Ben White

Incidental Pain and Suffering

01.22.23 // Medicine, Radiology

From Matthew Davenport’s upcoming article in AJR, “Incidental Findings and Low-Value Care“:

It is increasingly recognized that incidental findings are incompletely understood, expensive, and surprisingly harmful. Rather than a benefit of imaging, they are usually a harm. They are not sought, the odds of them being important is low, and they create tremendous uncertainty and low-value care.

A good primer on an often unintuitive and yet incredibly important problem in medical diagnostics (both for radiologists and clinicians).

Writing “Content”

01.17.23 // Writing

I’ve been writing online (“blogging”, cringe) for over 14 years now, and there can be a sometimes strange (and strained) relationship between writing-as-service and writing-as-expression. I’ve mostly written whatever I want, or at least whatever I thought had two or three of this magic combination:

  • interesting to me
  • would be helpful to other people
  • either no one else was doing it or I had an individual (ideally unique) perspective

And yes, sometimes I just wrote whatever.

Over the years, this site has focused on a variety of topics until they’ve covered the ground I wanted to cover or exhausted my interest. I wrote a lot about studying in medical school (choosing books, approaching questions, etc) until I wasn’t interested anymore (not a great financial decision, but hey). I wrote a lot about approaching the residency selection process.

I wrote the book for the Texas JP exam because that test was a stupid hassle and no one had made what I thought should exist. So I did.

I wrote a lot about personal finance specifically for medical students and trainees and especially about student loans, mostly because content on student loans just did not exist at the time (I know, hard to believe). Now it does, and I felt I covered that sufficiently in the book, so I mostly moved on (also not a great financial decision, but hey). I’ll probably return to personal finance again in the future. I still have more to say, but I’d be kidding myself if I pretended even for a second that my opinions are particularly unique or interesting or that this space isn’t being adequately covered (frankly, it’s saturated; there’s plenty of content and almost infinite noise to wade through already).

I’ve written a lot about medical training, radiology, and various topical issues related to organized medicine like board certification (ABR I’m looking at you) or healthcare trends like private equity takeovers. People like these posts. I (still) like writing them. I genuinely think these issues aren’t talked about enough, even though my fly buzzing on the internet probably isn’t going to move the needle much.

I was going through my archives at the end of the year, and I noticed just how much of the writing that I thought was evergreen is slowly aging out. Posts that used to be perennial traffic drivers have eventually lost their mojo. A lot of that may be because “the blog is dead,” and some of it just that Google overall favors fresh content all things being equal (even if the classics are still fire, thank you very much). But some of it is because even things that don’t change quickly sometimes still change slowly. 14 years is a long time on the internet. I guess that’s both a testament to how long I’ve been doing this and also a little sad.

There has never been a shortage of things I’d like to write about. I could easily fill up my days writing full-time, and my collection of potential post ideas and article fragments is comically long. It only gets longer. I get a lot of topic requests, and they’re almost always things I’d be happy to write about given time. But there’s also that unavoidable truth that every yes to one thing is a no to another.

I’d like to have more of my writing be timeless. (Maybe it’s time to go back to fiction too?) We’ll see. I also want to keep being a resource for radiologists and other physician readers, but I also wouldn’t mind writing things that might be interesting to someone who doesn’t work in a hospital. Morgan Housel, who wrote the excellent Psychology of Money, tweeted:

I think “know your audience” can be dangerous advice for writers.

Write stuff you yourself find interesting and entertaining.

Writing for yourself is fun, and it shows. Writing for others is work, and it shows.

One perk of jumping around over time is that I haven’t had to worry too much about audience capture.

As for me, I want you to know this has been fun, and I hope that shows. Thanks for reading.

FTC Chair Lina Khan on non-competes

01.10.23 // Miscellany

Lina Khan, in an op-ed for The New York Times:

Noncompete clauses systemically drive down wages, even for workers who aren’t bound by one. Every worker stuck in a job represents a position that isn’t opening up for someone else. And if employers know their workers can’t leave, they have less incentive to offer competitive pay and benefits, which puts downward pressure on wages for everyone.

F.T.C. economists conservatively estimate that noncompetes suppress American workers’ income by roughly 3 percent to 4 percent, or $250 billion to $296 billion.

Perhaps this would be more forgivable if noncompetes really did spur innovation, helping companies take big swings and bold risks. But here, too, the real-world evidence reviewed by the F.T.C. undermines the theory. As the name implies, noncompete clauses tend to make markets less competitive. Rather than encouraging dynamism and new ideas, they can enable stale incumbents to lock out new rivals.

Her essay is well worth reading. Khan makes a compelling case for the FTC’s proposed rule.

Competition is supposed to be a good thing.

Death of the Noncompete?

01.09.23 // Medicine

Last week the FTC announced a proposed rule banning non-compete agreements. You can read the announcement here and the actual rule here. The rule would, if enacted, not just ban all non-competes going forward but nullify previous agreements as well. Non-competes are ubiquitous in medicine and a big factor locking doctors into their jobs, typically by preventing them from practicing in the same geographic region for a period of time after leaving their employer. And, for example, whenever a large organization like an academic medical center or a private equity company buys a practice or otherwise dominates a region, these non-competes form an effective moat against competition by preventing doctors from reorganizing after fleeing.

In some areas/fields, noncompetes are universal and have been functionally unavoidable. Many employers rely on lock-in to mitigate their bad culture and sleazy practices; shifting that power dynamic would I think change things very quickly.

It’s intuitive and straightforward how such a rule would affect employed physicians: you can just quit and hang up your shingle elsewhere. And yes, that means a clinician could join an academic practice for a few years, build up a patient panel, get more comfortable in their skin as an attending physician, and then leave and use that experience as a springboard to a new practice. This is, of course, part of the fear that led to non-competes in the first place. Employers put money into new hires between training, onboarding, early decreased efficiency, marketing, etc. Perhaps in a world without non-competes, employers will be less inclined to invest in their employees; that’s the typical business counterargument. The counter-counterargument also holds water: perhaps, if employers don’t invest in their employees, then their employees will leave. Value shouldn’t be a one-way street.

Too good to be true?

Several immediate reactions have been common. One, that somehow doctors will be exempted because woe is us. Two, that companies will use the magic of lawyers to get around the intent of the law. Three, that practice owners/shareholders (think partners in a large private practice) will be exempted because they are business owners and not employees. Four, that this will be litigated into oblivion.

The announcement had this to say:

Companies use noncompetes for workers across industries and job levels, from hairstylists and warehouse workers to doctors and business executives. In many cases, employers use their outsized bargaining power to coerce workers into signing these contracts. Noncompetes harm competition in U.S. labor markets by blocking workers from pursuing better opportunities and by preventing employers from hiring the best available talent.

So the FTC specifically includes doctors when they think of who this rule will affect.

The language of the rule itself also addresses a few of these concerns:

(1) Non-compete clause means a contractual term between an employer and a worker that prevents the worker from seeking or accepting employment with a person, or operating a business, after the conclusion of the worker’s employment with the employer.

(2) Functional test for whether a contractual term is a non-compete clause. The term non-compete clause includes a contractual term that is a de facto non-compete clause because it has the effect of prohibiting the worker from seeking or accepting employment with a person or operating a business after the conclusion of the worker’s employment with the employer.

So, in theory, clever machinations to functionally bind workers without the use of naughty catchphrases would still be against the law. How easy it would be to prove a functional non-compete in court, how expensive and stressful that process would be for an individual worker, and how aggressive companies will be in toeing the line remains to be seen. How desirable/how effective of a deterrent such schemes would be for employers depends on those answers.

There is an exception for business owners:

The requirements of this Part 910 shall not apply to a non-compete clause that is entered into by a person who is selling a business entity or otherwise disposing of all of the person’s ownership interest in the business entity, or by a person who is selling all or substantially all of a business entity’s operating assets, when the person restricted by the non-compete clause is a substantial owner of, or substantial member or substantial partner in, the business entity at the time the person enters into the non-compete clause.

The FTC defines “Substantial owner, substantial member, and substantial partner” to “mean an owner, member, or partner holding at least a 25 percent ownership interest in a business entity.”

By that language, the ban would still apply to a physician owner in a practice of 5 or more people. Your average radiologist whose group sold to private equity, could, after the contract period, turn around and start working for other groups locally. They could, even, start a new group.

Well?

How is this likely to play out? I have no idea. In reviewing the media coverage, the overall consensus points towards the final rule being similar to the proposal, it not being stopped by congress (democrat-controlled senate), and then being litigated immediately. How long it takes to work its way through the courts and its eventual fate I don’t know. I’m sure plenty of lawyer and journalist ink will be spilled when the time comes to predict the outcome, but that is far outside my circle of competency.

For Radiology:

In radiology, the ability to do teleradiology work has taken some of the bite out of noncompetes, but this would still be a massive change for physicians in general. In particular, if the carve-out for owners/shareholders were to stay a similar size, the proposed rule provides a window into how a post-PE world might look for practices struggling after the sale.

No one has poured through every contract out there, but one of the common post-sale questions for the past few years has been: how can we get out of this? Common refrains: the things we were promised haven’t been provided, we can’t recruit, our rads are being poached to help elsewhere in the organizational umbrella, we can’t earn enough with the cut to make this sustainable. What recourse do the doctors who sold a practice have if things aren’t working out post-sale?

If this rule were to come to pass, there would be a light at the end of the tunnel. A failing group post-sale could run out the clock and conceivably form a new group to compete with the shell entity they’d leave behind (though presumably companies would still mitigate competition through non-solicitation agreements, for example). RadPartners and friends would still be buying the profits from your work and the goodwill of your relationships for several years, but the lack of a noncompete would make it impossible for them to guarantee their long-term stranglehold if/when their management fails. They’d have real skin in the game.

In practice, that could easily just hasten a lot more hospital-employed radiologists as institutions look to bring in rads and secure imaging services in this uncertain world. There are certainly groups out there that would rather work for the hospital they’ve been staffing for decades than the PE company they sold to. But even that trend could be temporary if a group of employed rads could then leave and form a group.

Boom.

The dynamism that such a rule enables is the real deal. The bargaining table permutations are infinite, and that’s exactly why the FTC wants to ban noncompetes.

WCICON23

01.05.23 // Finance, Medicine

Registering through the link here is also one of those effortless ways you can support this site while doing what you were going to do anyway.

I’m very much looking forward to speaking again this coming year at the Physician Wellness & Financial Literacy Conference (aka WCICON23), which will take place March 1-4 at the very nice JW Marriott Desert Ridge in Phoenix. If you have a CME fund to burn, I can’t think of anything else I’d rather spend it on.

 

 

Code CON23BW will net you $200 off an in-person registration through January 25.

What I Read in 2022

01.02.23 // Reading

2022 was the ninth(!) year that I’ve kept track of my book consumption. I’m still trying to get better at capturing even just some brief thoughts/impressions about what I read (especially the fiction, which sometimes fades from memory almost as fast as I can read it). I still read most of my nonfiction on my Kindle (or on the kindle app on my phone) because of the very handy highlight feature. A fraction of those highlights typically then find their way into my digital brain archive and some eventually become posts on this very site.

Prior years here: 2021, 2020, 2019, 2018, 2017, 2016, 2015, 2014.

  1. Atomic Habits (I’ve gone through this best-selling-in-whole-world book as a centering routine for the New Year a few times now)
  2. The Almanack of Naval Ravikant (some decent lines/ideas, my favorites are in this post)
  3. Appleseed by Matt Bell (environmental speculative fiction, a sprawling epic with well-crafted prose; Mr. Bell very nicely rejected a short story I wrote for his literary journal back in 2010)
  4. The Lies of Locke Lamora by Scott Lynch (Ocean’s Eleven meets epic fantasy; these books are awesome, and one of the unusual parts of these stories is that while this world has magic, the main characters are just blokes equally out of their element in dealing with it).
  5. Red Seas Under Red Skies by Scott Lynch (Gentleman Bastards #2)
  6. Republic of Thieves by Scott Lynch (Gentleman Bastards #3)
  7. The Poppy War by RF Kuang (way younger than me so we didn’t overlap, but Kuang apparently went to my high school)
  8. Termination Shock by Neal Stephenson (Stephenson, who first coined the term metaverse, writes super engaging sprawing near future speculative fiction. This is climate-related and just great)
  9. The Fifth Season (Broken Earth Trilogy #1) by NK Jemisin (2016 Hugo Award winner, gosh this is so good. May also be the only book where a partial second-person perspective totally works)
  10. Pangea Online: Death and Axes by SL Rowland
  11. Pangea Online: Magic and Mayhem by SL Rowland
  12. Pangea Online: Vials and Tribulations by SL Rowland
  13. Girl Logic by Iliza Shlesinger (my wife bought this but Iliza is probably now the most famous person I sorta knew growing up. She was a few years ahead of me in high school and probably even briefly knew my name at the time).
  14. Forward Collection edited by Blake Crouch
  15. The Obelisk Gate (Broken Earth Trilogy #2) by NK Jemisin
  16. The Stone Sky (Broken Earth Trilogy #3) by NK Jemisin (Again, very original. Not always the most fun read but a great story and incredible world-building).
  17. Stories of Your Life and Others by Ted Chiang (the title story is the mind-bender that gave rise to the movie Arrival)
  18. Exhalation by Ted Chiang (the newer collection of this award-winning writer of speculative short fiction, also unusually thoughtful)
  19. The Dragon Republic (Poppy War Trilogy #2) by RF Kuang
  20. Robot Dreams by Sara Varon
  21. Just Keep Buying by Nick Maggiuli (data-driven personal finance, some takeaways here)
  22. The Burning God (Poppy War Trilogy #3) by RF Kuang
  23. Lock In by John Scalzi (a master of the short, snappy, snarky, sci-fi thriller)
  24. Head On by John Scalzi (a sequel, but both are totally stand-alone)
  25. He Who Fights with Monsters by Travis Deverell (yes, it’s silly LitRPG, but the protagonist this time is Australian.)
  26. He Who Fights with Monsters 2 by Travis Deverell
  27. He Who Fights with Monsters 3 by Travis Deverell
  28. He Who Fights with Monsters 4 by Travis Deverell
  29. He Who Fights with Monsters 5 by Travis Deverell
  30. He Who Fights with Monsters 6 by Travis Deverell
  31. The Kaiju Preservation Society by John Scalzi (light, funny, enjoyable; though not as funny as Red Shirts)
  32. Wabi Sabi by Beth Kempton
  33. Warrior of Light by Paulo Coelho (I really liked The Alchemist. This was a bland platitude companion, 100% not worth it).
  34. The Cat Who Saved Books by Sosuke Natsukawa
  35. Man’s Search for Meaning by Viktor Frankl
  36. The Simple Path to Wealth by JL Collins
  37. Sufficiently Advanced Magic (Arcane Ascension #1) by Andrew Rowe (Meh. Magic system and plot, not so bad. Characters and writing, pretty painful even for YA.)
  38. On the Shoulders of Titans (Arcane Ascension #2) by Andrew Rowe
  39. The Torch that Ignites the Stars (Arcane Ascension #3) by Andrew Rowe
  40. Consider This by Chuck Palahniuk (Writing advice from the author of Fight Club among others; this was really good writing about writing).
  41. Good Omens by Neil Gaiman and Terry Pratchett (two of fantasy’s greats, working together in a way distinct from either alone)
  42. Jade City (Green Bone Saga #1) by Fonda Lee (Winner of the World Fantasy Award. The world-building is a bit a slow burn but this series ended up being exceptionally good.)
  43. Four Thousand Weeks by Oliver Burkeman (Refreshing “time management” that reads like happy nihilism)
  44. The Lion Tracker’s Guide to Life by Boyd Varty (briefly quoted here)
  45. Jade War (Green Bone Saga #2) by Fonda Lee
  46. Pacchi Festival (Bushido Online #4) by Nikita Thorn
  47. The Order by Jeremy Robinson (I didn’t get how Robinson was trying to pull together all of his stand-alone novels into a giant universe with a whole bunch of crossovers at first, but it’s working surprisingly well).
  48. Reckoning (The Beginning After the End #9) by TurtleMe
  49. Building a Second Brain by Tiago Forte (nothing convinced me to change my current workflow)
  50. Jade Legacy (Green Bone Saga #3) by Fonda Lee
  51. He Who Fights with Monsters 7 by Travis Deverell
  52. Rules for a Knight by Ethan Hawke
  53. Babel by RF Kuang (This was a singular book, nothing else quite like it)
  54. Dawnshard by Brandon Sanderson (Stormlight novella)
  55. The Android’s Dream by John Scalzi (I can see how the author who wrote this amusing book would go on to write the excellent Interdependency Trilogy)
  56. Unsouled by Will Wight (Cradle #1) (More progression fantasy)
  57. Soulsmith by Will Wight (Cradle #2)
  58. Blackflame by Will Wight (Cradle #3)
  59. Skysworn by Will Wight (Cradle #4)
  60. Ghostwater by Will Wight (Cradle #5)
  61. Underlord by Will Wight (Cradle #6)
  62. Uncrowned by Will Wight (Cradle #7)
  63. Wintersteel by Will Wight (Cradle #8)
  64. Bloodline by Will Wight (Cradle #9)
  65. Reaper by Will Wight (Cradle #10)
  66. Dreadgod by Will Wight (Cradle #11)
  67. Gilded Ghost (Ripple System #3) by Kyle Kirrin
  68. Agent to the Stars by John Scalzi
  69. Old Man’s War by John Scalzi
  70. The Doors of Eden by Adrian Tchaikovsky
  71. Throne of the Crescent Moon by Saladin Ahmed (Arabian Nights-esque fantasy. I’ve been meaning to read my copy of this ever since I published one of Ahmed’s stories in Nanoism, which was subsequently a finalist for the annual Best Small Fictions Anthology.
  72. Gallant by VE Schwab (Schwab is a great and very-bestselling writer. This ghost story reminds me a bit more of Neil Gaiman’s work.)
  73. The Black Prism (Lightbringer #1) by Brent Weeks (at first I wasn’t sold on the magic system/world-building but I was wrong. This series is great).
  74. The Blinding Knife (Lightbringer #2) by Brent Weeks
  75. The Broken Eye (Lightbringer #3) by Brent Weeks
  76. The Blood Mirror (Lightbringer #4) by Brent Weeks
  77. The Burning White (Lightbringer #5) by Brent Weeks (a rare satisfying series conclusion!)
  78. Farmer in the Sky by Robert Heinlein (some of these classic sci-fi books really haven’t aged well)
  79. Methuselah’s Children by Robert Heinlein
  80. He Who Fights with Monsters 8 by Travis Deverell
  81. The Lost Metal (Mistborn era two, #4, the conclusion) by Brandon Sanderson (Honestly fell kinda flat? The whole second arc just isn’t as good as the first, and I’ll admit I find the overall Cosmere integration slow burn to be mostly frustrating at this point)
  82. Noise by Daniel Kahneman (I’ll be quoting this book in more posts, but here’s a taste)
  83. Khaos by Jeremy Robinson (the penultimate volume in the Infinite timeline)

 

My son is getting older, so in addition to me reading to him, he also now reads a ton to himself, and sometimes I read a book or two in the series he’s currently enjoying or to introduce him to a new one:

  1. The rest of this Pokémon box set
  2. No One Returns from the Enchanted Forest by Robin Robinson
  3. Caveboy Dave by Aaron Reynolds and Phil McAndrew
  4. Sunken Tower by Tait Howard
  5. Some of the Wings of Fire graphic novel renditions by Tui T. Sutherland (talking dragons!)
  6. Boulder Brothers Mo and Jo by Sarah Lynn
  7. Cat Kid Comic Club Perspectives by Dav Pilkey
  8. Lightfall: The Girl & the Galdurian (Lightfall #1) by Tim Probert (such a beautiful art style; this was great)
  9. Lightfall: Shadow of the Bird (Lightfall #2) by Tim Probert
  10. Portions of the Minecraft Woodsword Chronicles by Nick Eliopulos
  11. Star Knights by Kay Davault (also a really cute standalone graphic novel)
  12. All five of the 5 Worlds graphic novels by Mark Siegel (which were awesome, he loved these)
  13. The first two books in the classic Chronicles of Narnia series by CS Lewis, which I kept in great condition from childhood for just this purpose!
  14. Several entries in the Amulet series by Kazu Kibuishi, which he thought were super epic. Fantastic art.

The ABR Finesses its Bylaws

12.09.22 // Radiology

A few years ago I published my deep dive into the bylaws of the American Board of Radiology. Bylaws are boring, dry documents that most people don’t care about and even fewer read. But they do shed light on the culture of an organization and its priorities. The ABR’s were comically nefarious. For example, their old conflict of interest policy (emphasis mine):

It is the policy of this Corporation that the legal duty of loyalty owed to this Corporation by a Governor serving on the Board of Governors of this Corporation requires the Governor to act in the best interests of this Corporation, even if discharging that duty requires the Governor to support actions that might be contrary to the views, interests, policies, or actions of another organization of which the Governor is a member, or to the discipline of which the Governor is a member. Consistent with a Governor’s duty of loyalty, a person serving as a Governor of this Corporation does not serve or act as the “representative” of any other organization, and his or her “constituency” as a Governor of this Corporation is solely this Corporation and is not any other organization or its members.

The ABR approved an update to their bylaws on November 2, 2022 (available here), and they’ve finessed that bit by removing the bolded language above. It now reads:

It is the policy of this Corporation that the legal duty of loyalty owed to this Corporation by an individual while serving in the capacity as a member of the Board of Governors or Board of Trustees requires the individual to act in the best interests of this Corporation. Consistent with the duty of loyalty, a person serving as a member of the Board of Governors or Board of Trustees does not serve or act as the “representative” of any other organization, and said member’s “constituency” as a member of the Board of Governors or Board of Trustees of this Corporation is solely this Corporation and is not any other organization or its members.

So they’ve removed that choice verbiage requiring selling out radiology itself in the interest of the ABR: “even if discharging that duty requires the Governor to support actions that might be contrary to the views, interests, policies, or actions of another organization of which the Governor is a member, or to the discipline of which the Governor is a member.”

Good for them.

On a related note, in case you’re wondering, the composition of the “executive compensation committee” is unchanged:

Executive Compensation Committee. The Executive Compensation Committee will carry out the Board of Governors’ responsibilities for designing, managing and annually reviewing Executive compensation and the Executive compensation policy. This committee will consist of the President, President Elect, and at least one (1) additional member from the Board of Governors appointed by the President. The President will chair the committee.

As I mused in my previous post:

I love that the committee that handles executive compensation is chaired by the president and then attended by the president-elect and “at least one additional” presidential appointee. Good thing that a conflict of interest for the ABR is just when a Governor cares about something outside of the ABR.

Asking AI about AI in Medicine

12.06.22 // Medicine, Radiology

I had a brief chat with OpenAI’s ChatGPT about noise, radiology, and AI in medicine:

Human: Summarize the book Noise by Daniel Kahneman
AI: Noise by Daniel Kahneman is a book that examines how our minds work in a noisy, uncertain world. It dives into the cognitive biases and heuristics we use to make decisions with limited information, and explains how they can lead us astray. The book covers topics such as perception, intuition, and decision-making, and explores how noise and confusion can shape our lives and our thinking.

Human: How does the book argue that noise impacts radiology?
AI: In Noise, Daniel Kahneman argues that noise can have a major impact on radiology. He explains that radiologists are often subject to cognitive biases like confirmation bias and anchoring bias, which can lead them to make decisions that are not in the best interest of their patients. Additionally, he shows how noise can affect diagnostic accuracy and decision-making, making it harder for radiologists to provide accurate treatments and diagnoses.

Human: How could radiology address those limitations?
AI: Radiologists can address the limitations of noise in radiology by taking steps to reduce cognitive biases and increase accuracy. These steps include utilizing evidence-based decision-making, double-checking results for accuracy, and employing advanced imaging technologies such as computer-aided detection systems. Additionally, radiologists should strive to keep up with advances in medical technology and imaging techniques so that they can identify any noise or errors in their images.

Human: What are the current limitations in utilizing AI in radiology?
AI: Currently, one of the biggest limitations in utilizing AI in radiology is the potential for errors and false positives. While AI systems have the potential to be more accurate than human radiologists, there is still a risk that the AI system will miss diagnoses or misinterpret images. Additionally, AI systems can be costly to implement, and require significant computing power, which may not be feasible in many medical settings.

Human: What would be the easiest type of medicine to outsource to AI?
AI: The easiest type of medicine to outsource to AI would be administrative tasks such as scheduling appointments and completing insurance forms. AI can quickly and accurately complete these types of tasks, saving time and resources for medical professionals.

Even the machines think there’s some low-hanging fruit out there.

Hindsight in the Valley of the Normal

11.16.22 // Miscellany

From Nobel-laureate Daniel Kahneman’s Noise: A Flaw in Human Judgement:

More broadly, our sense of understanding the world depends on our extraordinary ability to construct narratives that explain the events we observe. The search for causes is almost always successful because causes can be drawn from an unlimited reservoir of facts and beliefs about the world.

[…]

This continuous causal interpretation of reality is how we “understand” the world. Our sense of understanding life as it unfolds consists of the steady flow of hindsight in the valley of the normal. This sense is fundamentally causal: new events, once known, eliminate alternatives, and the narrative leaves little room for uncertainty. As we know from classic research on hindsight, even when subjective uncertainty does exist for a while, memories of it are largely erased when the uncertainty is resolved.

Noise is a good book. It’s not an exciting book—though neither is Thinking, Fast and Slow for that matter—but it’s an important book. Bias is important, but human noisiness and our imperfect and very noisy systems are also important: Judgments (predictions, decisions) are hard to get right, and so much of the world’s punditry is just storytelling.

Doctors make dozens if not hundreds of little and big decisions every day. And I know that not only I am noisy, but I’m noisy in a variety of ways. A big part of my deliberate practice as it pertains to radiology is to try to limit how much noise distorts my decision-making and the quality of my reports.

We want to be not just good but consistently so.