Sunday, October 31, 2010

Purging the moderates

I was thinking the other day about something that I think has pretty important implications, and so I am going to write it down. There were many reasons why I voted for Obama in 2008, but one of them was particularly relevant for conservatives. I've always considered myself slightly right of center, but I had grown to be so disgusted with the Republican party that I considered electing Obama to be an important repudiation of those policies. I mean here we have the "party of small government and fiscal conservatism" turning a surplus into a deficit, expanding unfunded entitlements, engaging in reckless and often aimless foreign was precisely the opposite of what "conservative" means to me. And so I told many of my friends and family in 2008, especially conservatives - vote for Obama to show the GOP how disgusted you are with them.

The problem is that over the last two years the GOP hasn't learned the lessons that I wanted them to learn. They've simply gone after the easy solutions and talking points and avoided the tough questions. The real issue Republicans should be grappling with is how we can efficiently reform our health care can we reform medicare, can we privatize or reform social security? How can we moderate our foreign policy aims? These are all very, very tough questions. These questions would require very intelligent people to grapple with in an effective way. But instead of doing that, who do we have? Well, most prominently we have Sarah Palin.

She is a know-nothing, and she is a perfect metaphor for the entire GOP "revival" in the last two years. The new batch of tea-party Republicans know how to get votes by appealing to religion and xenophobia, but they have no real ideas. They've retrenched into the worst excesses of the Bush era but have learned none of the lessons of Bush's mistakes. They are going to waltz into power November 2nd, and suddenly realize how none of them has the intelligence or the political courage to even begin to come close to grappling with some of our serious problems. The most they will do is cut taxes for the wealthy and defund Obamacare - both of which will actually worsen our deficit woes. No doubt, it IS a big step backward. And this is NOT what I had in mind when I wanted to vote for Obama to teach the Republicans a lesson. They've learned all the wrong lessons.

Anyway, the main point of this article is this insight I had. I was thinking about how Mitch Daniels basically got the smack-down by the conservative establishment for proposing a value-added tax. A VAT or consumption tax would actually be a pretty effective tax because it would provide lots of revenue, could be manipulated to be progressive, but wouldn't penalize investment and saving. But anything with the word "tax" is anathema to today's conservatives, so Daniels got put in his place.

I was thinking to myself how sad it is that an entire political movement could have become so close minded and outright committed to group-think. But you know what? That is the exact same thing I thought about Democrats in 2005. I used to HATE reading progressive blogs because I found them nauseating. Anyone who so much as lifted a toe out of the accepted "party line" was immediately put back into place. I used to think that was such a great sign of intellectual weakness.

I suppose I haven't been alive long enough to really draw a correlation here, but maybe that is what parties who are out of power do. They retract into a shell, where they coalesce around their more radical ideas and shun anyone who speaks of compromise. Even when they are out of power, they become more ridiculous, more insular, and more radical. Which, intuitively, would make them STAY out of power if everyone voted like me. But I guess what they are doing is waiting until the party that is IN power screws up badly enough that they win it back by default. I guess thats the state of our political system.

This insight was oddly comforting.

Wednesday, October 27, 2010

How to fix rising health costs: ax physician pay?

This was the thesis of a recent blog post by Matt Yglesias, who I regularly read. Here how I responded in the comment section:


I feel the same way about Yglesias' crusade against doctors as I do about his crusade for the oppressed rights of division-1 athletes. Which is, he is technically correct, but I really feel like there are bigger fish to fry in the worlds of labor exploitation and health care, respectively.

For starters, fully 1/3 of all health care spending is administrative; step 1 should be working to reduce some of this awful inefficiency. Step 2 in controlling health costs for me would be to devise a payment system that rewards outcomes, not service. We would see staggering increases in efficiency, as physicians respond to incentives just like everyone else if working in a market system (which our current health care system is not). We would also, incidentally, see a corresponding natural reduction in physician compensation, in particular as procedure-based specialties take a hit when there ceases to be funding for pointless interventions which have no proven benefit. This will solve a huge amount of the problem of physician overcompensation by itself.

And there is of course step 3, step 4, et cetera of things we could do to improve our health care system. Way down on that list somewhere I might include "axing physician pay". You should keep in mind though that the US economy has more inequality than Finland in general. That is of course a bad thing, but it applies to all industries, not just health care. Is the right way to approach a systemic problem like that really to just target the high earners in one field in particular? I'd be much more in favor of a more progressive tax code with drastic educational improvements, college assistance, and other things that will help reduce inequality across the US economy as a whole.

By the way, when you write "axing physician pay" on your list, you also better put in provisions that also allow for state funding of medical school. There will need to be drastic increases in resident salaries, too. Medical school and residency will also need to be less rigorous (in most European countries residents don't work over 40 hours per week).

I am a fourth year medical student. I will finish with about $ 230,000 of debt. It has been a tough four years, but I feel fortunate to be in medicine. Next year, I am starting residency in general surgery. My residency will be 9-10 years long. 5 years for general surgery, 2 years for fellowship in oncology, and 2-3 years of research built in. I will be working 80-100 hours per week during the 7 clinical years. I will be making about 45,000 dollars in salary in compensation during this decade, which incidentally will be covering the best years of my life (late twenties through mid thirties).

And sure, when I come out I'll be making 250,000 starting off. Perhaps overpaid, although I don't know anyone who is going into general surgery in particular for the money. There are a lot of battles to be fought, Mr. Yglesias, and its annoying to see you almost in passing mention that there are all of these lazy doctors who don't deserve half the compensation they get...and all we have to do to fix health care is pay them less. I will be more than happy to join you in calls for axing of physician compensation once the other dozens of awful inefficiencies and exploitations of the system have been ironed over.

Thursday, October 21, 2010

Intern work hours

Maybe some people wonder why I don't spill my beans about the medical profession the way that I do about politics. Ultimately it comes down to what is a career and what is a hobby. Politics / economics / et cetera is a hobby for me, and I'm not making a career in it. Thus I feel no inhibitions whatsoever (as is probably painfully obvious) and say pretty much whatever I feel like. If I was currently pursuing a political career, you can bet that this blog wouldn't exist. When it comes to medicine, since I am such an amateur and anyway am attempting to build a career, input (I need to learn a LOT) is far more important than output (nobody in the medical profession cares about my opinion).

I will comment about the new law regarding intern work hours, however. Previous restrictions implemented in 2003 or so limited residents to an 80 hour work week. In the last few weeks, a new law was passed that limits interns to a 16 hour shift only.

My perception on the issue is this: certainly, there should be reasonable limits to how much residents work. I don't care what anyone tells me, I don't think it is sane or reasonable to expect a resident to regularly work over 120 hours per week. Although I do know those crazy times come and go periodically; even as a medical student I clocked approximately 110 hours one week (it was a big funny joke at the time, but would get old if continued for 5 years). On the other hand, residents should not be limited too much; in Europe they can't even work over 40 hours. Training will certainly be inhibited.

I do think the 80 hour week is a reasonable goal. I don't like the new law, limiting us to 16 hour shifts though. This will compromise continuity of care, which is important for learning. Also, working 16 hours straight is easy. I'm just hitting my stride at 16 hours. Working 24-30 hours straight isn't really hard either, even when not used to it. So I think the 16 hour limit was misguided. That really doesn't make anyone's life better.

Wednesday, October 13, 2010

Enjoy your right to drive a car

Google has been successful in designing cars that drive themselves. I've believed for years that it is a matter of time before the average person can no longer legally drive. Here is how I foresee the chain of events:

1. Automated cars come on the market

2. Automated cars demonstrate vastly superior safety record and reduced accidents.

3. Insurance companies will think to themselves, "why should we insure a manual driver when we know automated cars have a near-perfect driving record?" Insurance costs will skyrocket for manual drivers.

4. At some point there will be a lawsuit involving a manual driver who errs and kills passengers in an automated car. Manual driver will be sued and lose the case. At that point, there will be legal precedent for suing every person who drives manually and makes a mistake.

5. Manual driving is made illegal by new legislation, or becomes de facto prohibited secondary to high costs and vulnerability in court.

Think about it this way: we used to let people drive and drink alcohol, right? At some point we recognized that driving under the influence of alcohol is significantly more dangerous than driving sober. Therefore, driving under the influence is illegal. Nobody will insure you if you drive drunk. You can go to jail if you drive drunk. What happens when we find that driving manual is significantly more dangerous than letting the computer drive? Probably the same thing.

I look forward to this inevitable outcome, and you should too. There are tons of advantages to a fleet of automated cars:

-Smoother traffic. Computer models have shown that traffic jams are due to sub-optimal spacing between cars that cause slight fluctuations in speed; these fluctuations ripple backward through traffic and amplify. Automated cars would never have this problem.

-Less traffic in cities. At any given time, a large percentage of traffic in a congested area is represented by drivers who are circling and looking for a parking spot. The computers of automated cars could automatically located the closest empty spot and drive straight to it, reducing the overall traffic load. Alternatively, the car could drop the passenger off at the destination and then drive to a nearby lot to wait until the passenger needs pick-up.

-No need to stop at red lights. Automated cars could perfectly time passage such that we travel through intersections seamlessly from all ways without slowing down. This might be a little harrowing at first, I'll admit.

-Faster average driving speeds, since the automated driver won't make mistakes.

-More relaxed travel. Instead of fighting traffic and dealing with road raging psychos, we could catch up on our reading, watch movies, or nap.

-Tens of thousands of people won't die in auto accidents every year.

I will finish this with a funny college humor article: what if Google released Skynet?. FYI, "Skynet" is the sentient artificial intelligence in the Terminator movies that attempts to destroy humanity.

Wednesday, October 06, 2010

Emulating Jesus Christ by being absolutely nothing like Jesus Christ

I honestly wonder if people like this have read the Bible even a single time.

If someone wishes to be a religious leader, serve the God of Abraham, AND be politically active, there is a religion for that - Islam. Muhammad was the messenger of Allah and he was also politically active, therefore following his example would necessarily involve both.

In contrast, it is very clear from reading the New Testament that Jesus Christ was decidedly apolitical. There are no ifs, ands, or buts about it. If you asked Jesus Christ if he was voting for Pelosi or Boehner, he would say "no comment". A Christian pastor who is politically active is about as representative of Jesus Christ as Pope Urban II was when he ordered the Crusades.

Make no mistake, I am not evaluating the merits of a religious leader being a political leader. I am just pointing out what should be obvious facts: Jesus Christ was not a political leader, Muhammad was one. If a Christian religious leader believes that they should act in a political way, they should consider converting to Islam, since that religion is probably closer to their core philosophical beliefs than Christianity.

Saturday, October 02, 2010

Heinrich Heine in 1834

Yes, 1834.

"Christianity - and that is its greatest merit - has somewhat mitigated that brutal Germanic love of war, but it could not destroy it. Should that subduing talisman, the cross, be shattered, the frenzied madness of the ancient warriors, that insane Berserk rage of which Nordic bards have spoken and sung so often, will once more burst into flame. This talisman is fragile, and the day will come when it will collapse miserably. Then the ancient stony gods will rise from the forgotten debris and rub the dust of a thousand years from their eyes, and finally Thor with his giant hammer will jump up and smash the Gothic cathedrals.

Do not smile at my advice -- the advice of a dreamer who warns you against Kantians, Fichteans, and philosophers of nature. Do not smile at the visionary who anticipates the same revolution in the realm of the visible as has taken place in the spiritual. Thought precedes action as lightning precedes thunder. German thunder is of true Germanic character; it is not very nimble, but rumbles along ponderously. Yet, it will come and when you hear a crashing such as never before has been heard in the world's history, then you know that the German thunderbolt has fallen at last. At that uproar the eagles of the air will drop dead, and lions in the remotest deserts of Africa will hide in their royal dens. A play will be performed in Germany which will make the French Revolution look like an innocent idyll."