Certainty and Uncertainty in Science

I was one of those medical students who was more impressed by what was wrong with what we were being taught than with what the professors extolled as truth.

This did not apply to static things, like anatomy, but to understanding how disease processes proceeded; it was a relevant mode of learning.


One of the most basic things we were taught was that heart attacks occurred when cholesterol plaque accumulated like rust in the pipes, concentrically layering until the stream of blood which could surge through the cylindrical arteries was so narrowed it simply couldn't keep up with demand downstream from the heart muscle which depended on that vital irrigation.

New York Hospital-Cornell Medical Center

There were problems even then, with this theory. Occlusions seen in arteries occurred a few months after a coronary catherization had shown that same artery to be mostly open.


Clots were found in arteries with not much internal plaquing. It wasn't clear if those clots were simply the result of post mortem changes--pooled blood simply clotting after death.

And always there were those perplexing marathon runners who dropped dead of heart attacks despite their low body weights, low cholesterols and high level of exercise.


Recently, the New York Times ran a piece about CHIP, clonal hematopoiesis of indeterminate potential, which is about stem cells in the bone marrow which carry mutations in the DNA of one or more of three genes (DNMT3A, TET, ASXL1--such memorable names) and what exactly these mutations do to the cells which harbor them is not exactly clear, but these mutated cells accumulate in the bone marrow, living in parts of the marrow "less hospitable" sort of like sickle cells live in a blood stream afflicted with malaria parasites. They survive, although the may cause trouble.


People with these mutations die of heart attacks and strokes at high rates, even if they have normal LDL cholesterol, blood pressure, body weight and even if they exercise.

Van Gogh

These mutations accumulate through life, but they don't seem to happen much before the age of 40, as if these stem cells just fray or pill like an old wool sweater.  Lots of 70 year old people carry these CHIP cells in their marrow; few 40 year olds do.


So now we have a new idea of how heart attacks happen, at least in some people.
Which means all those answers I marked on my medical school exams which were counted as correct and moved me toward my MD degree were wrong. The total cholesterol in the blood was not put there by eating too many eggs; the trouble in the coronary arteries was not caused by high levels of total cholesterol--it was the LDL portion of the total that wound up in the plaques; the plaques were not gradually strangling off blood flow but were gelatinous and would occasionally rupture, attracting clot which occluded blood flow and the plaques themselves may have formed and been vulnerable because of the accumulation of cells with CHIP mutations inside them.

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You may say, what I was taught was not really wrong, just incomplete. I beg to differ. Those professors were very certain of their knowledge.
I was the doubter. There were too many cases which didn't fit their theory.

That's the way science is: constantly changing, a work in progress.
So it is with climate science, climate change. I would not be so sure human activity is warming the planet, but living with uncertainty is the human condition. In the case of climate change you have to ask: If we are wrong and burning fossil fuels  has not harmed the planet, what have we lost by shifting to sun and wind?

Blog Clicks for Jesus

One of the cool and humbling things about the internet and the blogosphere is you can see how many times something you've written got clicked and not just that, but where, if not who, that click came from.

Clicks on the Phantom for the past week

This is not the same as how many different people actually read what you wrote--many clicks may not have resulted in somebody interested enough to read beyond the headline. Some clicks may be the same person coming back later.

But you do get some idea. 
The Phantom, for example, knows he has fewer than 10 steady readers, mostly members of his immediate family who use the stuff to open phone conversations. But it's the 21st century version of the Sunday evening family meal.

There are occasional clickers, and those numbers have sometimes drifted into the hundreds but mostly stay below.
What is really astonishing and inexplicable is the where.  You can see where your clicks are coming from.

For almost a year the greatest number of clicks came from Ukraine and Russia.
For the past six months Ukraine has disappeared and Italy is big. More clicks from Italy than even from the USA. 

Icelandic drama

For a week or two France will emerge as a leader-but that's almost understandable if he's  written something with a French personality or France in the headline.

The Phantom had a good run with Portugal for a while.

Island belonging to Norway

Almost never anyone from Africa. The Phantom guesses he is just not addressing topics of interest to Africans.

The Middle East does very few clicks--apart from the occasional few from Israel. 

Danish journalist

South America may as well not even be on the map, which is actually an accurate reflection of the Phantom's state of mind.
Asia and the subcontinent run hot and cold, but none from China, ever. Japan, occasionally, and Hong Kong.

My friend in Reykjavik 

A regret is the absence of Scandinavian clicks. The Phantom is a devotee of Nordic noir. He has watched every episode of every series on Netflix, Amazon etc set in Norway, Finland, Denmark, Sweden and Iceland. But the love and interest are not reciprocated. The Phantom is a non entity in Scandinavia. sad to say.
On the other hand, the Phantom has to this day never been able to keep those Scandinavian flags straight. They are all variations on the same cross. I think Denmark has a white cross on red, and Sweden a yellow cross on blue, but Norway has red and blue and white and so does Iceland and Finland. It's all very confusing. 

Swedish chess

Perhaps what the Phantom needs is a marketing consultant. Surely, there is someone out there who will try to sell the Phantom on the idea she actually knows why he has no appeal in those northern latitudes. 

Is Pride in Work a Virtue?

What is pride?
There may be many sorts of pride, but I think of pride as a positive emotion which has to do of a transfer of identification from yourself to another or others, to feeling better about yourself because of the virtues you see in others, virtues which may reflect back on you, to make you feel bigger, better or otherwise more praiseworthy than you would have felt alone.
You can feel pride in what you've done on your own, a problem solved, so it is possible to feel silently, inwardly proud, but, for the most part, pride is something you share with others or at least in relationship to others.

Is that too complicated? 
Maybe this is because there are so many different sorts of pride: the pride a father feels seeing his kid score the touchdown; the pride you feel when your team mate scores a wining goal, even if you were not on the field; the (phony) pride a fan feels when "his" team wins the Superbowl--as if he had anything to do with it; the pride you feel when you figure out how what was wrong with the car and you change the spark plugs and it starts right up--you want to tell somebody about it; the pride you feel when your regiment runs up the hill and overwhelms the enemy and bullets have whistled by your head and you've taken a risk with others and triumphed.

Growing up, I felt justifiably proud when I trained for a particular swimming meet and beat somebody I wasn't supposed to beat, when I won a wrestling match. I don't think I would have felt pride had I not also known defeat, known that it was not a given that I would win. 

The big pride sweepstakes culminating the end of childhood was college acceptance--the kids who got into Harvard, Princeton or Yale could be proud. The rest of us might not feel humiliated if we had to settle for Brown, Cornell or Dartmouth, but we weren't proud.

Through college, at the beginning of adulthood, people started to sort themselves out by what they were studying, the steps they were taking toward the future. Some people declared themselves engineers, others pre meds (candidates for medical school) and they set themselves apart from the guys who were just taking philosophy or English lit courses. Engineering, math, science, those were courses you could be proud of, because they entailed competition, struggle and the potential for victory.

As we trudged off the the library, past the frat boys on their porches, drinking beer, playing loud music, throwing balls, we did not respect them and we gained some respect for ourselves, some pride in our own self discipline, in our capacity for suffering. 

In medical school, the first two years, when we were learning anatomy, pathology, histology, there didn't seem to be much to be proud about. We looked at each other and realized we were studying stupid things mostly to keep faculty of microbiology and pharmacology employed. Scoring high or low on some mickey mouse pharm exam didn't enhance or injure your pride.

But when we hit the wards, there was pride. Could you hang in there, holding retractors for an eight hour surgery? Could you stick with that GI bleeder, running up and down the flights to the blood bank and following his numbers on well maintained charts to follow his progress? Could you keep your head when a patient suddenly frothed over in pulmonary edema and remember, step by step what to do to save him?

There was pride in picking up on clues others had missed to figure out what was going wrong. 

White Pride

There was pride in discovering a problem neither the patient nor his other doctors had appreciated.

But medical practice, distinct from surgical practice, has gone in a direction away from pride. 
The surgeon is still, clearly, the captain of the ship. If the surgeon is not good enough, it doesn't matter whether the pump team, the operating room nurses, the recovery room staff, the ICU staff are good--the patient crashes.

For physicians however, pride has vanished in a system of "team" and shift work. There is no ownership of the patient or what happens to him. 

The tasks are broken down for efficiency and cost control:  Just as the assembly line worker puts the wheel on the left front axel and doesn't notice, doesn't care if the windshield is broken or the steering wheel on backwards, the patient who sees the cardiologist might have a melanoma on his back and that is no concern of the heart doctor. 

When I arrived at a new clinic some years ago, I discovered there were no gowns or capes for patients in the exam rooms. "But how do you examine the patients without those?" I asked. The nurse looked at me puzzled. 
"Why would you need to have them get undressed?"
"To listen to their hearts."
"Doctor Jones just listened through their sweaters."
"Did Dr. Jones find many melanomas? And how can you hear wheezing or a soft heart murmur through a sweater?"
Just a shrug from the nurse.
There were complaints from nurses and staff alike when I insisted shoes and socks be removed so we could examine the feet of every diabetic every visit. It was unsanitary to have bare feet on floors. We would have to find a towel for the floor.

Listening to a heart one day I heard what sounded like atrial fibrillation on a patient and I asked the nurse to get an EKG machine. The endocrine clinic did not have one but we borrowed one from the oncology clinic next door. 

Later, one of the younger endocrinologist asked me why I had done the EKG. I told her the patient did not know she had atrial fibrillation and I had to call her primary care doctor and get her seen for that. 
My colleague looked aghast, "But if you do the EKG you have to read it. You could miss something," she said. "Then that's on you."
"Yup," I said,  "But I know how to read an EKG, and that worked out well for the patient."
"Oh," she said. "I would never want that responsibility."
This woman had passed her board exams in internal medicine. Fully certified. 

A dermatologist, a graduate of Duke medical school, who had trained at Harvard in dermatology came to Washington, D.C. to set up a cosmetic dermatology practice with a specialty in laser dermatology. She hired an architect to design a glam office in the West End of DC, down the street from the State Department. She came to me because I had been writing articles about various doctors around Washington for the Washingtonian magazine, people like Tony Fauci who was heading up the effort to identify and then to treat HIV at the National Institutes of Health, and Henry Masur, who actually wrote the first article to identify AIDS for the New England Journal of Medicine and he  worked with Fauci at NIH, and Martin Wolf, a tropical disease specialist who worked with the State Department treating the exotic parasitic diseases brought home to Washington by diplomats, who once got called to the emergency room in the middle of the night and diagnosed bubonic plague in a patient. 

These were doctors I was proud of. 

The dermatologist wanted me to write an article like that about her. She was model thin, had a great blond bob and had the looks of  a starlet on the Tonight show. 

I asked her if I could refer her a patient I had just seen that morning, who had a lesion on his shoulder I thought might be a melanoma. 

"Oh no," she said. "I could biopsy it, of course, but if it came back melanoma, then I'd have to call him with that bad news. That's such a downer, doing stuff like that. No, I'm just not into that."

I never wrote the article about her. Someone else did. She became the dermatologist to the stars, Washington, DC edition. 

I can't say I was proud to know her. 

The Olympic Bowel Movement

Recent revelations about a doctor who sexually abused girls and young women who were training for the Olympic gymnastic team is just another instance in the long, sordid history of the "Olympic movement."

The modern Olympics as we know the games with all their hype dates back to 1936 Germany when Hitler decided to showcase the Master Race and his Aryan nation by staging a huge spectacle with a massive Olympic stadium.


The way the story is usually told in America is that heroic America Blacks, like Jesse Owens managed to destroy the image of White Supremacy by winning the 100 yard dash and Hitler was humbled, but that was not what happened at all. Germany won 89 to the USA's 56 Olympic medals and Hitler got his propaganda feast.


Since then we have had the murder of Israeli athletes left unguarded at the Munich Olympics, the Russians staging a huge show before invading and annexing Crimea.

The Olympics have always staged jingoistic orgies with the national anthems of the gold medalist being played and the flags being run up the poles while Olympic officials reacted in outraged at the politicization of the pure Olympic movement by Black American athletes who raised protesting fists at the Mexico City Olympics in 1968. Those bad Black boys were sent home for spoiling Master's show.


And when the Olympic torch stunt was sullied by a high school student who stood outside his high school when the principal forced the students to stand along the sidewalks as the Olympic torch was born by, the student was thrown out of school for holding up a "Bong Hits for Jesus" sign and the Unites States Supreme Court held the principal had that right to defend Olympics Inc against satire from an American high school student who saw the hypocrisy and was slapped down for protesting it.


This whole show has been a sorry exercise in commercially motivated jingoism since Hitler and it has gone downhill ever since.

Shakespeare in Baltimore

Watching the 2nd season of "The Wire" (again) I'm trying to understand how it fails.


Of the 5 seasons, this is clearly the one disappointing one.


But that is not to say it is not essential or even without its pleasures.

It has some stunning set pieces, as when the slimy lawyer, Marvin Levy, piously attacks Omar on the witness stand, saying Omar makes his living robbing people, makes his living prowling the streets of Baltimore with a shotgun, so why should the good people of the jury believe a word he says?


Omar, who has been very open about his life, his livelihood, of course appears dangerous, but essentially looks more honest than anyone in the court and he replies he makes his living with a shot gun while Levy, who is just as deeply "in the game" makes his living with his weapon, the briefcase, and there is not a shred of difference, morally between the two.


Levy looks to Judge Phalen in mute objection, but Phalen simply raises his eyebrows: You asked the question. You got your answer. That's his opinion and there is no basis for a legal objection.


One wishes they had played that scene out a little more, but such is the discipline of "The Wire" they do not over write or say more than what is absolutely necessary. You have to wonder whether the listeners understood all that was not said but what was implied and the jury's verdict, which is only known as Bird is seen being led away, comes in a later episode.

And there is the story line in which the lethal Wee Bay, who loves aquarium fish, has his mechanical fish destroyed by a jailor, but Wee Bay is avenged  by Avon's Machiavellian machinations.
And there is the revelation of character of Diangelo, who wants to be free of his "family" and is destroyed by that wish, but first he finds his own story reflected in "The Great Gatsby" and he reveals he has got Gatsby far more deeply than any of a thousand suburban kids who went to Harvard, who had to read it as a class assignment, because Diangelo actually understands what it is to be trapped by your past, to be a boat beating ceaselessly against the current.




But Season Two has too many white characters who are simply poorly done. When the Wire's writers are doing Black characters, to this white ear at least, they sound completely real, but knowing what white people sound like, the writing of these white characters sounds strained and false as a pole dancer's eyelashes.


There are some funny bits as the Black cops listen to white street kids who have aped the cadences and language of the Black street kids and the Black cops look at each other and say, "They steal everything!" Even the language is stolen.


But the dock workers sitting around their bars with their stories about the old days and the "youse" instead of "you" all sound phony. Frank Sobatka, constantly brooding over the good old days when Baltimore harbor was busy and employing hundreds of stevedores, and he is being told by his younger workers those days are gone but he refuses to believe it. He does not ring true. Anyone heading a union down at the docks could see the trends just as coal workers' union heads must see that trend.


I cannot attest to the language of those doc workers, but I've spent enough time hanging around Dundalk and other down at the heels Baltimore areas to know the folks I heard sitting in gyms for weekends on end during wrestling tournaments sounded nothing like the guys on The Wire.


The white dock workers on The Wire sound more like the David Simon of Twitter, with all his affectation of a suburban white kid from toney Bethesda, Maryland trying to sound like a Baltimore tough guy.


And this is really too bad, because what Season 2 really does is to place the street side desperation in a larger context--it shows how the Baltimore street is just a small part of a much larger world of international crime which connects to South American drug cartels, which is sacrificed to decisions in Washington to simply abandon the American inter city in an effort to pursue the much higher profile effort against "terrorism." At one point an FBI agent tells a Baltimore City cop, he could help chase down the drug organization running the West Side markets and strewing bodies around the streets if only the drug kingpins had names like "Achmed or Abdul."




In the first season you learned, in detail, how arresting street hoppers and low ranking drug hoods has no impact at all on the drug trade. The loss of these pawns is simply factored into the business plan of the top dogs like Stringer Bell and Avon Barksdale. Huge packages of "drugs on the table" with top brass policemen grinning over the message they've sent to the drug lords are a travesty; the drug lords could not care less. Interdiction of any load of product is always just a price of doing business, like spoilage in a supermarket's green grocery.


There is much talk about how we no longer teach Civics in public schools.
I think we should simply show "The Wire" as a year long course to every suburban school child. The inner city kids don't need to see it. They live it every day.

One Million Dollars To Cure Your Blindness

Alexandre Yersin, who identified the bacteria which causes Black Plague, and who developed the first effective treatment for it, said he could never practice medicine because he could not bring himself to say to someone, "Your money or your life."

Yersin

How far we have fallen.

Spark Pharmaceutics, a company which spun off from research at the Children's Hospital of Philadelphia ( CHOP) a part of the University of Pennsylvania, has developed a gene therapy for a rare form of childhood blindness which can be injected once into each eye and this apparently cures the condition by providing a gene which makes a protein which makes eye cells sensitive to light.

When asked what this cure for blindness will cost, the CEO says $1 million dollars per patient--half a million per eye. When asked where that price came from, he did not try to justify it by the cost of production or by the cost of the research. He probably avoided alluding to the cost of research, to the salaries of the faculty who identified the gene, because, of course, those faculty of the University of Pennsylvania likely got significant taxpayer support in their training, in their laboratories.

Instead, the CEO said they looked at court awards in cases of blindness. A million dollars seems to be the going price for vision.

Charged $700 for a single tablet; a piker by comparison

The researchers, who went to medical school or got graduate degrees at universities underwritten by the US taxpayer,  spun off their academic work into a new company devised by lawyers to be separate from the University of Pennsylvania and CHOP, and they are now going to cash in.

We have come to this in the United States of America.

Alexandre Yersin, it might be noted was Swiss, trained by Pasteur in Paris--that's in France, where they have a national health system.. Neither ever became a millionaire.

Make America Great Again!

The Biggest (Penis) Button

We've finally got down to the core question here.

Among all the world leaders, who's got the biggest penis?

Twitter from Carrot Top fake Obama tweet "I'm the one in the middle"

Well, you can eliminate Angela Merkel, right off the bat. That much is safe to say.

Which leaves Macron (French), Trudeau (Canada), who may not be big, but they are considerable younger than the Dotard. But wait, there's that guy in China. And Netanyahu.
And how could we forget to mention Mr. Putin right up front, so to speak.
But look at that guy Putin. Do you really think? Naw.

One might argue it's not just size, although size matters, it's sustainability. I mean, you could argue that. But, then who am I to comment on this?

Perhaps I'm not the best authority to comment upon this debate.
Readers of this blog will know whose opinion we are all waiting for. 
She does not comment often, but when she does, she is usually definitive.
We are all waiting on seat's edge.

cartoon by pia guerra

Plastic into the Oceans: Shocking News In the Age of Twitter

The "Daily Mail" got my attention with the headline "Shocking Study Reveals Ten Rivers the Source of 95% of all the Plastic Dumped Into the Oceans."

But, reading on the National Geographic site, it turns out, yes, 10 rivers constitute 95% of all the plastic dumped into by the oceans by rivers, but that is not 95% of all plastic dumped into the oceans. 
"Most" of the plastic comes from coastal communities, whatever "most" means. It may be 51% of all the plastic in the oceans comes from coast communities and 49% from rivers. 
At any rate, we cannot blame all that plastic continent floating around the Pacific entirely or maybe not even mostly on those 10 Asian and African river communities. But likely those rivers play a big role.

Surprisingly, Vietnam seems to be a major culprit, which given Vietnam's agrarian profile might surprise us.
But as National Geographic notes, the Mekong River starts way upstream, passing Thailand, Cambodia, Laos, China on the way and by the time it gets to Vietnam plastic from places Vietnam cannot control is already floating in the currents.

All this  does make one wonder about all our local efforts in the US of A to reduce plastic in the ocean. Makes you feel a little sheepish about all the outrage, alarm and self flagellation about how America is responsible for befouling our oceans, when, in fact, it's the developing nations in Africa and Asia which, as developing nations bent on gearing up industry will do, are dumping their trash willy nilly into a handy river.

All this does remind the Phantom we live on Planet Earth and we cannot save this planet without convincing other people to change their behavior in directions we think best. 

Do you think folks in Asia and Africa are disposed to listen to our leader (s) now?

Chump U

A lovely lass told me she was working toward her B.A. in dental hygiene at Mt. Ida College.

A B.A. in what?
What would you need a B.A. for,  in dental hygiene when in 6-12  months you can likely get trained as a dental hygienist and your prospects for employment are working in a dental office, period.
Your salary with a BA will be exactly what it is without that BA and you will be earning it three years earlier and advancing in seniority 3 years earlier.

Now, don't get me wrong. I love my dental hygienist. She has changed my life. She has done my mouth a real service. But would I wish on her 4 years of going to school for something she could learn in 6 months and the debt that goes with it?

I asked my friend, a former college president about this and he said, "Well, maybe you'll need a B.A. to get into administration. Like nursing."
Administration? In DENTAL HYGIENE?

Got me thinking about the "medical assistants" in our offices. These ladies take blood pressures, a brief why-are-you-here history from the patients, get them into exam rooms, pull up laboratories and organize information to streamline the information flow for the doctors.

Community colleges, but most especially commercial colleges, now advertise courses to "certify" medical assistants. They make these women take a year's course which includes "anatomy and physiology" at the Great Bay Community College.
My medical assistants showed me the exams from this course:
Sample question:
Select the answers which are true:
a/The nephron  secretes glucose in the proximal tubule and reabsorbs it in the distal tubule
b/ The beta cell of the pancreas secretes insulin as a dimer connected by a connecting peptide
c/ Hepatic cells convert amino acids into glucose.

A and C
All of the above

The more I read the exam and heard the stories about this professor of A&P, and the high failure rate in his course, which meant the students had to sign up to take it all over again, the more  it became evident the man had a personality disorder, likely in response to having flunked out of pre med as an undergraduate.
He was the scourge of these women who had graduated high school and had high hopes of securing a job as a "medical assistant"  to secure a $18 K a year position.
And the corporation who employed them colluded with the community colleges and the for-profit colleges to wring money out of these ladies.
Well, we'll hired you without your medical assistant  degree, but you'd better get it within a year.

Really?  The fact is everything these folks need to learn they will learn on the job and whatever background they need, the doctors are only too happy to provide, or they read on the internet.

The other explanation the college president made about the bachelors of dental hygiene was perhaps if you got a 4 year BA in dental hygiene, you could then get into dental school.

I looked at him in wonder. Here is a college president who clearly had not the faintest idea what the path is from high school to dental school, which is through a four year college, then through a four year dental school. The kids who had the backing to go that route were not in the same boat as the kids who would consider becoming dental hygienists. This was a class divide.

The real problem for these aspiring dental hygienists is they come from poor or lower middle class families where nobody has the faintest idea what you really need to do to become a dentist or a doctor. Nobody in their family ever had; nobody they knew ever had and none of the high school guidance counselors, who themselves were just one chapter ahead, had any idea.

These same families think an associates degree from Northern Essex Community College is pretty much the same as a college degree from, say, Harvard, except Harvard is for rich kids. But how Harvard insures the rich kids stay rich is a mystery.

It's not that these folks are stupid--they are simply not privy to the secrets of this world.
And of course, the joke may be on the kids who struggle to get into Harvard--it's not clear, because Harvard and every school in the Ivy league is unwilling to say, exactly how many kids from Hardscrablle, USA actually get out of these elite places and wind up making big bucks at Goldman Sacks and how many wind up driving taxicabs. Harvard trumpets its successes in getting underprivileged kids into Harvard; what Harvard will not tell you is how many of those kids translate that glittering prize into affluence afterwards.

That information is jealously guarded by the institutions.

I would hazard a guess more Harvard/Yale/Princeton grads do move into the upper classes; not so sure about Columbia/Brown/Penn or, for that matter Notre Dame, Syracuse, Lehigh.  I suspect kids from families rich enough to support them through those colleges are rich enough to open doors for them afterwards.

I well remember my own parents who were the children of immigrants, telling me if I got into an Ivy League school I'd be living on Easy Street, could punch my own ticket. Would make easy money the rest of my life.

What did they know?
My father worked at an employment agency during the Great Depression and he told of seeing blonde haired, blue eyed boys from Yale being sent down to get jobs at Chase Manhattan. "We knew if we sent those guys down there, they wouldn't bounce back. They got the jobs at the banks. Kids from NYU, CCNY, don't even bother sending them."

But that was 1930, when the old school tie meant something. Does it still? In what fields? Banking? What kind of banking? 

And what is Easy Street? How many of the kids who go from Princeton to Goldman Sacks are still there three years later? 

The kids  Trump University preyed upon never had a chance. They were fools soon separated from their money. Yokels and bumpkins fleeced by the city slicker.

 But Trump U is just one of a whole spectrum of disease, which includes community colleges, state institutions and, of course, a whole cesspool of for profit scam colleges and "certification" mills.

The land of broken dreams.