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Part 3

Best books to prepare for college chemistry and physics?
Succeeding in college and medical school:  how I went from dunce to doctor
What to do if you get a bad prof
My organic chemistry professor and his wacky wife
What not to do
Expanding your brainpower:  it takes more than just schooling
Can geniuses be created?
An intriguing speculation on what will be "the next Internet"
Fostering the impetus to succeed
How I convinced a "10" that suicide wasn't the answer to being dumped
The biological basis of creativity
The role of creativity in enhancing intelligence

Q:  I was wondering if you might have a bit of advice for me.  What book(s) do you feel are the most conducive to gain a firm grasp on college level chemistry and physics?  I ask because I did not have any form of chemistry nor physics in high school.  Also, I've been out of school for about 5 years, so I've been trying to refresh my memory on all manners of subjects.  I already plan to pick up that memory book you seem fond of.  Even though I do not plan to go into emergency medicine, I also intend to pick up your ER book; I thoroughly enjoy your more candid approach to things.  Anyway, any advice you could provide I'm sure I'd find rather useful.

Thanks for your wonderful and informative web site; wit mixed with comedy and liberally sprinkled upon good advice make it a must-see for any would-be ER doctor.  I'll make sure to bookmark it and check back for updates.  Thanks for reading and your time.  Mike

A:  Before college, I read Physics Without Mathematics by Clarence Bennett.  In college, you're sure to have a prof who liberally uses math to define, elucidate, and quantitate concepts, but I still think that a non-mathematical introduction to physics is valuable because it helps provide an intuitive grasp of the subject.  If you possess an intuitive understanding of physics, you'll have a real advantage over most of your classmates, many of whom will be lost in a mathematical fog.  I'll never forget one time I visited my physics TA (teaching assistant), who was a graduate student in physics working toward his Ph.D.  I had a question pertaining to an aspect of physics that wasn't in my course.  Before he answered my question, he grilled me with questions to see if I truly understood physics.  After correctly answering every question, he told me that most students — even the ones who get A's in class — have a shaky grasp of physics.  Basically, he wanted to know if I intuitively understood physics, and knew it well enough to "really get it."  He told me he'd never before had an undergraduate student who could answer his questions.  With the aid of Physics Without Mathematics, those questions were easy.  I can't give full credit to that book, however.  My high school physics teacher developed a wonderful independent study program in physics that was tailored around another great book (the name of which I forgot long ago).  It had a moderate amount of math, but explained the concepts very well.  In college, we used Principles of Physics by F. Bueche.  I still refer to that book when I need to brush up on something.  If you read the foregoing two books, you'll have a good foundation for physics.

My favorite book for chemistry is General Chemistry by Nebergall, Schmidt, and Holtzclaw.  That text was not used in any of my classes, but I think it did a better job of explaining some things than the assigned course books — none of which seemed very inspired.  I wish I could give you more input on chemistry books, but I know far less about chemistry than physics.  I have a few inventions that pertain to chemistry, but they're very basic things.  I don't know why I never mastered chemistry as much as I did physics.  Perhaps it was the lack of good preparatory books (I didn't purchase General Chemistry until I was in college), or the absence of a truly gifted teacher who gave me a good head start.

Q:  Hello again! I wanted to send a quick thanks for your informative and alacritous response. Thanks!

However, I'm a bit fearful. I recall reading that you didn't have much trouble in college, and you still managed to pound out a 3.9+ GPA regardless of also working a fairly regularly job?

A:  A few jobs, actually. Mowing lawns, general yard work from gardening to resurfacing driveways, tutoring a few subjects in college, and occasionally filling in for my brother delivering newspapers and working as a security guard. Keeping my car running was sometimes a job in itself. Now that I'm on the subject of frittering away my study time, I suppose I should also mention my neurotic level of anxiety, which wasted untold amounts of time. Then there was my skin care regimen. In high school, I discovered that if I squeezed my facial skin in the same way I would to pop a pimple, I could express sebum that might otherwise form a pimple. Depending on how thorough I wished to be, this would take an hour per day, and sometimes two. (You know that stereotype about greasy Italian skin? It's true. Even at age 44, I still have acne!) And then there was the time I spent playing with my neighbor's son. She was 17 years older than me, but I had a crush on Maggie and blindly hoped that something would magically click with her if I spent enough time with him. I couldn't bring myself to ask her out, and, thanks to my shyness, I froze whenever she spoke to me. Still, I spent hours almost every day babysitting/entertaining him, dreaming of romance with Maggie.

If I told you about all the other ways I wasted time, you'd probably wonder why I was not booted out of college. It wasn't because of my innate intelligence. In fact, from what my sixth grade teacher said to me, I think he believed I was "slow." So how could I go from being a dunce to someone who aced college, the MCAT, and medical school? Additionally, I wasn't just accepted into an ER residency (the most competitive residency at that time), they rolled out the red carpet for me and were so desperate for me to say yes that they offered me an illegal, under-the-table deal. Furthermore, my aptitude for medicine pales in comparison to my talent for inventing. I am not mentioning this to brag; I mentioned it to address the fear you expressed in your question. Let me paraphrase it and read between the lines a bit to clarify what I think your concern is. You said you're fearful, and then mentioned my GPA and hours spent working. I think this is your fear: "Anyone who can work a few jobs and still get a 3.9+ GPA in college (in the days before grade inflation) must be some sort of genius; therefore his advice doesn't apply to someone like me."

My response? In terms of innate intelligence, I bet you're far ahead of me. I once suspected I was a dunce, and my sixth grade teacher confirmed it. My older brother was the one in our family bound for college, and I was the one who lifted weights and dreamed of being a world champion wrist-wrestler. That didn't pay anything, so I planned on supporting myself by mowing lawns or working in a factory. In fact, I ended up mowing a good chunk of southeastern Michigan, and I worked in a few different factories. Great college material, wasn't I? Now let me return to the central point I wish to make:  how can anyone with such an inauspicious beginning rocket to the top of his class in medical school? In medical school, even the worst students are bright. I beat them, and also the cream of the crop. As I mentioned elsewhere, many of my classmates had numerous advantages over me, but I still beat them. How on Earth is that possible? Even the kids destined to be shoprats were smart enough to escape the wrath of my sixth grade teacher. Hence, judging by that, I wasn't just destined to be a shoprat, I was destined to be a dumb shoprat. So how did I do it? I learned to be smart. I observed (either in person, or by reading) how smart people thought, and I learned to mimic these thought processes. Eventually, they were so well internalized that they became not just second nature, they became the way I thought. I discussed this process, which I term cognitive mirroring, elsewhere on my web site. An aside:  why don't educators teach this process? They teach the nuts and bolts of other topics in microscopic detail that they spoon-feed to their students, but they never mention this process. Why? Do they hope that students will pick it up on their own? Do they think that learning actually teaches people the best way to learn? (It doesn't.) Do they believe that routine learning is the best way to optimize intelligence? Wrong! Frankly, do they even know what cognitive mirroring is? I coined the term for an intellectual process I used, but surely others do this, too. Even babies mimic what adults do! I just took this process to a higher level. I suspect that once people learn to think and reason on their own, they make the mistake of believing that education is a process of acquiring new facts. I never neglected the acquisition of new information, but I was always on the lookout for new and better ways to think. By integrating those cognitive processes with an ever-expanding base of knowledge, I was able to transform myself from dunce to doctor.

Here is what all the foregoing boils down to, Mike:  if I, someone once labeled as a dunce, could perform so well in medical school, you can do it, too. In fact, if you apply my methods, you could probably do better than I did.

Q:  I've been harrowed by so many horror stories of organic chem and/or "pick your poison." And these anecdotes are actually from very intelligent and rather assiduous persons.

A:  I, too, have seen very bright students tremble with fear of organic chemistry and some other "killer" courses that supposedly separate the men from the boys when it comes to determining who has "The Right Stuff" to be the next generation of physicians. However, remember this:  even a onetime class dunce — me — aced those courses. In fact, some of those courses were so easy that I didn't even bother to fully apply myself; I'd just skim the textbook once at high speed, and that was it. I could tell you dozens of stories about those classes, but here is one. I took a class entitled Advanced Developmental Biology in my third year of college. Half the students in the class were graduate students working on their Ph.D.'s in biology. A few times after class the professor asked me to walk with him because he wanted to know why I was the only student who "got it" (understood what he taught). He was mystified that graduate students and my other classmates weren't able to comprehend the material. Well, so was I. I thought the material was so easy that it didn't merit anything more than a half-hearted attempt, so that's what I gave it. And I aced its final exam even though I arrived for it when half of the test hour was gone, because I'd spent the last 30 minutes lying in a half-frozen mud puddle fixing my car so I could make it to class. Hence, when my prof asked me if he was doing anything wrong that might explain why the other students were lost, I couldn't give him any advice. I thought the class was a dream come true in terms of being a breeze. That reminds me of my last ATLS (Advanced Trauma Life Support) class. That's a course taught to practicing physicians (ER and surgery) who care for trauma patients. After the written portion of the exam, I heard some university surgeons complaining about how difficult it was. Difficult, I thought? The last time I had such an easy exam was . . . never. I was going to say elementary school, but at that time, those exams weren't easy for me.

And then there was the supposed Big Daddy of the tough courses, organic chemistry (OC). Like all neurotic premed students, I spent a lot of time shaking in my boots about the fabled difficulty of mastering that subject. When I now reflect on that, I realize what a waste it was to fear OC. You really can't ask for a more straightforward class. There are some facts and principles to memorize, but they're a piece of cake compared to some classes (more about that in a minute). In my first OC class, I didn't bother studying it until three days before the final exam, but I still received an A. In my next OC class, I actually attended the classes, and when the prof would ask how to go from "Chemical A" to "Chemical B," I could instantaneously think of how to do that, even for complex reactions that required as many as 25 steps. (Keep in mind:  a onetime dunce did this. So, if I did it, you can, too.)

And then there was math, which I thought would prove to be my nemesis. I went a year without missing an exam question, and the prof threw in a few tough extra credit questions on every exam, and I got them, too. When I began college, I was so poor at math that I couldn't even do basic algebra.

And then there was genetics, the toughest class I ever had. Genetics is not an inherently difficult subject, especially if you keep to the basic stuff, but I was either blessed or cursed (depending on how you wish to look at it) with a professor who was such a genius and so much smarter than anyone I'd ever met before that I could not comprehend how anyone could be so intelligent. His exams were unlike anything I'd ever seen (both then and now, countless exams later). Instead of just asking a question and having students regurgitate pat answers, his questions were framed in such a way that the correct answers could only be deduced by possessing a comprehensive and integrated knowledge of all the class material, and then being able to extrapolate from that. If you had any holes in your knowledge, and if you couldn't rapidly use that knowledge to make a series of deductive conclusions for each question, you'd be utterly lost. You wouldn't have just the usual test uncertainty, you'd be as lost as a blind man in a dungeon basement on a moonless night. I walked out of that final exam absolutely stunned; I had no idea it was even possible to conceive of such questions. That test was the most challenging one I ever faced, but I aced it and received an A. If a onetime elementary school dunce could do that, you can, too.

Q:  I'm beginning to think that Physics/Chem has more to do with instructors than coursework/students.

A:  To some extent, it does.

Q:  As I said, I'm fearful I'll get stuck with a putz for a professor. Ugh.

A:  If you get such a prof, just drop him and choose a different one. I did that once. I had an organic chemistry prof who seemed very distracted. He was. His wife, a Ph.D. researcher at our university, was so twisted that I'm surprised she hasn't been the subject of a Hollywood movie. In a nutshell, here's the pinnacle of her nuttiness. She evidently didn't like the fact that there were students who did better in school and band than her kids, so rather than accepting this, she tried to eliminate the kids and their families by poisoning them. She planted various poisons in their homes and cars until one day when she was discovered in someone's garage wearing a long coat (presumably to hide her stockpile of toxins) and carrying a brown paper bag filled with more goodies. My professor was never implicated as being a participant in this attempted extermination, but he vigorously participated in her defense (which seemed to me to be synthesizing cockamamie excuses, à la Johnnie Cochran). In any case, in class the prof seemed a million miles away, and that's what I wanted to be from him. I realized his thoughts were elsewhere, so I dropped his class and enrolled in a different one.

Q:  Do you think it would be wise to take my organic chemistry and physics courses the same year (junior year?)

A:  I think premed students should take OC in their second year. However, let me address what seems to be your concern:  is it wise to simultaneously take two or more difficult courses? As a premed student, you won't be able to avoid this unless you stretch out the curriculum beyond four years.

Q:  I'm getting mixed signals from persons on this. One camp says that it would be difficult to maintain a high GPA with that schedule; camp number two maintains that it shouldn't be a problem, and it will actually be of significant benefit to have organic chem and physics so close to MCAT testing time.

A:  Camp number three (me) says that anyone smart enough to be a doctor can ace more than two difficult classes taken simultaneously. Now, on to the MCAT. The MCAT is more of an aptitude test than it is a test of knowledge. I re-read my physics text before the MCAT, but after the exam, I realized that was a waste of time.

Q:  When did you take yours? Same year? You remember at all?

A:  Heck, no. With the way this Alzheimer's is progressing, I can't remember what I ate for breakfast. :-)

Q:  I enjoy science quite a bit, but I was thinking of actually majoring in psychology. It seems that psychology/sociology have notorious reps for being "easy" and "fluff," but I feel they are very beneficial to many medical aspects, especially if you plan on going into pediatrics, psychiatry, etc.

A:  Your choice of a major shouldn't matter because all premedical students must fulfill the requirements of the medical schools to which they will apply — but your major matters, anyway. After you complete the year of chemistry, the year of organic chemistry, physics, biology, math, blah, blah, blah, you're well on your way to a degree in any of the basic sciences. Also, don't forget that majoring in one of the traditional premed degrees such as zoology (animal biology) does not prohibit you from taking several psychology courses. I did. I took an intro psych course, a somewhat more advanced psych course, a class in sexology, a class in abnormal behavior, and a class in criminal psychology. The prof for those first three classes was strange, even for a professor. He expected us to learn the material on our own by reading the textbook, so during lecture he'd rant about truly wacko stuff, such as how women in the class should direct all their sexual energy toward him. He instructed them not to have sex or masturbate, so they'd focus their sexuality on a better outlet:  him. No doubt he was hoping to have some wild flings during his office hours.

You think I'm digressing? I'm not. Such behavior is tolerated in the fluff subjects, but not in the serious subjects. If a math professor tried such shenanigans, he'd be working at Taco Bell the next week. But psych profs can run on five cylinders and have less morals than Bill Clinton, and keep on teaching year after year. Did I learn some psychology by reading my textbooks? Yes, of course. However, I would have learned even more if my horny prof had more on his mind than trying to seduce a few hundred coeds. Certainly, not all psych profs are unbridled sex maniacs (my last two profs were very knowledgeable and they disseminated a wealth of knowledge), but there are enough fruitcakes in that field to tarnish its reputation and dilute the value of taking such classes. Medical school Admissions Committee members know that psych classes are comparatively easy, so they often discriminate against psychology majors. You should take psych courses, because psychology is one of the underpinnings of medicine. However, to optimize your chance of acceptance into medical school, you should NOT major in psych. It's an automatic strike against you. Hence, your major does matter.

Q:  What do you think the admissions folks would think of such a major? Probably a question more pointed towards a "premed advisor," but I'm beginning to wonder if any of my college "advisors" even have their heads screwed on tight!

A:  I wondered the same thing about my advisor. I never met him until after I'd been accepted into medical school (I thought it'd be a waste of time to listen to someone who never attended medical school, so I didn't see him until I needed his signature for something), and his only suggestion to me was that since I would not obtain a college degree (I was accepted into med school after three years of college), that I might want to return to college after medical school to complete my degree in zoology. Yeah, right. I attended college for one reason:  to get into medical school. Once that was accomplished, what's the point in obtaining an undergraduate degree?

At the time I applied, my medical school accepted one person per year with just three years of college if their grades and MCAT scores were exemplary. Out of 256 students in my class, I was that person. Why do I keep harping on this matter? Because I was once so slow that even the dumb jock coterie was ahead of me. Sure, I had some good teachers along the way, but who doesn't? My classmates achieved incremental improvements in brainpower, but nothing like the transformation I achieved. In my medical school class, there were many bona fide geniuses, and I beat them. Perhaps I am guilty of patting myself on the back too often, but I think that anyone who can go from class dunce in elementary school to the top of his class in medical school deserves a lot of credit for knowing how to create brainpower. Think of all the Secretaries of Education we've had since the inception of that cabinet position. Have they produced any measurable improvement in our IQ's? Not one bit. (If that were true, the College Board that administers the SAT exam would not have found it necessary to "recenter" scores by giving every student an extra 100 points, as discussed in a recent Forbes FYI magazine article.) Now think of the good I could achieve if I were given that position and had its inherent advantages as a bully pulpit. I would teach students ways to magnify their intellectual potential so they could exceed their wildest dreams. I did it for myself, and I'm confident I could do it for them. However, I am also practical enough to realize that it'd be a cold day in Hell before I'd be nominated for the Secretary of Education, or any similar position. I'm too politically incorrect to ever stand a chance of being nominated or confirmed. Instead, we end up with politically correct, palatable nominees with the right paper credentials but without any real capacity to produce educational breakthroughs. That's one thing I detest about our culture:  it values style over substance.  Currently, the U.S. Department of Education employs 4615 bureaucrats.  Besides pushing paper and creating more paperwork for others with their heavy-handed meddling, what do these people do except increase your tax burden?  Our children aren't any smarter or better educated than they were before the creation of the Department of Education.  The September 15, 2003 issue of Time magazine reported that President Bush increased federal spending by 21% in three years, during which time spending on education rose a whopping 61%.  We spent massive amounts of money on education before Bush took office, and now our educational "investment" is staggering . . . but what do we have to show for it?  The educational bureaucracy is great at burning money, but poor at producing results that are commensurate with the expenditures.

In my mind, it's not just amazing that I did so well in school, it's a dang miracle. Why? I hated school. In all my years of college and medical school, there were a grand total of two lectures I enjoyed. I love learning, but I despise structured learning, so I had to force myself to study and attend classes. I think I have some elements of ADHD, and it's as difficult for me to sit through a lecture as it is for Bill Clinton to not flirt with women. I think I have an enormous fund of willpower, and that is what sustained me through those years of study.

Bottom line? If an elementary school dunce with ADHD who hates school can ace medical school, you can do it, too. But do yourself a favor:  don't worry about whether or not you can do it. There aren't many people less qualified than I once was, and look at how I did. I wasted too much time fretting about the future, and it didn't do anything except give me an ulcer. If there is one thing I learned in the ER, it's that life can be unpredictably short. You cannot shrug off the need to study and expand your mind, but once that's accomplished, let your mind be free. Don't waste energy worrying. Most premed students are imbued with more worry than an average college student. Do your work, but don't worry. Your future will take care of itself. Trust me, I'm a doctor. :-)

Q:  You make it sound so fantastic. I'm talking about your "transformation." After reading some of your anecdotes, it just seems so surreal. I mean, I believe them, but it seems like a different world to me. I'm wondering if there was something about the way things worked in college that made things "click" in your mind? It seems almost as if it was the different environment of college that proved to be a catalyst for your academic transformation. And if your success merely hinged on mimicry of your professors' habits, I'd think there must have been something more to it because even the majority of professors do worse than you did in college. You did say you also did this mirroring through reading as well, so I guess it would be possible.

A:  The onset of my "transformation" (or cognitive metamorphosis, if you will) preceded college, so it wasn't entirely due to exposure to my professors. I read extensively, devouring many books and countless magazines. Magazines are sometimes dismissed as being pabulum, but some are not, such as Scientific American. That magazine now seems much more simplistic than it once was, but there is still some value in it — and who is to say that you can't read the classic issues of a few decades ago? Other magazine favorites were Popular Science, Popular Mechanics, and the now defunct Mechanix Illustrated. In general, these magazines fueled my intellectual growth not by discussing abstruse, esoteric subjects, but by covering technology in such a way that it seemed tantalizing, fascinating, and utterly engrossing. If you pick up a current copy of Popular Science, you'll likely wonder why I was so intrigued. The operative word in the preceding sentence is "was," because that magazine is nothing like what it used to be. It now seems sterile and devoid of fervor. Popular Mechanics has succumbed less than its competitor (Pop Sci) to the trend for magazines to cover topics in a superficial, insipid, detached, and politically correct manner, yet it also is blander than before. My primary criticism of these magazines is that their editorial focus has shifted from "you can do it, and we'll show you how" to "you can't do it, so we'll assign one of our writers, who rarely ventures out of his New York high-rise condo, to cover a subject in which he won't need to get his hands dirty, God forbid." In the days of yore, those magazines covered some spellbinding subjects:  how to make your own submarine, Tesla turbine, rocket engine, or boat. DIY (Do It Yourself) magazines now think they're challenging their readers if they show them how to make a brick patio or change a lawnmower spark plug. Big whoopee.

However, if you wish to maximally expand your brainpower, you must do more than drool over the plans for a Tesla turbine. Your introduction to technology and science is provided by your classes and myriad other ancillary sources such as magazines and books. To achieve a greater intellectual boost than you can obtain by conventional learning, you must "strain your brain" (to use one of my phrases) by giving yourself difficult challenges to solve. To illustrate this, I'll synopsize a few of the ones I've worked on, either for the sheer joy of mental stimulation, or because I had a burning need to use the device (incidentally, I won't tell you exactly how I solved the problems, in case you wish to ruminate on that fodder):

Problem:  Make a printhead that is small and lightweight and uses very little power and is easily fabricated and is economical to manufacture and does not require complex interface circuitry and has a long life and is capable of producing excellent graphs. The difficult part was fulfilling all of those criteria. Using a dab of glue and two things you might find in a trash bin (a small scrap of thin plastic and a postage stamp-sized piece of aluminum or other foil), I thought of a way to do this.

Problem:  Try to reinvent the wheel. Literally. When people discuss reinventing the wheel, that familiar saying is often prefaced by an exhortation to not do it, or a rhetorical query that boils down to "why even try?" Aside from the fact that it is useful mental exercise, sometimes there is a need for it. I encountered this need a few weeks ago while working on a device for which the existing means of locomotion (wheels, tracks, legs) were not optimal. I scoured the Internet over the course of a week and found many variations on these themes, but nothing that was ideal for my application, so I invented my own solution that fulfilled all my design criteria and added some new functionality.

Problem:  Think of a way to make a complete circuit using no return wire.  Ever notice how even the simplest circuits have at least two wires?  Even if you just hook a light bulb to a battery, you need one wire to carry current to the light bulb from the negative terminal of the battery, and one wire to return the current to the positive terminal of the battery.  I discussed this problem in more detail elsewhere on my web site.  The solution is surprisingly easy, but only if you aren't locked into the notion that a circuit needs a complete loop to flow.

Problem:  Think of a way to program a memory chip (such as a ROM, or read-only memory) to behave as a complete computer for some simple tasks.  I did this years ago while working on a medical device for which size, weight, cost, and power consumption were critically important.

Problem:  Make a robotic lawn mower.  I did this in the summer between my first and second years of medical school, because I thought humans have better things to do than mowing.  The current robotic mowers are technologically unsophisticated; they mow at a snail's pace, and just wander aimlessly within a predefined area.  After a few weeks of mowing, some areas may be untouched while others were mowed a hundred times.  Aren't robots supposed to be smart, or at least efficient?  Mine would mow in lines straight as an arrow, turn itself around at the exact programmed spots, avoid existing and new obstacles of all sorts, and collect the grass clippings for people who prefer that to mulching.  The mower would even put the clippings in bags at a predefined spot whenever it sensed the grass catcher was full, then return to the point it left off and resume mowing.

Problem:  How could you make a snowmobile with zero inches of suspension travel give a smoother ride than the latest models with long-travel (10" to 16") suspensions?  It may seem axiomatic that suspension travel is a prerequisite for ride quality, but it's not.  If you can think outside the box, this one is a no-brainer.

Problem:  How can a hole be threaded from the inside out?  If you've ever seen a standard tap, you'd think it was impossible.  Trust me, it's not.  While working on my car in medical school, I botched a spark plug hole by cross-threading it and suddenly had a need for such a gizmo.  If you wish to see the first such device I made, it is pictured and described on my web site.

I've worked on hundreds of such problems, some of which were considerably more difficult.  The utility of such mental exercise is that thinking on your own in uncharted territory is far more challenging than correctly answering an exam question in college, which typically just requires a recall of the class material or application of a formula taught in school.  Parroting material is at best a second-rate challenge, so if you wish to develop a first-rate mind, you need to tackle something more formidable.  However, to make this exercise feasible, it must be palatable.  Otherwise, you won't be inclined to dwell on it.  Sometimes I'll think of a solution to a problem in a flash, but other times it takes hours, days, weeks, months, years, or even decades.  If you're bored by the subject, you'll likely drop it.  Hence, pick something that gets your juices flowing.

Most adults never stop to think about things around them, from wheels, to threads in holes, to circuits.  By ignoring them, they pass up opportunities for mental growth.  Albert Einstein attributed his intellectual development to the fact that he was "retarded" (to use his characterization) early on, which delayed his thinking about things that kids explore as they study the world around them.  By the time most people are teenagers or adults, they're adept at using things, but rarely give them much thought any longer.  Not Einstein.  He deeply contemplated things that most of us take for granted, and in the process, he revolutionized physics.  All of his deep thought may have done something else, too:  make him a genius.  Judging by facts such as his delayed onset of speech (at least the age of 2½, according to his sister in an unpublished biography), Einstein may not have been a born genius.  This raises an arresting possibility:  can genius indeed be created by intense, protracted rumination?  Bear in mind that I am not confusing correlation with causation.  You may think that geniuses are more apt to deeply ponder subjects, thus making it utterly unsurprising that genius is associated with such reflection.  However, unless there is preceding evidence of genius (and there was not in Einstein's case), this lends credence to the notion that it was the thought that created the genius, not the genius that created the thought.

The problem is that modern life is filled with too many distractions.  Some people are obsessed with computer games and spend almost every free waking moment playing them.  Others spend countless hours in computer chat rooms, while others veg out in front of the TV.  I am not opposed to some mental downtime, since I think that such R&R is essential.  However, I think that too many people fill their lives with things that occupy their minds but don't cause them to really think.

The more you learn about a wide variety of subjects (especially those pertaining to science and technology), the easier it is to conceive of a worthwhile intellectual challenge and its solution.  Creativity involves the formation of new links between seemingly unrelated facts.  An enhanced knowledge base makes this synergistic process more likely by providing more facts for you to link.  Hence, memorization is essential, but it isn't enough.

If devising a new printhead or wheel seems too daunting, begin with something easier, such as designing a home to optimize space efficiency.  Discard your preconceived notions of home design, and think of how to make every cubic inch count.  Or think of alternative methods of home construction.  I thought of a way to form the basic structure of a home that would require no skilled labor and could be erected in 30 minutes by just one person.  Or design a piece of furniture that isn't just a stylistic variation of an existing type of furniture.  Or think of a neologism.  Or think of a new kitchen appliance.  Or create a new toy or game.  Or devise novel ways to thwart an ongoing terrorist attack.  Imagine that you were a passenger on Flight 93.  Charging the cockpit as they did was heroic but did not allow them to regain control of the jet.  What else might they have done to heighten their odds of success?  Or think of an addition to our infrastructure that would revolutionize our lifestyles as much as the Internet.  Here is one inevitable addition:  imagine a subterranean network of "pipes" that could carry things from any home or business to another destination at hundreds of miles per hour.  The sheer convenience of such a system would be addictive.  Amazon.com could ship you books or other merchandise within minutes, or you could order food from a restaurant in another state.  If you need a cough suppressant in the middle of the night, you wouldn't need to trudge to a store.  If you're an ER doc needing an antivenin, it could be rapidly shipped from a regional distribution center.  If you're a manufacturer, your production line wouldn't grind to a halt if you ran out of microchips.  If someone were breaking into your home, you could dial 911 and the police could send over a small robot (a policebot?) capable of halting any attacker.  Or if your husband was dying from a heart attack and the nearest ambulance was 30 minutes away, the 911 center could dispatch a team of "EMSbots" to code your husband.  These aren't pipe dreams; I could whip up the policebot in a few weeks and the EMSbots in a few months.  Granted, the infrastructure that would deliver these saviors is not currently in place, but as an interim measure, a drone could drop them in your yard.

Although deep thought is vital for enhancing brainpower, in my opinion there are some adjuncts that enhance its effectiveness.  One of these things is poverty.  Not the degree of poverty that results in starvation and death (but that's essentially nonexistent in the United States), but a state of relative deprivation that fuels your desire to succeed and provides you with innumerable opportunities to solve the challenges that face you.  For example, when I was a teenager I could not afford to buy the exercise equipment that I wanted, so I made my own . . . and devised better machines than were commercially available.  I also could not afford the latest, greatest commercial mowers, so I took junked mowers and turned them into something that mowed better and faster.

For all the good that money can do, the one indisputably bad thing it does is to truncate the search for a solution to a problem.  If you have the bucks, solving a problem is usually no more difficult than finding someone who provides a solution to it.  This may be convenient, but it stymies your intellectual growth.  If long-term mental expansion means more to you than short-term convenience, don't solve all your problems with your credit card or checkbook.

I endured poverty for years when I grew up.  It never seemed oppressive at the time, even though we were poor enough that I was awed by people with enough money to eat at McDonald's whenever they wished.  That degree of poverty is increasingly nonexistent.  Is that good?  In some ways yes, and in some ways no.  The more things you get, the less inspiration you have.  That's a generalization and not always true, because some people (such as myself) retain the desire to solve our own problems even if we can afford to purchase a ready-made solution.  However, it's human nature to take the easy road.  There aren't many people with platinum credit cards who will spend days, weeks, or months contriving their own solutions when they can whip out their wallet and solve their want or need in a heartbeat.

It's natural for parents to desire to give their children every possible material advantage, but these good intentions often backfire.  I had some wealthy friends in my childhood, such as one fellow, Jim, whose father was a vice-president at GM.  I used to envy the things my friend had:  a luxury car in high school, his own credit card, a beautiful home on a lake, a couple of boats, a motorcycle, a snowmobile, neat toys, nice clothes, and on and on.  I stopped envying his freebies when I realized how they dissipated his gumption, or gut-level desire to succeed.  Jim was just as smart as I was, and his dreams were just as grand, but he was forced to drop one dream after another when he realized that he couldn't hack the demands entailed by those careers.  Success requires hard work in addition to intelligence.  Jim had the intelligence, but not the inspiration to endure a long period of hard work.  Had he been poor or simply not given so much, I think he would have achieved more on his own.

Another impetus for success is sexual sublimation, in particular the postponement of sexual activity with a partner.  I realize that I may come across as an old fogy for espousing abstinence, but I think that unmet sexual desire can be channeled into a tremendously powerful stimulus for success.  Let me be frank:  if your parents shower you with material possessions and your girlfriend fulfills all your sexual needs, what motivation do you have for the future?  At best, you can hope to replicate your current state of having every wish satisfied.  However, the desire to maintain the status quo is not as intense as the desire to obtain something you've always wanted but never had.  Our brains are intrinsically wired to prefer novel experiences, not the same ol' stuff.  Shooting for a target you already have is a great way to disincentify that pursuit.

I'm inclined to find the silver lining in every cloud.  If you can similarly appreciate that there is a positive aspect to many misfortunes, you may be more receptive to my next topic.  One of the most universal human desires is to find the perfect partner as soon as possible.  We don't want to wait until we're senior citizens to find true love, we want it now — even if "now" is age 14.  I've seen kids that age attempt suicide because they were so heartbroken over the end of a relationship with a person whom they thought was the perfect one.  Years ago, I had a patient of that age who was exceptionally attractive and physically precocious, but for reasons I cannot fathom, she had no conception of her appearance and believed that no other man would want her.  She told me that she tried killing herself because the thought of living without a boyfriend was too much to bear, and with her poor self-image, she was convinced that she was destined to live her life alone.  That was too much for me to bear, so I canned the pat responses that doctors often give and had a frank discussion with her.  I told her that she was so ravishing that virtually any male would find her attractive, so finding a new boyfriend would be easy.  She was more than skeptical, so I went to Plan B.  I generally eschew pumping up the egos of women who are tens, but in this case I wanted to do everything possible to avert the tragedy of another suicide attempt — which in my mind would make as much sense as Bill Gates killing himself because he didn't have enough money.  Hence, I crafted a solution to her problem that didn't meet the standards of staid propriety that often constrain physician recommendations, but yet was powerful enough to inculcate my message that she was no dog destined to become an old maid.  I took her on a walk in the hospital and had her introduce herself to ten teenage males.  After a brief conversation, I told her to mention that she was looking for a boyfriend, and to casually inquire if they knew anyone she might date.  The patient was convinced she would strike out and get not one nibble in ten tries, but the results were hilarious.  After hearing her plea for a boyfriend, each male she approached enthusiastically — even rabidly — said that he'd like to date her.  Their responses were utterly predictable from my standpoint, but a shocking revelation for my patient, who was finally convinced that she could find a boyfriend.  For the first time, I saw her smile.  Another life saved.  Ah, the arduous life of an ER doctor.

OK, enough reminiscing about my medical stories.  That patient is hardly alone.  When I was 16, I considered ventilating my skull with a 20-gauge shotgun when I was distraught over some sappy teenage crisis that is so trivial I can no longer recall what it was, other than the fact that it involved despair over the difficulty of finding a suitable partner.  (Given that I'm still looking, perhaps I should have pulled the trigger!  :-)  Flippancy aside, there is a benefit to not finding a wonderful partner, or at least not finding her right away.  The unfulfilled desire for love and companionship can be sublimated into a more intense yearning for success in other ways.  I channeled this frustration into academic success and a perpetual quest to enhance my creativity and brainpower.  Had my needs been fully contented years ago, I'm sure I would have achieved less.

Update:  I recently read two articles that pertain to the above discussion on enhancing brainpower.  I will synopsize these articles, then discuss the implications.

• As reported in the September 26, 2003 issue of Science, Professor Terrence Sejnowski from the Salk Institute and Professor Simon Laughlin of the University of Cambridge are generating a new paradigm for how the brain operates.  The old view was that the brain is a fixed network of bewildering complexity.  Professors Sejnowski and Laughlin theorize that the brain is a dynamic network that changes to adapt to new demands and needs.
• The September, 2003 issue of the Journal of Personality and Social Psychology contained an article by Professor Jordan Peterson from the University of Toronto and Shelley Carson and Daniel Higgins from Harvard University in which they discussed their discovery of one of the biological bases of creativity.  They found that creative people are more cognizant of environmental stimuli.  Most people usually filter out information or stimuli that they think is inconsequential "old news" by subconsciously using a process termed latent inhibition.  Generally, ignoring irrelevant stimuli and focusing on relevant ones is a good thing because we are all bombarded with countless stimuli that are usually unrelated to the matter at hand.  However, this selectivity can suppress stimuli that may be useful in a new context. In the article, entitled "Decreased Latent Inhibition Is Associated With Increased Creative Achievement in High-Functioning Individuals," the authors said that when previously irrelevant stimuli are not screened out, this might contribute to original thinking, especially in people with high IQs.  Such individuals exhibit more creativity, openness, imagination, intellectual curiosity, unconventional attitudes, flexible and divergent thinking, and less rigidity of mental categories.  Perhaps not surprisingly, these people tend to be productive high achievers.  Previously, reduced latent inhibition was associated with a propensity toward schizophrenia, especially when coupled with low IQ.  However, in certain personality configurations, reduced latent inhibition is now known to impart cognitive advantages that magnify the potential of high IQ.  A person with normal levels of latent inhibition tends to classify objects and forget about the ones they deem to be unworthy of further attention, thinking that they are irrelevant to survival or the attainment of a particular goal.  This helps people with normal IQs avoid being sidetracked by overwhelming their ability to process many simultaneous thoughts.  However, a person with reduced latent inhibition, good working memory, and high IQ can think about many things at once.  This enables them to take information that seems irrelevant to ordinary people and synthesize new ideas.  This is the crux of advanced creativity.

The work of Sejnowski and Laughlin explains why someone like me (an erstwhile dunce) can metamorphose into an intelligent person, given a sufficient demand that "strains the brain" (to use my old terminology).  The current educational system is laughable in terms of its ability to really stimulate people.  Far too many courses involve nothing more complex than "monkey see, monkey do."  This game is too simple to spark marked improvements in intelligence and creativity.

Step 1:  The teacher presents a fact.
Step 2:  You echo this fact on a test.
Step 3:  Repeat from step 1.

The repetition of this process does not compensate for the fact that it is not inherently challenging, but this is the foundation of most educational systems — and it is why most of them are abject failures in terms of being able to produce marked improvements in brainpower.  Take a slow kid and give him traditional education, and he's still slow.  Take an average kid, repeat the process, and you typically have a graduate with average intelligence.  Take a smart kid, educate him, and he usually isn't any smarter . . . just more knowledgeable.  Why can't educators improve IQ?  Is it immutable?  No!  The brain can respond and essentially rewire or reprogram itself, if it is challenged in the right way.  Memorization fosters creativity by providing a larger set of facts that can be combined in novel ways, but building a larger database will not automatically enhance creativity.  I am obviously not opposed to memorization, but teachers give scant attention to something that is equally important:  the process of thinking.  If computer engineers made the same mistake, they'd focus their attention on the memory chips and ignore the CPU.  It's the CPU that is the processing "brain" of the computer.  If you want a "smarter," more capable computer, you need to focus on the CPU, too.  However, teachers figuratively zero in on the memory chips, thinking that sufficient stimulation of them will somehow improve the CPU.  Wrong.  No gold stars for this uninspired stagnation of education.  And we're paying several hundred billion dollars per year for this?

Creativity is not given sufficient emphasis in education.  I think that educators view creativity as an unnecessary embellishment — sort of an icing on the cake that might benefit students in "soft" subjects like art, but not in "serious" classes in science and math.  Nothing could be further from the truth.  Once creativity does its magic in augmenting brainpower, that intellectual boost is generalized, improving what we think of as intelligence.

You might ask, "If creativity can amplify IQ, then why aren't more art students as smart as rocket scientists?"  The answer is because not all types of creativity are equally capable of improving intelligence.  You could spend a decade sculpting and painting, and you wouldn't be any more able to rise to the top of your class in medical school.  The creative process can be either a mindless series of whimsical choices, or an intriguing challenge that launches you into protracted deep thought.  It is that arduous thought process, repeated countless times in a variety of situations, that helps rewire the brain.  The hallmark of intelligence is the ability to perform difficult mental tasks.  I am no better at adding two plus two than an average high school dropout.  The differentiating factor is not the ability to do the simple stuff, but the hard stuff.  Since intellectual challenges are an essential component of expanding brainpower, they should be an essential element of education.  Instead, teachers typically show students how to do something, then ask them to replay that process.  Imitating the actions of others is not sufficiently challenging!  Instead of being guided down a well-worn trail, you need to head off into uncharted waters.  Fortunately, the creative process can be easily tailored to provide stimulation that is challenging but not overwhelming.  In other words, don't begin by searching for a cure for cancer.

Improving brainpower requires the proper mix of creativity and traditional learning, which is primarily memorization followed by regurgitation of facts and procedures.  Now that I am discussing this topic, isn't it ironic that while traditional education is focused on memorization, teachers usually ignore techniques that are proven to foster memorization?

I will segue into my next topic by presenting an excerpt from Fascinating Health Secrets:

Besides caffeine, there are several drugs that can potentiate cerebral performance.  The utility of these agents should not be underestimated.  A person's baseline level of intelligence, concentration, memory, association, and creativity can be enhanced by the judicious use of various drugs.  Those who object to the augmentation of cerebral performance are usually blissfully unaware of the role played by this phenomenon in the technological advancement of the world.  Thomas Edison, for example, used cocaine.  Whether or not he could have conceived all of his inventions without cocaine is problematic, but it is likely that he would not have been so creative without it.  As discussed above, neurostimulants like caffeine and cocaine enhance the association of apparently unrelated information, a process central to creativity and invention.  An average person has about as much use for this capability as a housewife does for the muscle-building effect of anabolic steroids.  However, there are people who have jobs in which their performance can be heightened by the use of drugs.  It is indisputable that the performance of a football player, wrestler, or other strength athlete, can be substantially advanced by steroid use.  Society may find this unpalatable, but their moral objections cannot negate the veracity of this benefit.  Similarly, there are people with intellectually demanding occupations (scientists and inventors, for example) who could, with the use of drugs to enhance mental performance, improve their ability to conceive of new solutions to problems.  With such enhancement, they would be more likely to achieve significant breakthroughs, possibly devising a cure for AIDS or cancer, or a solution to the energy problem.  The utility of such advances would be immeasurable, and of perpetual benefit to society.  Yet a scientist caught with cocaine would be stripped of his job, thrown in jail, and mankind would be forever denied the potential fruits of his mind.  The notion that all men are created equal, are equal, and should be treated equal in the eyes of the law sounds good to most people, but it ignores the fact that progress is dependent upon the achievements of a relatively small number of people, and that the latitude bestowed to them is sometimes a prerequisite for the realization of their full potential.  In his day, Edison was one of these people.  So was Nicola Tesla, a contemporary of Edison.  Their collective works are integral to the present and future world, and our debt to them will never be fully repaid.

Enhancing the mental performance of such individuals via the use of cocaine, or more modern alternatives, is justifiable because the potential benefit to society is immeasurable.  The risk, in contrast, is negligible.  The societal danger imposed by Edison's stash of cocaine, relative to that of an urban junkie, is inherently disparate and essentially incomparable in either a moral or functional sense.  Any attempt to view Edison's drug use in the same light as that of a common addict is an execrable simplification.  Society often makes allowances for certain groups of people to engage in behavior that is proscribed for the rest of us.  It tolerates, and even encourages, such behavior because the potential benefit is thought to outweigh the potential risk.  On a mundane level, for example, police officers and ambulances are allowed to speed while driving.  In the end, one must realize that there are risks and benefits associated with all behavior.  Society either encourages or discourages certain activities based upon whether the net good is positive or negative, respectively.  To allow drug use by modern-day Edisons, irrespective of the potential good engendered by the pharmacological enhancement of their creativity, would to most people smack of elitism and favoritism.  Society obviates the need to justify such exceptions by issuing a blanket condemnation of such behavior.

My vehement objection to the universal prohibition of certain neurostimulants is based upon the nefarious and increasingly common tendency for society to ignore the uniqueness of people that are truly unique and capable of great good.  If their achievements could be aided by the use of certain drugs, then society should accept this as being another instance in which the overall benefit overshadows the potential risk.  However, there is an onerous trend in America to intransigently disallow anything that smacks of elitism.  The apparent nobility of such a concept is appreciated only by those who are oblivious to the horrific consequences of uniformity.  The egalitarian concept of bland conformity is a recipe for intellectual stagnation.

Luckily for you, there is no need to use illicit drugs to enhance mental performance.  Today, there are a number of legal drugs that can enhance the workings of the mind.  Most people have no need for them, but scientists, doctors, inventors, students, artists, authors, and engineers can benefit from their use.  Progress is dependent upon the achievements of such people, and anything which enhances their ability will simply accelerate the advancement of the world.  In my mind, that is a benefit which cannot be ignored.

If you research the subject of latent inhibition, you will likely encounter a discussion of drugs that increase it (dopamine receptor antagonists with antipsychotic action, such as haloperidol [Haldol^®]), and drugs that reduce it (amphetamine, nicotine*, and corticosterone**).  I don't advocate using drugs to reduce latent inhibition because there is a better, safer way to tap into your creative potential:  just begin working on creative challenges.  This may sound somewhat circular, but the best way to get better at something is to do it.  The brain is plastic, not fixed.

* By increasing dopamine release in the nucleus accumbens.
** Shalev U, Feldon J, Weiner I.  Latent inhibition is disrupted by acute and repeated administration of corticosterone.  Int. J. Neuropsychopharmacol. 1: 103-113.  Comment:  This makes me wonder if stress might indirectly reduce latent inhibition.

An "entry-level job" as an ER doc?  Sorry, but there are no shortcuts

Q:  (Regarding being an ER doctor) How would a person get an entry-level job in this field?  Thank you very much for your time!  Sincerely, Jill

A:  An entry level job as an ER doctor? Go to college, medical school, do an ER residency, pass your boards, and pay for a medical license. Obviously, an entry-level job in medicine is more difficult to attain than an entry-level job in most other fields.

Should I call my doc at home?  (Seguing into another negation of the "rich doctor" myth)

Q:  (A long story involving multiple doctor visits, trips to the ER, various tests, and ongoing pain.  The question boiled down to the following.)  Should I call and bother the doctor at home?

A:  Yes, I would.  It's clear that you are in distress, and that's why doctors are around:  to help people.  It doesn't matter if it's Sunday, during the day or at night, or when Santa is making his annual trip down the chimney . . . a doctor's responsibility is 24/7, 365 days per year.  In the old days, we used to be paid to accept such responsibility.  Now we must live with the fact that high school dropouts can make more than we do.  For example, a friend of mine told me about his brother-in-law who makes over $250,000 working six months of the year putting in basements — more than I ever made working a full year in the ER.  Incidentally, the basement man effectively made more than that, because many of his jobs were "cash deals" that he never reported to the IRS.

Why is it so risky to be an ER doc?
An illustration of how our tort justice system is reprehensibly unjust

Q:  Why is the practice of emergency medicine so risky from a legal standpoint?  I've heard that obstetricians and neurosurgeons often pay sky-high insurance premiums, but why is the same true of ER?

A:  I will begin by explaining why obstetricians and neurosurgeons face such risk:  because people often possess unreal expectations of perfection, and when docs can't deliver that, a witch-hunt often ensues.  The same is true for ER doctors.  A number of factors conspire to make emergency medicine a risky profession:

• Many people don't know that the science of medicine is not nearly as impressive and complete as it appears to be.  This leads to people thinking that docs can fix 'em up in a jiffy whenever they're sick.  When expectations exceed capabilities, this breeds the potential for disappointment and anger that may engender a lawsuit.

• When people are sick, they want attention now, not three hours from now.  This isn't always possible in an ER, because such places are sometimes filled with dozens and dozens of people who want the same thing.  I've always been amazed by the sudden transformation in behavior when patients complaining about their wait suddenly become understanding when they see us wheel a patient out of the cardiac room or trauma room, and that patient is covered with IVs, breathing tubes, catheters, wires, and beeping monitors.  I've seen their faces melt from a "why aren't you taking care of me?" scowl to a "holy shit, there are patients in here a whole lot worse off than I am" look of surprise.  Hence, I'm not entirely kidding when I say that one way in which ERs could reduce patient complaints is by hiring an actor to play the role of the critical patient, and periodically wheeling that person around whenever patients are livid about their waits.  I don't relish the duplicitous nature of this charade, but it's far more effective than trying to explain the wait to each and every patient.  I used to work in an ER that seemed to be perpetually busy, and at the beginning of my shift at 11 PM there would often be a backlog of patients who'd been waiting since 7 or 8 PM.  When I'd walk in to see them, many were so furious that they'd vent for five minutes.  If twelve patients did that (and this was not uncommon), I'd just wasted an hour, so everyone's care was delayed by yet another hour!

• Patients usually don't know the ER doc, so if something goes wrong — or even if they think it did — they're more likely to sue.

• Knowing that people are so apt to sue, ER docs must be very careful in what they do and how they document it in the medical record.  Unfortunately, this takes time, and delays the care of subsequent patients.  Family doctors can be much more lax about documentation, because they often have a bond of goodwill with their patients that prevents lawsuits.  Some family docs take advantage of this by being far less thorough than ER docs.  For example, I saw the medical record of a patient who saw his family doc for a sore throat.  His chart said, "Sore throat."  That was it for that visit!  That was the history, physical, and diagnosis all rolled into something that's more of a symptom than it is a medical diagnosis.  No treatment was listed.  If I saw a patient in the ER complaining of a sore throat, at a minimum I'd look in his throat, nose, eyes, and ears, then listen to his lungs, heart, and abdomen, palpate his belly, examine his skin, assess his mental status, and then document in his chart everything I found and did not find.  These days, thanks to lawyers, it doesn't suffice to document just the positive findings; we need to go on and on and list all the pertinent negative findings.  I'd also document the tests I performed, the true primary and secondary diagnoses (not some brainless and meaningless "diagnosis" such as "sore throat"), the prescriptions I gave, and the aftercare instructions (e.g., "see your doctor if _______, _______, or _______; return to the ER if you have _______, _______, or _______").  Depending on the patient, thoroughly documenting that would take a page or two of typed, single-spaced notes.  Can you see the potential for a snowball effect developing here?  ER docs must be more careful, so that slows them down, and makes people more angry, and hence more likely to sue.  A family doc doesn't need to worry as much about a lawsuit, so he can do a half-ass job and get away with it.

• Merely being in an ER changes people's expectations of how quickly their evaluation can be completed.  For example, I've had many patients complain about waiting two or three hours for a complex evaluation that involves blood and urine tests, an EKG, a CT scan, an ultrasound, and x-rays.  Sheesh!  A comparable workup directed by a family doc might take weeks and involve the patient running around town for various appointments . . . and, of course, often waiting for each of those tests.  If I could compress that into three hours (all the while taking care of a few dozen other patients), they ought to give me a tip or at least a half-hearted "thank you."  Instead, I've seen patients write complaint letters because a three-hour workup for them or a family member caused them to miss their golf tee-off time!

• Too many people harbor the notion that ER doctors aren't "real doctors."  This was true in the days when emergency rooms were staffed by interns, but times have changed.  As usual, perceptions lag behind.  Thus, people often walk into the ER thinking they're going to see an idiot, so they reflexively assume their care will be substandard.  This increases the likelihood of a suit.

• While ER docs aren't idiots (in fact, they're the cream of the crop, given the competition for ER residency slots), they can't know everything about everything.   I'll never forget one day in medical school when I worked in a dermatologist's office and gave a case presentation to the almighty zit and rash Pooh-Bah.  I rattled off the patient's meds, one of which was Dyazide^®.  Here's how our conversation subsequently went:

Dermatologist:  What's that?
Me:  It's a combination of hydrochlorothiazide and triamterine.
Dermatologist:  What's it used for?
Me:  The patient takes it for hypertension.
Dermatologist:  Hmm, never heard of it before.  Are you sure that's the correct name?
Me:  Yes, it's a very common drug.  I've had hundreds of patients who use it.

This man knew dermatology, but little else.  How he could be oblivious to Dyazide was beyond me.  I wouldn't be surprised if he didn't know which end of an EKG was up, or how to read an x-ray.  Trust him to save your life when your heart stopped?  Heck, you'd be better off summoning a Boy Scout.  In contrast, an ER doc must know how to manage common dermatology problems (e.g., impetigo, cellulitis, hives, diaper rash, contact dermatitis, pityriasis rosea, folliculitis, assorted fungal infections, herpes simplex, herpes zoster, genital herpes, scabies, lice, etc.) and some fairly uncommon ones (e.g., dyshidrotic eczema) in addition to a far more extensive knowledge in a few dozen other medical fields.  We can't just be experts at reading EKGs and unclogging arteries that grew up on Happy Meals and graduated with triple cheeseburgers, we must know how to treat thousands of different problems.  Not only that, but we must do it in a few minutes for patients we've never seen before, some of whom have multiple medical problems, a foot-thick medical chart, and can't speak English.  We have to treat these people at the same time we're treating scores of others, then repeat this process several thousand times per year and hope that we do it with such perfection that the inevitable ticked-off patient won't have any grounds for a suit.  Even then, a doc's worries are not over.  Until the day arrives when physicians can prevent all disease, disability, and death, people are going to have adverse outcomes.  Even when care is perfect, people still suffer and die.  Attorneys sometimes capitalize on this and sue when they know the doctor isn't negligent, simply because they know they can often extort a settlement from the doc's insurance company.  There is an even more nefarious incentive to sue:  plain ol' revenge.  Sometimes an attorney is friends with someone we'll call Bob, and he will agree to sue a doctor who treated Bob even if he knows the doc did nothing wrong.  If the patient is mad at the doc, the attorney can attack just as a favor to Bob.  It's an abuse of power, but people — politicians, judges, police, prosecutors, bureaucrats, building inspectors, you name it — sometimes abuse their power.  So when attorneys do it, it's no surprise.  Even apart from their doctor shakedowns, I think attorneys are often disgustingly unprincipled.  My brother Ray used to work for a company that sold books and software to lawyers, and Ray told me how some attorneys would smugly brag about how they overcharged and otherwise bilked their clients.  Hence the shark appellation.

Speaking of dermatologists . . .

For a moment, consider if the various specialists had to justify their incomes before God or some other authority who cannot be hoodwinked.  Imagine if the following specialists pled their cases:

ER doctor:  "I will treat anyone who walks in the door, even if they're abusive and can't pay me.  I'll work any shift any day of the year, including holidays.  I'll work in a noisy, stressful, and chaotic environment.  I'll put up with some co-workers with obnoxious personalities.  I'll accept the legal risks of practicing emergency medicine, even though I know that lots of patients and most attorneys just want a scapegoat in case something goes wrong, even if that's the fault of the patient or Mother Nature, and not a medical mistake.  I don't care — I just want to help save lives."

Dermatologist:  "I want to help people have better skin, but I'll only treat paying patients who don't cough or sneeze on me.  If they scream or make threats, I'll call the police.  I want to work banker's hours.  Working holidays?  Forget about it!  Furthermore, I want to work in a nice, cushy office with pleasant employees.  If anyone so much as looks at me wrong, I'll fire her.  I want to leave the high-risk cases to the ER doctors and other suckers.  Oh, by the way, I want to make more money than ER doctors."

Viewed in this way, the fact that dermatologists are better paid than ER doctors is unjustifiable and absolutely ludicrous.  So why do they make more money?  Because the government and insurance companies who place a value on physician services think that popping a pimple is more valuable than saving a life.  Nuts, isn't it?

Lately, there's been a lot of discussion about whether the government should cap liability for companies making the smallpox vaccine.  Interestingly, all of these discussions are predicated on one assumption:  that the vaccine company will produce the safest, most technologically advanced vaccine that current technology allows, but yet the relatives of the small minority of patients who die should nevertheless be able to sue and get rich quick.  Why are they justified in suing?  The last estimate I heard was that 37 people receiving the vaccine would die, out of over 250 million vaccinations.  If 99.99999% of people don't die, is the vaccine truly faulty?  Obviously not.  Through no fault of the vaccine manufacturer, some people have weakened immune systems or other factors that predispose them to an adverse reaction.  That's the real culprit — not the vaccine.  If patients are that feeble, they might die in the near future from inhaling dust or some other trivial exposure that most people shrug off with ease.  The only thing that would justify punishing the vaccine manufacturer with a lawsuit is if they made a flawed product that was inferior to what another vaccine manufacturer could make.  If no existing company could do any better, why punish them?  Smallpox is not a trivial disease; without a vaccine, an epidemic could wipe out a significant proportion of our population.  Hence, we should be willing to tolerate more risk in the prophylaxis of smallpox that for less serious diseases.  Viewed in this context, it is a blessing to have a vaccine that protects 99.99999% of us and hastens the demise of only a very small minority of biologically enfeebled people.  So what's the justification for suing the vaccine manufacturer?  The fact that anyone can seriously discuss suing them for making the best smallpox vaccine ever produced underscores just how warped our legal system is — and just how unrealistic people have become with their expectations.

Product liability laws and malpractice laws were intended to punish faulty actions that resulted in harm, not create a lottery system that gives millions to anyone with a bad outcome whether or not that result was attributable to a definable error.  However, in our rush to be a compassionate society that attempts to right every wrong, we've gone too far and created a horrendously unjust system that punishes corporations and doctors even if they didn't screw up.  This is one reason why I urge people to think long and hard before they choose to become a doctor.  Until you've been sued for something that was not your fault, you have no idea how devastating and infuriating this is.  Being charged with a crime that you're not guilty of is one of the most heinous fates that can befall a person.  Even if you're lucky enough to win the suit or have it dismissed, you will still lose:  you'll have a perpetual black mark on your record, it'll cost you money (e.g., for your insurance deductible) and time, and it will subject you to untold hours of anguish.  Attorneys know all this, and they use it to help extort the largest possible settlements from doctors and their insurance companies.  They just want the suit and the threats to go away, so all too often they succumb to even outrageous demands for unwarranted claims.  As I previously mentioned, sooner or later a doctor who is livid about such injustice will "go postal" on the lawyer.  Instead of being a tragedy, I think that day will be a turning point in American justice because it will finally send a message to attorneys that they cannot ride roughshod over innocent people without one of them snapping and turning an attorney into hamburger.  In reality, such an action will likely save lives and improve healthcare.  The drawbacks of being a doctor in this era are so numerous that some of the best and brightest students choose another career.  This forces medical schools to now accept people who once stood no chance of acceptance.  Will these second-rate students become first-rate doctors?  Dream on.  Those second-rate students will become second-rate doctors, and they'll give more second-rate care than will the first-rate docs.  Hence, someone will suffer from this diversion of the cream of the crop.  Will it be you?  Your son or daughter?  Me?

If you're smart enough to see the big picture, you will realize that when attorneys unjustifiably make a medical career more noxious, this is not a victimless action.  It's hurting people, and that is wrong.  Yet the nexus is indirect, so it is often overlooked.  Therefore, don't look for any immediate solution to this problem.  If you want to go ahead and fight the battle, well, be my guest.  Personally, I think battles are best avoided.  That's why I try to deter people from a medical career, and I'm not alone.  Many of my physician friends discourage their children and relatives from pursuing a medical career, because they don't want to see them subjected to such a noxious lifestyle.  My strategy is simple:  deter the deterrable, and help the undeterrable become the best possible doctors.

Do docs always do their best job?
How to increase the chance you'll get a 110% performance rather than a half-ass job

Q:  I am researching how physician attitudes affect the quality of their performance.  In speaking with doctors, I keep hearing the same old rhetoric:  "We're professionals.  Of course we always try our best and give 100% . . . blah, blah, blah."  I'm trying to find a doctor who has the guts to tell me what he really thinks, rather than just reciting the old party line.  It's my contention that a doctor will do a better job if he likes a certain patient.  Judging from your web site, you seem to be a real straight shooter, so I'm hoping you're willing to spout off on this subject.

A:  I am.  Anyone who claims that physicians always give 100% isn't living in the real world.  Unfortunately, cutting corners is now so routine in medicine (and especially emergency medicine) that suboptimal performances have become the norm, leading many docs to think they're doing everything even when they're not.  For example, let's say that a patient sees an ER doc for repair of a cut.  The docs sutures the cut, gives some cursory wound care instructions, and tells the patient when to have the sutures removed.  This would pass as "doing everything" in the minds of most ER docs, but it is far from complete.  Here are a few more things I'd do:

• Assume the doc removing the stitches knows less than I do about wound care, which he probably does.  Hence, while I'd give a recommendation as to when the stitches should come out, I'd explain that suture removal may need to be delayed if healing is slower than expected.  Too many docs think, "You're here for suture removal?  OK, let's yank out your stitches."  Instead, they should assess the wound and determine if removal is warranted then.

• Whenever sutures are removed, too many patients and doctors think that the critical period is over.  In reality, healing is just beginning, and the wound is nowhere near maximum strength.  Hence, I'd advise placing Steri-Strips^® (butterfly bandages) over the wound to reduce the chance of wound disruption and scar widening.  I'd give the patient Steri-Strips^® and instructions on how to apply them, care for them, and remove them.

• I'd discuss various factors that might disrupt the wound or widen the scar.  This discussion would include local pressure, referred pressure or tension, joint position, etc.

• I'd discuss how various factors affect wound healing, including smoking, certain medications, nutrition, and even seemingly esoteric subjects such as hydrostatic forces and venous pressure.

Granted, emergency rooms are often so busy that docs might wonder how I had the time to cover so many subjects.  If I was short on time, I'd begin my lecture while I cleansed the wound and continue it during suturing.

I realize the foregoing does not address your question about how physician attitudes affect performance, but I first wished to illustrate that docs often do not do a complete job even when they think they are.  Now on to the topic of attitudes and performance.

In the ER, I had some truly loathsome patients, including murderers and men who'd raped children.  While I would have liked to test their allergy to hot lead (that is, shoot the bastards), I didn't think it was my role to mete out punishment.  Hence, I'd give them 100%.  But would I give 110%?  Nope.  Of course, I didn't give 110% even for most of the decent patients because there simply wasn't time.  In a busy ER, it isn't a question of whether the doc will need to cut corners, it's a question of who he chooses to shortchange.  Ah yes, another hot potato topic, and one that'll never be covered in a chatty hospital newsletter or hometown newspaper.

Assuming I wasn't rushed, I'd give a 110% performance for everyone, unless the patient was radiating enough bad karma to make me think that a perfunctory 100% performance was good enough.  However, it wasn't often that time was never a consideration.  Now it's time to perk up your ears.  Yes, I had favorites.  Yes, I did a better job for people I liked.  Yes, I'm human.

Here's an example.  I repaired the wounds on countless people whose faces were mangled in car accidents.  Overall, I think I'm better at suturing than an average ER doc, so most of these repairs turned out very well.  However, if I liked someone and the ER wasn't filled to the rafters with patients on their deathbeds, I'd do not just a good job, but a job so superb that even the surgeons were impressed.

In regard to giving better care for patients I liked, I know I'm not alone.  One study showed that docs spent more time with patients who give them a piece of candy at the onset of the visit.  If such a trivial token can make us go the extra 10%, it is no surprise that something which really matters — such as being treated with kindness — can elicit a similar desire to go the extra mile.

Why structured play is inimical to intellectual growth
Television and Attention Deficit Disorder

Q:  I wanted to become a physician, but for various reasons (an unplanned pregnancy, less than stellar grades, etc.) I never accomplished my goal.  I'd like to help my children succeed in medicine or a similarly prestigious profession.  In addition to the tips you've previously enumerated, what can I as a parent do to foster their success?

A:  Don't subject your kids to structured play.  Too many children are now ferried from band practice to soccer practice to yet another organized function.  What do I have against such activities?  They stymie independent thought and intellectual development.  Play is often disparaged as being an aimless pursuit whose principle value is entertainment.  I disagree.  Play has been shown to stimulate intellectual development, but not all play is equally beneficial.  When children are very young, they need adult interaction and guidance to reap optimal benefits from, say, playing with alphabet blocks.  However, by the time kids are in the soccer age group, they don't need to have their play spoon-fed to them.  In fact, structured play at this time hinders their individuation and suppresses creativity, which is an important facet of intelligence.  That brings up another point:  just what is intelligence?  In our culture, intelligent people are recognized by their ability to perform well in school and on tests of intelligence or aptitude, such as the SAT or MCAT exams.  The American Heritage dictionary defines a genius as one who possesses "extraordinary intellectual and creative power."  However, standardized tests and most schools do little to either spur or test for creativity.  That's a shame, because I think creativity is a better measure of true intelligence than the ability to do well in school, which entails little more than mimicking or regurgitating what was taught.  Is this the best measure of intelligence?  Monkey see, monkey do?  Not in my opinion.  It's easier to robotically repeat what you've been taught than it is to conceive of something truly novel.

Some people who have a bone to pick with standardized ways of assessing intelligence harbor their grievance because they didn't score very well.  Hence, their criticism is sometimes dismissed as an attempt to mitigate the import of their shortcomings.  That isn't the impetus behind my criticism of anything that purports to measure IQ but ignores the fact that creativity is one of the cornerstones of intelligence, because I did very well in school and on intelligence/aptitude tests.  Therefore, in my case, it's not sour grapes.  With that in mind, I will continue assailing robotized play.

Structured, regimented activities do an abysmal job of fostering creativity because participation in those activities is often governed by a rigid set of rules and expectations.  Such cookie-cutter regimens do an abysmal job of catalyzing intellectual growth because they do little or nothing to encourage or reward creativity.  One can be an automaton and do very well in those activities.  Our culture gives lip service to championing individualism and creativity, but it is really a fairly repressive intellectual climate that champions an increasing narrow range of behavior and thought.  The collateral damage from this enforced uniformity affects individuals and society as a whole.  When was the last time that our society gave birth to an Einstein or Edison?  It's been far too long.  Had Edison's mother monopolized his time by ferrying him from one organized activity to another, it's quite likely that he would not have grown into the multifaceted inventor that he became.

Another tip.  As much as possible, keep your kids away from the television unless the programs they watch are truly educational.  Most aren't.  Furthermore, it wouldn't surprise me if television is eventually implicated as contributing to Attention Deficit Disorder.  Look at how rapidly scenes change on television.  For TV shows, a scene change every few seconds is common; for commercials, scenes change sometimes a few times per second.  In real life, things don't flit by so rapidly, so its glacial pace may seem boring.  In reality, it's life that is exciting, and television that is boring.  Take away the adornments that make television seem palatable — beautiful people, exotic situations, racy language, clever quips, lots of money, and a dearth of morals — and what do you have?  Not much.  Certainly not enough to justify the enormous number of hours people spend watching TV.

Want to be smarter?  Start inventing

Q:  I'm a high school junior interested in expanding my intelligence.  I haven't settled on a career goal, but whether I choose medicine or another career, being smarter will help me achieve my dreams.  Hence, I'm writing to ask if you can give me more tips on this subject.  I read all the tips you gave on the various pages of your web site, but I wondered if you have even more.  Thanks, Jenny

A:  Yes, I do.  Here is one recommendation:  read the four-volume set Ingenious Mechanisms for Designers and Inventors.  Or, if you don't read it, at least look at its pictures — like men do with Playboy.  Why should anyone who isn't a designer, inventor, or engineer read these books?  Because the ability to invent, make, and use tools is one of the foundations of human intelligence.  Many people are adept at using tools, but the facet of intelligence involved in creating them is sadly neglected by most.  If you wish to maximize your intelligence, you should stimulate your brain as much as possible in as many ways as possible — not totally neglect something that is one of the hallmarks of human intellectual superiority, as most people do with the creative aspects of inventing and making things.  If you think about it, you will realize that one of the most basic elements of intelligence is to take various building blocks (such as objects or words or ideas) and assemble them into something that is greater than the sum of its parts.  The steps involved in this cognitive synthesis don't merely benefit the process of creating tools, because the enhanced neural circuitry confers more global benefits.  For example, when children learn to use a toy hammer, they learn more than just how to use a hammer.  They improve their eye-hand coordination, and they learn the effects of one type of tool.  These skills benefit them in using hammers and manipulating/understanding a number of other things in the future.

Studying mechanical mechanisms is akin to studying the dictionary.  You need to understand words if you wish to use them to construct sentences, and you need to understand mechanical things if you wish to use them as building blocks, too.  Even if your eventual occupation has nothing to do with actually building things, I think the intellectual potentiation is sufficient justification for mechanical tinkering.  So, after you complete those four books, buy an Erector set or a Lego set and build something that you've conceived, not something for which you're just following directions.  If you feel adventurous, buy a metal lathe and milling machine and turn some nondescript hunks of steel, aluminum, or plastic into something truly unique and useful.  Or learn how to make electronic circuits, and create a circuit that solves a problem for you.  For example, a couple decades ago I built a circuit to automatically compensate for road noise near my home, which was too close to a major road frequented by loud gravel trucks that would drown out the TV sound.  When a truck or another noise source approached, the circuit I made would automatically ramp the TV sound upward.  When the noise source retreated, the TV volume would proportionately taper down.

Many people make the mistake of assuming that the world is already so complex and so advanced that they'd have no chance of conceiving anything unique.  I disagree.  You're probably far more creative than you ever imagined.  If you exercise your creativity, it may blossom into something that will surprise you.  Your creation need not be stuffed with microchips for it to be significant.  Do you think all the basic things (wheels, paper clips, etc.) are perfected?  No way!  A few weeks ago I sat down and thought about the shortcomings of current wheels/tires for a specific application I had in mind.  I did what I usually do while working on a project:  come up with some ideas, write them down, and go on to something else.  In time, alternative ways of achieving this goal will pop into my mind, and in the case of the wheel/tire idea, it didn't take long.  Within two days I thought of a wheel/tire that is totally unlike anything I've seen before.  I'm not talking about minor refinements such as a new tread or cord design (that's engineering, not inventing), I'm talking about totally re-thinking the whole concept of a wheel/tire.  I spent a few days scouring the Internet and performing patent searches to check for the existence of a similar creation, but found nothing remotely similar.  The basics of wheels seemed to have been perfected by an unknown caveman eons ago.  A wheel, an axle, that's it.  Subsequent developments have been nothing more than refinement.  Until now.  Frankly, before I took this task on, even I would have guessed that creating a wholly new type of wheel was a pipe dream.  Thank God I've never stopped dreaming.  Nor should you.  Too many people let others do their dreaming for them.  In the process, they allow their neural circuits that govern creation to wither away.  That's a recipe for intellectual stagnation, not growth.  If you want to expand your mind, you must stimulate it in every way possible.  You've heard the slogan, "Milk.  It does a body good."  I have a new one.  "Invent.  It does a mind good."

Still more ER questions Part 1

Still more ER questions Part 2

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