Medical School 2020: Year 2, Second Half

one section of a Fifth Chance Media book, ISBN 978-1-944861-02-5.

To preserve patient confidentiality, ages and other details are slightly altered. Students and teachers are also pseudonymous. Our story continues in 2018...

Year 2, Week 22

We return for the New Year after a one-month break to study oral health. Exquisite Emily, a 26-year-old Iranian-American traveled to Thailand with her boyfriend, a Deloitte consultant. Type-A Anita and her boyfriend, a work-from-home web developer, took a 1.5-week trip to Japan. She sent a snapchat of the opening "In a galaxy far away" with Japanese subtitles on opening night of Star Wars: The Last Jedi in Japan. Most students flew home to visit family for this extended break.

A recently retired 65-year-old hospital dentist ("former section chief turned professional grandpa") leads a total of eight hours of lectures on head anatomy, the basic oral exam, and common oral pathologies. He described the various lesions of the oral cavity, such as leukoplakia (unscrapable white thickening of mucosa) and thrush (scrapable white plaque of fungus). "Whenever a patient comes in with an oral lesions that I am unsure about, I tell them, come back in two weeks. Most harmless things will go away on their own in two weeks as the mucosa is turned over. If I do nothing, it will disappear in two weeks. If I give you something, it will disappear in 14 days."

"The dentist is the last bulwark of arrogance. Dentists do not like to refer anything out. We are notoriously bad collaborators. Compare that to you guys [doctors]. You are completely dependent on radiologists, hold extended cancer panels, reach out to specialists, etc. This collaboration ensures the very best care for the patient." The dentists summarized why dentistry and medicine are separated. "There were two milestones in this divide. First, dentistry schools completely separated from medical schools. The second occured in 1965 when Medicare was begin created. The ADA [American Dentistry Association] lobbied to be excluded from Medicare. Dentists did not want to be involved with insurance." Lanky Luke whispered, "Dentists are looking pretty smug now that they are still in private practice without having to negotiate with government insurance." The internet at our school is quite slow as we attempt to play several linked videos in the slide. Gigolo Giorgio joked: "This must be the result of Net Neutrality being overturned. ISPs must be slowing our bandwidth because they think we are watching porn with all our anatomy searches."

Wednesday was led by the "Dane", a Danish-trained dentist and researcher. She was supposed to teach us oropharyngeal cancers but we never made it past the title slide as she answered questions. One student asked how is dental care different in Denmark than the United States. "Every child has free dental care. As an adult you pay for it, but it is much cheaper and we do not have such income inequality as you do. Only people with cavities are the immigrants. Our statistics are lower because of them." She continued, "It is truly amazing the income disparity in the United States. And mark my words. This is only made worse by this horrible tax plan that will just make the wealthy wealthier. And this idiot president."

[Editor: Denmark is not a paradise for everyone. An American child support plaintiff who collects $200,000 per year tax-free would be capped out at $8,000 per year per child in Denmark (see ). The American who lives rent-free in means-tested public housing in an expensive neighborhood of Manhattan, San Francisco, or Cambridge would in Denmark wait many years for public housing in a dreary suburb.]

Lanky Luke: "If she thinks so little of our country, why doesn't she go back to Denmark?" Gigolo Giorgio to the GroupMe: "Will they post the title slide?" Lanky Luke: "If not, I will report this infraction to the LCME." Both got over 10 likes.

On Thursday we go over to the clinic to interview five patients with oral pathology. I started with a 70-year-old patient treated for squamous cell carcinoma of the oral cavity requiring surgical removal of most of his hard palate. He had a surgical obturator filling the space. He removed the obturator revealing a 3 cm diameter hole in the top of his mouth. Looking up into his mouth, we could see his maxillary sinus and nasal cavity, specifically the inferior turbinate! Gigolo Giorgio gasped. "What does it feel like to touch that with you finger?" "The gentleman responded, "Oh, nothing abnormal, it can be a little sensitive." He described his routine for cleaning the obturator and cavity every evening: "Just like brushing your teeth!" A dentist explained the anatomy of the teeth. "If a dentist is asking you to replace amalgam filling with a fancy composite, they are just trying to steal your money. It frustrates me so much. Amalgam works just as well and lasts a lot longer. Composite will need to be replaced within 10 years. These dentists figure, they can get more money by fixing that in a decade. Amalgam will last a lifetime." (This was in contrast to another patient we interviewed who had only a small indentation in his tongue remaining after recovering from a squamous cell carcinoma tumor that had spread all over his throat and oral cavity.)

At lunch, students debated if welfare benefits should include dental care when many Americans not on welfare cannot afford dental care. Students all agreed that dental health is an important part of people's overall health. Nervous Nancy: "This is clearly a good investment. Inexpensive procedures like cleanings prevent the more costly deterioration of health." We googled the dental care benefits for welfare and students were surprised to learn that states are required to provide dental care to children on Medicaid. Lanky Luke: "I do not see how our system is much different than Denmark's. Children are guaranteed dental care if they cannot afford it, if they are on Medicaid." Straight-Shooter Sally expressed concern for the working poor, potentially ineligible for Medicaid. Luke responded, "I wonder if the increased demand for dentistry from welfare participants might price out some of the working poor."

Mischievous Mary changed the subject: "Guys, I need your help. I am applying for a grant tailored to women in science. The essay asks: How do I promote other women in science? Any ideas?" Lanky Luke: "Tell them you empower students and patients to feel comfortable in their chosen identify." (Our Office of Student Affairs keeps us advised weekly regarding scholarships targeted to specific subgroups of Americans. This week's email mentioned the BuckFire Law Firm's Diversity & Disability Scholarships. A requirement is "a disability diagnosis from any person qualified to make a diagnosis," so perhaps medical students could diagnose each other?)

Our patient case: Harold, a 35-year-old grocery clerk with a history of alcoholism and tobacco use presents for worsening ear pain over the past two months. He reports a decrease in appetite, and denies fever. On physical exam, the external ear canal is not inflamed and the tympanic membranes are transparent. He has hard lymph nodes palpated on both sides of his neck. Erythroplakia (a nonscrapable white plaque with blood vessels) is noted on the posterior lateral border of the tongue. Smoking and alcohol use account for 80 percent of oral cancers and therefore squamous cell carcinoma is high on the differential. A biopsy reveals an invasive squamous cell carcinoma. He is referred to a oncology who initiates radiation therapy.

Harold described how he had to quit radiation therapy after 12 rounds. His ENT explained that Harold's gold fillings caused the radiation to unexpectedly scatter and deliver higher does to his oral mucosa and salivary glands." Harold: "I could barely drink, let alone eat, because it hurt so much. My mouth was so dry my tongue would get stuck to the top mouth, and I would have to take several painful sips of water to pry it down."

Two years after the radiation therapy, Harold presents for a sense of "fullness" in the back of his throat. Harold's cancer had returned. His ENT explained recurrence is not uncommon for oral cancer. "Field Effect" is the theory that a carcinogen, for example, smoking can cause mutations in a large area of tissue, but on different time tables. This time the cancer was far more advanced, spreading to his mandible.

Harold underwent a partial mandibular resection (jaw removal) with a fibular transplant and chemotherapy. A section of his mandible, from midline to the temporomandibular joint is removed, and replaced by a section of his fibula (a small bone in the lower leg not needed to support the body). "We preserved his temporomandibular joint so he still has some range of motion." Mischievous Mary: "Oh my god! I would never have known. We can do that?"

Harold has lost most of his teeth due to periodontal disease and removal of unhealthy teeth prior to radiation therapy. As he described: "More teeth, more problems." He eats mostly soft foods such as yogurt, fish, and smoothies.

At lunch students complete the 30-minute Y2Q medical school questionnaire conducted by the AAMC. Examples:


After classes end at 4:00 pm on Friday, we drive 3.5 hours through a snowstorm to a ski resort for the second annual ski weekend (Jane and I did not go last year). 32 students, 28 classmates and 4 significant others, cram into a four-bedroom ski lodge located in a prime location that is walking (shuffling?) distance from entering a Black Diamond slope. Jane and I drive up with Nervous Nancy, soon to be celebrating her 29th birthday. "I feel like everyone from my former life is getting older and moving on with their lives. My best friend bought a house. My other friend is pregnant. When I went back to school, I got younger." The car that booked the AirBNB had to drive down the other side of the mountain to pick up the rental keys. The rest of us sat in our heated cars for 1.5 hours drinking beer and wine until the keys arrived at 10:00 pm.

Once in the house, our class switched from drinking to drinking games, beginning with Kings. Tailgate Todd, a Clemson graduate with charming southern hospitality, suggests the game  Fishbowl. Every Fishbowl participant writes down two or three words on small pieces of paper. We then divided into two teams, male versus female. One participant from each team tries to act out the words while the remaining team attempts to guess correctly as many words in one minute. The women destroyed us. We settled the score by beating them at Flip Cup, four rounds to one.

Persevering Pete who has been a teetotaler, due to a history of alcoholism in his family, had his first alcoholic drink, a Tito's vodka cranberry with seltzer water. Around 1:00 am, students began to slumber off to bed for skiing tomorrow. The limited beds and bedroom floor space was settled according to who signed up and paid first. Jane and I were subjugated to the living room with Anita, her web-developer boyfriend and Nervous Nancy. Anita had brought a Queen size, self-inflating air mattress that took up most of the space. Nervous Nancy was relegated to the couch, while Jane and I inflated our twin air mattresses squeezed between the frigid sliding door and Anita's mattress. I did not sleep the entire night.

[Editor: I wonder if alcohol consumption and lack of sleep may explain why the U.S. healthcare system is in trouble.]

At 5:00 am, Stoner Suzy, a wealthy daughter from Southern California, and her (unbeknownst-to-me) boyfriend Gigolo Giorgio were moving around the house. Tonight she was experiencing chest pain, difficulty breathing, and peripheral angioedema (leaky blood vessels causing swelling). Her feet were swollen to the point that she couldn't put on shoes and her fingers were swollen enough to cause pain around a ring. A few students performed rapid exams, and the general consensus was a combination of anxiety and dehydration. Suzy was concerned that it was a heart attack. Giorgio wanted to take her to the hospital, at least a 30-minute drive in terrible conditions.

After waking up the owners of three cars that were blocking Giorgio's Subaru, he determined that it wasn't safe to drive down the steep driveway, slick with new snow and ice accumulation. They called an ambulance, which arrived in 20 minutes. Five paramedics came into the trashed house with mattresses strewn across the living room. They drove off around 7:00 am, as the remaining students were waking up for a day on the slopes. Due to lack of coverage, we didn't get any updates on Suzy's condition until the much-improved couple returned at 4:00 pm. Suzy's EKG was normal, which ruled out a myocardial infarction (heart attack). She was given IV fluids and worked up for a PE with a chest CT (negative as well). She had been upgraded from her usual dose of marijuana to fentanyl and discharged. (Tom Petty, Prince, Shiloh actor Blake Heron, and rapper Lil Peep all died from fentanyl overdoses.)

Jane and I return early from the bunny slopes and drink mimosas with the 10 non-skiers. Around 2:00 pm, a large group of students return from the slopes including Persevering Pete, Nervous Nancy, Tailgate Todd, and Steve. Following his pioneering sampling of alcohol the night before, this was Pete's first time on skis. By choosing a classmate as an instructor, Pete found himself on a black diamond slope with the experts. Thirty seconds later he was in a ditch. "We couldn't even see him there was so much snow thrown into the air," recalled Nancy. "We thought he was going to have to be carried off." After 60 seconds, Pete slowly rose, perhaps saved by the rented helmet, and walked the remaining half mile. "I lost vision for a few seconds, but I remember the whole experience." Pete decided to forgo drinking that evening.


Statistics for the week… Study: 8 hours. Sleep: 4 hours/night; Fun: 2 nights. We are all zombies.

Year 2, Week 23

Neurology week is shortened by two days of snow cancellations (the hospital and rotations for M3 and M4 students are on a normal schedule).

A 45-year-old neurologist with a British accent lectures on neuromuscular disorders such as Parkinson's disease, Huntington's disease, Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease), and Multiple Sclerosis. Gigolo Giorgio asked about why deep brain stimulation (DBS) works for certain conditions? Neurologist response: "All of DBS is voodoo. There is not real science behind it, but it works. We just do not know why."

He teaches us about tardive dyskinesia, a permanent movement disorder after exposure to antipsychotics. In a healthy person, dopamine from the substantia nigra (black pigmented neurons in the midbrain) acts to facilitate muscle movement via stimulation of the basal ganglia, a network of neurons located deep in the brain ("deep nuclei"). Antipsychotics block dopamine signaling, an attempt at reducing the symptoms of bipolar disorder and schizophrenia. This can have the same effect as damaging the substantia nigra, as happens in Parkinson's disease. "Tardive dyskinesia happens after long-term use of the drug. We believe it is the brain trying to rewire around the drug. There are lawyers filling courtrooms around the nation suing doctors and pharmaceutical companies for this. There are more lawyers focusing on it than neurologists!"

He concluded: "The history and physical exam are are a dying artform. Some conditions, such as Guillain-Barré, you see nothing on imaging. Surgical residents, if they even have a stethoscope, put the diaphragm on the "Surgeon's triangle" -- where they can hear the abdomen, heart and lungs in one place. I ask what they got out of it and they respond, 'Umm, they are alive.' The answer is in the patient. You should know what is wrong with 95 percent of patients after taking the history. If you leave the room without knowing, DO NOT order tests. Go back in and take a good history, then do a good physical, and then order those unnecessary $5,000 imaging studies.

A 55-year-old neurologist reads through slides on seizure disorders. Several students doze off or check social media. She went five minutes over the 10:50 am official end time. The next lecturer, a 75-year-old neurologist, had snuck into the room five minutes early for the 11:00 am block and blurted out, "Are you done? I'll just do this another day." She then storms out. We have found a reason to have a PhD block facilitator in our lectures. She ran out of the third floor classroom and managed to corral the senior citizen on the first floor.

Despite a late start time due to the chase scene, the older neurologist did not disappoint. She lectured on myelopathies (disorders of the spinal cord). She ignored her uploaded powerpoint and used the chalkboard. We started with basic anatomy of the spinal cord and its blood supply. She asked, "Does anyone surf?" Buff Brad raises his hand. "How do you surf?" He slowly responds, "I wade out on my stomach, then pop up." She responds: "You are clearly a novice. First time surfers lay on their stomach and extend their back as they surf out to catch the next wave. This prolonged hyperextension of the spine causes compression of the anterior spinal artery in what is termed Surfer's myelopathy, potentially causing permanent paralysis." The class laughs. [Correct technique is a yoga-style pose on one's knees.] She concludes: "My husband died, so I have no one to not listen to me except medical students. It is such a pleasant surprise you are all listening to me." In the Age of Universal Offense, students were divided over her lecture. Everyone agreed they learned a great deal, but some were turned off by her sense of humor.

Wednesday morning, our chief of neurosurgery, a man in his 50s (see Year 1, Week 15), lectures for two hours on traumatic brain injury (TBI). The IT staff as usual comes in before the lecture to to ensure that the required-by-regulation PowerPoint slides were ready and that the video is recording. The Chief: "I don’t think I will be using it at all. PowerPoint is a way to present material you do not know." He made chalk drawings on the blackboard.

Any patient presenting for TBI will be scored using the Glasgow Coma Scale (GCS), which evaluates the patient's eye, verbal and motor responses to stimulus. "Glascow Coma Scale is like the SAT. You get a score for just showing up. Glascow Coma Scale starts at 3. Don’t say 2 to an attending. You'll sound like an idiot." Pinterest Penelope wrote this advice down. The Chief: "What are you doing? Pens down and listen." [Editor: Research shows that students who take notes learn more, even if they later discard those notes. See "The Pen Is Mightier Than the Keyboard: Advantages of Longhand Over Laptop Note Taking" (Mueller and Oppenheimer 2014, Psychological Science) and its references.]

Gigolo Giorgio was startled by the Kernohan's notch phenomenon. Kernohan's notch phenomenon typically occurs due to a hematoma (extravascular blood in the brain) causing the uncus, an inferior lobe of the brain, to herniate through the connective tissue floor of the brain into the brainstem canal. Nerves exiting the brainstem, namely CN III that innervates muscles of the eye, are compressed and lose function. "If the pupil is dilated on the left side, I go in on the left side, right?" However, occasionally the uncus can push the midbrain to constrict the contralateral CN III instead of the ipsilateral CN III. "I can operate on the wrong side of the brain because of this false localizing sign," he continued. "This was not unheard of before we had stat CTs commonplace in hospitals."

The Chief: "Medicine is a language. Isn't medical school so easy compared to crazy particle physics you did in undergrad. If you approach it just like a language it is not that difficult. Medicine is learning to convey complex data in succinct phrases. If a resident calls me and says there is 4mm midline shift after trauma I am going to run out of bed. If a resident says there is a 1mm midline shift with a small hematoma, I am going to say, 'Yep that's a old alcoholic brain that is compensating for a subdural swell. We can deal with it tomorrow.' I just downloaded a lot of information quickly. Practice presenting patients, that is what we will be evaluating you on in rotations."

Straight-Shooter Sally: "I don't think I learned much for Step 1 [the exam we're taking this summer]. He did not get past his 2nd PowerPoint slide, but who cares."

[The neurosurgeon's life was also educational for us. His wife loyally managed the home front, including two kids, through a 7-year residency. As soon as the surgeon began earning a surgeon's wage, she went down to the courthouse and shed the husband while keeping the kids and his income.]

Our patient case: Jimmy, a 69-year-old recently retired internist, was celebrating his 50th wedding anniversary with a trip to Scotland. "We were traveling with a group tour. I started to feel terrible. I was vomiting and felt weak. I was getting on the next train when I fainted. I initially attributed it to dehydration." He continued, "When we were walking on the cobblestone paths in one of the beautiful small towns, I started to see double. I did not know which of the two people in front of me was real. As physicians we know double vision under the context of systemic symptoms is a serious concern, but denial is powerful. Because I did not want to ruin our wedding anniversary, I tried to hide the symptoms from my wife. We had been waiting so long for this trip and my retirement."

His wife interjected, "I made us fly home early. He just looked weak. He was barely eating." Once back, their son, also an internist, realized something was amiss, and interrogated Jimmy. GI symptoms are rare for Lyme disease, but the presence of diplopia, malaise, and hiking in endemic areas prior to the overseas trip caused the son to immediately suspect disseminated Lyme disease. The family took him to the ED.

Lyme disease is a tick borne illness caused by the Borrelia burgdorferi that is easily treated with antibiotics. Lyme disease is divided into three phases: early localized, early disseminated, and late disseminated. Jimmy never had the classic early localized symptoms of the  "bull's-eye" rash (erythema migrans), present in 80 percent of patients. Early disseminated Lyme disease occurs weeks to months after the initial tick bite. Jimmy's double vision was caused by inflammation of peripheral nerves (peripheral neuropathy). He was also diagnosed with myocarditis (heart muscle inflammation) and atrioventricular ("AV") heart block, under-diagnosed complications of early disseminated Lyme disease.

Jimmy arrived at the ED and was worked up for Lyme disease only due to the persistence of the internist son. "They were trying to work him up for a MI [myocardial infarction] and PE [pulmonary embolism]. I kept saying, 'no, no get Lyme serology'." Once the test came back positive, he was started on doxycycline (antibiotic). His EKG showed mild AV block, and he was placed on cardiac monitoring. Over the course of five days, his symptoms improved remarkably, and he was discharged on day seven."

Gigolo Giorgio: "Why is there not a Lyme vaccine?" The internist son: "There was a Lyme vaccine. [FDA approved in 1998] GSK withdrew it after the early 2000s vogue for class action lawsuits against vaccine manufacturers. There is a new product in development using injected antibodies against burgdorferi bacterium that would protect for one season and then wear off. Has anyone gotten IVIGs [intravenous immunoglobulins] before traveling? They hurt! Great business model though. Europe is further in testing the vaccine now even though the US had it first." Another physician in the audience jumped in: "All my horses and dogs have the vaccine!"

[Editor: Mindy the Crippler, our Golden Retriever, got Lyme vaccines in 2014, 2015, and 2016. In 2017, less than a year after the most recent shot, she got... Lyme disease. This is in the tick-plagued hell of the western Boston suburbs ("woodsy").]

During lunch, we split into small groups in small groups to talk with M4s about Step 1 and the match process. My group was led by two women who are both applying to Ob/Gyn. Step 1 exam is an 8-hour exam with seven 1-hour, 40-question blocks and a 1 hour optional break split between each block. It costs $610 to register for the exam. "Do not study First Aid or any textbook," said the Florida native "Just do questions on UWorld, and go over each answer." She explained that she cried in the middle of Step I. "I had to call our school counselor for support."  The Bostonian, engaged to a recent graduate of the school visiting for support, described her Step 1 experience: "I had to get my fiancé to hold me [fortunately, he's one year ahead of her in his medical training]. I threw up the breakfast he made me. Fortunately, he packed me sandwiches and granola bars so I did not take the exam on an empty stomach."

After the M4s left, we stayed to consume the catered sandwiches and chat. Anita led the discussion: "Now no one can deny that our president is a racist pig." [Donald Trump had recently characterized Haiti as a "Shithole"] Anita explained that she preferred immigrants from unsuccessful countries: "We want immigrants who understand hardship. They will be grateful, educate us, and create jobs." Why not a merit-based system? Anita did not want immigrants taking the high-paying jobs. [Editor: like hers!]

Jane and I attend a late afternoon reception for applicants to our medical school who have come for final interviews. Most were fresh out of college and wanted to know about research opportunities at our school as well as nightlife (they don't seem to have an accurate estimate of how much time they'll have for partying). Some of the male applicants asked about the dating scene. The female applicants gathered around Southern Steve. We'd spread the (completely false) word that he had invented a successful medical device in between college and medical school and the women wanted to know more about him.Thursday night means Burgers and Beers. Tonight we celebrate Sarcastic Samantha graduating PA school and finishing her Board exam. She will not get her results for two weeks, but is already excited about starting work: "I am 27, and have never had a real job!" U.S. labor force participation will not be growing, however, because my college friend who works as a project manager at Amazon exiting to "travel and reflect," as soon as his stock options vest in March. "I do not respect or want to become any of my bosses," he explained, adding that eventually he wants to work in the nonprofit sphere.

[Editor: Nobody gave him the standard briefing "If you have a job without aggravations, you don't have a job." Even sadder, apparently nobody told him about SSDI!]

Samantha plans to search for puppies if she passes her exam. "It takes several months to get all the licences and paperwork processed to begin to practice." Luke wants to stick with their beloved cat. "I do not want a dog. Samantha wants a dog. So… we compromised and we're getting a dog."

[Editor: They're using the same "one-woman, one-vote" system that we have in our house!]


I ask Samantha and Luke, "When are you going to have kids?" My plan is to have kids after Luke gets into residency and I have a job there. I do not want to be moving and searching for a new job in a foreign city while pregnant." Luke: "I don't want kids soon. Samantha wants kids soon. So… we've compromised and will have kids soon."

Friday's 2.5-hour weekly ethics seminar is taught by the 55-year-old director of our Masters in Public Health program. The topic is "Social Determinants of Health." We had been assigned the first 30 minutes of the seven-part PBS documentary series Unnatural Causes: Is Inequality Making Us Sick? (2003). "Power, typically framed in political terms, is the ability to control an individual's destiny," she opens. "Power is used in public health as a goal because this is destroyed in a lot of communities and groups."

[Editor: The government spends $trillions on Medicaid and then spends $millions funding a documentary about how Medicaid doesn't work?]

MPH director: What did you take away from the video?

Orthopod Oliver: More money, less problems.

Pinterest Penelope: I was shocked by the discrepancy. CEO has 10 years longer to live than workers.

Straight-Shooter Sally: I was surprised that the discrepancy is not just low versus high income. Middle class is also on the scale.

MPH lecturer: "The video cited the famous Whitehall study of british civil servants in 1967 and 1985. People theorized that the CEO would die prematurely due to a heart attack from stress. What we found was the idea of a social gradient of health." The low-level workers were the ones to drop dead first. [Editor: Another great argument for collecting welfare rather than meekly taking one's place at the bottom of the bureaucratic pyramid!]

She emphasized that the term health disparity is out of fashion. "Health disparities is about what communities do not have. There is a certain victim-blaming mentality in this terminology. We now use the term health equity because everyone deserves the right to health. Health inequalities must be addressed to achieve health equity."

Donald Trump's proposed border wall might be the biggest public health improvement since the USDA stopped promoting carbohydrates via its food pyramid, according to our lecturer: "In public health there is something called the Latino paradox. As people settle in LA from Mexico and South America, they acclimate to US culture. We know their health declines. They no longer have the support system of, say, their small Guatemalan town. We think our lifestyle and communities are great, but in a lot of ways it is not. Our kids eat fast food, don’t exercise, don’t have strong community and family ties. They come from a good diet, strong ties, little screen time, etc. Their health declines as they try to live the American dream."


Empowered by Oprah's speech at the Golden Globes, Anita changed her cover photo to a Lord of the Rings frame reading "The Age of Men is Over." Her next post:


In response to the escalation of hateful incidents since the 2016 national election, the National Abortion and Reproductive Rights Action League is pleased to offer a Bystander Intervention Training. Join us to learn how to step up and be supportive when fellow community members are facing harassment and hate speech. This training will provide a grounding in the principles of nonviolence and de-escalation, followed by interactive scenarios where we practice our new skills. …

Statistics for the week… Study: 12 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: Winter formal begins at 8:00 pm, but our class, dressed in tuxedos and ballroom gowns, gets delayed at a pregame. While most play beer pong, Jane, Buff Brad, his girlfriend, and I play couples pool at the bachelor pad apartment. Faculty begin leaving when we arrive around when "Get Low" comes on. I never understand why they play hip hop music at this formal. Faculty might enjoy themselves more if they could partake in the dancing. No one threw up to my knowledge but several people fell down dancing and taking selfies in front of the photo backdrop.

Year 2, Week 24

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What other changes had she noticed? "He has some balance issues. He used to love playing basketball with our grandchildren. He fell one time and has had to stop. He has the same preferences. He likes the same food." Ambitious Al asked about intimacy. Martha: "He looks the same, but I know he has become a different person. We do not sleep together. I have not slept with other people, but I have considered it." Connor was visible uncomfortable.

Mischievous Mary asked the geriatrician: "What are the guidelines to getting genetic testing for Alzheimer's?" "As of now, the guidelines do not support testing patients, early or late despite the genetic risks. This may change as the costs come down, but until there is some prevention therapy, the test will not change management of the disease."

Mischievous Mary: "Martha made the disease all about her. I wish we heard a little more from Connor." Pinterest Penelope: "That was 45 minutes of trashing poor Connor."

[Editor: Anyone who stays with an Alzheimer's-afflicted spouse in our age of no-fault, no-shame divorce, should be celebrated for heroism, not criticized for speaking frankly. Martha could walk down to the local family court at any time and get a warm reception by saying "Connor is annoying me with his illness so I'd like to take 50 percent of the cash and pension and move to a beach condo in Florida."]

Straight-Shooter Sally: "This was the most powerful patient case." Jane: "It gave me chills."


Rather than drive one hour to her rural home, Jane's sister used her key to move into our house for stomach flu recovery. We diagnosed her with norovirus based on profuse diarrhea, fever, and chills. The sister's nursing colleague bought over IV kits and saline bags, and we used the skills we learned in Year 2, Week 13 to hook her up to a saline drip. Rather that welcoming this this opportunity to practice her skills at establishing IVs, Jane was concerned about catching the bug.

Jane and her Health Professions Scholarship Program (HPSP) military comrades did not get paychecks on time due to a one-day government shutdown. "I only learned because the HPSP Facebook group is blowing up. People are yelling at each other about whom to blame -- Trump or the democrats."


Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 2 nights. Example fun: MedProm. Nervous Nancy hosted a pregame before the short walk over to the conference center ballroom. The rumors of Persevering Pete dating an M1 are true and his M3 ex departed shortly after the new couple arrived. Faculty exited en masse as students stormed the dancefloor to Justin Timberlake's Filthy.

Year 2, Week 25

Musculoskeletal week features 14 hours of lecture.

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

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

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

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

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

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

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

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

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

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


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

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


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

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

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

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

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

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

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

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

Straight-Shooter Sally gives a 20-minute presentation on tobacco cessation. She presents the findings of a "landmark study" ("A Randomized, Controlled Trial of Financial Incentives for Smoking Cessation", NEJM, 2009) in which people who could receive $750 over a one-year period were three times more likely to quit. All of us have seen COPD [chronic obstructive pulmonary disease] patients during our shadowing. They can barely walk, but they still smoke. Might they be more likely to quit if Medicare or Medicaid didn't pick up nearly all of the cost of their care? Type-A Anita shut the question down: "No, people would die."

I shadowed my family medicine physician mentor that afternoon. Regarding the first patient, a 54-year-old male with chronic hepatitis C infection, my attending says, "Ask him about his alcohol intake." I ask, "Sir, how much alcohol do you drink per week?" He responds, "A bit." "What do you mean by a bit?" Patient X: "Well it depends on the day. I have a few beers most days. If there is a football game on, at least a six pack. If there is a NASCAR race, then at least 12 beers." The attending came in, explaining"We cannot treat your Hep C until you quit drinking." Patient responds: "Doc, I cannot. NASCAR is coming up. I… I… I just can't. After NASCAR season we can talk."

Our patient case: Elizabeth, a 22-year-old female diagnosed with spinal muscle atrophy (SMA) at the age of 2, presents for excruciating hip pain and lower back pain not managed by her pain medications. She has had two spine surgeries for scoliosis and three hip surgeries to prevent hip subluxation (partial dislocation) that are common in SMA due to muscle deterioration.

SMA is a genetic disorder where a defect in the survival motor neuron 1 (SMN1) gene results in progressive loss of the anterior motor horn neurons in the spinal cord that innervate muscles.  These muscles begin to atrophy causing joint weakness, joint instability, and pain. Elizabeth's neurologist explained: "If you ever see these patients, your heart will break. They have full cognition, full sensation. Their minds are trapped in their bodies." (Don't go to North Dakota if your heart is easily broken; SMA prevalence there is 3-10X more common than in the rest of the U.S.)

Elizabeth: "I was quickly put in a wheelchair. I have a less severe form of SMA, but I still work hard on PT to maintain my function." Her 55-year-old mother added: "Elizabeth of course needs help going to the bathroom, putting clothes on. She cannot rotate herself from one shoulder to the other while she sleeps. You cannot imagine how difficult it is to try to help your child in the middle of the night while she screams out of pain from you touching her."

Elizabeth has minimal strength in her arms and legs. Her atrophied back muscles cause severe spine deformities. These have required three separate spine and hip surgeries within two years. She is unable to walk.

"I enjoy therapeutic horseback riding and training service dogs," continued Elizabeth, who had brought her enormous shaggy service dog. "Service dogs are not pets. They are medical equipment." The Bernese Mountain Dog helps pick up and carry items and also prevents depression. "Emotional support dogs are a fraud. I go shopping with my mother and one time a dog wearing a service vest started barking at my dog who was working on a task for me. The owner did not even apologize. It was fake. Emotional support dogs are ruining things for people who really need service dogs." (Type-A Anita blushed. She has been obtaining emotional support dog documentation to facilitate flying her black Labrador puppy to fly home during upcoming vacations. Nearly all of the couples in our class have been adopting puppies lately and getting together at a local dog park.)

[Editor's Christmas gift idea for Anita: "Black Labs Matter" poster, with optional yellow Lab holding an "All Labs Matter" sign.]

What did Elizabeth wish people knew about the disability community? "People with disabilities are not stupid. I still have a brain. When I am at the grocery store with my mom, people come up to us and ask: 'What is her name?' My mom just turns around and ignores it. I respond, 'I am right here!'"

Mischievous Mary asked the mother how she learned about the diagnosis. The mother, today in her late 50s explained, "I have two older children. I knew something was wrong with Elizabeth quickly. I kept bringing her to the pediatrician because she was missing her milestones. The pediatrician brushed them aside and said she would be fine. 'She'll be sitting up in no time.' I called a doctor who is a family-friend. He agreed that something was seriously wrong and scheduled an an appointment with a neurologist. The neurologist called with the rest results one evening while my husband was out with the kids. I was all alone as he said, matter of factly, 'Your daughter has spinal muscle atrophy and will not live for more than five years.' I do not remember what happened for three days after that. I had a nervous breakdown." (Straight-Shooter Sally afterward noted that it was possible that the doctor had good intentions, citing an HIV patient's doctor who called the patient at home so as to avoid a public scene in the medical office.)

"I hated people after that phone call," the mother continued. "I hated anyone who had a healthy child. 'Why me?' I would ask. When I went to my oldest son's basketball games, it would knock me down seeing these healthy kids and their happy parents in the stands. It sounds terrible to say, but when my sister had a healthy baby girl, I hated her too." She continued: "I dropped everything and devoted my whole life to my baby. This destroyed my marriage. I regret this, but my marriage was destroyed by my daughter."

There is some hope for SMA patients. Elizabeth's muscle movements improved dramatically after starting nusinersen (Spinraza), an orphan drug approved by the FDA in December 2016. "The new drug is amazing. I did not notice anything until my fourth dose. I used to have to use two hands and struggle with all my might to lift an object like a cup. One day I noticed I could pick up a cup with one hand!"

There may be even more hope for Biogen, the marketing partner for Spinraza. The list price is $125,000 per injection ($750,000 in the first year and $375,000 annually after that). The geneticist explained: "No one pays the sticker price. Most people are in a clinical trial, or the insurance company is negotiating behind closed doors to bring the price down. The only challenge I have faced is with the hospital pharmacy carrying these expensive orphan drugs. We have learned to never bill the patient. It just creates mayhem. Before we purchase the drug we get pre-approval from insurance or deal directly with the drug company."

Elizabeth concluded by saying, "Do not listen to what other people tell you. Everyone told me I would never be able to ride a horse. I can now trot a horse all by myself." Elizabeth goes on dates with other women and advocates for the local LGBQT community.

Friday concludes with a suture workshop. A plastic surgeon lectures on the types of sutures and various suturing techniques. Each student is gifted a basic suturing kit with forceps ("pickups"), needle drivers, and scissors. We practice on chicken breasts and a suturing model that incorporates synthetic material to mimic the epidermis, dermis, and subcutaneous fat. Mischievous Mary, an aspiring cardiothoracic surgeon, schmoozed with the general surgery clerkship director who helped with the workshop. Pinterest Penelope: "God, she was sucking up so much." Jane and I steal a few sutures to practice at home.

Statistics for the week… Study: 12 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Jane's father, an internist, rents a three bedroom ski condo for a nearby medical conference. Jane, her sisters, and I join for a weekend getaway. I am falling behind in my studying for the upcoming block exam.

Year 2, Week 26

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

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

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


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


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

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

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


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

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

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

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


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

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


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

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


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


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

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

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


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

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

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

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

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

He described anxiety disorders: "The frontal cortex and amygdala are at war with each other. The amygdala is the old part of the brain, tens of millions of years old versus 1.5 million for the cortex. New always loses to the old. Our brain is wired to assess if something is trying to harm you. It's not wired to feel good about yourself. I have lots of patients that park their cars next to the ED when they're going to sleep because they are so afraid of these attacks." (Their treatment might stay within our lecturer's family: "I tried to be flexible with my son and let pursue his own dreams. I told him, 'You can do any psych residency that you want.' He ended up choosing EM. The problem is he now has more interesting stories that I do!")

Thursday afternoon, 16 of us visit the inpatient psychiatric wing of the hospital. "We did not have to prepare because we always have a few schizophrenics and bipolar patients admitted to our service," explains the attending as we arrive. The psych wing is in an old part of the hospital. My favorite retired trauma surgeon pointed out that the wealthy love to donate money to put their names on new pediatric wings, not for geriatrics and apparently not for psych. The hallways are a muted grey with occasional peeling chips of paint. Many of the sliding doors are glass so that staff can see inside. We divide further into groups of four to sequence through two or three patients, 5-10 minutes at a time, with a psych resident.

Our first patient has her face touching a wall of her room as she attempts to walk through it. The resident instructs Gigolo Giorgio to ask her something. "Hello, Meredith. Are you okay?" No response. She explains, "This patient has catatonic depression. Her neighbor brought her in yesterday. When she first came in she had her right arm raised above her head for two hours."

Our next patient is hospitalized for a hypomanic episode. "Just ask him what brought him here," chuckled our resident, "He'll do the rest." Ambitious Al: "What brought you here today, Gregory?" Gregory responds, "Well, let me tell you from the beginning. I've had bipolar disorder for seven years. I do not take any medications. I've been bounced around different hospitals, but this place is great. They got all my medications in order. I just want to be able to talk to my family. They are so sick of dealing with me. Every time they ask me something, they can't shut me up!" Students head home from the session at 7:00 pm.

Friday morning is our patient case: Sarah, a 25-year-old bank teller with a history of depression and anxiety since the age of 12. She presents to the ED for uncontrollable crying, a lack of energy, and a plan for suicide. The previous month, she felt "amazing," though she slept less than 3 hours per night for 3 weeks straight. Her boyfriend accompanied her to the ED and reports that she recently cleaned the house from top to bottom, and cooked tremendous amounts of food for her extended family and neighbors. She scores 20/30 on the MME (mini mental status exam; not the challenging Montreal Cognitive Assessment on which President Trump purportedly scored a perfect 30!). She is not oriented to place or time, is unable to subtract serial sevens, and can't recall three words from the beginning of the encounter. She agrees to be admitted to the psychiatric ward for Bipolar Type 1 disorder.

This turns out to have been a watershed moment for Sarah, who had previously been bounced around among multiple psychiatrists and multiple drugs, few of which were appropriate for bipolar disorder. Antidepressants can exacerbate the swings of mania and depression for patients with bipolar disorder and thus, during the seven-day admission, Sarah is taken off her antidepressant and started on a mood stabilizer.

Over the next two years, she tries 11 different medications to control her mood, finally settling on a three-drug cocktail. Sarah, now a skinny 29-year-old boasting long dyed red hair with streaks of purple, is well controlled. She told her own story: "My father committed suicide when I was 14. From what I remember, my depression started then." (She was hospitalized for an attempted suicide at age 14.)  Pinterest Penelope asked about other relatives with psychiatric disorders, such as depression, bipolar, or schizophrenia. Sarah responds, "Yes, my father, my cousin, and my aunt. All on my father's side."

The psychiatrist added, "You will quickly realize psych disorders run in families. We don’t know exact mechanisms, but it is both genetic and environmental exposure. How difficult is it for a mother or father to fear the child might suffer from their own disease?" Sarah's mother, a portly 58-year-old with a wide smile and gregarious laugh, nodded her head: "As a mother you want to see your children reach their potential. I have son who is a computer science professor at a university and a daughter who has bipolar disorder. I am proud of both of them. My daughter holds a job. My daughter is independent. My daughter has built meaningful relationships. She is a functioning member of society. My daughter recognizes the impact her choices have on others. You should have seen her growing up. The change is unbelievable. When she was in high school, I had to wrestle her to the ground with all my strength. She had cut herself horizontally with a knife, and was threatening to finish herself off with a vertical cut."

What advice did she have for us? Sarah: "Tell your patients they can get to normal if they really try with an invested psychiatrist. It might be different than other people's normal. But you do not always have to be a homeless alcoholic substance-abuser. You can have a job... and not be on disability."

Sarah continued, "From a young age, my dream was to be a mother. Dreams die. I have to respect myself, and respect those around me. If I were to have a baby, I would have to come off my drugs before and during pregnancy [her meds would interfere with a baby's brain development]. Also, after if I want to breastfeed. I do not know if the meds would work again because my hormones would be all whacky. I recognize that there is a high likelihood that my child would be taken care of by my mother, boyfriend, or husband. It has taken me a long time, but I cannot do that." Straight-Shooter Sally asked if Sarah had considered adoption. Sarah responded that she did not consider her condition sufficiently stable to take on the responsibility for a child, even without the pregnancy.

Type-A Anita asked for Sarah's view on abortion. Sarah paused, then answered, "I believe in God. But if I become pregnant I will not be having the child. I do not care what you believe about abortion, if I get pregnant, I will not keep the baby." (Sarah is unlikely to be a Planned Parenthood abortion customer due to the fact that she is currently "in a relationship" with another woman.)

Gigolo Giorgio ask Sarah's psychiatrist how he persuaded patients to continue taking their medications despite serious side-effects. "I tell them to treat their psych problems just like any other disease. Would you stop taking your blood pressure medications because they make you have orthostatic hypotension [lightheadedness when you stand up]?"

Afterwards at lunch in the common area, Gigolo Giorgio commented: "You can tell she is drugged up. She would pause for a long time responding to each question." The table agreed, and then moved on to an abortion debate. Jane: "Although Sarah is a unique case, and most women do not have similar reasons for why they can't be pregnant, this is a good argument for legal abortion." Type-A Anita: "To all those far-right deplorables, this is an example that disproves their anti-abortion views." Lanky Luke: "Look, I agree with you, but you don’t hear the pro-choice people agreeing to allow abortion for these cases and prior to say 25 weeks, but not after that." Straight-Shooter Sally: "Oh, please! 99 percent of abortions after the first trimester are for medical necessity. That's such a bogus argument."

After lunch a Step 1 panel was held with four M3s and four M4s. Next week will be our last week of lectures in M2. After that there will be a week for block exams and then a six-week individual study period before the Step 1 test. Lanky Luke whispered, "Our tuition is the same as last year even though we are not in school for six weeks?"

The eight panelists explained that most students used Pathoma, First Aid and a question bank to study for Step 1. Three of them had taken all eight of the NBME practice exams at a cost of $60 each. A fit M3 joked, "I've never been in better shape than studying for Step 1. I would get up in the morning, cook a luxurious breakfast of eggs or pancakes, then head off to the library from 9:00 am until 1:00 pm. I would get lunch then switch to Starbucks for another 4 hours." What is your advice about the day of the exam? "Bring lots of coffee. If you do not want to pee between breaks, bring 5-hour energy or caffeine pills." The panel explained that Step 1 is a one-day test with seven one-hour 40-question blocks. You can take a total of one hour of break in between the blocks, e.g., 30 minutes for lunch and a few 5-minute restroom breaks.

I spoke afterwards with two M4s, one applying to Gen Surg (general surgery) and one to Ob/Gyn. The aspiring Gen Surg resident is somewhat of an outlier in her class, enjoying hunting and skeet shooting. Any advice for rotations? The huntress responds: "Ob/gyn can be tense. The residents became cautious a few years ago when a  [female] medical student wrote up a [female] resident. The resident spent 30 minutes teaching the student how to do a fetal ultrasound, then asked the student to do the next one. The student freaked out, and the resident went off on her. Two weeks later, the resident was called into the Chief's office for a reprimand. You do have to demonstrate competence and then chill out. They do curse a lot in Ob/gyn, which is kind of surprising given their job of delivering cute babies. Just don't be offended."

The Ob/Gyn: "I loved Gen Surg. Internal medicine is a lot longer hours, it drains you. My best advice is to separate the people from the profession. You'll do some rotations with amazing attendings and residents, and you'll do some rotations with people that do not click with you. For example, I loved the people in Gen Surg, and they almost convinced me to become a surgeon." Why didn't she do it? "I realized that I don't want to do that stuff. The smell is terrible when you open the abdomen." The huntress giggled, "See I love that stuff."

Aziz Ansari's dating habits have been in the news and classmates are commenting. Type-A Anita posts the original article featuring a description of a Manhattan date:

"It was white," she said. "I didn’t get to choose and I prefer red, but it was white wine."

Jane: "Well, that is just rude." [Editor: White wine? Ansari identifies as a woman?]

Jane and Pinterest Penelope thought that the article was positive for our culture and agreed that non-religious American women in this day and age would likely have had a similar experience while "hooking up with a guy".  Penelope elaborated, "You do not want to be mean or insult the other person, so you just freeze and go cold when you're not having any more of it. It's not realistic to justify this behavior and say, 'Well the woman should have just left.' It would have been even harder to leave a celebrity." Jane: "Whether or not it is true or justified, people will be more cognizant because of this article."

Type-A Anita's introduction to the article on Facebook:

TW [Trigger Warning]: sexual assault, rape

@ people who think I "hate all men," when I talk about how hard it is for me to trust men or add new men to my friend group:

It is so exhausting trying to figure out which men are "the good ones," and which will require a ton of energy on my part to discuss with them and educate them about how what they're saying/doing is sexist/misogynistic/reinforcing rape culture... Can men take a second to read this and appreciate that a lot of people, particularly survivors of sexual assault, looked up to Aziz as a guy who "gets it." It's a sad realization that so many survivors have had to experience over and over again in their own relationships and friendships, and I am tired tired tired.

Statistics for the week… Study: 18 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun: Burgers and Beers with Mischievous Mary and Lanky Luke. Mary gleamed as she recounted her day. She scrubbed in on an open heart surgery in the morning and spent the afternoon in the cardiac care unit (ICU for heart patients). She heard a pericardial rub (inflammation of the heart lining that produces a "walking on fresh snow" sound) with her stethoscope.

Year 2, Week 27

Our last week of classes. Next week we take the block exam and after that we study independently for Step 1.

An endocrinologist specializing in thyroid disease leads 5 hours of lectures on the thyroid, the adrenal glands, and the gonads. She dedicated an additional 1.5 hours for the master pituitary gland, a pea-sized gland on the underside of the brain that regulates all the endocrine glands. "20 percent of normal individuals have a pituitary adenoma (benign tumor). Most are non-functional, and never will give the patient any issue. When I started teaching, there was a much lower threshold for removing these adenomas with transsphenoidal surgery [through the nose]. Now we typically wait and monitor."

She described how several types of pituitary adenomas can now be managed with drugs instead of surgery. For example, the most common functional pituitary adenoma, a prolactinoma, which secretes the breast milk-producing prolactin hormone, causes amenorrhea and breast formation in both males and females. It can be managed with bromocriptine, a dopamine agonist. "These are much more common in females, but I do not know if this is because they are diagnosed easier in females than in males. Males predominately get breast formation, but with all the obesity in this country, most people will attribute this to the obesity horse, not the tumor zebra."

What else is new in her practice? "Patients now have complete access to the same imaging reports we read. The patient reads her report and thinks, "Oh my God, cancer." We call these incidentalomas." She continued: "What do you do with this information? If we want to rule out a functional pituitary adenoma, we need to run another more expensive MRI study. It's hard to tell these patients to not worry about this small tumor in their skull. I mean, I would want to know. It will be up to your generation to decide the the right course. With great power comes great responsibility!"

A fertility endocrinologist leads 2-hours on hormonal pregnancy changes. She described Sheehan's syndrome, a emergent condition in which the pituitary gland infarcts (dies due to blood flow loss) because of loss of blood during delivery. "Throughout pregnancy, the blood volume expands considerably to supply the baby and all the demands on the mother's body. The pituitary gland enlarges to meet the hormonal demand. If you lose too much blood during delivery, you are at risk of causing ischemic necrosis of the pituitary from hypoperfusion." She concluded: "This is a terrific example of how medicine can improve lives. In the US, Sheehan's syndrome occurs 3 times in 1 million births, whereas in India it occurs 3 times in 100 births!"

A recently-retired, Russian-trained physician discussed acromegaly (enlarged skull and soft tissue structures) and gigantism (enlarged bones). He brought in his former patient and current friend Conan, a 45-year-old accountant with acromegaly due to a growth-hormone pituitary adenoma. "Look at his chin, look at his forehead," exclaimed the Russian. Mischievous Mary was a little taken aback by the physician's bluntness in front of his friend. "If the adenoma occurs in childhood before the growth plates fuse, the child gets gigantism. This creates the tallest people in the world. If the pituitary adenoma occurs in adulthood, it causes soft tissue swelling (e.g., heart, tongue, hands, feet) and facial bone protuberance (brows, chin)." Patients die of hypertrophic cardiomyopathy and associated-arrhythmias if left untreated.

Thursday morning features an applied workshop with five stations, each run by a physician covering a rare endocrine disease. "In all your future careers you might see one of these diseases," joked my first station internist. "The boards believe if you understand the pathology of the disease, though, you can understand more common issues."

We had a station on John F. Kennedy. Most people know that John F. Kennedy had Addison's disease (primary adrenal insufficiency) requiring cortisol shots. This is believed to have given him his characteristic bronze skin and round face. In addition to Addison's, a review of JFK's health records revealed a multi-endocrine autoimmune disease including hypothyroidism. We learned about other multi-endocrine organ disorders such as Multiple Endocrine Neoplasia 1 (parathyroid, pancreas, and pituitary adenomas; prevalence 1:100,000) and Multiple Endocrine Neoplasia 2 (pheochromocytoma, an adrenal tumor that secretes life-threatening levels epinephrine, and thyroid cancer; 1:50,000). The physician concluded: "both are highly testable on board examinations."

Endocrine disorders may impair kidney function because hormones can determine how much salt and fluid to absorb. A station on renal disorders is led by a 75-year-old physician. Straight-Shooter Sally: "He must have had had a mid-life crisis and turned Zen." My group struggled through the case on Conn's syndrome (primary hyperaldosteronism), an adrenal tumor that secretes too much aldosterone, which increases fluid reabsorption in the kidney. Patients with Conn's syndrome have hypertension (high blood pressure) due to increased blood volume. Most doctors work them up for idiopathic hypertension (unknown cause, as with 95 percent of U.S. cases). He continues: "Patients keep getting put on more and more anti-hypertensive drugs. This patient was taking 5 drugs at once. One simple lab test is all it takes." Patients with Conn's syndrome can be successfully managed with spironolactone ( aldosterone antagonist) or a curative surgical resection of the affected adrenal gland. "Listen up. If you want patients to love you, this is your chance. The patient that I diagnosed with Conn's syndrome gave me the 'World's Greatest Doctor' plaque that hangs in my office. I mean this is what it is all about."

Our patient case: Janet, a 26-year-old ED nurse presents with fatigue, cold-intolerance, and dry hands after delivering her second child Charlie nine months ago. She is frustrated that, despite eating a restricted diet, she has not been able to lose 25 pounds of her pregnancy weight.

"I was a healthy person up until this. When this happened, I realized I really never had a general practitioner. It took several weeks to get an appointment with a doctor accepting new patients."

[Editor: I wonder if Janet stuck around long enough to learn that her entire audience was seeking desperately to avoid becoming stuck in primary care.]

She continued, "My primary care physician's first thought was depression." (Postpartum depression afflicts 1 in 9, typically resolving within a year of giving birth.) Janet continues, "I was depressed because i was tired, not the other way around. Simple tasks were exhausting." On the second visit, the physician tested thyroid function, which showed low thyroxine levels despite normal thyroid-stimulating hormone response. Janet was diagnosed with primary hypothyroidism due to Hashimoto’s thyroiditis  (immune destruction of thyroid gland) and started on Synthroid, which she has been taking now for 30 years. Her aunt and sister are also on Synthroid for hypothyroidism.

Janet and her husband George are retired now and he joined her at the session. George said, "it is so clear in retrospect. Immediately after delivering Charlie, she lost all of her usual spunk and energy. I had just started a new job as a history professor when Charlie was born. I was working non-stop, but we hosted a family reunion. We were both so excited about the party when we planned it, but for most of the party she was sitting on the coach. When the party ended, she went straight to bed. Did not help clean up at all."

Janet describes her cold-intolerance: "I returned to work a few months after Charlie was born. It was a beautiful spring day, but I just felt freezing everywhere I went. I took out my packed winter clothes and put them on to get to work. I just could not put on enough layers." She added, "It did not stop there. I would get to work and go straight for the coffee machine. Not for the coffee, but to grab the pot to warm my hands. It was a physician co-worker in the ED who noticed that a crazy lady bundled up in winter jackets hogging the coffee pot should be seen."

Janet concludes: "You guys are all young and healthy but you still need to get a doctor. You'll need it when you least expect it. I truly believe this whole episode would have been resolved much sooner if I had a regular internist. You are not invincible!"

Fashionable Fiona, who has hypothyroidism as well asks, "Have you had any issues once you began Synthroid treatment? Have you switched doses?" Janet: "I have never had to adjust my dose. I once tried to switch to the generic version, but started to feel tired again, so my physician switched me back to the brand-name." Our professor added: "I hear that a lot. The generic is identical for most drugs, but I see variability in biologics. The patent describes the chemical formula of the drug, not the manufacturing process. So different companies may prepare the compound differently."

Despite Janet's positive response, our lecturer cautioned us to be careful in prescribing Synthroid. "Everyone hears about the energy-boosting, weight-busting miracle of thyroid hormone. There are serious health complications if you take too much, and long-term use can damage the health of the thyroid. Be conservative in diagnosing hypothyroidism."

I attend a conference for working orthopedic surgeons on Friday. An example hour-long lecture was on anterior lateral cruciate (ACL) ligament tears in female athletes, 4-6 times more common than among men playing the same high-risk sports. This is believed to be from several factors, including wider hips, decreased femoral notch width, and the impact of estrogen on connective tissue tensile strength. "Title IX is the gift that keeps on giving for orthopedic surgeons," said the lecturer, but researchers are looking at screening and training processes to reduce injuries. "Sports physicians may be able to screen for ACL tear risk by measuring the mechanical forces with various exercises. Individuals with high risk need to begin training before they jump straight into competition. Several companies are developing tests to monitor neuromuscular synchronization to strengthen muscle tone via biofeedback to minimize the ligament load."

Several classmates appear right before the free catered lunch. I overhear a few orthopedic surgeons discuss the impact of reimbursements being tied to outcomes and customer-reported feedback. "Medicine is now a product, health systems need good reputations, not just good care. In the past I might have told a patient that he didn't qualify for disability, but today I would not confront him. I will just refer him out."

An email titled "Self-Defense Class Sign-Up" from our Dean of Diversity and Inclusion: "This course is taught by [police officer] and [yoga instructor]. It is designed to help individuals who identify as female protect and defend against unwanted physical advances. Participants will learn general safety tips as well as defense techniques including kicks and strikes during the session. Every individual (faculty, student, physician, staff) who identifies as female is welcome to contact [yoga instructor] to participate."

We are done with classes for our second year of medical school.

Statistics for the week… Study: 20 hours until burn out. Sleep: 8 hours/night; Fun: 1 night. Example fun: After our last day of class, 25 students go downtown to our favorite burgers and beers joint. We discuss our most memorable moments so far. Our class VP: "This was Year 1, Month 2. I was working at the free clinic with Dr. House. He asked, 'The patient in Room 3 is having stomach pain, can you go in and report back your abdominal exam findings.' I come out after a few minutes, and say, 'Looks all good to me.' He had gone in beforehand and diagnosed her with metastatic ovarian carcinoma that had spread to her peritoneum (abdominal cavity). Dr. House said, 'Now you won't make that mistake again'." Lanky Luke: "I was waiting in the lab for a Path report for my research project. After 30 minutes, a freaking leg came through the door and the severed leg was just plopped on the pathologist's table."

Year 2, Week 28

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 we read the texts aloud. "Why don't they just come out and say what they mean. They want more of everyone except white males." Our class VP, from a family of Vietnamese immigrants: "I've heard being Asian now hurts applying to colleges and medical school. It is not right to group all Asians together on the application box. Chinese and Indians are probably over-represented, whereas South-East Asians are probably underrepresented." He did not want race to be disregarded in admissions, but was lobbying for Vietnamese applicants to be given a higher priority.

Jane yelps as she gets an email that she was nominated to the position by Hardworking Harold. She does not post her position on diversity and inclusion to the GroupMe: "Best campaign is no campaign." On Friday we learn that she was right. The Google poll results are in. Jane, Adrenaline Andrew, Buff Brad, and Fashionable Fiona have been selected for the committee.

Facebook is quiet this week due to exams and GroupMe activity. Type-A Anita: "RELEVANT: Happy International Women's Day… except for the 53% of WHITE women who voted for trump"

Statistics for the week… Study: 18 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Annual "Champagne and Shackles" at Nervous Nancy's apartment with every class in our school. People are shackled together with zip ties. You are not allowed to cut this until you and your partner finish a bottle of "Champagne" each. Jane and I cheat by consuming only half to two-thirds. Several couples are typically formed at this annual event. Buff Brad, his girlfriend, Jane and myself struggle to play pool while zip tied. Several class pictures are taken. Luke promises to get a pool table for his new house. "It cannot be that difficult to find one on Craigslist. People give away that stuff if you can move it. I become the most popular person for the yearly moving season with my F-150."

End-of-Year-2 Study Period

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:

If 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 crisis, I found that RAICES is helping reunite immigrant parents with their children. Over $6 MILLION has been raised this week which is incredible and gives me some hope in Trump’s America. …  Oh, and 2 hours ago Trump announced he will be signing ‘something’ to keep families together... Still no plan of action on wtf will be done to reunite these families and fix this horrible, inhumane shitshow

[Editor: Penelope is from Massachusetts, whose winner-take-all family court system permanently separates more children from at least one parent in a typical week than ICE temporarily does in a typical year.]

Perhaps 10 percent of students delayed the exam by paying a $50 fee within one week of their original test date. Pinterest Penelope moved it back twice. Mischievous Mary before her exam: "I've become so frustrated, so numb from studying, that I am not even nervous. I am anxious to get it over with." Roughly as many students moved the exam up. Sometimes this was from study exhaustion. Jane moved it up four days to earn more free time before boot camp.

Statistics for a typical week Study: 50 hours. Sleep: 8 hours/night; Fun: 2 nights. Example fun: class winery tour and tasting set up by Pinterest Penelope attended by 15 students.

Year 2, Step 1 Exam

Jane takes Step 1 today. She was tossing and turning most of the night. I wake up at 4:45 am to make pancakes and pack her lunch. She departs at 6:15 am for the 30-minute drive to a Prometric test center for a 7:00 am start time. The average Step 1 score for 2017 was 229 out of 300, with a standard deviation of 20. You must score at least 194 to pass the exam, otherwise you have to take the exam again. If you do pass, however, you are unable to take the $600 exam again. Thus, you're better off getting a 193 and having the opportunity to retake than you are getting a 194 and being doomed to primary care.

[Editor: What do you call a guy who graduated last in his class at medical school? "Doctor."]

As was explained to us in Year 2, Week 26, during an eight-hour period there are seven one-hour sections, each with 40 questions. You can use the remaining hour however you like, divided up as breaks between sections. You can snack, look at First Aid, express righteous outrage regarding Donald Trump on Facebook, or call a friend. Out of the 280 questions that we've been torturing ourselves regarding, 40 of them don't count at all. These are experimental questions that might appear on a future exam. Test proctors can view students through a glass window and also through a webcam on every monitor.

Jane powers through four sections in a row, then takes a 30-minute snack-and-bathroom break, and finally chugs the last three sections. She finished before any other classmate I've talked to. "There were so many questions I had no idea about. I would look them up afterwards and still have no idea. They are not even on the internet." She adds: "Some questions have this essay long prompt, and I when I get to the end, I would literally mouth, 'What the hell?' The test proctor must have been laughing watching the webcam feed: 'Look at this girl. She is really struggling.'" Doctors need not be numerate: "I practiced so many statistics questions, but on the exam itself  I used the calculator only once."

We celebrate her finish by going downtown for $5 happy hour martinis at a fancy patio bar.. Asked how she thought she'd done, Jane stuck to "I plan to use the mature defense mechanism of suppression until my score comes. Nothing to do but wait." (She will get her score in three weeks.) Regarding the celebration: "This is such a finisher prize. I probably failed."

I slept well the night before my exam, two weeks later. Jane packs me a large lunch. Every computer is filled at the test center. Some of my classmates are taking a mock Step 1 exam in the test center for $80. The software format and some questions are nearly identical to UWorld's. Example: What part of the urethra gets injured in pelvic trauma? Membranous urethra.

I do three blocks with no break, then take a 30-minute break for lunch. I power through four in a row, with a 1-minute breather break in my computer chair in between blocks.

I nearly ran out of time on two blocks. Several questions have three-paragraph prompts even if the question only requires the last two sentences, e.g., What is the mechanism of a mentioned drug? I had to rush through perhaps ten questions total. Overall, I do not think studying more would have changed much. I should've completed more UWorld questions, but this might have affected only a few borderline questions. I did about 50-60 percent of the 2200 available questions. Advice: Start studying UWorld in September, reset it at the beginning of the study period, and try to get through all 2200 again.

I was surprised at the number of questions on the immune system. They asked about various inflammatory mediators: What causes swelling after a sprained joint? Histamine or C3a (complement factor). Which of the following growth factors stops proliferation? PDGF, TGF beta.

When I return, Jane has mojitos prepared from our organically grown mint plant. We went downtown and I avoided talking about the experience, use of the mature defense mechanism of suppression: consciously ignoring information. Jane: "Are you sure you're not repressing this information?" (a reference to the immature defense mechanism of unconsciously ignoring bad news.)

Jane gets her score back the next day. She scored 248. That should be one standard deviation above the mean or roughly the 85th percentile, a great achievement considering her four weeks of study. Wow!

Nobody expressed complete confidence in his or her performance. Mischievous Mary:  "I convinced myself every question that I got wrong is a mock test question." Geezer George: "Unbelievable, those questions. I had to take solemn walks after each section." Gigolo Giorgio: "I just had to laugh at some questions. It was a tragic comedy."

Jane and I relax before she departs for boot camp. We go on hikes, organize the house, and do yard-work before she departs. Although she will be required to do a residency at a military hospital, they are advertising residencies to her for specialities on which the military is current short. One powerpoint for a psych residency features beach-front facades of Hawaii and an ocean photo with a resident quoted as saying, "This is our view from our conference room, fyi."

Pinterest Penelope's two exam delays shortened the trip to Thailand with her M4 boyfriend to only one week. They post photos of themselves drinking oversized fruit-and-booze concoctions next to elephants on the beach. Type-A Anita, meanwhile, is more interested in the white elephants of Washington, D.C. On a resignation from the Supreme Court: "Fuck that cowardly limp dick Justice Kennedy." Later she shares a post regarding an ICE checkpoint on a Manhattan subway train. I didn't ask her how many of her Facebook friends she thinks might be undocumented immigrants and therefore able to use this information.

We'll all be back in July for M3 clerkships (informally known as "rotations").