This is Going to Hurt

From the original UK version of Adam Kay’s This is Going to Hurt: Secret Diaries of a Medical Resident:

Asked to review a patient in labour ward triage and repeat a PV as the midwife is uncertain of her findings. Her findings were of cephalic presentation with cervix 1 cm dilated. My findings are of breech presentation, cervix 6 cm dilated. I explain to mum that baby is bottom-down and the safest thing to do is to deliver by caesarean section. I don’t explain to mum which part of the baby the midwife has just stuck her finger in to 1 cm dilatation.

Good medical humor is rare.

ABR Wins Round 2 in its Antitrust Lawsuit

Judge Alonso dismissed the amended class-action lawsuit against the ABR on January 8, continuing the trend of denying a duel by trial in the ongoing saga of various doctors against the ABMS hegemony. You can read his opinion (~15 pages) here (and my most recent prior lawsuit-related post is here).

I can’t speak for its legal merits/basis, but as a non-lawyer, it’s pretty uninspiring. He largely turfs his interpretation to the prior ABIM lawsuit ruling.

The synopsis is that the judge is not convinced that initial certification (IC) and maintenance of certification (MOC) are different products because they were never sold separately. While IC was sold by itself, MOC was merely added decades later and never sold as a standalone product (never mind that a real monopoly would smartly generally avoid doing such a thing in real life).

This is probably a flaw in US antitrust law. When Microsoft got hammered for bundling Internet Explorer with Windows, Microsoft argued that IE was an inseparable part of Windows. This bundling crushed the browser war competition, further cemented Microsoft’s dominance, and stifled innovation for years. But part of what caused Microsoft to lose that argument was that IE was available on Mac, proving it could be a separate product. That detail, which in real life is functionally ancillary nonsense, was nonetheless key to proving Microsoft’s violation of the Sherman Antitrust Act.

Judge Alonso also doesn’t buy that there are separate markets for IC and MOC, not agreeing with the plaintiff’s new argument that MOC is essentially the same thing as other CME offerings. I agree that’s a hard sell, but he does discount that the NBPAS is selling its own MOC product as proof that separate demand for MOC exists (and that said NBPAS is struggling to compete given the ABMS monopoly in physician certification).

Would opening the gates to further scrutiny help? Should there be a chance to develop evidence? Would seeing some raw material from the ABR change the narrative?

It is true, as plaintiff argues, that many of the cases on which both parties rely throughout their briefs were decided, unlike this case, at the summary judgment stage or later, after the parties had the opportunity to develop evidence in discovery.

But then Alonso goes on to say he doesn’t believe the evidence will bear out the claims, so he’s not interested in seeing it. And even if it did:

On top of all of this, even if the Court assumes that initial certification and MOC are separate products, the Court still fails to see in what sense the tying arrangement alleged here poses a risk of foreclosure of competition in the tied market. “The traditional antitrust concern with [a tying arrangement] is that if the seller of the tying product is a monopolist, the tie-in will force anyone who wants the monopolized product to buy the tied product from him as well, and the result will be a second monopoly.”

The argument here is that essentially only MOC from the ABR has value because the ABR has a monopoly on IC. That MOC, even if untied, would be its own monopoly, because MOC from any other entity in this context would be meaningless. This is probably true in the current regulatory climate but is also guaranteed by rulings like Alonso’s.

Ultimately, the issue in medical certification isn’t necessarily the tying of MOC. It may be meaningless rent-seeking, but it may well be within the purview of the ABMS member boards. The underlying problem is that the complex regulatory and credentialing environment now includes (historically optional) certification to such an extent that no competitor can feasibly provide an alternative to initial certification. And this lack of competition and accountability has led to bloated organizations with outsized revenues and debatable value.

Although the Court doubts at this point that plaintiff will be able amend the complaint to state a claim, it cannot say so with certainty, so the dismissal is without prejudice and with leave to amend. Alternatively, plaintiff may elect to stand on the amended complaint and ask the Court to enter a final and appealable judgment.

And so, round two formally concludes.

Any amended complaint is due by February 5, 2021, but I suspect this may be the end given the legal costs. One guy against a monolithic organization with deep pockets was always going to be a tough battle. I doubt there’s much more here to amend for Alonso’s sake, but certainly appealing a final judgment to a higher court would be conceivable.

Carving out a Creative Routine

From Keep Going: 10 Ways to Stay Creative in Good Times and Bad by Austin Kleon:

In his book Daily Rituals, Mason Currey catalogs the daily routines of 161 creative individuals: when they woke up, when they worked, what they ate, what they drank, how they procrastinated, and more. It’s a wild collage of human behavior. Reading about the habits of writers alone is like visiting a human zoo. Kafka scribbled into the night while his family slept. Plath wrote in the morning before her children woke up. Balzac slugged fifty cups of coffee a day. Goethe sniffed rotten apples. Steinbeck had to sharpen twelve pencils before starting his work.

It’s undeniably fun to read about the routines and rituals of creative people, but what becomes clear after a while is that there is no perfect, universal routine for creative work. “One’s daily routine is a highly idiosyncratic collection of compromises, neuroses, and superstitions,” Currey writes, “built up through trial and error and subject to a variety of external conditions.” You can’t just borrow your favorite artist’s daily routine and expect it to work for you. Everyone’s day is full of different obligations—jobs, families, social lives—and every creative person has a different temperament.

I’m not always sure that what I do here qualifies as creative work, but it’s so easy to fall into the jealousy trap looking at the routine of a full-time professional creative. It’s not hard to read a book like Cal Newport’s excellent Deep Work and think, yeah, that’s how you do it–if you’re an academic or knowledge worker.

I’m an academic physician working in a private practice. When you break it down transactionally, I trade time for money and then do a whole bunch of unpaid work on top that helps give my job extra meaning.

I’m a dad and a husband.

And that’s why it’s so much easier to have an amateur’s mindset instead of a professional’s: to do something because you like it or when the stars align.

But I’ve also found that I do better work and find more satisfaction in the work when it’s part of a routine (i.e. a modified professional mindset). My routine just isn’t one that involves long uninterrupted periods of deep work or a cabin in the woods.

I think the key is carving out a habit–or maybe a better word is a pattern–that allows you to fold in your avocations in a way that allows for regularity despite dominant competing obligations, recharges your battery, and still results in enough forward progress on your larger projects (if you have them) as to not be demoralizing (and it’s actually that last part that’s the hardest).

Productive Procrastination

From Indistractable: How to Control Your Attention and Choose Your Life:

I discovered that living the life we want requires not only doing the right things; it also requires we stop doing the wrong things that take us off track.

If distraction costs us time, then time management is pain management.

That’s a catchy line.

Being okay in your skin, being okay within your own mind is part of it. We reach for the phone because it’s easier.

There’s a lot of navel-gazing writing about how you should just stand in the grocery line and be mindful: to find space in that brief time to just be.

And that sounds so nice.

But…I also start a lot of drafts in those in-between moments. I haven’t conquered being alone with my thoughts, and maybe I never will. But at least I’ve practiced sublimating them into something I consider meaningful.

If you’ve ever chewed over something in your mind that you did, or that someone did to you, or over something that you don’t have but wanted, over and over again, seemingly unable to stop thinking about it, you’ve experienced what psychologists call rumination. This “passive comparison of one’s current situation with some unachieved standard” can manifest in self-critical thoughts such as, “Why can’t I handle things better?”

But there’s the rub.

I’m not sure it’s really possible to avoid the rumination and bad habit loops without dealing with that pain management directly. I see a lot of workaholics that are good at doing things but not so good at just being alive, and perhaps our work-focused, over-scheduled, and outcome/comparison-focused society is at least partially to blame.

Certainly, the resume-fluffing requirements we place on students for competitive colleges, graduate schools, and jobs like medical residencies are teaching those lessons early enough at young enough ages that we’re likely still susceptible to making them part of our personalities.

What I Read in 2020

I said at the end of my 2019 reading list that I thought 2020 was “going to be a good year.”

Well.

I did, however, manage to read some books.

I also said last year that I’d discovered an absurdly dorky subgenre called LitRPG (basically fantasy novels crossed with role-playing games) and that I probably wouldn’t ever read any again other than the one series I stumbled on. Well, I lied. I read a lot of them, because full-throated absurdist escapism is what I needed this year (this is a no-judgment zone, thank you).

Since my son turned five and we started reading chapter books together, I’ve included a separate list of those at the bottom.

  1. The Boy, the Mole, the Fox, and the Horse by Charlie Mackesy (this was a mega-bestselling award-winning illustrated story-ish thing. I read it myself, and then I read it to my son. I enjoyed reading it to him more because it’s full of morals and nice thoughts and stuff and it has pretty pictures).
  2. Calypso by David Sedaris (who really does write excellent personal essays)
  3. The Minimalist Way by Erica Layne (meh)
  4. The Beginning After the End by TurtleMe (this reads like a YA shonen anime novelization but not necessarily in a bad way)
  5. The Calculating Stars by Mary Robinette Kowal (Lady Astronaut #1. Winner of the Hugo and Nebula awards. Excellent alternate history following the story of the first female astronaut in an Earth where an asteroid impact spurs humanity to ramp up space exploration in the 1950s)
  6. Starsight by Brandon Sanderson (Skyward #2)
  7. The Med School Survival Kit by Wendall Cole MD
  8. The Odyssey by Homer and Emily Wilson (this such a seamlessly modern-feeling translation. Kudos to Wilson).
  9. Dear Girls by Ali Wong (Ali Wong is very funny)
  10. New Heights by TurtleMe (The Beginning After the End #2)
  11. Becoming Fates by TurtleMe (The Beginning After the End #3)
  12. Horizon’s Edge by TurtleMe (The Beginning After the End #4)
  13. Why We Sleep by Matthew Walker
  14. The Last Emperox by John Scalzi (The Interdependency #3; this was a very enjoyable space opera trilogy)
  15. The Children of Hurin by J.R.R Tolkien (kinda)
  16. Seveneves by Neal Stephenson (the scope of this story is bonkers huge)
  17. Maybe You Should Talk to Someone by Lori Gottlieb
  18. Ascend Online by Luke Chmilenko (this is pure LitRPG, and the cover art is atrocious)
  19. Hell to Pay by Luke Chmilenko (Ascend Online #2)
  20. Legacy of the Fallen by Luke Chmilenko (Ascend Online #3)
  21. How to Defeat a Demon King in Ten Easy Steps by Andrew Rowe (adorable little novella, basically a subverted Zelda and Dragon Quest mashup/love letter. I found the subverted tropes amusing.)
  22. The Things You Can See Only When You Slow Down by Haemin Sunim
  23. Convergence by TurtleMe (The Beginning After the End #5)
  24. The Happiness Project by Gretchen Rubin
  25. The Land: Founding by Aleron Kong (A physician and author of a very (the most?) popular LitRPG saga, an Audible 2018 customer favorite; Chaos Seeds #1)
  26. The Land: Forging by Aleron Kong (Chaos Seeds #2)
  27. The Land: Alliances by Aleron Kong (Chaos Seeds #3)
  28. The Land: Catacombs by Aleron Kong (Chaos Seeds #4)
  29. The Land: Swarm by Aleron Kong (Chaos Seeds #5)
  30. The Land: Raiders by Aleron Kong (Chaos Seeds #6)
  31. The Land: Predators by Aleron Kong (Chaos Seeds #7)
  32. The Land: Monsters by Aleron Kong (Chaos Seeds #8; by this point in the series, we’ve gradually but now pretty firmly devolved into the grinding halt of the overall plot in favor of increasingly complex and tedious player statistics and points distribution. Literally nothing happened in this book.)
  33. Trigor by Tom Merritt (Pilot X #2; pretty enjoyable, though the first was better.)
  34. NPC by Jeremy Robinson (it’s no Space Force)
  35. White Fragility by Robin Diangelo
  36. Notes of a Crocodile by Qiu Miaojin
  37. The Art of Living by Thich Nhat Hanh
  38. How to be an Antiracist by Ibram X. Kendi
  39. Together by Vivek H. Murthy (he seems like a true aspirational model of a physician)
  40. Will Save the Galaxy for Food by Yahtzee Croshaw
  41. Transcendence by TurtleMe (The Beginning After the End #6)
  42. Doctor’s Orders by Tania M. Jenkins (reviewed here)
  43. The Plot Against America by Philip Roth (an alternate history where FDR loses the 1940 election to aviator Charles Lindbergh; currently an HBO series)
  44. WCI Bootcamp by James Dahle (more thorough and updated relative to his first book, which I still think he should go back and lightly revise).
  45. Bad Blood by John Carreyrou (the tale of the rise and fall of Theranos. What an absurd story and a stark illustration of the business world we live in. Discussed briefly here)
  46. Ham on Rye by Charles Bukowski
  47. Nobody Wants to Read Your Sh*t by Steven Pressfield (impressively concise, which is apt given the subject matter)
  48. The Psychology of Money by Morgan Housel (possibly the best non-technical book on money currently available)
  49. How to Fight a Hydra by Josh Kaufman (the extended metaphor gets a little tired if you ask me)
  50. How the Internet Happened by Brian McCullough (parts of this book felt like reading a history of my childhood)
  51. Reamde by Neal Stephenson (I read this after Fall, which is sort of a loose sequel, but it was almost more fun that way for some reason)
  52. The Circle by Dave Eggers (I never saw the movie with Tom Hanks and Emma Watson, but this is a chilling novel)
  53. Joy at Work by Marie Kondo and Scott Sonenshein (I really just had to know if being happy at work meant cleaning your desk and canceling all meetings that don’t spark joy)
  54. The Reluctant Adventures of Fletcher Connolly on the Interstellar Railroad Vol. 1: Skint Idjit by FR Savage
  55. The Reluctant Adventures of Fletcher Connolly on the Interstellar Railroad Vol. 2: Intergalactic Bogtrotter by FR Savage
  56. The Reluctant Adventures of Fletcher Connolly on the Interstellar Railroad Vol. 3: Banjaxed Ceili by FR Savage
  57. The Reluctant Adventures of Fletcher Connolly on the Interstellar Railroad Vol. 4: Supermassive Blackguard by FR Savage
  58. Is This Anything? by Jerry Seinfeld
  59. Girl, Wash Your Face by Rachel Hollis (I’m always curious about the #1 NYT bestselling things that get recommended to my wife)
  60. Girl, Stop Apologizing by Rachel Hollis
  61. Didn’t See That Coming by Rachel Hollis
  62. Divergence by TurtleMe (The Beginning After the End #7)
  63. Children of Ruin by Adrian Tchaikovsky (sequel to amazing and unique award-winning Children of Time)
  64. The War of Art by Steven Pressfield (this is one of those books referenced a lot, but I found his newer book [#40 above] to be much, much more enjoyable).
  65. Looking Within by Cullen Ruff
  66. Tiny Habits by BJ Fogg
  67. The Fated Sky by Mary Robinette Kowal (Lady Astronaut #2)
  68. Recursion by Blake Crouch (this is going be a Netflix movie, and I bet it’s going to end up really neat)
  69. Glory to the Brave by Luke Chmilenko (Ascend Online #4)
  70. 2001: A Space Odyssey (does this count as a classic?) by Arthur C. Clarke
  71. Ready Player Two by Ernest Cline (other than the devastating pandemic, this is a solid #2 for the most disappointing part of 2020)
  72. Rhythm of War by Brandon Sanderson (Stormlight Archive #4; I’ve enjoyed everything I’ve read from Sanderson, but I think his wild success has resulted in a book here that’s too long (1200+ pages! More than 500,000 words!), had too much filler, and fell back on some really irritating tired character tropes. A firmer editorial hand would have done so much for this, and I’m not sure any other fantasy author writing today other than Martin would have gotten away with it. I will still absolutely read the fifth and final book in the series, which from the publisher’s perspective is probably all that matters.)

 

What I read to my son:

  1. The Fantastic Mr. Fox by Roald Dahl (We actually bought this big Roald Dahl box set and made some good progress through it. I’d forgotten just how weird Dahl’s books were).
  2. The Chocolate Touch by Patrick Skene Catling
  3. The Magic Treehouse #1-15 (these are pretty short, he’s a big fan, and we just got 16-29 in the mail).
  4. Cat Wings by Ursula K. Le Guin (a four-part series for young children by one of my very favorite authors)
  5. Cat Wings Return by Ursula K. Le Guin
  6. Wonderful Alexander and the Catwings by Ursula K. Le Guin
  7. Jane on Her Own by Ursula K. Le Guin (Catwings #4)
  8. Jedi Academy by Jeffrey Brown (This series is actually three trilogies, though for some reason the current box set is only books 1-7. These are absolutely delightful, especially the first series by Brown, which was genuinely clever and so much more pleasurable to read as an adult than most children’s books)
  9. Jedi Academy: Return of the Padawan by Jeffrey Brown
  10. Jedi Academy: The Phantom Bully by Jeffrey Brown
  11. Jedi Academy: A New Class by Jarrett J. Krosoczka
  12. Jedi Academy: The Forces Oversleeps by Jarrett J. Krosoczka
  13. Jedi Academy: The Principal Strikes Back by Jarrett J. Krosoczka
  14. Jedi Academy: Revenge of the Sis by Jarrett J. Krosoczka
  15. Jedi Academy: Attack of the Furball by Jarrett J. Krosoczka
  16. Jedi Academy: At Last, Jedi by Jarrett J. Krosoczka
  17. Esio Trot by Roald Dahl
  18. The BFG by Roald Dahl
  19. The Magic Finger by Roald Dahl
  20. The Giraffe And The Pelly And Me by Roald Dahl
  21. George’s Marvellous Medicine by Roald Dahl
  22. The Twits by Roald Dahl
  23. Billy And The Minpins by Roald Dahl
  24. Danny the Champion of the World by Roald Dahl
  25. James and the Giant Peach by Roald Dahl
  26. Charlie and the Chocolate Factory by Roald Dahl
  27. Charlie and the Great Glass Elevator by Roald Dahl
  28. Rowley Jefferson’s Awesome Friendly Adventure by Jeff Kinney (author of the Diary of A Wimpy Kid books)