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A Doctor’s Penetrating Fear

Question: Does emotion ever come into play in the operating room?

Atul Gawande: You know, I think they -- I think emotions were from the very beginning. Your biggest emotion is fear. I remember that first time I got handed a knife, and you know, the surgeon opposite me had drawn the dotted line where I was to use the knife. And I pressed down on the skin, and half of my thinking was, oh my God, what if I cut too deep? And instead I found that skin is springy, it's tough, it's rubbery, and drawing the knife through that very first time, I didn't go nearly deep enough. I had to cut a couple of times in order just to get through. So fear and learning not to be paralyzed was fundamental to what it was to get good at surgery, grappling with it in ways that you weren't ignoring the fear. I think the worst surgeons are the ones who have no fear, and therefore can become almost cavalier and not learn from inevitable errors. But I've also seen folks who can become paralyzed by the fear and the choices and the proliferating complexities as a case goes on. And all of that fascinated me, and I was trying to get a handle on how do you temper yourself in ways that you can be effective individually? And then later on, as I grasped that there are whole teams involved, it got more and more complicated.

Question: What was your greatest difficulty in becoming a surgeon?

Atul Gawande: You know, I don't know that they were issues that were unique to me personally, but my experience going through surgical training was tempered by an unusual set of experiences. My fifth day of surgical training, the fifth day of July in that first internship year, my son was born. And then 10 days later at home, he went into congestive heart failure. And I was in the operating room, doing -- assisting in my first gall bladder operation, when I got called to -- that my son was in the emergency room at Children's Hospital and I needed to go over. When that happened, I left the operation, walked over still in my scrubs, and walking over the bridge between the Brigham and Women's Hospital, which is an adult hospital, and the Children's Hospital, which was right next door, I felt myself transforming from doctor to father, and arrived in time to see my son failing to breathe, everybody scrambling, and the nurse saying they weren't sure he'd make it. He did pull through. They got him intubated, they got him into an intensive care unit, they slowly figured out what was going on. It was a -- part of the arch of his aorta was missing and needed to be reconstructed. He was in the hospital for two weeks. He left still quite ill. It was two months before he really was on the mend, and during that whole time I got two days off, and then needed to be seeing my patients, and then walking back and forth between the hospital where I was a surgical trainee and the hospital where I was a dad.

And that sense of being in the middle of my training, trying to talk to people about, well, I'll be assisting you in your case today, and then walking over to the other side, seeing one of my own fellow interns come to me and say, I'll be assisting the surgeon in your son's case today -- it was revealing; it gave me a kind of double sense of what it meant to be on both sides of the scalpel. And I think that has pervaded the way in which I've tried to think. What does it mean for us to be good at what we do in medicine? It's also been personal because, growing up in a small town where my parents were local doctors, where everybody knew them, where people would call on the phone and have medical emergencies or minor problems, and trying to sort through it all as a kid picking up the phone, my parents saying, ah, tell them to go to the emergency room -- that sense of seeing it from afar and from up close, the micro and the macro, has been a way that fed into my training and my writing.

Question: What did this experience with your son teach you about medicine?

Atul Gawande: Well, I think that there -- one of the things that surprised me was that there was an art to being not just a doctor that I had to learn, but an art to being a patient. We are in a realm where there is constant awareness of the ways in which we're no longer assumed to be gods. We are fallible in medicine, and I understood that extremely well. My son had his fair share of complications, bleeding that forced them to rush him back into the operating room within an hour after his operation. And yet his heart problem was one that they couldn't repair 15 years before. They used a new procedure on him that still hadn't -- they didn't have all the data on. And as a patient, as a family member of a patient being on the other side, I was trying to grapple with when do you ask for second opinions? When do you push the team? And when do you just back off and say, okay, I understand they're fallible human beings, but the best thing for me now is to trust in them as a team?

And so what I came away with was two things: a sense that our relationship with medicine has changed enormously since the days when we could just believe that everybody was infallible in medicine; and second, that none of this was in our textbooks, none of this was in any of what I was being taught about, that there was a kind of second education going on in the course of my training. And I wanted to identify it and describe it and show what was good about it and show what was not so good, what needed to change.

Imagine the shock of being told for the first time to grab a knife and cut along a dotted line on a patient’s body. Does the fear from this initial incision ever go away? A surgeon and Harvard professor explains why patients should hope not.

The “new normal” paradox: What COVID-19 has revealed about higher education

Higher education faces challenges that are unlike any other industry. What path will ASU, and universities like ASU, take in a post-COVID world?

Photo: Luis Robayo/AFP via Getty Images
Sponsored by Charles Koch Foundation
  • Everywhere you turn, the idea that coronavirus has brought on a "new normal" is present and true. But for higher education, COVID-19 exposes a long list of pernicious old problems more than it presents new problems.
  • It was widely known, yet ignored, that digital instruction must be embraced. When combined with traditional, in-person teaching, it can enhance student learning outcomes at scale.
  • COVID-19 has forced institutions to understand that far too many higher education outcomes are determined by a student's family income, and in the context of COVID-19 this means that lower-income students, first-generation students and students of color will be disproportionately afflicted.
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Giant whale sharks have teeth on their eyeballs

The ocean's largest shark relies on vision more than previously believed.

Photo by Koichi Kamoshida/Getty Images
Surprising Science
  • Japanese researchers discovered that the whale shark has "tiny teeth"—dermal denticles—protecting its eyes from abrasion.
  • They also found the shark is able to retract its eyeball into the eye socket.
  • Their research confirms that this giant fish relies on vision more than previously believed.
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A massive star has mysteriously vanished, confusing astronomers

A gigantic star makes off during an eight-year gap in observations.

Image source: ESO/L. Calçada
Surprising Science
  • The massive star in the Kinsman Dwarf Galaxy seems to have disappeared between 2011 and 2019.
  • It's likely that it erupted, but could it have collapsed into a black hole without a supernova?
  • Maybe it's still there, but much less luminous and/or covered by dust.

A "very massive star" in the Kinman Dwarf galaxy caught the attention of astronomers in the early years of the 2000s: It seemed to be reaching a late-ish chapter in its life story and offered a rare chance to observe the death of a large star in a region low in metallicity. However, by the time scientists had the chance to turn the European Southern Observatory's (ESO) Very Large Telescope (VLT) in Paranal, Chile back around to it in 2019 — it's not a slow-turner, just an in-demand device — it was utterly gone without a trace. But how?

The two leading theories about what happened are that either it's still there, still erupting its way through its death throes, with less luminosity and perhaps obscured by dust, or it just up and collapsed into a black hole without going through a supernova stage. "If true, this would be the first direct detection of such a monster star ending its life in this manner," says Andrew Allan of Trinity College Dublin, Ireland, leader of the observation team whose study is published in Monthly Notices of the Royal Astronomical Society.

So, em...

Between astronomers' last look in 2011 and 2019 is a large enough interval of time for something to happen. Not that 2001 (when it was first observed) or 2019 have much meaning, since we're always watching the past out there and the Kinman Dwarf Galaxy is 75 million light years away. We often think of cosmic events as slow-moving phenomena because so often their follow-on effects are massive and unfold to us over time. But things happen just as fast big as small. The number of things that happened in the first 10 millionth of a trillionth of a trillionth of a trillionth of a second after the Big Bang, for example, is insane.

In any event, the Kinsman Dwarf Galaxy, or PHL 293B, is far way, too far for astronomers to directly observe its stars. Their presence can be inferred from spectroscopic signatures — specifically, PHL 293B between 2001 and 2011 consistently featured strong signatures of hydrogen that indicated the presence of a massive "luminous blue variable" (LBV) star about 2.5 times more brilliant than our Sun. Astronomers suspect that some very large stars may spend their final years as LBVs.

Though LBVs are known to experience radical shifts in spectra and brightness, they reliably leave specific traces that help confirm their ongoing presence. In 2019 the hydrogen signatures, and such traces, were gone. Allan says, "It would be highly unusual for such a massive star to disappear without producing a bright supernova explosion."

The Kinsman Dwarf Galaxy, or PHL 293B, is one of the most metal-poor galaxies known. Explosive, massive, Wolf-Rayet stars are seldom seen in such environments — NASA refers to such stars as those that "live fast, die hard." Red supergiants are also rare to low Z environments. The now-missing star was looked to as a rare opportunity to observe a massive star's late stages in such an environment.

Celestial sleuthing

In August 2019, the team pointed the four eight-meter telescopes of ESO's ESPRESSO array simultaneously toward the LBV's former location: nothing. They also gave the VLT's X-shooter instrument a shot a few months later: also nothing.

Still pursuing the missing star, the scientists acquired access to older data for comparison to what they already felt they knew. "The ESO Science Archive Facility enabled us to find and use data of the same object obtained in 2002 and 2009," says Andrea Mehner, an ESO staff member who worked on the study. "The comparison of the 2002 high-resolution UVES spectra with our observations obtained in 2019 with ESO's newest high-resolution spectrograph ESPRESSO was especially revealing, from both an astronomical and an instrumentation point of view."

Examination of this data suggested that the LBV may have indeed been winding up to a grand final sometime after 2011.

Team member Jose Groh, also of Trinity College, says "We may have detected one of the most massive stars of the local Universe going gently into the night. Our discovery would not have been made without using the powerful ESO 8-meter telescopes, their unique instrumentation, and the prompt access to those capabilities following the recent agreement of Ireland to join ESO."

Combining the 2019 data with contemporaneous Hubble Space Telescope (HST) imagery leaves the authors of the reports with the sense that "the LBV was in an eruptive state at least between 2001 and 2011, which then ended, and may have been followed by a collapse into a massive BH without the production of an SN. This scenario is consistent with the available HST and ground-based photometry."

Or...

A star collapsing into a black hole without a supernova would be a rare event, and that argues against the idea. The paper also notes that we may simply have missed the star's supernova during the eight-year observation gap.

LBVs are known to be highly unstable, so the star dropping to a state of less luminosity or producing a dust cover would be much more in the realm of expected behavior.

Says the paper: "A combination of a slightly reduced luminosity and a thick dusty shell could result in the star being obscured. While the lack of variability between the 2009 and 2019 near-infrared continuum from our X-shooter spectra eliminates the possibility of formation of hot dust (⪆1500 K), mid-infrared observations are necessary to rule out a slowly expanding cooler dust shell."

The authors of the report are pretty confident the star experienced a dramatic eruption after 2011. Beyond that, though:

"Based on our observations and models, we suggest that PHL 293B hosted an LBV with an eruption that ended sometime after 2011. This could have been followed by
(1) a surviving star or
(2) a collapse of the LBV to a BH [black hole] without the production of a bright SN, but possibly with a weak transient."

NASA releases first sounds ever captured on Mars

On Friday, NASA's InSight Mars lander captured and transmitted historic audio from the red planet.

NASA
Surprising Science
  • The audio captured by the lander is of Martian winds blowing at an estimated 10 to 15 mph.
  • It was taken by the InSight Mars lander, which is designed to help scientists learn more about the formation of rocky planets, and possibly discover liquid water on Mars.
  • Microphones are essentially an "extra sense" that scientists can use during experiments on other planets.
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Changing the way we grade students could trigger a wave of innovation

How students apply what they've learned is more important than a letter or number grade.

Future of Learning
  • Schools are places where learning happens, but how much of what students learn there matters? "Almost all of our learning happens through experience and very little of it actually happens in these kinds of organized, contrived, constrained environments," argues Will Richardson, co-founder of The Big Questions Institute and one of the world's leading edupreneurs.
  • There is a shift starting, Richardson says, in terms of how we look at grading and assessments and how they have traditionally dictated students' futures. Consortiums like Mastery.com are pushing back on the idea that what students know can be reflected in numbers and letter grades.
  • One of the crucial steps in changing how things are done is first changing the narratives. Students should be assessed on how they can apply what they've learned, not scored based on what they know.
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