Bar exams moved online during the pandemic, fueling attention to issues under discussion, such as widely varying bar pass rates from state to state, and large costs to graduates of prep courses needed even after three years of law school.
Law school administrators and members of the profession wrung their hands: Are we really turning out so many graduates incompetent to practice law?
Some modest reforms are under way. There’s a next generation bar exam on the horizon that diverges a bit from the old style. But a lot of state bars are still just thinking about it, and bar exam modifications continue to be (rightfully) criticized.
And in the midst of this debate, along came ChatGPT—never a law student—and passed the bar exam. Academia is in turmoil over the significant potential for AI-assisted papers and exams.
Out of the chaos sown by these developments, might we possibly reap a whole new perspective on how to train lawyers? It is, after all, overdue to reform legal education, which has changed only marginally for many decades.
Of course law students still need to learn legal doctrine, and how to find and understand case law, statutes, and regulations. And clinical legal education, which is now often a graduation requirement, has been a valuable addition to legal education.
But should law school consume three mostly-classroom years and then be followed by a bar exam that requires lots of memorization and lightning-fast essay and multiple-choice responses that don’t reveal the kind of in-depth thinking attorneys are called on to do? Especially considering the great expense in time and money for law school and then bar prep?
What should we be teaching and then, if not testing, evaluating? A long and well-researched report from 2020, “Building a Better Bar: The Twelve Building Blocks of Minimum Competence,” suggests a helpful framework to answer that question.
Most critically it focuses much attention on what we in the legal academy have mostly failed to teach: the genuine practice of law. It’s about time we do so.
Consider medical education. It begins with two years immersed in the textual, classroom, and lab study of subjects necessary to the practice of medicine. Then students progress to two years learning the clinical—the actual—practice of medicine, even before years of post-graduate residency training. And some medical schools are even introducing clinical practice into those first two years.
What would “medical model” legal education look like?
Lawyers for America, invented at UC Hastings (now UC Law San Francisco), is a model that provides students with a different route to learning to be a lawyer while simultaneously helping to Strengthen our country’s massive access to justice problem.
Ponder: Two years of classroom learning and a third year devoted entirely to a well-supervised externship with a legal nonprofit or government legal office. Given the current bar exam, summer is then devoted to study and the test, and then after the bar exam the fellows return for a full year of fellowship-paid work.
The participating organizations pay LFA enough to support the fellowship stipends—less than their cost of hiring a new lawyer, enabling the stretching of their always tight budgets. Bonus: They’ve already trained their new fellow for all of their 3L year. Supervisors are very committed to their training because fellows will soon be their colleagues for a year.
Our fellows so far have engaged in great public service through the program and have moved very successfully to careers. Many of the fellows have stayed in public interest or public service careers, some clearly achieving positions that just on the basis of grades and pedigree could have been difficult to obtain. Their excellent experience—and thus meaningful recommendations—has propelled them forward.
Can we do more to make law school-affiliated hands-on experiences not only necessary but sufficient for licensure as a lawyer? Or at least sufficient along with passage of a much-simplified written exam, perhaps focusing on a limited number of subjects chosen by each examinee from a larger selection, and with dramatically reduced emphasis on speed and memorization?
Alas, change comes hard both to legal educators and to bar examiners. We started LFA after a dean told us we should ask for forgiveness rather than permission, or the idea might never have moved forward. Other law schools have considered joining us and hit various barriers.
For their part, bar examiners have put together committees to recommend change, but things move slowly—if at all. A California Blue Ribbon Commission spent about two years and still couldn’t reach consensus on a non-bar-exam route to licensure. A subgroup of that commission has just prepared a lengthy draft urging a “portfolio bar examination” in hopes of obtaining full commission approval.
For a good starting point to consider change, law school administrators should look to the medical school model and take to heart the feedback in the “Building a Better Bar” report about the value of experiential learning in the careers of many law graduates.
We need to train lawyers for the needs of today, under the conditions of today’s world. Yesterday’s ways shouldn’t be forever.
This article does not necessarily reflect the opinion of Bloomberg Industry Group, Inc., the publisher of Bloomberg Law and Bloomberg Tax, or its owners.
Marsha Cohen is a professor at UC Law SF. She taught podium classes and for many years supervised an extensive Judicial Externship Program which fueled her interest in “medical-model” legal education, on which Lawyers for America was built.
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When testing was simple, the inefficiencies involved in having independent testing efforts distributed throughout a company were acceptable, although not optimal. Today, these costs are less acceptable. The product-testing needs of various parts of a medical device company have always differed, and the increased sophistication of today's products amplifies those differences. Understanding such differences, along with the commonalities underlying all testing needs, is an important first step toward a different approach to product testing.
Developing an understanding of the drivers of product testing during R&D, manufacturing, and service phases opens the opportunity to extract lessons from the systems-thinking approach taken in the development of complex products. Testing relatively low-volume, high-complexity products from a top-down, system-level view is a paradigm shift for most companies. However, viewing overall product testing this way is a more complete, consistent, and cost-effective approach.
This article examines the fundamentals of a systems-based approach to the testing process. It identifies the benefits of a system-level testing model in medical products that have moved up the technical sophistication curve. The examples outline real-world challenges, demonstrating both the complexity of the problems and benefits that may be derived by adopting a systematic view of the test process.
Systems Thinking Applied to Medical Device Testing
Systems thinking entails taking a system-level view of the project under study, or more specifically, a top-down deconstruction of the product or process. In our experience, the range of R&D spending that the medical device industry typically allocates to testing is between 30 and 50%. Manufacturing has its own subassembly and system-level testing. Service group testing in the field or in the factory is used to verify product operation in the event of a field failure or to preemptively verify that no service is required. By any measure, that is a lot of testing. Central to much of this testing is the development of test software: board tests, component diagnostics, and functional and system tests. It is important to address whether the testing is comprehensive or overlapping and whether isolated parts of the company are developing the same tests for different users.
Traditionally, each department develops its own test capabilities, focusing on specific areas of responsibility. The enormous investment in engineering test specifications, procedures, and automation is often not leveraged by other parts of the company. The test applications may be manual or too complex for manufacturing staff to use. The tests most likely have been developed to look for specific design failures that are not deemed meaningful at the production stage. Or they may be too slow to be economical in the volume testing of manufacturing.
By the same token, manufacturing test capabilities do not address the challenges of product testing in the field. Manufacturing tests are optimized to quickly cull out improperly operating product. They are not designed to identify the source of the failure. In addition, the size of the manufacturing test equipment, or the trade-off between test speed versus flexibility, may also render the investment in subassembly testing useless to the rest of the organization.
Service test facilities are typically the last—and most sporadically—developed. It can take years to develop service test capabilities for high-end products such as imaging systems and clinical chemistry systems, which contain a large number of complex subsystems. In contrast, low-complexity products may have little or no support from a diagnostic perspective.
A system-level approach to testing in this environment would start with a composite view of what types of testing are required to fully evaluate a design, verify an integrated product, and diagnose component failure. If the test process is part of an integrated system that contains different users (use contexts) and different organizational needs (drivers), it may be useful to think of it as analogous to a complex system design. These different use contexts (e.g., R&D's need for depth and flexibility focused on verifying design and completeness compared with manufacturing's need for coverage and speed with a focus on pass-fail) drive the tests needed to support different parts of the organization. And there may be other use contexts, such as integrated diagnostics that the end-user may access, that require simplicity of operation and communication of steps to diagnose a problem. Built-in tests can verify product performance integrity upon start-up.
Although at first these use contexts may seem mutually incompatible, after synthesis into an integrated system, it is possible to find areas of commonality across these different contexts. An overall test approach allows definition and creation of test modules that are usable in different test contexts. Tests may include board tests from R&D that provide the basic functionality for subassembly test or software unit tests that provide the basic diagnostics required by service. Once the concept of a testing system is constituted, any core testing capability may be defined with modularity and interoperability. This allows interdepartmental leverage of test components in much the same way that it is possible to drop an Excel spreadsheet into a Word document.
There is a limit to how integrated the test system can be. However, there can be tremendous leverage across development, manufacturing, and service test systems. To see this in practice, look at a simplified example of a moderately technically complex product. The product comprises several control boards, each with control logic and a programmable gate array (a semiconductor device that allows for hardware function to be put into a design without use of conventional software). The boards are integrated into a product that has a control application running on a conventional PC platform.
In a traditional test environment (see Figure 1), the electrical group of R&D would develop test protocols to verify the board logic. A separate effort would be focused on verifying the gate-array design to ensure that the board behaved in the proper predictable manner. The software group would develop its control and application code, hopefully developing unit tests to verify various control modules, with special effort focused on verifying software-hardware interaction. The software quality engineering group would look at the system requirements and develop tests to verify the software design. In many cases, this test represents the overall system test of how the software and hardware behave when integrated.Assuming that the product passes these tests, the product would be released to manufacturing. The manufacturing test group would have been developing its own tests, focused initially on individual boards as they come out of subassembly test (or incoming inspection if assembly is outsourced). The product would then be integrated and the manufacturing test group would run a test suite that verifies product operation as a final test before shipping. Depending on product volume and complexity, final testing may only take a few minutes or may last several hours or days. The service group is the last group to address any problems with the test. Upon release, there are often only rudimentary test capabilities—typically manual tests requiring technical skills. Over time and continuous product releases, a suite of tests is accumulated, sometimes with correlated data to aid in the diagnosis of a problem.
A systems approach to product testing would be fundamentally different, requiring a strong understanding of the interrelated nature of product tests. As illustrated in Figure 2, a system-level view of all significant test needs is assembled. Core elements of testing revolve around hardware testing and diagnosis and system functional testing. As shown in Figure 2, both R&D and service may need low-level, flexible access to hardware diagnostics. The software organization and subassembly test groups may need to verify the operation of embedded software and board electronics.As product configuration changes over time, an encapsulated-board test approach isolates both the automated regression testing required by R&D and the automated final test in manufacturing. It may also be beneficial to tie service diagnostics to data collected in subassembly or final test in manufacturing. A systems approach to this problem allows similar test needs to be addressed by reusable components. A software module that is developed to implement a full hardware design test can easily be used as part of a service application tasked with looking for failed components. Modules developed as part of an automated regression test may provide the basis of a final product test. A module developed to verify a gate-array design could be applied to a subassembly test to verify board operation.
There are environments in which reuse across departments will be limited. For example, in high-volume production environments that use automated test systems (ATEs), reuse may be limited due to differences in run-time environments between development and the ATEs. Even with this limitation, reuse of test documentation and designs, standardized failure-mode terminology, and common test data formats have small beneficial results. And, in nearly all cases, there can be direct reuse of R&D test modules within a service diagnostic application, accelerating the process of developing sophisticated failure analytics.
Approaching Testing from the Systems Perspective
After identifying the potential contexts of testing, the overall system must be evaluated for areas of commonality and variability. Tables I and II show a typical, but not exhaustive, list of these characteristics. Looking at these tables, it is clear that there is significant commonality in the testing needs of the various parts of the organization. In most cases, manufacturing needs faster, easier-to-use implementations of R&D tests. These manufacturing tests are similar to the black-box tests developed by R&D, in which all functional subsystems and interconnects are verified. In fact, the low-level test primitives often can be identical, but their assembly and the interaction between them must be different.The reason for the different interaction is that despite the similarity in test functions, the various groups have widely varying goals. R&D wants detailed system access for verifying module designs. Service needs identification to a field-replaceable unit. Manufacturing needs to rapidly identify failed components and identify either a vendor problem or one in the production or manufacturing process. These differences can be explained using the example of a board-test application. In R&D, board-test applications are highly interactive, allowing the engineering staff to individually access specific elements on the board, namely the activating signals, and read outputs. Each low-level component of the board must be individually accessible in order to verify board functions.
In service, the interactions may be similar but the application typically guides the technician to perform specific tests in a specific sequence as the diagnostic process progresses. The goal is to systematically evaluate board operation looking for a board-level failure. The manufacturing test application, while performing all the low-level functions available in R&D, must perform the test in an automated fashion with a rapid test result. All of the complexity of the component test is hidden below the application interface.
The Benefits of a Systems Approach to Device Test Tools
Identifying the opportunity to use a systems approach to testing is the first step. Designing a test system and process that accommodate reuse of common test assets requires the use of system analysis methodologies. It also requires a strong understanding of how to design system architecture. Although a detailed discussion of system architecture is beyond the scope of this article, key characteristics of the approach are worth mentioning.
Tables I and II provide simplified views of the areas of overlap and the differences between the various use contexts. In addition to this analysis, a more detailed understanding of the system drivers and complexity drivers of these different contexts must also be developed. In essence, system drivers are characteristics required to make the system useful to the user, and complexity drivers represent characteristics of the system that make it difficult to create. Tables III and IV list examples of these drivers. The similarities among the requirements of the various contexts and the differences between their system and complexity drivers are strong indicators of a product-line approach to the system. Over the past decade, there have been advances in how to design product-line architectures and the development of a strong academic underpinning for the objective evaluation of various architectures for specific business and system drivers.1,2 Using these formalized methodologies leads to the development of an architecture that accommodates having different parts of the organization, to design of test components that maximize reuse in support of different user goals.The identified complexity drivers of the various user contexts directly translate to the architectural design of the test platform. These user contexts include flexibility and deep access for R&D, speed and simplicity for production, and interactive directed workflow for field service. Ensuring that early decisions in the development of the test platform support, not preclude, usage modes by other groups guarantees that additional functionality required by those groups can easily be integrated into, or layered onto, the previous test platform framework. Real benefits, in terms of the robustness of the test platform, the cost of development, and the time line for test platform availability, can accrue directly from this approach.
Such platforms can be designed to allow for the integration of new capabilities over time, with these new capabilities designed to be built on existing infrastructure and functionality. Using this approach, the manufacturing test group can quickly understand of the preexisting test support developed by the R&D test group.
The definition of testing primitives that provide the lowest level of system testing (such as the verification of hardware control functions), along with complete technical specifications of how to exercise this functionality, can be provided to the manufacturing test group as a starting point for its test development. The test platform system architecture should specifically address how to augment the test system with additional tests or testing capabilities such as life-cycle tests, automated system tests, advanced diagnostics, or creation of a test database.
The manufacturing group need only add the missing test functionality required to support its specific needs. It is also possible to design the system in a distributed manner so that new capabilities integrated by other groups use the core functionality but do not interfere with or modify the testing environments of other parts of the organization. Additional functionality, such as support for setup of product localization, device serialization, and integration into the enterprise resource planning system, can be plugged into the existing test platform backbone.
Functionality to support product servicing can also be added with the major advantage of much simpler integration to the manufacturing product database. This connection enables more fluid interaction to determine as-built configuration and initial manufacturing test data and results.
Ultimately, it is feasible to design a test system that supports all stages of the product life cycle. It should not exist as a single monolithic application, but as a coordinated, interacting system, with defined interfaces and shared functionality.
Systems Thinking in Test Suites
An example of this integrated testing approach can be seen in a manufacturer of a remote surgical device. The product exhibits the characteristics of a low-volume, high-complexity
medical device. As the capabilities of the device increase with product evolution, the control board design techniques also evolve from discrete integrated circuit devices to field programmable gate arrays (FPGAs). These arrays are programmed to provide a wide variety of hardware functions—a boon to board designers and a bane to board and system testers. The flexibility of an FPGA supports dramatically increased capability in very small packages, but for tests to be effective, it requires a completely different approach to the development of board test functions.
To thoroughly test the control board, a complete understanding of the systems architecture, the interface between the software and hardware, and the various use modes of the control hardware are prerequisites. In essence, much of the software functionality developed in the product must be duplicated in order to test the functionality of the control board.
In order to verify the control board design during the development program, the R&D test engineers developed a full suite of low-level test functions. As expected, these tests Verified each board requirement in each operational mode—a task that entailed years of effort to complete.
When nearing completion of product development, the manufacturing test department initiated its preparation for production tests. The group started by developing subassembly tests to verify the new control boards as they came out of board assembly. However, the group quickly realized that developing tests to verify these boards was a nontrivial task. It was impossible to develop board tests without a complete understanding of how the boards were to be used in the complete control system.
Once this was recognized, an effort was made to leverage the test tools utilized by the development organization. However, those tests had been developed solely from the perspective of requirements-based testing for product development. There were a large number of test tools and manual procedures that met the quality system regulation requirements for R&D testing but were of little value outside of that environment.
The manufacturer decided to develop a test platform that met the requirements of production and field service. Additionally, it decided to support the R&D requirements and ultimately to provide faster development turnaround for product enhancements that were anticipated throughout the product life cycle.
In another example, a manufacturer of a blood glucose meter incorporated production testing into the planning process from the outset. The development of a next-generation device was undertaken several years ago, with the expectation of building a product that would support five to seven years of enhancements. Although the device itself is much simpler than the remote surgical device, the extensive configurability and globalization support considerably drove up the production testing complexity.
At the outset of the development program, the company decided to develop the test platform so that it could follow the device into the manufacturing environment and beyond. The platform was conceptualized to be a test, configure, and verify suite, responsible for verifying hardware and analytical elements of the meter.
To support production, the test platform was also extended to allow for automatic configuration of the device for shipment to various geographical regions. Additionally, the platform could store the initial test results in a centralized database. The integrated test capabilities developed to support R&D were encapsulated to support the production functionality in an automated mode. They were also used in the development of a directed-workflow diagnostic system. This functionality supported problem identification during manufacturing, and was used to service returned product.
The effort to use a systems approach resulted in a single testing system with the ability to perform complete R&D tests, as well as supporting both manufacturing and service.
Conclusion
Properly testing high-complexity medical devices is an increasingly difficult task. The development of manufacturing test tools and platforms is expensive in terms of time, money, and skilled labor resources. With competitive pressures mounting, a streamlined process to facilitate the rapid and cost-effective development of manufacturing and service test tools can make the difference between a successful product launch and one that does not achieve anticipated market penetration or revenue expectations. In addition, costs associated with the potential liability from the launch of an insufficiently tested product into the marketplace make the case for a systematic approach to the testing of safety-critical, software-based products even more compelling.
Changing to that approach takes effort because it requires pulling together siloed organizations. But the benefits are real, and can be very large. Properly conceived and developed, such test platforms can provide exceptional support throughout the life cycle of many products in an integrated product line.
Timothy Bowe is co-CEO of Foliage, a consulting firm in Burlington, MA. He can be reached at 781/993-5500.
1. Timothy Bowe and Charlie Alfred, “Formulating Product Family Architectures: Techniques for Analysis & Strategy” [online], white paper; available from Internet: www.foliage.com/thought-leadership/whitepapers.php.
2. Paul Clements, Rick Kazman, and Mark Klein, Evaluating Software Architectures: Methods and Case Studies, (Boston: Addison Wesley, 2002).
Copyright ©2008 Medical Device & Diagnostic Industry
Kogan loved his atrocious work, especially those of his dead who left at the proper time—old, weary of life, bald, having lost lush growth in armpits and crotches, their well-worn feet knobbly and calloused, their breasts and scrotums sagging. Slowly pulling on his chain-mail gloves, he looked over a petrified body, an unread book, and formed a first superficial impression, evaluating the body according to a gauge known to him alone—whether the dead man had died at his allotted time or had failed to live to the limit set him by nature. Those who lived well beyond that limit he called “the forgotten,” and he was a little panic about himself joining their number. He did not like to dissect children and young women, preferring his reliable and lawful contingent.
Shortly before their divorce, Kogan’s first wife, a gynecologist, said to him a phrase he never forgot: Only a pathological type can choose the profession of pathoanatomist. . . . Women’s foolishness. A pathoanatomist, in Kogan’s mind, was a priest of pure corporeality, the last caretaker of the temple abandoned by the soul. By contrast, his second wife, Ninochka, was a librarian and did not even know the word “autopsy.” And that was wonderful.
A careful autopsy usually took two hours. And during that time he was able to read the history of a life, as doctors read the history of an illness. Beyond the body of a feeble or slightly obese child splayed on a zinc table, his intelligent eye saw all the measles and scarlet fevers, the puberty crisis, the healed broken bones, the small traumas. . . .
In most cases he confirmed the diagnosis of what led to death, but occasionally the open book of the dead body presented unexpected subjects: here was a fifty-year-old man who died of a heart attack but had an undiagnosed last-stage tumor of the digestive tract. Or a famous actor killed in a car accident with blood vessels in such a state that the car accident delivered him from an impending, inevitable stroke. Or a woman suicide with undiagnosed leukemia . . . as if several illnesses competed in a still living body, and it was not always the strongest one that came out victorious.
Kogan was one of the oldest pathoanatomists and long retired, but from time to time he was invited to deal with particularly complicated autopsies and cases needing forensic expertise. This time they called him on Friday, but he had already gone to his summer place and did not want to go back. It was his former student, now the chief physician of a big Moscow hospital, a whole medical town, who asked him to come in on Monday, because the case was especially disturbing, and it would be good if it was Kogan who examined it first, before the investigators arrived.
On the table lay a young man, lean, impeccably built, with yellowish marble skin, a knife wound in the chest, multiple bruises on the facial part of the head, abrasions on the forehead, and broken feet. . . .
The morgue attendant, the old nurse Ivan Trofimovich, came up and lisped something unintelligible. Kogan had become hard of hearing lately and indistinct muttering to the side annoyed him. He grunted, the attendant nodded and turned the body so that part of the dead man’s back could be seen: on both sides of the spine, from the third to fifth ribs, parallel to the dorsal part of the shoulder blades, yawned two strange incisions, which seemed to have been made after death. The attendant again mumbled something indistinct, and Kogan, touching the strange incision, barked:
“Speak louder, Ivan Trofimovich, I don’t hear well. Has anyone touched the body?”
“No, they brought him like this on Friday. . . . I’m surprised myself.”
“All right, we’ll sort it out,” Kogan grunted, looked into the medical report, and shook his head. The patient had been brought to the hospital by an ambulance on Friday at 10:45 P.M. and had died an hour later. The cause of death was most likely the knife wound. . . .
Kogan looked at the laid-out instruments. A complete set: a scalpel, a saw, dissecting knives, a craniotome, a raspator . . . He began, as usual, with the skull.
Two hours later Kogan signed the report on the autopsy. Death had occurred as a result of the knife wound and the subsequent bleeding. The beating and the slight traumas to the head, as well as the crushed feet, could not be the cause of death.
He came home depressed and completely exhausted, having firmly taken a decision—this was the last autopsy of his life. . . . But the two symmetrical cuts on the dead man’s back would not leave his thoughts. His knowledge of human anatomy was perfect, yet it was the first time in sixty years of practice that he had met with anything like those two pockets within these cuts, those elastic bags of unknown purpose.
He was a medical professional with a broad horizon and rational frame of mind, without any metaphysical deviations, but this dead man’s anatomy directed his thoughts toward fantastic novels fashionable in the last century about extraterrestrials, alien visitors, or else toward textbooks in mythology for schoolchildren. . . . He was confused and perplexed.
It was the second day that Marya Akimovna had been sitting on a bench in the garden by the hospital. First she sat by the information window, and, when it closed, she went outside and sat down on the garden bench.
Her son, Vsevolod, Volechka, had gone out on Friday evening for a concert and had not come back. On Saturday morning his friend Misha, a pianist with whom Volya often performed, called and asked whether Vsevolod was home.
“I’m worried, Misha. He didn’t come home, and he didn’t warn me.”
“I’ll come right now,” Misha replied.
An hour after the phone conversation, Misha, his nose disfigured and with a bruise over half his face, arrived at Marya Akimovna’s on Delegatskaya Street.
“Yesterday, after the concert, we walked out. Some guys, also musicians, drove up on three motorcycles, very tough guys. . . . They disliked us intensely. From long ago. First they grabbed Volya, tore the case out of his hands. He reached for the guy, but another one drove his motorcycle over his feet, and he fell down. At that point somebody hit me in the eye, and I fell down, too. I didn’t see what happened next. Passersby must have called an ambulance. Where Nadya and Dasha were I don’t know. I called them in the morning—no one took the phone. . . . We should call now . . . now. . . .”
And Misha began to call around, trying to find out which hospital Volya had been taken to yesterday. Then Marya Akimovna called the churchwarden to tell her that she would not be able to come to the evening prayers, because her son was in the hospital, and that it would be good to invite Kirillovna or Zina to clean up in the evening. The warden was a stern woman, but she was nice, though condescending, to Marya Akimovna, and, having known her from long ago, called her Masha. Everybody except her son and his musician friends was condescending to Marya Akimovna, but she did not even notice.
They arrived at the hospital on Leninsky Prospekt between eleven and twelve. At the reception they were told that Volya had been transferred to the surgery section and that they had to go to the information window. At the information window a young woman with a bun and a bow looked into some papers and said, “Deceased.” At first Marya Akimovna did not understand and asked how she could see her son. . . .
“You can’t. He’s in the morgue. You’ll be able to see him only after the autopsy,” the woman in the window said. “You’ll get his documents in the surgery section.”
Misha, who understood what had happened before Marya Akimovna did, seated her on the bench and burst into tears. Marya Akimovna sat next to him, looked straight ahead, and said nothing.
Her life collapsed, ended, and she realized that she had always known, anticipated, that this was how it would be. The picture of her whole life unfolded before her, from the very beginning. How her mama had died, how she had lived with her father, a stern and silent priest in the village of Novoselovo, how she had gone to school and been the last in her class. Then the village school was closed, and the children were sent to Ples, five miles away, and she could not go so far, because she was very small, weak, often sick, so she stayed home, and her father did not make her go. She stayed home, stoked the stove, cooked soup and kasha, and when she grew up her father’s relative Uncle Osip came from Moscow. The two men talked for a long time—about her, she thought. And in the morning her father said that now she would live in the city, at Uncle Osip’s. Her father left for the North, to Pskov, and became a monk there. Masha had seen him only once since, when Volechka was born. At the time Uncle Osip, whom she had married on paper, because he was old and there was no other way that she could inherit his room, took her and Volechka to the monastery to see her father. Her father did not say a word to them, did not ask anything, but he baptized her little son under the name of Vsevolod, according to the church calendar.
The family returned to Moscow, to Delegatskaya Street, where they lived in their own room in a big communal flat. Masha and Volya were now registered in it. Soon Uncle Osip died. Masha took a job as a cleaning woman at the nursery school. She and Volechka stayed there for three years, and then he was sent to kindergarten. And again she was lucky: there was a vacancy for a cleaning woman, she was accepted, and so it went smoothly later on. All her life she was together with her son, at school and at the Conservatory.
Volechka was an angel, not a child. He did not keep company with hooligans but mostly with girls, both in kindergarten and at school. At the age of ten he made himself a reed pipe. He kept blowing into it, and tender sounds poured out. At school he was a poor student. He never finished his studies. Masha was not angry with him; she herself had not been so good at studies. She could read and write, but she had no use for the one or the other. Whenever she had free time, she knit scarves and jackets. Also sweaters for Volya.
Everything went well: they had their room; her salary, though small, came every month. Volya studied at the Conservatory; they accepted him although he had not studied at a music school. But the professors liked him; they said he had musical talent. Masha was taken as a cleaning woman there, too. She did her work very well—quietly, inconspicuously, cleanliness surrounded her somehow of itself. But Volya did not finish the Conservatory. He could not pass the social subjects—history of the Party, scientific atheism, all sorts of political economy—and he accumulated so many “gaps” that they expelled him. He was immediately called up for the Army, being of draft age. But he did not pass the medical examination—the commission found that he had tuberculosis. Marya Akimovna began to worry. The boy had always been in good health; what had happened? But a priest she knew said, Get him treated, pray, and trust in God. Doctors prescribed pills, he took them, got better. And he went to work in a woodworking shop. He liked it there. The workmen were all handicapped; they carved toys, spoons, bowls. Vsevolod learned to carve well. And he went on playing the flute. He played from scores, and sometimes his own music without a score. Masha loved it when he would stand in his corner, take the flute, and the flute would play now Haydn, now Mozart, now some very simple music Volya had composed himself, only three or four notes, but they were so modulated that it made you now weep, now smile. . . .
It was then that Misha, his former classmate at the Conservatory, who by then had already finished the piano class, came to Vsevolod, and they began to play together; later other musicians joined them, Nadya the violinist and Dasha the cellist. They organized a quartet, began to perform. And Volechka became their head. He composed his own music. His flute kept weeping and smiling, and without him it was not as good. Still, he did not abandon his woodworking, because music did not provide them with any income. There were only unnecessary expenses. They tried recording their music in a studio, but the recording did not sound very good. You could not hear the flute; the other instruments swamped its singing tone, and all the magic disappeared. Yet people came to their concerts. Not so many of them, but those who came kept coming. And brought others like themselves, who found a particular joy in the old-fashioned sounds of the flute trills. This music was as if childlike and transparent.
Masha was the same as ever, only she had aged and become Marya Akimovna, and she now did cleaning not at school, and not at the Conservatory, but at the church on Tverskaya Street. They offered her a job at the candle stand, but she did not want to deal with money, she was not so good at counting, was afraid to make a mistake, or—worse still—she could easily be cheated. And she got along very well with a rag and a bucket.
She knew, she had always known, that her boy was extraordinary, there was not a pennyworth of evil in him, everybody loved him. It was as if he did not see evil, and for a time evil did not look at him. But the girls did look at him, and many of them liked him. They would circle around him for a bit. There were not so many free men in our city, always more women. He never offended any of them, never promised anything, nor did he offer any male attention, and they withdrew from him one after another. . . . Obviously each of them would have liked Vsevolod to marry her. But Marya Akimovna never talked with him about it. . . . It was too bad, of course. Dasha was a nice girl, and Nadya, too. . . .
So Marya Akimovna sat on the bench by the information window, without a single tear, and next to her Misha sat and wept. She was going over her past life and saw clearly that Volya had gone just as he had come, in a miraculous way. She did not know who had made her pregnant, where Volya came from, and did not know where he had gone now. One thing alone was horrible—why was he killed? Who did it? Who had a grudge against him?
Obviously Misha was thinking about the same thing, because he embraced her—she was small, and Misha tall, a head taller—and said, “It’s Volya’s music, it’s all because of the music. They couldn’t stand it, it simply burned them. It’s fiery, his music. Heavenly. . .”
“Yes, yes,” Marya Akimovna nodded. She agreed that the music was heavenly. She tried to recall it, but could not. The music had gone along with him.
The pain was so enormous, astounding—greater than one could imagine. It was all located in the forehead, and he hung on it like a towel on a nail. The pain came to a point. It had a cone shape and was concentrated precisely in this point. There was nothing left in the whole world besides the pain. Then suddenly a tiny shining dot appeared; it seemed to move, spinning slightly and drawing him to itself. The walls of the black cone grew still more black, and it became apparent that they were moving, as if this bright dot made them turn, pulling them into itself. He sensed the pull of this movement. The dot expanded, a sharp ray of light burst from it, and he headed toward it. The pain was with him, but it was also spinning and had ceased to be so tormenting. In this expanding dot the note “la” emerged, and he adjusted himself to it and moved in the direction of the light. The corridor of the darkness spun, pressing him, but also expanded slightly, as if becoming larger, and his movement toward the bright dot was becoming ever more perceptible. He was being pulled there against his will, but his will was also directed there.
“Like a toilsome return home” flashed in his mind. The pressure of the black walls was weakening. He was already almost out into the ever-expanding light. But the pain returned, no longer as a cone piercing his forehead but now in his back—sharp and as if double. And then a powerful force pushed him out of the black tube, the pain in the back flared and went out. With a last effort he spread the big moist wings that had sprouted from his back.
His legs performed light movements as if he were swimming lazily, his arms were spread freely, the lifting power of the wings carried him upward, and he felt that all the dimensions had changed, the habitual grid system had collapsed, and the sound “la” expanded unimaginably, as if absorbing all the nuances of sound as well as all those that did not belong to the auditory span of a human ear. . . . He was higher than the pain, it remained under his feet.
“They think they killed me. But that’s impossible. It’s impossible to kill anybody. Poor wicked children. . . .” And now he saw with his side vision the tips of his new wings, semitransparent and iridescent. They did not have their own color; they reflected the radiance that spread around him, shimmering with pink and green, and it was as easy to work them as to drink or to sing—just a little effort, like walking or swimming. And he swam, enjoying the movement, the gentle wind, and the tingling light.
“But I didn’t fulfill my task. Could I have fulfilled it? I’m not the first one to fail. How many were they, the immaculately born ones? One spoke and wasn’t heard, another wrote and no one understood what he wrote, there was one who sang, and he, too, wasn’t heard. And I played the flute. . . . Where’s my flute? That wretched fellow in the black leather jacket, did he take it? What a pity.” But the flute—he suddenly realized—was there! Tucked into a wide belt that tightly girded his body. He pulled it out. A blockflute, wooden, warm, with seven holes in the front and a thumb hole in the back. He put it to his lips, blew. And it sang in the best of voices.
He was flying in an unfamiliar world, which was becoming familiar moment by moment, like a decal, gleaming under the layer of swelling cheap paper. No, this world is not unfamiliar. We’ve been here, been here. . . . He gave himself entirely to the movement, and to the melody, and to the elusive thought. This unuttered thought called him somewhere. And he floated to where it was sending him. There was no “in the beginning” and “then”—everything was happening simultaneously, and in all its fullness. Ah, time is no more, he realized.
For many years now Kogan had not slept in the bedroom with his wife but had made his bed in the study on a narrow couch. That evening he read for a long time, then wrote a letter to his son, who had lost his mind over some Kabbalistic books. The son lived in Bnei Brak, a little town near Tel Aviv, and old Kogan kept trying to have at least a semblance of contact with him. Then he wrote a letter to his daughter, a professor at an American university. She taught contemporary psychology. From time to time she sent him references to her work, and he read her articles with disgust and with the same feeling of protest his son’s reflections evoked in him. . . . He recalled today’s autopsy. Those mysterious cuts along the shoulder blades were inexplicable; their inexplicability was irritating, it flew in the face of his strict and exact knowledge.
He looked at his watch—it was already past two. He went to the bathroom, took out his dentures, put them in a glass of water, rinsed his mouth, urinated with some difficulty. Lay down and quickly fell asleep. But he soon woke up. Before him stood a hazily bright figure, unrecognizable yet familiar. Kogan stirred toward it, rose a little on his bed. Right, right, this was today’s dead man. No words were pronounced. Only the soft sound, as if from behind the wall, of poor, bright music. A flute. The visitor was inviting Kogan to follow him. And Kogan did. There was not the slightest trace of mysticism in what was happening. A convincing reality. . .
In the morning his wife twice called him to come and have breakfast. He did not come. She went into his study. The dead Kogan lay under a plaid blanket, smiling. ♦
(Translated, from the Russian, by Richard Pevear and Larissa Volokhonsky.)
This is drawn from “The Body of the Soul: Stories.”
CAVITE, Philippines – Sam Jeffrey Tiongco, 22, dreamed of becoming a medical technologist and a doctor, but the journey towards this dream has been a challenge.
He was having a typical day at Saint Louis University (SLU) when his friend showed him the August 2023 Medical Technologists Licensure Examination results.
“That time akala ko inedit niya, kasi ‘yun ‘yung trip ng mga kaibigan ko (At that time I thought it was edited by my friend to prank me),” he said.
“So when he showed me that it was actually the PRC (Professional Regulation Commission) board, I was really shocked, I dropped my pen and then I cried [out] of joy, ” Tiongco added in a mix of English and Filipino.
Tiongco scored 93.30%, placing first among 3,982 passers out of 5,401 examinees. His alma mater Saint Louis University also ranked first among schools with students taking the exam nationwide.
While everyone saw Tiongco fulfill one of his dreams, only few knew how physically and emotionally draining his preparation was towards this result.
“I pressured myself into delivering the best results thinking I could ignore the physical hardship because I was used to sleepless nights anyway, but it wasn’t the case,” said Tiongco in his Facebook post.
Life as a student in SLU
Tiongco moved to Baguio City, where he studied senior high school at SLU Basic Education School. He later enrolled at SLU for his undergraduate degree in medical technology.
“When I was in high school, I fell in love with blood bank, especially blood typing, so I intended to pursue medical technology,” Tiongco shared.
He was an active student leader in SLU. When asked how he managed his time, he said, “Very difficult siya. Actually nung high school hanggang 2nd year college, BS major in org (organizations) talaga ako, hindi ako BS major in medical technology.”
(It was very difficult. From high school until 2nd year college, I was actually a BS major in organizations, not a BS major in medical technology.)
He served as student council executive president when he was in Grade 12. In college, he served as a secretary, secretariat head, and academic committee head at SLU KASAMA.
Despite this, Tiongco, just like every other student, struggled in school. “First year pa lang mahirap na talaga yung subjects, i-te-train ka na talaga nila. Ang hirap ng mga quizzes namin, super (The subjects are already difficult in my first year because the university is training us. The quizzes were super difficult.),” he said.
He also admitted that he barely passed the university’s comprehensive exam. “Sobrang hirap niya to the point na meron din akong line of seven [na grade] (It was very hard, to the point that I received a grade with a line of seven)
Such events would have discouraged other students, but Tiongco did not let it get through him.
“Honestly hindi masama ‘yung feeling ko, at the very least pasado ako. Hindi ko na kailangan ulitin ‘yung process kasi grueling ‘yung process tapos uuliit ka nanaman (Honestly, I did not feel bad, at the very least I passed. I don’t need to repeat the process because the process is grueling for me to only do it once more),” he said.
The setbacks
Studying for the board exam was not child’s play for Tiongco. He even had few people around him doubting him.
“Very contradictory ‘to doon sa [Facebook] post ko, sinabi ko roon na walang nagdoubt sa akin pero meron at meron talaga (It’s very contradictory to my [Facebook] post, I said that no one doubted me but there actually were.), ” he said.
Tiongco admitted experiencing several breakdowns before the board exam. “One month before the board naka-apat or limang breakdowns yata ako. Sinabi ko na hindi ko kaya [pumasa], baka bagsak ako. (A month before the board exam, I think I had four or five breakdowns. I said I can’t pass, I might fail.)”
Tiongco originally intended to take the board exam in March 2023. “Unfortunately, ‘yung TOR namin late na na-release (Unfortunately, my transcript of records was released late),” he said.
“Medyo masakit sa feeling, kasi I had plans for the entire year. Sabi ko nga after ng March magtuturo ako sa mga schools tapos magpapaopera pa ako ng mata ko kasi yung grado ko sobrang taas na,” he said.
(It was a bit painful, because I had plans for the entire year. I planned to teach after March and then I planned to undergo surgery to fix my blurry eyesight.)
But these setbacks did not stop Tiongco from achieving his dream. He started reviewing again from April to August.
“During those times sila [family] ‘yung nagbubuhat sa akin, pagkain [and] everything para makapag-focus ako sa review ko (During those times they supported me, they gave me everything so that I can focus on my review.),” he said.
“Na-postpone ‘yung plan ko pero kailangan tanggapin kasi ‘yun talaga eh, pero at least nagpayoff ‘yung mga desisyon ko,” Tiongco said.
(My plan was postponed but I have to accept it because that’s how it is. At least my decisions paid off.)
Aside from his family, his motivation to make his alma mater proud kept him going throughout the review process.
“I really wanted to deliver for our institution. I wanted to provide the best results that I can,” he said.
And delivered he did. Tiongco is currently a first year medical student at SLU and is on his way to provide back to the people who believed in him. – Allysa Areglo/Rappler.com
Allysa Areglo is a Cavite State University student pursuing a bachelor’s degree in journalism. She is a digital communications intern at Rappler.
More than three decades ago, John E. Sarno, MD, published Healing Back Pain, a popular book that garnered something of a cult following. Looking at his own practice, Sarno, a rehabilitation medicine specialist in New York City, saw that most of his patients with chronic pain did not have evidence of acute injury or degenerative disk disease. Their persistent pain appeared to be independent of any structural damage to the spine. Sarno attributed the pain to what he called tension myoneural syndrome (TMS), or the body’s reaction to suppressed stress and emotional turmoil. Resolving that psychological conflict, Sarno believed, would lead to an improvement in pain.
Dr Ira Rashbaum
Sarno’s theory has met skepticism from the mainstream community, but glowing testimonies from patients who say they benefitted from his strategies fill the internet. Sarno wrote several books on his ideas before his death in 2017. But he published only one peer-reviewed study, a 2003 review in the Archives of Physical Medicine and Rehabilitation co-authored by Ira Rashbaum, MD.
Medscape Medical News spoke recently with Rashbaum, a physiatrist and chief of tension myoneural syndrome at NYU Langone Health, New York City, about TMS and how he manages patients with chronic pain.
This interview has been edited for length and clarity.
Medscape: What is your theory of back pain?
Rashbaum: My null hypothesis is that back pain is not due to psychological issues, so as to not be a biased doctor, I try to accept the null hypothesis or reject the null hypothesis. In most cases chronic back pain is not due to structural etiology. My sense is it's a mind-body issue — the avoidance of feeling strong emotions like anger, rage, sadness, fear, shame, and guilt. Patients can embrace psycho-educational programs and if they don’t get better, we work with a psychotherapist or a or licensed mental health counselor to help work through the patient’s feelings. That's my experience over a number of years.
Medscape: How do you determine if a patient has back pain from a mind-body issue or another cause?
Rashbaum: I do a very careful medical history, including a physical examination and review of any diagnostic studies they’ve undergone. In most situations, there’s not really a medical cause of the back pain. For instance, a lot of asymptomatic individuals have all sorts of horrible findings on medical imaging like CTs and MRIs, and the reverse is also true — many people with negative findings on imaging tests experience significant pain. My job as a diagnostician is to see how much of this is really a mind-body problem or something that stems from structural pathology.
Medscape: How well do your patients react to being told that their back pain is, in a way, "in their head"?
Rashbaum: I have a skewed population. I'm sort of like a guru in mind-body back pain, so the people who come to me are already thinking along those lines. I ask, "What's going on in your life?" Maybe there are job issues, marital issues, health issues, and I'd say that it's certainly possible that stress can be causing this back pain.
Sometimes when I see a patient referred from another physician, I'm a bit hesitant to ask about what's going on in their life. Even earlier today, I'd seen a patient with back pain and I had a sense that they were not really going to be open to a mind-body approach. So I said, do physical therapy.
Medscape: What do you recommend primary care clinicians do with patients with back pain?
Rashbaum: You have to do a proper neurological examination and musculoskeletal examination. It’s a tough situation because doctors in primary care have limited time to take care of patients. It's difficult to have a deeper dive just to kind of see what's going on in their life. But you can recommend useful agents like acetaminophen and muscle relaxants, which are sometimes okay.
Medscape: What sorts of things do you tell patients to say to themselves when they're experiencing pain?
Rashbaum: If the pain is severe, I recommend they take medication — over-the-counter analgesics or a muscle relaxant, if they have them — and take a warm shower or bath. I prefer acetaminophen up to three times per day, if that’s OK with the patient’s primary care physician, over nonsteroidal anti-inflammatory drugs because most pain is non-inflammatory in nature. Once the pain is more manageable, patients should journal about what’s going on in their lives and/or meditate, and try to feel any strong emotions, such as anger, sadness, or fear.
Medscape: What do you say to clinicians who are dismissive of the notion that chronic pain may stem from emotional repression, and that addressing the latter can resolve the former — particularly those who point to a lack of peer-reviewed data for such a link?
Rashbaum: I would tell them they could be looking harder for that evidence. For example, in a patient page from JAMA from April 24, 2013, on low back pain, often the cause of back pain is unknown. There are data in spine surgical journals that patients with psychological issues do worse with spine surgery. And in 2016 JAMA published a study from Cherkin et al which found that among adults with chronic low back pain, treatment with mindfulness-based stress reduction or cognitive behavioral therapy resulted in greater improvement in back pain and functional limitations at 26 weeks compared with usual care.
My feeling is that these psychosocial interventions are easy to try, relatively inexpensive, noninvasive, and, in my experience, often can lead to marked improvements. I believe that, for the vast majority of people with chronic pain, it makes much more sense to start by addressing mind-body issues than turning to that approach as a last resort.
Rashbaum reports no relevant financial relationships.
For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.
The Connecticut Supreme Court ruled “medical malpractice claims” is broad enough to include a mother’s emotional distress damages during an allegedly traumatic birth caused by health care professionals, and waived the state’s sovereign immunity.
Under General Statutes § 4-160(f), the state’s sovereign immunity is waived in qualified medical malpractice lawsuits, which allows the actions to move forward without the authorization from the Claims Commissioner. The General Assembly enacted this statute to prevent case backlog, the opinion said.
Former Chicago-area OB/GYN faces more accusations of misconduct
Shocking allegations of misconduct against a former suburban OB/GYN continue to pile up.
DuPAGE COUNTY, Ill. - Shocking allegations of misconduct against a former suburban OB/GYN continue to pile up.
There are now a total of 53 women who have come forward to file civil lawsuits against Vernon Cannon, who formerly practiced in DuPage County.
Among the allegations are negligence, battery/lack of informed consent during examinations, and inappropriate behavior.
The claims first came to light in January, when a handful of women detailed their disturbing experiences while under the doctor’s care. It led to an investigation by the Illinois Department of Financial & Professional Regulation, which permanently placed Cannon’s license on ‘inactive status’ – revoking his ability to practice.
"We think because of the brave actions of our clients, Dr. Cannon is not practicing medicine any longer, he can’t," said Michael Mertz, partner, Hurley McKenna & Mertz, P.C.
While the former OB/GYN has not been criminally charged in connection to these claims, dozens of women are speaking out in hopes no one else is violated in the same way.
"Looking back and remembering the red flags, it was really disturbing for me," said Amy Fuentes, plaintiff.
Former patients, like Fuentes, are sharing unsettling details about what unfolded behind closed doors – with a doctor they thought they could trust.
"I’d like to point out that Duly Health and Care uses the word ‘trust’ 282 times on its website. We intend to find out why they betrayed that trust for all 53 of our clients," said Evan Smola, partner, Hurley McKenna & Mertz, P.C.
The complaints also allege that DuPage Medical Group, now known as Duly Health and Care, did not properly investigate the doctor's background, claiming if it had, it would have learned that he was arrested in Warrenville and charged with two counts of domestic battery in 2016.
Attorneys for the women claim the medical group chose "profits over patients."
"Being a minor, too, I was scared, I was scared," said Elizabeth Gudella, plaintiff.
In a press conference with their attorneys on Wednesday, two women said that during exams, Cannon commented on their tattoos, then took it a step further.
"He is now undressed showing me his tattoos in this position," said Gudella.
"What medical personnel would be taking off their shirt and showing their patients all their tattoos, where he would unbutton his shirt, take off his lab jacket, and proceeded to show me that he was fully tatted," said Christina Deeke, another plaintiff.
Attorneys for the women say that some of their clients suspect Cannon was intoxicated during appointments.
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"I speak with a lisp and he did have a little slur but I assumed he spoke that way as well. I gave him the benefit of the doubt thinking, ‘no way a doctor would be working in Wheaton under those kind of situations,’" said Vesta Eddings. "Seeing the news in January, I just felt betrayed, I felt worried."
Eddings, who had a high-risk pregnancy, said she now questions the care she received.
In a complaint filed this week, former patient Amy Fuentes explains that in 2020, during the birth of her fourth child, Cannon exhibited concerning behavior.
While in labor, court documents state that Cannon, "stared blankly at a supply cabinet, appearing disoriented and not knowing what to do next."
The complaint goes on to say that Fuentes asked the nurses, "Is he high?"
"He was on-call that night, and I was ready to deliver, and they had to call Dr. Cannon multiple times to come to the room, and when he finally got to the room, his eyelids were really droopy, and he was moving slow," said Fuentes. "Seeing the media coverage in January confirmed some of the thoughts that I was having."
Fuentes’ delivery, according to her attorneys, came after Cannon returned from a leave of absence – one that was sparked by nurses who had raised their own concerns.
"We’ve discovered evidence since [January] that nurses at Northwestern’s Central DuPage Hospital reported to higher-ups at the hospital that they were concerned that Dr. Cannon was intoxicated, and Central DuPage Hospital sent that back to Duly right away and said, ‘you need to deal with this,’ and we think they took too long, they waited two weeks before they pulled him out of service," said Mertz.
Duly Health and Care provided the following statement to FOX 32 Chicago:
Duly takes allegations of physician misconduct extremely seriously, including those that have been raised concerning former DuPage Medical Group (DMG) physician Vernon Cannon. The actions alleged are unacceptable and inconsistent with Duly’s mission to provide outstanding patient care and the ethical standards we expect our physicians to uphold. Duly vehemently denies that it knowingly allowed Dr. Cannon to engage in misconduct, and Dr. Cannon has not had any patient contact at Duly since he departed the practice in 2020.
