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What Money Buys

10.14.20 // Finance, Reading

From How to Think About Money by Jonathan Clements:

First and foremost, money buys time and autonomy. Secondarily, it buys experiences. Last, and least, it buys stuff, and more often than not, the stuff we buy makes us miserable.

Most people live their lives with these in the opposite order, but Clements is absolutely right.

You don’t have to be a FIRE-fanatic to realize that setting up your professional life, spending, and saving to optimize for number one is the winning strategy.

Simple Sabotage

10.12.20 // Miscellany, Reading

Simple Sabotage: A Modern Field Manual for Detecting and Rooting Out Everyday Behaviors That Undermine Your Workplace is a book inspired by a real World War II CIA field manual called “Simple Sabotage” that was written to help “guide ordinary citizens, who may not have agreed with their country’s wartime policies towards the US, to destabilize their governments by taking disruptive action.” You can read the declassified original document at that link.

It’s short and fascinating and much of it is timeless. Operationally, it functions as a “how-not-to” for creating an efficient organization. The CIA’s top 3 takeaways:

1. Managers and Supervisors: To lower morale and production, be pleasant to inefficient workers; give them undeserved promotions. Discriminate against efficient workers; complain unjustly about their work.

2. Employees: Work slowly. Think of ways to increase the number of movements needed to do your job: use a light hammer instead of a heavy one; try to make a small wrench do instead of a big one.

3. Organizations and Conferences: When possible, refer all matters to committees, for “further study and consideration.” Attempt to make the committees as large and bureaucratic as possible. Hold conferences when there is more critical work to be done.

These points were once felt to be a great way to sabotage Nazi Germany, but they seem to have been voluntarily taken up by most modern American businesses.

A good example from the book is the “obedient saboteur,” someone who—by doing exactly what he’s told to do—is actually making things worse:

This problem can be particularly acute in organizations with a culture of “continuous improvement.” Continuous improvement is a business philosophy created by W. Edwards Deming in the mid-twentieth century. This philosophy thinks of processes as systems and holds that if each component of the system constantly tries to both increase quality and reduce costs, efficiency and success will follow. But taken to an extreme, even continuous improvement can lead to sabotage.

One company we know had a call center manager driving his team to move from an average pickup speed of 1.4 rings to 1.2 rings. The division head asked, “How often do callers abandon us after only 1.4 rings?” “Almost never,” he was told. “Virtually no callers who actually intended to call us hang up before the third ring.” Yet the call center manager persisted in trying to ensure that all calls were answered more quickly each year. Why? Because getting the phones answered quickly was his job—by definition, quicker was better. He never thought to question whether he had crossed the threshold where process had overridden outcome. He had become one of the Obedient Saboteurs. If you asked him why he was trying to lower pickup times, he would tell you that faster pickup means improved customer experience. That’s true—but the threshold is three rings. Once you get below three rings, faster pickup times don’t continue to improve the customer’s experience anymore.

The problem we see, time after time, is that nobody bothers to go back and tell the call center managers of the world to go continuously improve something else.

To keep this kind of sabotage out of your group, step back and conduct a formal review of any continuous improvement programs you have in place. If they aren’t relevant anymore, pull the plug.

Also see: measure what matters.

To fight back, ask yourself:

What is the stupidest rule or process we have around here?

What are the three biggest obstacles you face in doing your job?

If you could rewrite or change one process or procedure, what would it be and why?

A lot of quality improvement isn’t real:

It’s adding clutter. It’s replacing content with process.

We should be just as ruthless when evaluating quality measures and metrics as we are with the fail points that inspire them.

Studying during residency

10.09.20 // Medicine

Here are some questions I received a long time ago about studying during residency:

  1. Do you have any thoughts on studying to become a better doctor?
  2. What and how do you study when not preparing for some fun standardized test?

The easy answer for the latter is that in our modern system of medical education and board certification, you’re always preparing for a fun standardized test.

But I think the real answer to both of these questions to make it about your patients as much as possible.

Approach

You should always consider a broad differential and use real patients as opportunities to consider and learn about alternative diagnoses. If you have the motivation, consider further broadening your differential or treatment considerations unnecessarily just to have a relevant excuse to learn more about given topics. Think “I know it’s not disease X, but what if it was?”

Grounding as much learning as you can with patient care will give you the broad foundation you need in your field to build on when new things come along. But on top of that, linking up the information you learn from resources and articles with real live patient memories gives that information more staying power and helps you fight against the forgetting curve.

In medical school, you are hyper-directed in the content you must master, though in many cases toward low-yield material and wasted energy. In residency, you have more leeway toward becoming an expert in things that will directly impact your practice.

Content

I think for many residents it’s generally difficult to “study” in the medical school sense of systematically sitting down with a book or resource without a test looming in the near future. You’ll have the in-service, which you can use as motivation for dedicated review and MCQ fun, but preparing for your patients/daily activities is something you can do continually and, when done aggressively, can cover a large fraction of the relevant material. You may find relevant book chapters helpful on occasion, but squeezing in UptoDate articles and occasionally reading their references, the infrequent Google Scholar/PubMed search, and reading up on the next day’s procedures/surgeries (or the equivalent for your field), are going to work well in general.

I do think that Anki style flashcards and question banks are still good tools. If you have rotations that contain relatively well-defined material, these may even be straightforward to consider and implement on a schedule. In radiology, for example, it’s pretty easy to (at least plan) to read a book on chest radiography and do the chest RadPrimer MCQs on a dedicated chest rotation.

You may need to give yourself a long-term curriculum to work through, whether that’s guided by a commercial question bank or just following the table of contents of a gold standard textbook.

The Crux

The real limitation here is time and energy. Residency is busy. Call shifts can be brutal, and by the time you recover, you’re on call again. You may have a spouse who needs support and children who deserve a parent. And people keep trying to dump boring research projects on you. Sometimes, something’s gotta give.

But what I would say is that you’ll be more able to learn efficiently if your outside-work-life is harmonious enough that you can be fully present for your daily work. That part is almost non-negotiable. So before you guilt yourself for not studying enough at home, make sure you’re doing the things that you need to in order to recharge your battery to be a thoughtful physician for your patients. The trite lines with all the burnout talk out there is that you need exercise, eat healthily, and spend time nurturing your meaningful relationships. And you know what? That’s probably a good start.

Most of the things that really have an impact will come up as you engage actively with patient care, but some of the other BS will only come when its time to review for that next standardized high-stakes exam.

Ultimately, you caring about your patients as individual human beings and paying attention are the two most important things you can do to provide good care and to learn.

Status Quo Bias

10.07.20 // Miscellany, Reading

From Machine, Platform, Crowd: Harnessing Our Digital Future by Andrew McAfee and Erik Brynjolfsson:

Research in many different fields points to the same conclusion: it’s exactly because incumbents are so proficient, knowledgeable, and caught up in the status quo that they are unable to see what’s coming, and the unrealized potential and likely evolution of the new technology.

This phenomenon has been described as the “curse of knowledge” and “status quo bias,” and it can affect even successful and well-managed companies.

There are a lot of bad actors in healthcare that I would love to see fall prey to the curse of knowledge.

When “value” became shorthand for “economic worth”

10.05.20 // Reading

From Doughnut Economics: Seven Ways to Think Like a 21st-Century Economist by Kate Raworth (emphasis mine):

Despite such misgivings from the twentieth century’s two most influential economists, the dominance of the economist’s perspective on the world has only spread, even into the language of public life. In hospitals and clinics worldwide, patients and doctors have been recast as customers and service-providers.

There may be no perfect frame waiting to be found, but, argues the cognitive linguist George Lakoff, it is absolutely essential to have a compelling alternative frame if the old one is ever to be debunked. Simply rebutting the dominant frame will, ironically, only serve to reinforce it. And without an alternative to offer, there is little chance of entering, let alone winning, the battle of ideas.

But when political economy was split up into political philosophy and economic science in the late nineteenth century, it opened up what the philosopher Michael Sandel has called a ‘moral vacancy’ at the heart of public policymaking. Today economists and politicians debate with confident ease in the name of economic efficiency, productivity and growth—as if those values were self-explanatory—while hesitating to speak of justice, fairness and rights. Talking about values and goals is a lost art waiting to be revived.

I love that.

And the example of healthcare I think is exactly right. Everything is a business—that’s unavoidable. It isn’t even a bad thing. Lose money and you won’t be in business very long. But not all businesses need to be organized with the primary purpose of optimizing productivity and growth.

Good patient care is inefficient. Talking to people—understanding their perspective and helping them become active participants in their health—takes time. A patient visit was never meant to be an assembly-line 15-minute med check.

It’s not that we should applaud or celebrate inefficiency. There is plenty of waste to trim in any enterprise. It’s that these ideas—efficiency, productivity, and growth—should be tools to achieve meaningful ends, not the primary endpoint. Measure what matters.

And if some of that extra “value” makes it to the actual workers? Much of our economy is predicated on individuals misallocating their income away from savings and away from optimizing their time:

As economist Tim Jackson deftly put it, we are ‘persuaded to spend money we don’t have on things we don’t need to make impressions that won’t last on people we don’t care about’.

ABR & Guessing the Cost of a Lawsuit

10.01.20 // Radiology

All non-profits have to file a Form 990 with the IRS detailing their finances. The ABR’s 990 says “THE BYLAWS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST.” I’ve already read and discussed the bylaws, but I thought I’d ask for the financial statements. Two emails went unanswered, but after I asked publically on Twitter I got a polite and professional email within a day.

Unfortunately, the statement I received was a broad profit and loss statement even less detailed than the 990. I’m not going to lie, I was really hoping they would send me something more granular that would further break down categories like travel to get a feel for how the ABR really operates. Travel expenses would likely include paying for coach airfare for volunteers to come together for question writing committees and the magical Angoff process, but they might also contain expenses related to annual getaways to Hawaii for the board. I don’t begrudge a working vacation, but big categories undeniably make it difficult to evaluate financial stewardship. Trolls on the internet talk a lot of smack about the ABR’s supposed largesse, but all we’ve really seen is a generous chief executive salary, a large pile of money in reserve, and some broad expense categories that I’d love to drill down. Large boxes hide their contents.

But since we can’t break down the big boxes, we may never know details the radiology community is interested in seeing. One recent example would be, how much is the ABR paying to fight off that class-action lawsuit?

The best we can do is a wild guess because all “legal” expenses are a single category in the ABR’s publically available tax documents (most recent filings are available on Guidestar).

Legal fees according to ABR Form 990:
2011: $57,280
2012: $70,811
2013: $78,271
2014: $114,563
2015: $44,776
2016: $48,703
2017: $45,439
2018: $25,294
2019: $119,445

We can see that earlier in the last decade, the fees were all over the place but mostly in the high five figures with exception of 2014. We then had several years in a row of lower numbers, primarily in the $40k range.

The initial complaint in the class action ABR lawsuit was filed on February 26, 2019, and the case is still ongoing.

The reported legal fees in 2019 were $119,445.

The average of the preceding 4 years prior to 2019 was $41,051.

If the costs of the lawsuit were responsible for the difference, that would be approximately $80k to fight the lawsuit in 2019 over 10 months. Is all that excess actually the lawsuit? Who knows; I don’t think they were sued in 2014 and that was a pricey year as well. Some likely additional one-time fees that I can think of like trying to deal with the legalese debacle of the ABR agreement earlier this year won’t appear until the 2020 Form 990 that will be filed next year. But we definitely have an upper bound.

The ABR’s legal counsel has filed three motions dated 6/27/2019 (54 pages), 03/13/20 (54 pages), and 07/21/20 (26 pages). It would seem likely that the overall cost will be at least double the 2019 amount if not substantially more. Just extrapolating on page count would put the estimate at $200k so far (though I would venture the research for the initial motion to dismiss would have taken longer and cost more).

While the case seems destined for dismissal, certainly an actual trial would increase costs exponentially. These lawyers presumably don’t charge for value like radiologists; they charge for time.

In 2019, there were (according to the ABR) approximately 31,200 diplomates paying for MOC (the very thing the lawsuit is about). Our very broad completely unscientific estimate would therefore suggest that each MOC-compliant radiologist, through their annual fee, paid about $2.50 in 2019 against their own interests (depending on whose side you take), which is less than 1% of their dues and which is, if we’re being honest, a trivial sum.

If the judge dismisses the current amended complaint and the case is subsequently dropped without further back and forth, then a non-grandfathered MOC-radiologist might expect to have contributed the equivalent of a beverage of indeterminate size and composition to support the ABR’s hegemony.

Anger and Outrage: Features, Not Bugs

09.29.20 // Miscellany, Reading

From Cal Newport’s Digital Minimalism: Choosing a Focused Life in a Noisy World:

The techno-philosopher Jaron Lanier convincingly argues that the primacy of anger and outrage online is, in some sense, an unavoidable feature of the medium: In an open marketplace for attention, darker emotions attract more eyeballs than positive and constructive thoughts. For heavy internet users, repeated interaction with this darkness can become a source of draining negativity—a steep price that many don’t even realize they’re paying to support their compulsive connectivity.

Encountering this distressing collection of concerns—from the exhausting and addictive overuse of these tools, to their ability to reduce autonomy, decrease happiness, stoke darker instincts, and distract from more valuable activities—opened my eyes to the fraught relationship so many now maintain with the technologies that dominate our culture. It provided me, in other words, a much better understanding of what Andrew Sullivan meant when he lamented: “I used to be a human being.”

Doomscrolling is so insidiously toxic.

I am not a heavy social media user. I mainly use Twitter to make sure I interact with readers who use that medium and to share my newest articles. Since 2009, my main use of Twitter has been to publish other people’s tiny stories in Nanoism, an admittedly bizarre hobby and a largely one-way broadcast (@nanoism). I actively dislike Facebook.

And yet.

Sometimes I find myself scrolling and scrolling, clicking on a shared link to another depressing rantorial and then reading the awful comments from strangers on the internet who didn’t read the actual article acting out their respective caricatures. It all makes me wonder if humans are actually the creatures of morality and reason as argued by some philosophers. For most internet platforms, anger and outrage are features. Yelling at strangers on the internet is gold for companies that serve you targeted ads and profit from your attention. Everything is tailored for engagement.

One app I desperately needed when I was a student is Freedom, a service that allows you to block certain activities either on-demand or on a schedule. It would have saved me from a lot of my old internet demons. I should probably even turn it on more now, but I’m usually in a better place these days. Having young kids to soak up my time and attention has helped me hone my focus.

But Newport takes it a step further, and I think he’s right. It’s not enough to try to limit the damage of new technology or platforms on your life:

I’ve become convinced that what you need instead is a full-fledged philosophy of technology use, rooted in your deep values, that provides clear answers to the questions of what tools you should use and how you should use them and, equally important, enables you to confidently ignore everything else.

Many finance gurus talk about the need for all of us to have “Investor Policy Statements” or a “Written Financial Plan.” The reason being that if you don’t articulate a specific position, you may react inappropriately to the vagaries of life in a way that is counter to your goals. The plan keeps you honest and helps you deal with anxiety.

It makes sense to plot out “use criteria” so that you know if you should be incorporating the newest social media service that comes along and not just reactively picking something up because it’s popular.

Likewise, it makes even more sense to look critically at your use and see where the utility lies. You may not want to delete your Facebook profile or remove Instagram from your phone. Fine, right? But what—specifically—about using those services makes you happy, and what makes you angry, hurt, or jealous? And, knowing that, how can you structure some rules for engagement that can help you get what you want from the platform instead of letting it became just another automatic behavior?

 

Good ideas need to outlive the old guard

09.25.20 // Miscellany

Nobel-prize winning physicist Max Planck argued in his autobiography that change takes time because good ideas need enough staying power to outlive their detractors:

A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it…An important scientific innovation rarely makes its way by gradually winning over and converting its opponents: it rarely happens that Saul becomes Paul. What does happen is that its opponents gradually die out, and that the growing generation is familiarized with the ideas from the beginning: another instance of the fact that the future lies with the youth.

Clearly not always true, but it’s so broadly applicable a principle that it’s worth adding to your library of mental models.

Frozen Meat: A New Standard for COVID-19 Research

09.23.20 // Miscellany

As a physician, I mostly read medical journals. I also occasionally read economics and psychology literature, usually because they are frequently cited in popular books for laypersons.

But I don’t normally read business or communications literature.

That is until I saw this paper about frozen meat company Steak-umm’s surprisingly awesome Twitter account:

I haven't actually read this, but I can tell from the title it's better than most of the COVID-19 preprints I've seen in medical journals. https://t.co/ScgobNBfGn

— Ben White, MD (@benwhitemd) September 18, 2020

The title of the paper is too good to ignore. Anytime you can employ the phrase “frozen meat” in a way that only might be ironic is a communications victory from my perspective.

To give you an example of what the content Steak-umm generated to become worthy of intense positive scrutiny:

friendly reminder in times of uncertainty and misinformation: anecdotes are not data. (good) data is carefully measured and collected information based on a range of subject-dependent factors, including, but not limited to, controlled variables, meta-analysis, and randomization

— Steak-umm (@steak_umm) April 7, 2020

and then…

we're a frozen meat brand posting ads inevitably made to misdirect people and generate sales, so this is peak irony, but hey we live in a society so please make informed decisions to the best of your ability and don't let anecdotes dictate your worldview ok

steak-umm bless

— Steak-umm (@steak_umm) April 7, 2020

From “Frozen Meat Against COVID-19 Misinformation: An Analysis of Steak-Umm and Positive Expectancy Violations“:

To examine another possible factor contributing to the success of Steakumm’s response to the pandemic, we analyze the case through the lens of expectancy violations theory (Burgoon & Jones, 1976), which predicts how individuals will respond when others communicate in unexpected ways. Although expectancy violations can be positive or negative depending on the situation, research has shown that positive expectancy violations resulting in positive communication appraisals and outcomes can happen when publics are pleasantly surprised by an entity’s communication (e.g., Yim, 2019).

Sometimes beautiful, sometimes terrible—but it’s always an interesting world we live in.

RBG on Writing

09.21.20 // Writing

Former two-time law clerk for Ruth Bader Ginsburg, David Post:

Most of what I know about writing I learned from her. The rules are actually pretty simple: Every word matters. Don’t make the simple complicated, make the complicated as simple as it can be (but not simpler!). You’re not finished when you can’t think of anything more to add to your document; you’re finished when you can’t think of anything more that you can remove from it. She enforced these principles with a combination of a ferocious—almost a terrifying—editorial pen, and enough judicious praise sprinkled about to let you know that she was appreciating your efforts, if not always your end-product. And one more rule: While you’re at it, make it sing. At least a little; legal prose is not epic poetry or the stuff of operatic librettos, but a well-crafted paragraph can help carry the reader along, and is always a thing of real beauty.

Even paraphrased, that’s a satisfying approach.

When Ginsburg was in law school, she was passed over for clerkships literally just because she was a woman. Later she became one of the most influential justices on the supreme court while consistently applying the principles of equality and fairness to her jurisprudence.

American law didn’t just change during her lifetime, she helped make those changes.

What a legacy.

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