Coronavirus: The Hammer and the Dance

Another excellent follow-up from Tomas Pueyo about the need to stop doing half-assed mitigation measures.

On one side, countries can go the mitigation route: create a massive epidemic, overwhelm the healthcare system, drive the death of millions of people, and release new mutations of this virus in the wild.

On the other, countries can fight. They can lock down for a few weeks to buy us time, create an educated action plan, and control this virus until we have a vaccine [ed: or treatment].

Governments around the world today, including some such as the US, the UK or Switzerland have so far chosen the mitigation path.

That means they’re giving up without a fight. They see other countries having successfully fought this, but they say: “We can’t do that!”

We can do better together with decisive action and cohesive government intervention/support.

Humans are a communal species. While we need to be alone, right now, we should act together.

Maxims for Academic Medicine

Highlights from Joseph V. Simone’s “Understanding Academic Medical Centers,” published way back in 1999 (hat tip @RichDuszak):

  • Institutions Don’t Love You Back.

A wise colleague once told me that job security was the ability to move to another job (because of professional independence).

  • Institutions Have Infinite Time Horizons to Attain Goals, But an Individual Has a Relatively Short Productive Period.

There is little incentive for an institution to rapidly cut through the bureaucratic morass. An institution will always outlast a dissenting individual, regardless of the merit of the case.

  • Members of Most Institutional Committees Consist of About 30% Who Will Work at It, Despite Other Pressures, and 20% Who Are Idiots, Status Seekers, or Troublemakers.

Generous.

  • Institutional Incompetents and Troublemakers Are Often Transferred to Another Area, Where They Continue to Be Incompetent or Troublemakers.

They force others to pick up the slack or repair their mistakes, reducing everyone’s efficiency. If this continues for long, those who are consistently unproductive may become the majority because the competent learn that the institution sees no virtue in hard work and collaboration.

  • Leaders Are Often Chosen Primarily for Characteristics That Have Little or No Correlation with a Successful Tenure as Leader.

Examples of such criteria include a long bibliography, scientific eminence, institutional longevity, ready availability, a willingness to not rock the boat, or to accept inadequate resources. Choosing leaders is not a science, but it is surprising how often management skills, interpersonal skills, and experience are undervalued.

See: Academic Medicine & The Peter Principle.

  • In Recruiting, First-Class People Recruit First-Class People; Second-Class People Recruit Third-Class People.

Some hesitate to recruit a person who is smart enough and ambitious enough to compete with them. Others want a position filled at any cost because of “desperate” clinical need or other institutional pressures. If that approach continues for long, the third-class people will eventually dominate in numbers and influence and ultimately chase away any first-rate people that remain.

  • In Academic Institutions, Muck Flows Uphill.

Leaders often try to ignore or deflect the unpleasant mess, but the longer it incubates, the harder it will be to sanitize.

See: the dropped balls nationwide with current COVID-19 pandemic.

  • Personal Attitude and Team Compatibility Is Grossly Underrated in Faculty Recruiting.

A faculty member may be very productive personally but create an atmosphere that reduces the productivity of everyone else.

Annoying people are the black holes of camaraderie and joy.

Coronavirus & Distance

There have been lots of good articles about the novel Coronavirus and the embarrassing state of America’s public health response.

This one from Vox has some excellent charts.

This one on Medium breaks down some of the underlying relationship mechanics of social distancing measures and spread as well as how one estimates the number of hidden (but transmitting) cases in a population (which does require some assumptions).

Here’s what I’m going to cover in this article, with lots of charts, data and models with plenty of sources:
— How many cases of coronavirus will there be in your area?
— What will happen when these cases materialize?
— What should you do?
— When?

When you’re done reading the article, this is what you’ll take away:

The coronavirus is coming to you.
It’s coming at an exponential speed: gradually, and then suddenly.
It’s a matter of days. Maybe a week or two.
When it does, your healthcare system will be overwhelmed.
Your fellow citizens will be treated in the hallways.
Exhausted healthcare workers will break down. Some will die.
They will have to decide which patient gets the oxygen and which one dies.
The only way to prevent this is social distancing today. Not tomorrow. Today.
That means keeping as many people home as possible, starting now.

Important reading.

Fragmentation and the Family

Affluent conservatives often pat themselves on the back for having stable nuclear families. They preach that everybody else should build stable families too. But then they ignore one of the main reasons their own families are stable: They can afford to purchase the support that extended family used to provide—and that the people they preach at, further down the income scale, cannot.

[…]

For those who have the human capital to explore, fall down, and have their fall cushioned, that means great freedom and opportunity—and for those who lack those resources, it tends to mean great confusion, drift, and pain.

From conservative columnist David Brooks’ “The Nuclear Family Was a Mistake” in The Atlantic.

Even in medicine, we are seeing a disturbing trend. While the mean and median student debt are rapidly increasing due to high tuition rates, this is actually partially masked by the increasing percentage of medical students graduating with no debt. This suggests that a greater fraction of students come from means and have family support to cover medical school’s incredible cost. And those without that family support are either not getting in or are looking elsewhere.

It doesn’t stop at admission. These disparities and resource differences play out in specialty selection as well:

Over just a six-year period, the number of debt-free graduates almost doubled. And, overall, more competitive specialties like ophthalmology, ENT, urology, radiology have substantially more debt-free graduates than family medicine. Yet, we know we have a specialization problem in medicine. Free tuition at NYU isn’t going to change this massive headwind. The system needs retooling from far, far earlier.

Pass/Fail Step 1: Initial Thoughts

I was going to write a lengthy post, but then my medical education spirit animal Bryan Carmody did and said most of what I have time to say at the moment better than I would have anyway. Take the time to read it: USMLE Pass/Fail: A Brave New Day. He’s created an impressive collection of excellent writing about acronym fiends like the AAMC, NBME, and NRMP, and this is no exception.

This is a Brave New World. It will be a period of change, and it may very well be a rough transition. I know in this post-fact world we live in that people are cynical and want to cling to an objective measure. The system was flawed but in many ways predictable, and that comfort goes a long way. Students know what to expect. For those who put the time in and succeed, doors can be reliably opened.

Everyone’s concerns about shifting pressure to Step 2 CK, replacement by other likely useless metrics, elite schools, etc etc are all valid. A better future isn’t guaranteed, and Step 2 CK will certainly be the new default if it’s allowed to be (though even that would be an improvement since it’s a better test; I suspect it will become pass/fail within a few years as well).

But Step 1 is not good measure.

It doesn’t measure what matters, creates false distinctions across similar applicants, and may even select for some negative qualities. It’s turned medical school into an overpriced correspondence course and forced students to waste all of their energies spending more and more time mastering less and less useful material. None of our knowledge assessments from the MCAT to the USMLE to any of the board certification exams actually do what they are designed to do. And that’s a huge problem when we’ve absolved ourselves of meaningful holistic and true performative review and instead let a bunch of basically anonymous Angoff panels decide what it is a doctor is and does.

Arthur Jones of Proctor & Gamble once remarked that “all organizations are perfectly designed to get the results they get.” Well our system–from medical admission to MOC–is designed to get unsustainable negative results.

Schools and residency programs have a couple of years to figure out a more meaningful way to evaluate students and select residents. Pass/Fail Step 1 is a lit fire under everyone’s tushes. It’s not a solution; it just opens a door.