlink stations,” he pleaded. Musk agreed. Two days later, five hundred terminals arrived in Ukraine. “We have the US military looking to help us with transport, State has offered humanitarian flights and some compensation,” Gwynne Shotwell emailed Musk. “Folks are rallying for sure!” “Cool,” Musk responded. “Sounds good.” He got on a Zoom call with President Volodymyr Zelenskyy, discussed the logistics of a larger rollout, and promised to visit Ukraine when the war was over.

Every day that week, Musk held regular meetings with the Starlink engineers. Unlike every other company and even parts of the U.S. military, they were able to find ways to defeat Russian jamming. By Sunday, the company was providing voice connections for a Ukrainian special operations brigade. Starlink kits were also used to connect the Ukrainian military to the U.S. Joint Special Operations Command and to get Ukrainian television broadcasts back up. Within days, six thousand more terminals and dishes were shipped, and by July there were fifteen thousand Starlink terminals operating in Ukraine.

How much of a difference did this make?

“Without Starlink, we would have been losing the war,” one Ukrainian platoon commander told the [Wall Street Journal].

Musk is lucky that the Russians don’t currently have a space machine like Bird One (from You Only Live Twice) that can vacuum up the Starlink satellites!

Elon Musk ended up making decisions at least as consequential as any made in Kyiv, according to Isaacson:

“This could be a giant disaster,” Musk texted me. It was a Friday evening in September 2022, and Musk had gone into crisis-drama mode, this time with reason. A dangerous and knotty issue had arisen, and he believed that there was “a non-trivial possibility,” as he put it, that it could lead to a nuclear war, with Starlink partly responsible. The Ukrainian military was attempting a sneak attack on the Russian naval fleet based at Sevastopol in Crimea by sending six small drone submarines packed with explosives, and they were using Starlink to guide them to the target. Although he had readily supported Ukraine, his foreign policy instincts were those of a realist and student of European military history. He believed that it was reckless for Ukraine to launch an attack on Crimea, which Russia had annexed in 2014. The Russian ambassador had warned him, in a conversation a few weeks earlier, that attacking Crimea would be a red line and could lead to a nuclear response. Musk explained to me the details of Russian law and doctrine that decreed such a response. Throughout the evening and into the night, he personally took charge of the situation. Allowing the use of Starlink for the attack, he concluded, could be a disaster for the world. So he reaffirmed a secret policy that he had implemented, which the Ukrainians did not know about, to disable coverage within a hundred kilometers of the Crimean coast. As a result, when the Ukrainian drone subs got near the Russian fleet in Sevastopol, they lost connectivity and washed ashore harmlessly.

He also called the Russian ambassador to assure him that Starlink was being used for defensive purposes only. “I think if the Ukrainian attacks had succeeded in sinking the Russian fleet, it would have been like a mini Pearl Harbor and led to a major escalation,” Musk says. “We did not want to be a part of that.”

Isn’t this a bit like the United Nations in Gaza? For 75 years, they’ve been providing nearly everything that the Palestinians to raise the next generations of soldiers/martyrs and simultaneously claiming to be involved only in peace/defense. Musk strengthened Ukraine’s defensive capability, which gave them more resources to put into offense.

Like the UN, Musk tried his hand at diplomacy:

He took it upon himself to help find an end to the Ukrainian war, proposing a peace plan that included new referenda in the Donbas and other Russian-controlled regions, accepting that Crimea was a part of Russia, and assuring that Ukraine remained a “neutral” nation rather than becoming part of NATO. It provoked an uproar. “Fuck off is my very diplomatic reply to you,” tweeted Ukraine’s ambassador to Germany. President Zelenskyy was a bit more cautious. He posted a poll on Twitter asking, “Which Elon Musk do you like more?: One who supports Ukraine, or One who supports Russia.” Musk backed down a bit in subsequent tweets. “SpaceX’s out of pocket cost to enable and support Starlink in Ukraine is ~$80M so far,” he wrote in response to Zelenskyy’s question. “Our support for Russia is $0. Obviously, we are pro Ukraine.” But then he added, “Trying to retake Crimea will cause massive death, probably fail and risk nuclear war. This would be terrible for Ukraine and Earth.”

Eventually he ended up in a text message exchange with Ukraine’s Vice Prime Minister Fedorov:

Musk: “Russia will stop at nothing, nothing, to hold Crimea. This poses catastrophic risk to the world…. Seek peace while you have the upper hand….”

After his exchange with Fedorov, Musk felt frustrated. “How am I in this war?” he asked me during a late-night phone conversation. “Starlink was not meant to be involved in wars. It was so people can watch Netflix and chill and get online for school and do good peaceful things, not drone strikes.”

In a world of war profiteers, Starlink seems to have been the only involved company that didn’t get rich off the conflict:

[SpaceX President/COO Gwynne] Shotwell also felt strongly that SpaceX should stop subsidizing the Ukrainian military operation. Providing humanitarian help was fine, but private companies should not be financing a foreign country’s war. That should be left to the government, which is why the U.S. has a Foreign Military Sales program that puts a layer of protection between private companies and foreign governments. Other companies, including big and profitable defense contractors, were charging billions to supply weapons to Ukraine, so it seemed unfair that Starlink, which was not yet profitable, should do it for free. “We initially gave the Ukrainians free service for humanitarian and defense purposes, such as keeping up their hospitals and banking systems,” she says. “But then they started putting them on fucking drones trying to blow up Russian ships. I’m happy to donate services for ambulances and hospitals and mothers. That’s what companies and people should do. But it’s wrong to pay for military drone strikes.”

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Randomized controlled trial of therapy for teenagers

by philg

“These Teens Got Therapy. Then They Got Worse.” (Atlantic, by Olga Khazan; paywalled, but readable in the Google cache):

Researchers in Australia assigned more than 1,000 young teenagers to one of two classes: either a typical middle-school health class or one that taught a version of a mental-health treatment called dialectical behavior therapy, or DBT. After eight weeks, the researchers planned to measure whether the DBT teens’ mental health had improved.

The therapy was based on strong science: DBT incorporates some classic techniques from therapy, such as cognitive reappraisal, or reframing negative events in a more positive way, and it also includes more avant-garde techniques such as mindfulness, the practice of being in the present moment. Both techniques have been proven to alleviate psychological struggles.

The author and editors forgot to capitalize “Science”!

This special DBT-for-teens program also covered a range of both mental-health coping strategies and life skills—which are, again, correlated with health and happiness. One week, students were instructed to pay attention to things they wouldn’t typically notice, such as a sunset. Another, they were told to sleep more, eat right, and exercise. They were taught to accept unpleasant things they couldn’t change, and also how to distract themselves from negative emotions and ask for things they need. “We really tried to put the focus on, how can you apply some of this stuff to things that are happening in your everyday lives already?” Lauren Harvey, a psychologist at the University of Sydney and the lead author of the study, told me.

But what happened was not what Harvey and her co-authors predicted. The therapy seemed to make the kids worse. Immediately after the intervention, the therapy group had worse relationships with their parents and increases in depression and anxiety. They were also less emotionally regulated and had less awareness of their emotions, and they reported a lower quality of life, compared with the control group.

Most of these negative effects dissipated after a few months, but six months later, the therapy group was still reporting poorer relationships with their parents.

Last year, a study of thousands of British kids who were put through a mindfulness program found that, in the end, they had the same depression and well-being outcomes as the control group. A cognitive-behavioral-therapy program for teens had similarly disappointing results—it proved no better than regular classwork.

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Elon Musk and videogames

by philg

When not working, does the world’s greatest innovator sit in a cardigan reading books, à la Jimmy Carter or Bill Gates? Elon Musk by Walter Isaacson:

One key to understanding Musk—his intensity, focus, competitiveness, die-hard attitudes, and love of strategy—is through his passion for video games. Hours of immersion became the way he let off (or built up) steam and honed his tactical skills and strategic thinking for business.

Musk had enjoyed all types of video games as a teenager in South Africa, including first-person shooters and adventure quests, but at college he became more focused on the genre known as strategy games, ones that involve two or more players competing to build an empire using high-level strategy, resource management, supply-chain logistics, and tactical thinking.

His only indulgence was allowing breaks for intense video-game binges. The Zip2 team won second place in a national Quake competition.

In 2021, he became obsessed with a new multiplayer strategy game on his iPhone, Polytopia. In it, players choose to be one of sixteen characters, known as tribes, and compete to develop technologies, corner resources, and wage battles in order to build an empire. He became so good he was able to beat the game’s Swedish developer, Felix Ekenstam. What did his passion for the game say about him? “I am just wired for war, basically,” he answers.

This seems like a good time to drag out a TED talk by a neuroscientist, Daphne Bavelier. This was sent to me by a neuroscientist who hates video games and has spent years trying to prevent his son from playing them. He admits that there is no scientific basis for his hatred and cites Prof. Bavelier.

What is the rationale for telling kids to get off their Xboxes if Elon Musk thrived on shooter games and #Science says that games are beneficial?

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What’s the military situation in Gaza right now?

by philg

There have been active battles since October 7, 2023 in and near Gaza (I wouldn’t call this a new “war” because these battles are still part of the war that Arabs declared on Israel in 1948). The Israeli counterattack seems to have started in earnest on October 28 (Wikipedia), though that was preceded by some bombing. So Israel’s campaign is about a month old.

If this were a battle between two conventional armies, that might be long enough for one side to win a decisive victory (see the 6-week Battle of France during World War II, for example). The continued existence of the Islamic Resistance Movement (“Hamas”), complete with plenty of rockets, ammo, and tunnel ventilation, and Palestinian Islamic Jihad, could, in that case, be evidence of failure by the Israel Defense Forces.

Israel, however, seems to be treating these battles as a fight against insurgents. That description seems to fit Hamas to some extent. Hamas mostly attacks civilians, e.g., via launching rockets into cities or the October 7 attack. On the other hand, Hamas also exhibits many of the characteristics of a standard national government with army. Hamas won a free and fair election and should be the legitimate government of all Palestinians in the West Bank and Gaza. The West Bank was stolen from Hamas, but the majority of Palestinians in both the West Bank and Gaza continue to support Hamas. See a 2021 poll, for example, and a poll taken earlier this month:

A larger percentage of Palestinians support the October 7 attacks, in which civilians were raped, maimed, and killed, than strongly support Hamas. This might be accounted for by the fact that Palestinians overwhelmingly expect their side to “emerge victorious”:

Israel seems to have constructed a fictional world in which only 10 percent of Palestinians are in favor of eradicating Israel, via violent means if necessary. Thus, the IDF has been tasked with going into Gaza and sorting through the 2 million residents to find the 100,000 who either carry guns on behalf of Hamas, Palestinian Jihad, or a similar group, or who provide substantial administrative and logistical support for those who carry the guns. (And maybe it is more like 10,000 people that Israel is seeking, on the assumption that the ordinary soldiers won’t cause trouble once officers are captured and imprisoned.)

A few weeks ago, I asked how this project could possible work. From How can Israel’s encirclement of Gaza City work if Hamas fighters can simply head south via tunnel?:

What stops the Hamas fighters [encircled in the north] from simply evading the IDF by proceeding south via tunnel? Once in the southern zone, the fighters can melt into the population that elected Hamas and continues to support Hamas according to opinion polls

How long has it taken other militaries to accomplish similar goals? I.e., sift through a population to find the 1 in 20 or 1 in 100 who are insurgents when the general population supports the insurgency. We can look at Russia’s Second Chechen War, a decade-long operation. There was the 25-year civil war in Sri Lanka. There is the Syrian civil war, now in its 12th year.

“Military briefing: has Israel achieved its war aims in Gaza?” (Financial Times, November 23):

For all Israel’s military gains in northern Gaza, Israeli officials admit that if they are to achieve the aim of defeating Hamas, the next phase of the fighting will have to involve an advance into the south of the strip.

Israeli forces have already begun to prepare for such a move, and officials have begun warning residents of Khan Younis to flee towards what they have said will be a “safe zone” in Muwasi, a 14 sq km area in the south-west of the territory.

Aid groups have dismissed the idea of cramming hundreds of thousands of people, many of whom have already been displaced from the north of the strip, into such a tiny space as unworkable. But Israeli officials insist there is no other way to defeat Hamas, as its top leaders in Gaza, such as Yahya Sinwar and Mohammed Deif, are thought to be hiding there, and because Hamas has also redeployed numerous fighters from the north to the south.

“I’m quite sure that hundreds, if not thousands, of Hamas members who are originally from the northern part of Gaza are right now in the south,” said Michael Milstein, a former IDF intelligence official. “And of course, they also transferred their weapons and rockets to the south with them.”

What about the tunnels? I’m hesitant to quote either side in any war as an authoritative source, but here’s what Israel says:

Israel’s military said on Wednesday that its combat engineers had destroyed the shafts of some 400 tunnels. But officials concede this is only a limited dent in a system that is thought to be more than 500km in length.

“Once we [take all of Gaza] it will probably take almost a year to clear the whole Gaza Strip, and to explore all their underground infrastructures, and find all their rockets and missiles . . . The strip is one big bunker,” said [Amir Avivi, former deputy commander of the Gaza Division of Israel’s military]. “It’s full of booby traps, full of IEDs everywhere, bombs, munitions — it’s unbelievable what they built. So there’s going to be a lot of work.”

Is Israel actually on track to succeed in accomplishing what it has promised to accomplish, from a purely military point of view, in Gaza? (Obviously, Israel has already lost in the court of world popular opinion. This post is about the purely military aspects of the conflict, not whether progressives and/or Muslims are right to accuse Israel of war crimes, genocide, etc.)

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Medical School 2020, Year 4, Week 33 (Residency Prep, week 1)

by philg

Six weeks until graduation. Before the last two-week elective, we have four weeks of Residency Prep (“RP”). It is March 16, 2020, and the deans are changing policies every few days, trying to stay ahead of COVID-19. M1 and M2 classes have been on Zoom for a week. Lanky Luke was facilitating an 8-student “Medical Education” elective. “Life is pretty normal for them,” Luke said. “Less than 10 percent of the class even went to lecture pre-COVID-19 so they are used to it.” He adds, “It’s odd to see people in pajamas. I don’t complain! I am too!” 

M3s are the most affected. Initially, their rotations continued, with instructions to stay out of rooms that require PPE (gowns, gloves, masks, etc.). Students are forbidden to take care of any COVID-19 patient, although our hospital has only one, a 91-year-old woman in the ICU transferred from an outside county.

This policy existed for three days.

On Tuesday, we get an email canceling all clinical rotations until further notice. Students are reassigned into non-clinical rotations. Our options: Medical Spanish via Zoom, Pathology via Zoom, Medical Education, and Advanced Anatomy (cadaver dissections; 2-3 students and one teacher in a large lab). We also have the option to take another two weeks of research or study time (a.k.a. “vacation”). Mischievous Mary is quite annoyed as she has to complete a “medical” elective before graduation so she doesn’t have the vacation option. She would have done in-person cardiology consults, but instead must do remote pathology. “FML!” she texts.

After communicating to us the critical importance of these social distancing guidelines, the administration summons us all into an auditorium to sit side-by-side and learn about a new policy for Match Day (Friday, March 20). While we breathe whatever viruses everyone else has acquired during various rotations, two deans explain that Match Day will be restricted to class members and essential staff (e.g., Deans and Chairs of Departments). University-sponsored events are now limited to 100 people.

Before the coronavirus, this would be a two-day party starting at 10:00 am with a ceremony in the auditorium. Friends and family would fly in from around the nation, with tickets capped at 10 per student. After speeches by various dignitaries, each student individually goes into a private room to open a printout of a letter  that the school would have received the night before. Students emerge to go up to the microphone and give an Oscars-style talk about how grateful they are to have matched at whatever institution. All of this is recorded on video for posterity. Everyone in the audience toasts with Champagne, followed by a catered reception. Groups of friends, accompanied by their out-of-town visiting family members, go to local restaurants for lunch. The gatherings continue into the evening in restaurant and bar private rooms and patios. There would be brunches and barbecues on Saturday and continuing into Sunday for the hardcore.

We will get none of this.

Chaos ensues as already-anxious students absorb the fact that they will not be able to open their Match letters with family and friends. Students talk over each other trying to negotiate with the deans for 2-ticket or 1-ticket allotments. Nervous Nancy quiets the room. “Some of us have loved ones that are old and vulnerable. This is serious. Let’s just have a small ceremony and leave.” Father Fred, a 30-year-old whose children are now 3 and 6-months old, asks, “Could we can pick up our letters and leave the premise to open with family instead of staying around?” The decision is that we will stay for one hour to hear shortened speeches, and then leave after we are handed our Match letters at noon to open them with loved ones outside. We’ll communicate our Match results to classmates via a group spreadsheet.

GroupMe erupts before Jane and I get to the car. 

Gigolo Giorgio: “PSA: you will get an email from NRMP at 1:00 pm, so you could just wait in bed.” 

Pinterest Penelope: “Another hour of my life wasted.”

Lanky Luke: Question- what if only significant others (perhaps fiancé and spouses or something) are allowed? It would probably be only a few individuals who are mostly local. This option would allow them to enjoy the experience with individuals who are equally impacted by this decision, while minimizing exposure. (likes and “I agree” responses accumulate)

Buff Bri: They really should cut nonessential faculty and staff. We might be able to squeeze a few more in there.

Pinterest Penelope is the camel nose under the tent: Would [Jeffrey] count? He’s not my fiancé, but we’ve been together over four years and he lives here.

Gigolo Giorgio: not opposed to the +1 idea, but still think it needs to be that everyone gets the invite or nothing. just not fair for some people to have their person there and not everyone 

Class president: The other thing we could do, which I have heard students from other schools are doing, is to take our envelopes and have our own [enormous] ceremony and opening party somewhere away from school. we could hold it in [local venue] and rent the space for longer and do everything as planned there.

Nervous Nancy: I’m not sure how great this visual would be if it got out to the public that the esteemed medical graduates are partying it up downtown while pandemic is ensuing. I wasn’t gonna ask my SO to attend cause I really really don’t like ceremonies and I’m immunocompromised [from treatment of Crohns disease]. Basically I totally get that my POV might not be the majority.

Straight-Shooter Sally: Y’all hiding behind your computers and phones acting like we didn’t meet in majority with the deans, talked it through, and decided to play our part in social distancing. We already have it better than so many people. (attaches Excel sheet from reddit with canceled Match days by medical school.)

Fashionable Fiona: If the +1 option is pitched to [the deans] and then shut down, I’m amenable to our leadership then pitching the just SO option for the 30 or so people that have one. I get it’s not ideal or fair for everyone, but I recognize that SOs are as heavily invested in our med school experience and equally impacted by Match day. Just because I can’t have someone there, I don’t want all of you to be robbed of your SO being there. Although if they’re shooting down the +1 option, they’ll likely shoot down to the SO option for similar reasons. But still, maybe worth a shot? Desperate times. 

Gigolo Giorgio: So one student’s SO is more important than another student’s mom or dad? I don’t have any family coming either way, but it sounds like it would be unfair to do just SOs

Gigolo Giorgio: With so many other schools canceling Match day, undergrad campuses closing the campus and having online classes across the nation, and Virginia being in a state of emergency- what makes us the exception? What if the 100 limit is changed to 75 tomorrow? Or 50? I understand we’ve worked for this moment over 4 years and its a once in a lifetime opportunity to celebrate with our loved ones, but we also need to do our part to address this pandemic. Again, my family doesn’t love me enough to come so idc either way

Nervous Nancy:  Tbh y’all I’m embarrassed. The Match is supposed to demonstrate that we are almost doctors, we shouldn’t need the admin to tell us that we should respect social distancing, limit travel, etc. Come on we’re better at epidemiology than this. This a global pandemic out there y’all, people are dying. (And we bitching about our special day being less special for those with [left-home] SOs). Ton of people are not having the special moments that they worked years to earn, for be those moments Athletic or academic, we are doing it to keep people safe. Let’s not be petty, foolish. While probably having a 1+ would most likely be totally OK, imaging how dumb we’re gonna look if something does spread, and it went public that [our school] looked for a loophole with the magic # of 100…. so please pretty please, we are better than this 

Gigolo Giorgio:  “Super spreader event at local medical school: [School] overrules decision to keep Match day private and decide to invite guests! ‘F*ck the virus, I wanna be with my SO if I’m gonna die anyways,’ says a group of students. What a headline.

Ambitious Al: @Georgio you forgot the #YOLO in there 

Buff Bri: Hey everyone! Love you guys and can’t wait for us to all celebrate this next great step 😍 I spoke with [fancy restaurant with fantastic cocktails] and they said that they were ok with having 40-60 of us going to the courtyard at 1PM on March 20th. I know things are constantly changing but I think this will be an awesome chance for us to celebrate over drinks. I will keep you all updated if anything changes, but [restaurant’s] management is aware of Match Day and is very excited to host us

He follows up: Seems like we have almost the whole class who has RSVPed Yes but if anyone else wants to come, let me know!

Fashionable Fiona:: Hi all ~ Now that we *tentatively* have some plans for Match Day, we wanted to let you guys know that we have booked the basement of [local bar/club] (same place we have Halloween!) for our official match night celebration. Given that the yearly school reception has been cancelled (and with it the lovely rice krispie treats) we wanted to have an opportunity to enjoy and celebrate together with good food and drink. Things are definitely fluid right now in [our city], but I have confirmation from [the bar] that they are still allowing events to happen. Guests are also invited but obviously, please do not come/invite your guests to come if any of you are currently sick or are traveling from a high risk area. – We will have a cash bar for food and drinks and rockin’ dance floor! Hope to see you guys there! – Your Match Day Committee 

This week turns into a vacation for me. Residency Prep classes have been rescheduled for next week to allow the IT department to figure out logistics. I go in on Wednesday for individual meetings with two administrators to prepare graduation paperwork, such as NPI and documents that will be needed for state medical license applications.

GroupMe updates from classmates allow us to identify recently stocked stores for hard-to-find goods. Bri: “I found paper towels and toilet paper, but not hand sanitizer.” Jane and I grill with Luke and Sarcastic Samantha almost every evening because the weather is so nice. Samantha is still working as a hospitalist PA: “The hospital is so empty that department heads are asking physicians to take voluntary leave. This is what a hospital should look like. Finally just the actual people who should be in the hospital are here.”

Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 7 days. Example fun: Jane and I attend a Thursday party at Buff Bri’s apartment. We set up tables outside for beer pong and spike ball while drinking White Claws and cheap beer basking in the beautiful 70-degree sunshine. Jane and I left around 4:30 pm. We learned that several students went downtown to “support the bars”. Nervous Nancy scolds them over the GroupMe: “I want to thank everyone who is socially distancing and did not go downtown after [Buff Bri’s] party. We are going to be seeing a lot of each other over the next few weeks until graduation, and some of us have loved ones that are vulnerable.”

[Editor: For reference regarding the evolving thinking about social distancing and coronavirus, Li Wenliang warned colleagues about what he believed to be an outbreak of 7 SARS cases on December 30, 2019. China isolated Wuhan on

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