All posts by Peter

Chinese Anki decks now available for sale!

A while back, I wrote about my experiences learning Chinese as an ABC, sharing the trials and errors I’ve made along the way.  What started as a personal chronicle picked up steam as I’ve gotten numerous inquiries about best practices and in particular about the Anki decks I’ve created and continue to use to reinforce character learning.

Vocabulary building, along with immersion, is one of the most important steps in taking learning Chinese from a duty to a pleasure.  As with most languages, a little goes a long way – by the time you have your first 500 characters under your belt, you can recognize over 75% of the characters you’ll see on a daily basis.  Kick that up to 1,000 and you’re pushing 90%.  And using spaced repetition decks with Anki is the most effective way I’ve found to make new vocabulary stick.

Please email me if you have any questions or run into any problems.  There’s a lot of us out there trying to brush up our language skills, for cultural as well as practical reasons.  So I hope that this resource can be useful for our little community of Chineselearners.

Grab a sample of the deck here to get started, and the full decks are available for purchase here!

Elder Care, Now By Robot

I have some friends who are planning to homeschool their kids one day.  When I’ve asked them why, they said their decisions was not a slam against teachers – in fact, one of them was a teacher herself.  Rather, they felt that teachers are put in an impossible position, and education suffers as a result.  On one hand, teachers are charged with teaching every child to the best of their ability.  On the other, they’re given dozens of often rowdy students to manage and are mostly evaluated not by teaching quality but by the mounds of paperwork – lesson plans and so on – that dominate their evenings and weekends.  Each individual teacher might be a paragon of educational talent, but they’re working in a system whose goals are a combination of teaching, warehousing kids so they stay conveniently out of grownups’ way during the daytime, and doing the occasional heartbreaking bit of social work.  And so if you really want to educate your kids, the argument goes, you’re better off teaching them at home, where you can really make teaching the focus.

I’m not sure I totally buy that argument when it comes to schooling, but it definitely applies to nursing homes.  Our Lady of an Undisclosed Location is the hospital of choice for several nursing homes, and so even though I haven’t seen the inside of the local nursing homes myself, I began to build up a picture from the patients that they send our way, like an astronomer inferring the existence of a planet from the debris it drags along its orbit.

I was once taking care of a frail old woman who insisted on getting up to go to the bedside commode by herself.  Usually, we’d have the nurse help pull them to a stand and then walk them over to the commode, but because she insisted, we instead hovered worriedly beside the bed, ready to catch her if she started to stumble.  But I had to ask – why was she so insistent about this, of all things?  And the story she told went something like this.

Imagine you run a nursing home.  You want to take the best possible care of your patients, but the nursing home makes money from each patient they carry.  So of course the natural strategy is to expand your census until you’re just barely able to keep up with the patients you have.  As a caring human being, of course, you might not want to go this route.  You might want to just take good care of a smaller number of patients.  But you know that even if you don’t expand, your competitors will, and soon you’ll be out of business and unable to take care of any patients at all.

Imagine you work for Medicare.  You’re glad to see so many elderly people being taken care of, but you’re well aware of the temptation for nursing homes to cram in so many patients that they can’t take care of them all.  Now, for most normal service businesses, you might just let the market work it out.  Word of mouth would let people know which nursing homes to avoid, just like people learn to avoid bad restaurants.  But the sort of people who need to be in nursing homes are not, as a rule, the sort of people who are actively posting reviews on Yelp, so you decide to take matters into your own hands by creating quality metrics to judge nursing home performance.

Now, one of the worst things that can happen to an elderly person is a fall.  As people age, their bones become more brittle, and their ability to heal falters.  Of patients sent to the hospital after a fall, 40% never regain independent function, and 25% die within a year.  Now, it’s hard to tell someone living at home alone to never fall, but in a nursing home, where you have people supervising the patients at all times, it’s pretty reasonable to expect falls to be extremely rare.  So, you institute a new rule: every time someone falls in a nursing home, you dock the nursing home a good chunk of its pay.  Not quite as good as getting those Yelp reviews maybe, but having some quality metrics is a lot better than letting nursing homes run amok.

Except when we go back to the nursing home, we see the vast yawning gulf between the letter and the spirit of the law.  Oh, the law works – the nursing home is keen to prevent falls and avoid paying the fine.  If anything, the fear gets magnified each step down the chain of command.  If you’re a shift nurse, you really don’t want your patient falling on your shift.  It would mean no end of paperwork, having to explain yourself to your supervisor, and worst of all, getting that “friendly reminder” mass e-mail that doesn’t quite refer to you by name but nevertheless has everyone gossiping the next day.

So you are careful to prevent falls.  Very careful.  So careful that you hover anxiously around whenever patients try to get up out of their beds, and insist on carrying most of their weight when they do.  And so patients have to go through a whole process just to get up to go to the bathroom, and their muscles and coordination get weaker and weaker for lack of practice.

This may be a good point to mention that muscle mass is one of the strongest predictors of mortality in the elderly.  By overzealously preventing falls in the short run, we’re literally making our elders weaker and likely increase their overall mortality.

So, despite everyone acting in perfectly good faith, we have a system that makes nursing home residents less independent, less happy, and sicker in the long run. That’s why this old lady was so eager to do something as simple as try to get up by herself.  As soon as she was outside the watchful eyes of the nursing home, she wanted to regain some of the function that the well-meaning nursing home had drained from her.

But hey, at least the fall statistics look great!

There are other ways, too, that nursing homes managed to systematically fail in taking care of the elderly. For instance, a lot of patients in nursing homes are demented to various extents.  One way that we grade how demented patient is to assess how much they’re alert and oriented, or “A+O” in our shorthand.  If you’re A+O times 3, that means you know your name, where you are, and what year it is.  As people get older, they start to lose these abilities. First they forget about some faraway abstract facts like what year it is or who the president is. Then they lose awareness of where they are and how they got there. Finally, they forget even their own name, although they can still carry on conversations and attend to their own simple needs. And when you’re that demented, when you’re “A+O time zero,” the world becomes this terrifying place – you’re in a strange building, with no memory of how you got there. Strangers are around you all the time doing incomprehensible uncomfortable things to you. Understandably, some of these patients become quite agitated by this turn of events, which hardly wins them many friends among the nursing staff, and the story often ends with the patients sedated by medications with some pretty nasty side effects, just so the staff can take care of them properly. Again, it’s a sad situation, but it’s hard to really blame anyone involved.

Except that one of the simplest interventions to reduce delirium and improve quality of life for the elderly is to give them a predictable environment, preferably with familiar faces around them. It stands to reason that even a fairly confused old lady would still be comforted by being at home in familiar surroundings and seeing her children around taking care of her. But instead, we put them up in these dorm rooms, with antiseptic lighting, noisy roommates, and a new nurse at the end of every shift.  Once again, nursing homes full of caring and attentive staff members manage to be uncaring and inattentive in the most ironic way possible.

To be fair, taking care of old people is really hard. It demands time, attention, and patience, and to a large extent we as a society have decided that we don’t want adult children to have to carry the full burden of all that. I’m as much a free-market man as anyone else, and it makes sense that once we’ve decided to outsource the care of the elderly, we’d have groups of professionals that try to replicate these services, for a fee. This approach works for a lot of everyday life. I don’t want to change my own oil, so I pay my mechanic to do it. I don’t want to build my own bookshelf, so I run down to IKEA. But what nursing homes show us is that there are some services that simply do not survive the transition to the marketplace. A loving daughter taking care of grandma is qualitatively different from three shifts of nurses checking off the boxes from Medicare guidelines.

There is a philosophical puzzle called the Chinese room that goes something like this. Suppose we have a room full of books, each of which has a set of rules pertaining to Chinese characters. A man with no knowledge of Chinese goes into the room, and sits there. Once in a while, a slip of paper with some Chinese characters comes in through the mail slot. The man examines the paper, applies the rules in the books, and scribbles out some characters in response. It turns out that the man on the other side of the door is a Chinese scholar. And he thinks that he is having a very interesting conversation with his mysterious penpal. Now, the question goes, if the man in the room is doing nothing but following a set of rote instructions, can we really say that he “understands” Chinese? One answer to this dilemma is to say that no, the man does not understand Chinese but the room as a whole does. So while the inside of the room looks a little odd, from the outside, the room is a whole does have the emergent property of understanding Chinese.

Well, in a nursing home we have nurses following instructions from both the administrators of the nursing home and from Medicare. The nurses themselves don’t intrinsically care about the patients in the same way that a son or daughter would – it would simply be impossible to expect that level of emotional labor. Instead they want to go to work, get their work done, and go home, just like anyone else. The administrators know this, and try to write up rules and guidelines that would allow them to treat the patients the way you’d want an elderly parent cared for.  But unlike the Chinese room, even with the best crafted rules, the system demonstrably lacks the emergent property of caring for the elderly.

It would be nice if we could simply revert to the old model of taking care of their parents in multi generational households. But that’s not terribly realistic to ask of everyone. However, there is one area of elder care which I think works reasonably well: the visiting skilled nurse. The notion here is simple. Instead of moving grandma into an institution that takes care of all aspects of her care, the family manages most of the mundane stuff; feeding, conversation, taking walks – and a couple of times a week, a nurse comes by and takes care of the tricky stuff – bathing, making sure the medications are being taken correctly, wound care, and so on.  This, in the best case, is outsourcing done right – with the difficult portions farmed out but done under the supervision of the caring children.

But doing this requires both discipline and courage.  Discipline, because the children need to step up to take on some of the duties of taking care of their parents.  Courage, because in a world where convenience is prized and nursing homes are trusted institutions by family and insurance companies alike, it requires a level of courage to say that no, for some things, care by strangers is simply not the same thing as care by loved ones.  But as my homeschooling friends would probably say, when it comes to the welfare of someone like a child or a parent, the sacrifice is no sacrifice at all.  And so, as strongly as they argue for homeschooling your kids, I would argue in favor of home-care for your parents.

The Paper Chase

Back when Facebook was a new exciting thing, you’d have these outraged stories pop up once in a while, complaining about the way that Facebook kept changing their privacy settings, gave out their data to advertisers, and generally wasn’t that concerned about their privacy. The most cogent response I heard was that these users weren’t paying Facebook money, so they shouldn’t be too surprised that the company had to figure out how to find revenue elsewhere. “If you’re not paying money,” they said, “you are not the consumer. You’re the product.”

Well, when patients are in the hospital, they’re usually not the ones paying their own bills. And in many little ways, the way healthcare is set up really drives home the point that patients are not the consumer. The insurance companies are the consumers.  The patients are the products.

The simplest way to see this is just to look at how doctors spend their time throughout the day. The average day in a hospital looks something like this. I get in around 6:30 AM, get the report from the night intern about what happened with my patients overnight, and have a quick meeting with my resident about the plan for my patients that day. I then take an hour or so to examine all of my patients in person, giving them a little update on their status and our plans but spending no more than 10 minutes per patient. Most of the rest of the morning is then taken up with rounding with the attending (our senior supervising doctor), where we once again go over what we think is going on with each patient and what our plan is. Sometimes during these rounds we would actually go and examine some of the patients in question, but more often, we’d simply crowd around a computer or refer to our notes, and just talk about the patient as an abstract cloud of clinical data.

The entire second half of the day is spent in front of a computer. Some of this computer work is part of patient care – keeping an eye out for a crucial lab result, or pulling up an x-ray that was just taken. But mostly, what we’re doing is documentation. Reams and virtual reams of documentation.

In the old days, documentation meant simply scribbling a couple lines on a clipboard at the foot of the patient’s bed. Maybe something like “Bobby, 30 yo M, here with pneumonia.  Continuing IV penicillin (or whatever they used back in those days), appears to be responding.  Will observe for improvement.”  They’d mention any additional orders for the nurses, and move on.  Then as now, doctors were always in a terrible hurry, which is where we got the stereotype of doctors’ terrible handwriting. But each of them had a dozen patients or more apiece.  No matter how fast they scribbled, all this documentation might take a whole hour out of their day.

Nowadays, of course, technology has advanced, and most of our documentation is done on the computer. And with this great leap forward in technology, we call it a good day if we get our notes done in three hours.

What’s in all this documentation?  Well, it’s not the important clinical data – vital signs, lab results, and so on.  Those are recorded by nurses and lab techs – left in much more careful hands than ours.  Rather, what we spend our time on is the paperwork that ensures that the hospital gets paid.  As before, this includes brief reports like the update on Bobby the pneumonia patient.  But it also involves documentation with much less clinical significance – things like a mandatory review of ten organ systems (“Oh hi there Mr. Heart Attack Guy, just for billing purposes, have you had any skin rashes since last night?  Problems urinating?  Anxiety or depression?”) and exquisitely worded diagnoses corresponding to the official ICD-9 table.

These little details mean big money for the hospital.  If a patient comes in with heart failure, and we notice an unrelated ulcer in his buttocks, that nearly doubles the amount the hospital can bill the insurance company.  And so hospitals naturally throw a ton of resources at making sure that every last box gets checked.

This dynamic is also what’s driving the adoption of hugely expensive electronic medical records.  You see, the most part, EMRs are heavily optimized for billing.  Yes, the idealistic talk about electronic medical records revolves around nice-sounding things like improving hospital workflow, having better access for research, and making information portable between hospitals.  But in reality, DOS-level user interfaces abound, many EMRs are inaccessible for research purposes, and almost none of them let you easily take your information to another hospital.  But the one thing that every EMR worth its salt has done is improve compliance with insurance regulations, with hard-coded forms that ensure that every last insurance requirement gets met.  And for that, hospitals are willing to pay whatever it takes.

Back when I was in medical school, Duke signed a contract to purchase Epic, one of the most advanced EMRs, for $700 million.  Now that’s a lot of money, much more than an impoverished resident is used to visualizing.  To put that in perspective, SpaceX, a private rocket company currently sending supplies to the ISS and hoping to send astronauts soon, was founded with an investment of $100 million.  So for what Duke paid for that EMR, you could go to space – seven times over.  And I have every expectation that that was a totally reasonable expense compared with how much Epic will help the hospital improve its billing in the coming years.

But even after this expense, the game is still not done.  Hospitals also hire roving clinical documentation specialists, who virtually peer over our shoulders like English teachers marking up our papers with red ink.  We’d get emails politely inquiring “That patient with heart failure, could you specify whether it’s systolic or diastolic heart failure?” “That patient with a pressure ulcer, could we give a specific grade of pressure ulcer?” Now, to be fair to the documentation specialists, most of their corrections are relevant, and sometimes they’re even clinically meaningful.  But some of them end up sounding hilariously bizarre to medical ears.  I once received a call about a patient whose kidneys had failed and was on dialysis, asking me to specifically “document the extent of her kidney injury” (“Uh, complete and total kidney failure…which is why she’s on dialysis?”)

And for each bit of bureaucracy the hospital adds, with the goal of eking a bit more money out of the insurance company, the insurance company has an equal and opposite piece of bureaucracy, with the goal of denying payment to doctors and hospitals.  Sometimes these denials are for good reason, such as noting that a procedure was unnecessary or that care was substandard.  But often any excuse would do when it comes to saving money.  Some insurance companies throw up clouds of paperwork that need to be done every time an expensive test is ordered, hoping to discourage doctors from ordering those tests for fear of wasting time on that paperwork.  When there’s conflict over whether a procedure should be reimbursed, hospitals and insurance companies alike hire physicians as consultants to help them argue their case.  Like the trenches of WWI, both sides bring incredible resources to bear, and yet the front never moves.  And as residents we just do our duty and try to keep our heads down.

It’s worth emphasizing here that I’m not criticizing doctors or even hospitals for being callous money-grubbing businessmen.  All this effort is absolutely necessary to keep the lights on and be able to continue treating patients who need medical attention.  In fact, it’s a strong endorsement of the ethics of the medical profession that doctors care for patients as well as they do, given the high stakes of the distracting paperwork game.  We still check in on our patients daily, comfort them and address their concerns, and spend considerable time agonizing what treatment would be best for them.  None of this behavior is economically optimal, but we do it because we care.

Still, on a good day I get to spend maybe 20% of my time face to face with patients.  I wouldn’t be surprised if they secretly suspected we all go out golfing in the afternoons.

Dude, where’s my hover-gurney?

Star Trek Into Darkness came out when I was in med school, and so like a good little geek I went with some friends to go see it.  The movie was entertaining enough, but for my fellow med students, the best part had nothing to do with spaceships and lasers.  It was a brief scene near the beginning, set in a futuristic hospital.  The building was a glass and steel tower and the doctors were carrying tablets, but the real gee-whiz gadgetry was the hover-gurneys floating in the background as orderlies carried patients from place to place.  As soon as we got out of the movie, we turned to each other excitedly: “Did you see the hover-gurney?” “Neat, hover-gurneys!”  But to me, the hover-gurney was more than a cool prop – it was, probably by accident, a perfect encapsulation of how healthcare adopts new technology.

Think about it.  Let’s say you had all of this miraculous technology.  You’ve got robots with practically human intelligence, teleportation, let alone whenever advances in genetics and nanotechnology they’ve invented.  Imagine how different the hospital would look if instead of having to do a operation, you could just teleport out a tumor.  Or if you could program a nanobot to sweep out a patient’s coronary arteries.  When it comes to moving patients from place to place, you could teleport patients to their destination, getting them there in perfect comfort.  Or maybe you could have robotic gurneys, eliminating the need to have an orderly whose job is just to push patients around all day.

Instead, what we saw on the screen was a hospital that simply swapped out one technology (wheels) with a slightly superior technology (antigravity) while leaving the rest of the process exactly intact.  I don’t know if the producers had a healthcare consultant on staff, but that scene was a great illustration of how healthcare tends to react to change.

Take a doctor from 1900 and transport him to 1960 and he wouldn’t even know where to begin.  In that interval we developed antibiotics, chemotherapy, x-rays, and the modern medical school curriculum.  Life expectancy in the US increased by over twenty years.  Since then, progress has been much more incremental.  Our chemotherapy is more refined, and we’ve developed a few less invasive surgical techniques.  But take a doctor from 1960 and transport him to modern times, and after little studying and a lot of computer training, he’d be ready to get back into practice.

Why the slowdown?  In part, you might chalk it up to low-hanging fruit.  Going from “no antibiotics” to “antibiotics” is a huge leap, one that’s hard to replicate by, say, developing a next-generation antibiotic that happens to have a couple fewer side effects.  But to a large extent there are also active forces that make it harder to incorporate technology.  Many a promising idea using proven technology has failed to revolutionize the clinic, because it somehow failed to navigate the institutional incentives towards becoming accepted into daily practice.  Let’s take a closer look at four promising technologies.  Two of them have successfully been adopted within healthcare.  Two of them failed to make the grade.

Back when doctors still scribbled on paper charts, there were two great ideas about how the computer might revolutionize medicine.  The first was the electronic medical record: basically taking the same documentation that doctors did and putting it into a computer so it can be searched and accessed anywhere.  The second was the expert systems: designing computer algorithms that could diagnose patients on their own, replicating the thought patterns of clinicians when they first hear about a patient.

Recently IBM’s Watson wowed the world by beating Jeopardy contestants, and there’ve been some exciting news stories about using the same system for medical diagnosis.  But in fact even as early as the 70s, researchers have developed “expert systems,” computer programs that can diagnose as well as fully trained doctors.  INTERNIST-I was a general purpose diagnostic system at the University of Pittsburgh, Stanford’s MYCIN system beat out infectious disease specialists in diagnosing infections and recommending antibiotics.  These proven technologies had a ton of potential – just imagine having expert diagnostic talent deployed in third-world countries, or having a computer system double check your doctor’s work to reduce medical errors.  And yet, while the electronic medical record has taken off, these expert systems were never deployed in clinical practice and remain mothballed in academic labs.

Why did EMRs get adopted while expert systems languish in obscurity?  A big part of the answer is that EMRs fit slid neatly into an already-existing niche in a hospital’s workflow.  Instead of writing a paper chart, doctors and nurses typed the same stuff into a computer.  There was no need to change any other part of the process.  As time went on, EMRs started to be increasingly optimized for billing insurance companies.  They could then promise hospitals not just searchable medical records but also more billing revenue, and so installing EMRs increasingly became a no-brainer.

Expert systems, on the other hand, didn’t fit into a niche.  There’s no way that an algorithm would entirely replace doctors in practice – patients expect to see a comforting person in a white coat, and of course doctors would fight tooth and nail for their jobs.  So how would you integrate this system into the hospital?  The best you could do is use it as a double check on doctor’s judgment.  But busy doctors wouldn’t really have time for this delay, and no insurance company is offering to pay extra for computer diagnosis.  So even though in theory expert systems had a lot of potential to produce better decisions and deliver better patient care, its very disruptiveness prevented it from making any headway.  As Peter Thiel said, disruptive technology may be cool, but disruptive kids get sent to the principal’s office.

Our next set of case studies involves a different sort of computer-aided diagnosis – computer diagnosis of pap smears and lung cancer screening CTs.  Every woman between 20 and about 60 is scheduled for a Pap smear every couple of years.  This test, a screen for early signs of cervical cancer, involves interpreting a large microscope slide full of cells.  Today, almost every single one of the slides is read by a computer, with no human intervention at all.  At the same time, many elderly smokers are recommended to get a high resolution CT scan to look for early signs of lung cancer.  Interpreting this study means scrolling through many images of the lung on a CT, looking for small lung nodules.  But despite being a similar needle-in-a-haystack problem, almost nobody uses computers for this study.

Why is the use of computer aided diagnosis so different in these very similar cases?  Again, a lot of it goes back to history.  By the time computers came on the scene, it wasn’t doctors reading most Pap smears.  Instead, a trained technician screened all the studies – the vast majority were normal – and only passed on the really tough cases to the physician to read.  So the notion of having a pre-reading screening process was already well established.

Not only that, at that point in time, there was an undersupply of these technicians, and new work hour rules were limiting the number of slides that a technician could read in a day.  This became a real bottleneck in doctors’ ability to read lots of slides (and bill for the service.)  So when computer-aided diagnosis company started peddling their wares, doctors were eager to take them up on their offer.  The largest of these companies, Cytyc, was worth $6.2 billion when it was acquired.

For radiology, there’s no such tradition of pre-reading studies.  So adding a computer into the mix would represent a much bigger disruption of the workflow.  In theory, radiologists could adopt the same workflow as the pathologists and let computers pre-read the studies, letting them read faster and bill more.  But this would represent significant behavioral change, and there isn’t as much legal precedent to make them feel comfortable trusting their medical licenses to the computer.  There might still be a fortune to be made here, but the fact that it has not happened yet suggests that the barriers are a good deal greater.

And this is the overall sense I get when it comes to incorporating technology into healthcare.  If a new gadget neatly replaces an existing gadget, it’s adopted relatively quickly.  If it directly impacts the bottom line, such as EMRs offering hospitals better billing revenues, so much the better.  But true disruption – something that fundamentally changes the way medicine is done – is extremely difficult to sell, even if the technology works and the benefits could be enormous.  That’s why doctors are happy to carry around iPads but only a few are willing to Skype with patients.  That’s why radiologists were happy to swap keyboards for Dictaphones, but screening patients’ genomes is a niche pursuit.

In some ways, this conservatism is a necessity.  There aren’t many cowboy doctors left; the trend today is towards highly specialized medicine and enormous hospitals.  A solo practitioner might be able to tinker with new technology, but for something as complex as a large hospital, any disruption has huge ripple effects that administrators are eager to avoid.  And yet, there is an unfortunate side too.  A lot of the great advances in medicine – sterile surgery, radiation therapy, even the residency training process – were innately disruptive, with some doctors losing turf while others gained, and with everybody having to figure out how to deliver medical care in fundamentally different ways.  It seems no coincidence that the death of the cowboy doctor and the rise of bureaucratized medicine has come with a slowdown in medical innovation.  But savvy medical entrepreneurs still find ways to produce some innovations that can make patients’ lives better.  And one day, I hope, they’ll at least give us that hover-gurney, because that thing looked pretty awesome.

Frequent Flier

“Oh wait, I know that guy!”

My senior resident and I were catching up early in the morning, going over all the new patients that came in through the ER overnight.  I looked at the notes scribbled on my patient list: “41M, history of iv drug abuse, presents with fever/chills, WBC elevated, vital signs stable.”

My resident was already looking up his history on the computer, and sure enough, his name pops up a year ago – another admission to the hospital, about a week long.  “Yeah, I remember writing notes on this guy.  Same stuff, IV drug abuser, got an infection from his needles, gave him vanc/zosyn for a few days and he went home.  So it’s gonna be a pretty standard admission.  Fix him up, send him out.  He’ll be back soon anyway.”

“Great,” I say.  It’s never a good thing when your resident knows an incoming patient by name.  Oh, sometimes it’s harmless, a little old lady who comes down the flu every year or two.  But for the most part, people who keep coming back to the hospitals aren’t just suffering from bad luck, they’re doing something else wrong – not taking their medicine, or in this case, taking a bit too much medicine of his own on the side.

When I examine him, he looks barely sick at all – well built, sitting upright on his bed, cheerful and polite.  When I ask him about drug abuse, he admits to shooting up “a little more than is good for me.”  I smile and say “Well…you know that I’m going to say here” at which point he sheepishly grins and says “Yeah, yeah, gotta knock that off, I guess.”  With honor satisfied on both of our parts, I head out and start writing notes.

It’s a pretty uneventful couple of days.  We give him broad-spectrum antibiotics, and a few days later the blood cultures we drew in the ER come back positive for a species that the antibiotics can treat well.  So far so good.  But as the days go on, we notice a strange pattern.  Every few days, he’d spike a fever and have elevated white blood cell counts in the morning, which then quickly subsided by the next day.  At first we chalked this up a glitch in the lab, but by the second time we started getting suspicious. We were blasting him with antibiotics that should easily treat the infection he came in with, so why was he having relapses?

In the end, it was a diligent nurse rather than clever detective work from our side that uncovered the truth.  Overnight, our patient kept requesting pain medications, saying he was unable to sleep and that nothing but opioids helped.   The night intern, playing it safe, gave him a small dose of one of the weaker opioids, Percocet.  The patient said thanks and promptly stepped into the bathroom.  Fifteen minutes later, the nurse got suspicious, tried to open the door, and found that it was locked.  Negotiations ensued.  Eventually, it was revealed that the patient had chewed up his tablet of Percocet and spit it directly into his IV line, in order to get a nice short high rather than a slow release of pain relief.

In the morning, sure enough, he spiked a fever and had an elevated white blood cell count.  We drew blood cultures and found that he had started growing an exotic species of bacteria found only in the human mouth.  The next day, he had a heart murmur that he didn’t have before.  We consulted the cardiologists and as we suspected he had developed endocarditis – an infection of his heart valves – in spite of our antibiotics.  If the antibiotics weren’t going to do the job, he’d need surgery.  As the week went on, the murmur got worse and worse, and he started getting noticeably short of breath as the valve deteriorated further.  Finally, the surgeons said enough was enough, and took him in to get the valve replaced. Throughout these days, he remained unfailingly polite, kept requesting pain medications, and steadfastly denied that The Incident With The Percocet Pill ever happened.

This case was a memorable one, but a large fraction of the patients we saw did come in with conditions that were essentially self-inflicted.  The alcoholic who comes in to sleep it off for three days.  The cocaine abuser who presents with a cardiac arrhythmia from just having used cocaine.  The guy who passes out every time he smokes weed, who came in…after passing out while smoking weed.

But if taking drugs was one route to admission, so was not taking drugs that you should be taking.  Just down the hall from this patient was a woman coming in with an asthma exacerbation, her third admission this year.  And when I asked her what medications she’s been taking, she immediately mentioned that she hadn’t been taking her long-acting inhaler, the very one that is supposed to help prevent these flare-ups.  We’re not talking about forgetting a dose or two, we’re talking about flat-out not filling her prescriptions and not taking them.  When I asked why, I got the answer I always got: “If I don’t feel sick, why take these medications?”  She was happy to take medicines that help immediately solved her problems – she had no problem with taking a short-acting inhaler right when she got short of breath.   But if a drug didn’t give an immediate payoff, like a long-acting inhaler, then she didn’t see a reason to take them.  And multiple admissions to the hospital, and all the eloquence I could muster, couldn’t dissuade her.

Keep in mind, she was an otherwise normal woman, with a respectable job and two kids, and our conversation went fine as I explained the treatment plan while she was in the hospital.  But as soon as the topic turned to those long-acting inhalers, it was like running up against a glass wall: she believed me when I said that not taking them was one of the reasons she kept having to come to the hospital, but couldn’t wrap her mind around why she should take them after getting discharged.

This sort of conversation was mind-boggling when I first came across it.  It’s hard for me to imagine any of my friends intentionally letting a disease get out of hand through neglect – doctors proverbially make bad patients, but not that bad!  But one of the fascinating aspects of medicine is that it exposes you to a true cross-section of the population, and one of the bizarre realities you pick up is that this sort of elementary planning is foreign to a fair number of otherwise unremarkable people.

And health policy statistics agree.  There’s perennial debate about how much we should spend on end-of-life care for the elderly, with one side shouting “death panels!” and another pointing out that the last few days of life gobble up huge quantities of money. But what neither side mentions is that the majority of the high-cost patients are actually what they rather blandly call “non-elderly high spenders.” Take the top 5% of patients who incur the highest healthcare costs, and you’ll find that the majority are under 65.  And for people under 65, the spending is distributed incredibly unequally – almost half of the spending is done by just 5% of patients – like our IV drug abuser and our asthma patient. The debate over end-of-life care for mortally ill patients is an important one, but it overlooks the cost of these younger patients, who are merely irresponsible. The former question rouses passions; the latter just feels kind of sad and intractable.

And it’s not as though we aren’t moving mountains to prevent readmissions.  Frequent readmissions carry huge financial penalties for a hospital, and so our hospital administrators are as frustrated by the problem of frequent fliers as doctors are.  So we have all sorts of initiatives to help these patients get back on track.  We gave the asthmatic lady bucketloads of free medications and meticulously demonstrated how to take them.  We carefully write up prescriptions for any conceivable medical equipment they need so that they won’t have to pay much out of pocket.  We staple printouts explaining the same concepts in simple language.  We even offer to send home care nurses around to reinforce the lesson at home in a few weeks.

And, well, all of these are good things to do, and I’m sure some patients on the margin benefit from all this.  But ultimately, it all still relies on our patients’ willingness to take their medication, and if they don’t want to, we can’t make them.  So we give them a bag of medications, declare them fit to make their own medical decisions, and wait expectantly for their next admission a few months from now.


Stanton, Mark W., and M. K. Rutherford. The high concentration of US health care expenditures. Washington, DC: Agency for Healthcare Research and Quality, 2006.

Where’s the Baby?

Every morning the hospital, we have a big meeting with all of the residents, nurses, and attendings from the entire floor. The ostensible reason is to make sure that everyone was on the same page about which patients are ready to go home, and to make sure that all the boxes are appropriately checked before they do so.  In reality, I suspect that at least half of the reason is so that Dr. Khan, who runs the meeting, can review the troops, drill sergeant style. It’s a very formal, spit and polish affair, everyone decked out in white coats, standing around the largest nurse’s station, the only one large enough to accommodate the two dozen people who show up.

“All right, let’s get started. Room 401,” comes Dr. Khan’s crisp voice. One of the interns straightens up, takes half a step forward, and reports “This patient came in for a stroke workup, CT and MRI were negative.  We’re awaiting the results of the echo, and once we have that back as well as a PT evaluation, they shall be ready for discharge.”

“All right. Call the cath lab and make sure the patient’s on the schedule today.”


“PT, you’ll be able to see this patient today?”

The physical therapist, a grizzled veteran of the hospital, barely leans up from his paperwork and says that yeah, he’ll see the patient this afternoon. He, of course, is outside the medical chain of command and has nothing in particular to fear from Dr. Khan, and always seems quietly amused by these proceedings.

And on it goes to room 402. It someone else’s time to jerk to attention, and God help you if you miss your cue even by a couple of seconds. The whole thing takes about 45 minutes, and it’s just one of those things that you grin and bear as part of the job.

One day, we got a call from the ER that we were admitting a patient who was sent to the hospital from a nursing home for “altered mental status.” This is a pretty broad symptom that includes anything from a little forgetfulness to confusion to being in a coma. And usually, you need to take a very careful history and to identify exactly what has changed recently, and what might be causing it.  Ideally we’d also ask her family members, because they have the best sense of how the person’s thinking has changed over time

In this case, though, it wasn’t exactly a mystery. As soon as he walked into the room, she started shouting “Where’s the baby? WHERE’S THE BABY?” and wouldn’t calm down for another five minutes.

Well, we had our mystery, and we immediately started to do the medical workup for altered mental status, which is pretty extensive. A lot of things can cause this sort of presentation, anything from a stroke to an infection to a psychiatric disorder. (You’d be surprised how often elderly people develop new mental illnesses – it’s not just a young person’s disease.)

Ultimately, both the CT and the MRI were normal, which pretty well ruled out stroke. The blood cultures were negative for any infection, but we had been treating her with antibacterial and antiviral medication just in case. The hospital’s psychiatrist got wind of this case and paid her a visit one afternoon. I’m not sure what exactly they talked about, but he slunk out of the room less than five minutes later, gave a long, multisyllabic sigh, grabbed the chart and wrote “please rule out medical causes and re-consult psychiatry as needed.”  Translation: “your patient – your problem.”

While all of this was going on, she was sitting outside the room, accosting anyone who’d walked down the hall with more questions.  “Where are you going?  Come back here!  WHERE’S THE BABY?” Usually this was just an occasional annoyance, something you’d chuckle uncomfortably at and laugh off as you walk past. But the one time we couldn’t avoid it was during Dr. Khan’s rounds. Every morning we’d start filing into the hallway around the nurse’s station, right in front of her room, and you could see her eyes widen as the hallway outside her room filled with a sea of white coats. As the last stragglers filed in and the hallway fell to silence, Dr. Khan would clear his throat and start, “Okay, let’s get started. Room – ”


Her self-control, never that great to begin with, would give way. A nurse would rush over to her chair and try to calm her down and after a minute or two she would be pacified enough for us to continue. And another minute or two later, when some poor intern’s in the middle of getting grilled, she’d burst out again.  “WHERE’S THE BABY?”

Dr. Khan gave us a look. It wasn’t an angry look, or even a frustrated one. It was an incredulous look – “wait, patients can actually do the sort of thing? On my rounds?” It was all we could do to keep from bursting out laughing.

Ideally, once we’d ruled out the most common culprits, we’d want to get a lumbar puncture – a spinal tap – to retrieve a sample of the fluid in her spine and brain to make sure there is no infection there. But she was incredibly anxious, and would start hollering and thrashing around as soon as you spoke to her, so sticking a needle in her back was not exactly going to be a simple operation.

First we chased down the neurologist, who routinely performs this procedure all throughout the hospital. With our best pretty-please-with-a-cherry-on-top voice, we gently suggested that at this point in the patient’s workup, might it be a reasonable time to consider getting a lumbar puncture in this patient? The neurologist adjusted her glasses, looked us up and down a couple times as though wondering if we were the ones presenting with altered mental status, and said “gentlemen, with the way she is thrashing around on the bed, I really don’t feel comfortable doing a procedure at this time.”

Next, we called interventional radiology, where they have special expertise in doing these minimally invasive procedures. But when we tracked him down and told him the story, he took a deep breath and said “look, we really don’t just want to be the LP guys for the whole hospital. Try anesthesia first, and if they can’t do it, then get back to me.”

By this point it was getting late in the afternoon and I was getting pretty desperate.  I wasn’t even sure if the anesthesiologist was still there in the hospital, and if we couldn’t get this LP, there was no way we’d ever be able to send this lady back. The nursing home representatives would come out, take one look at her, and say “Wait, so you’re telling me that you gentlemen with your fancy degrees and white coats that only can’t fix her, but didn’t even do a complete workup on her?” Then they have a stern word with Dr. Khan, and Dr. Khan would have a stern word for me, and I’d spend the rest of the year mopping the floors, which wouldn’t be so bad, really, if not for the fact that every time I walked by her room I’d trip over my own feet when she let loose with another “WHERE’S THE BABY?”

But no, fortune was with me, and after a few minutes of phone tag I managed to get ahold of the anesthesiologist and breathlessly explain our plight. I waited with bated breath, but after a few minutes all he said was “okay, bring her down.”

The art of getting a patient into an elevator when she’s thrashing in a wheelchair, hollering “WHERE’S THE BABY,” and occasionally grabbing at doorways and passersby, is not something they teach in medical school. It ultimately involves a great deal of reassuring, deflecting her grabs whenever possible, and even singing some soothing songs. By the time we got her down the hall and into the elevator I felt I’d both aged a decade and been forcibly inducted into the mysteries of fatherhood.

But we got her down there, and sure enough, the anesthesiologist was able to get the procedure done with minimal fuss. We sent the fluid down to the lab for analysis, and I headed home for some well-deserved rest.

The next day, before we could get any of the lab results back, we finally succeeded at another arm of the investigation: getting in contact with the patient’s daughter so we could let her know that her mom is in the hospital. I carefully explained her mother’s condition to her, and described all the medications that we started her on and all the tests that we’ve tried. I asked her if she had any questions.

“You’re doing all that for my mom?” she asked.

I smiled warmly.  In a time when patient’s families often expect us to work miracles, it felt really good to bask in the gratitude of a patient for whom we really had gone above and beyond.   “Yes, of course,” I said. “It is a bit of a challenge to take care of her, at least when she’s in the state, but all of us are really coming together to do everything we can to make sure she gets the best care. It’s really just part of the job, and she deserves nothing less.”

“But why all the tests?  She always acts like that.”

I suppressed the urge to swear.  So she didn’t have some incredibly mysterious infection. This was just normal dementia which she’s been having for years and years. Someone in the nursing home either didn’t get that message or decided to send her to the hospital anyway. All the work we did in the last week, and all that she had endured in the course of these tests, was chasing after a mirage.

I took several deep breaths. I thanked her for her time, promised to update her as things progressed, and told her to call us if she had any questions. Then I had a terse conversation with the nursing home manager. Later that afternoon, an ambulance arrived to take our patient back to the nursing home.

The only silver lining of this saga is that for the rest of the rotation, I could make my resident jump two feet in the air by creeping up behind him and shouting “WHERE’S THE BABY?”

I did not try this with Dr. Khan.

The City as Drill Sergeant

I recently got back from a road trip through New England with a friend.  The trip itself was fun – scenic drives, picturesque towns, and some beautiful remote hikes.  But one of the things that made the strongest impression on me happened the day before we left.

My friend had some business to take care of before we headed out, so I spent the afternoon strolling around Cambridge and Boston.  It’s a good town for walking, with handsome campuses interspersed with humbler neighborhoods of houses and shops.   That day, it was clear and unseasonably warm out, and the whole town turned out to enjoy the weather after a record-breaking winter.  Everywhere I went I’d see young, thin, well-educated people – a pretty different demographic than I’m used to in West Philadelphia.

On the subway I’d see students with their noses buried in books or Economist articles on their iPhones.  On the banks of the Charles I saw young couples strolling hand in hand, or lounging on the grass watching the antics of a group of boys on paddleboards in the river, who were whooping as they got splashed with frigid water.  In cafes I’d see small groups of grad students with heads together, talking animatedly over their beers.  And everywhere, there were the ubiquitous joggers, running from nowhere to nowhere in easy loping paces.

And as the afternoon dragged on, I noticed a little voice in the back of my head start saying things like “Hmm, I wonder what that gaggle of students is working on?  What’s that guy learning about right now?  How did that couple meet?  Hmm, maybe I should swing by the gym myself,” and so on.  Nothing terribly obtrusive, but just a tiny low-level paranoia that I was missing out on some important improving experience that these other people around me were taking advantage of.  It was a funny feeling that I hadn’t really encountered except for back when I was in college.

But when I sheepishly mentioned it to my friend, he immediately recognized it and said that he felt it all the time, walking around the campus of business school and seeing other highly competent people going about their business.  And really, it was no bad thing.  This brief experience did, in fact, inspire me to hit the gym more seriously once I got back, and to bang these musings into essay form on the flight back home from Boston.  Certainly, I could imagine it growing into oppressive insecurity if it were stronger, but on the whole it resembles exercise – a hormetic stressor that makes you stronger.

Paul Graham wrote an essay about what messages cities send to ambitious people.  I suspect that something like this is the actual medium by which these messages get sent.  Nothing obvious, just a constant reminder that other high-level people are out there improving themselves, and that you’d better keep doing the same or else fall behind.  And this is what helps to produce both talented individuals and talented ecosystems.

Everything else is an epiphenomenon.  All the ads on the subway exhorting people to work for a company trying to cure cancer, or to go back to school to get on the cutting edge of robotics, the indie bookstores and small museums, even the tech companies that get started, fundamentally derive from the existence of smart people whetting one another’s appetites.  I didn’t notice its absence in Philadelphia, but I certainly noticed its presence in Cambridge.  I suspect that this feeling of “fire in your belly” is underrated as an ingredient in the good life.

Elasticity to innovation

I’ve been doing a book club with a few friends on The Idea Factory, a history of Bell Labs. I’ve previously written about this book, but in thousand ideas around it came across the concept that I hadn’t thought of before.

The obvious question that comes up when thinking about Bell Labs is “what made Bell Labs awesome, and what are the analogous institutions today?” Some of these factors are obvious. Bell Labs was most creative during the period when innovation information technology was one of the most dynamic fields of science; they were lucky because they picked the field that had a lot of low hanging fruit and which was not, in the end, regulated to death, unlike medicine and aerospace. They also had the benefit of recruiting a lot of top talent during a period when bright Midwestern kids were being recruited to places like Caltech MIT for the first time. In a previous article, I suggested that one hidden advantage was that Bell Labs had a very specific planning horizon that let it look farther than the next quarter but didn’t let it have its heads entirely in the clouds.

Another idea that came up, though, is the notion that Bell Labs also had a high “elasticity to innovation.” That is, the company was positioned in a way so that every innovation ended up having a large effect on the company’s bottom line.

There are two reasons why this is the case. One, which we’ve mentioned before, is that the company was a monopoly. There weren’t any phone companies of comparable size, and so that meant that there was no worry that any innovation they adopted would be quickly adopted by its competitors as well. If Dell adopted a new way to make computers, they’d only have a short window before HP did the same, but if you’re a monopoly, that by definition means you get dibs on the innovation forever.

In the second and more interesting reason is that this period of history is one where the telephone network was just beginning to really take off. Less than 10% of homes had a telephone, and this meant that the company knew that if they could improve the telephone experience, they were looking at a 10x increase in phone adoption and a 100x increase in call volume.  Innovation meant dollars, lots of them. And rather than taking innovation to be some magical, highly contingent process, we could think of it as something that responds to incentives, and appears only when it’s really needed.

This helps shed some light on why some monopolies are innovative and others aren’t. This is a question that I had struggled with earlier, and which Peter Thiel also touched on in his book Zero to One. Clearly, some of the really innovative companies have been monopolies, but lots of monopolies didn’t innovate much at all. I think that this notion of elasticity to innovation helps to explain the difference. If you are a diamond mine or the only bridge across the river, there’s no way for you to increase your revenue by 10x by adopting some new process. Your main asset is your location and monopoly status. Rationally, then, these companies would invest mostly in maintaining their monopoly status and exploiting their pricing power, giving relatively little thought to innovation. Only in its monopolies where you are creating the market as you go along, such as Bell Telephone or early airplane manufacturers, do you have a strong incentive to innovate. And indeed, we see that monopolies in these areas tend to be the ones that we think of as innovators.

This theory helps us make some predictions about which modern monopolies we might expect to be unusually productive. Companies like Microsoft for enterprise software or Google for search we wouldn’t expect to be extraordinarily productive, despite the monopoly status. However, the same companies may end up being innovative in different areas. Googles self-driving car, for example, is a case where the market, and by extension the company’s revenues, will only exist in as much as they were able to create meaningful innovation. Disruptive companies are innovative for the same reason; their market only exists in as much as they can wrench it from the control of incumbents. But there’s no special DNA in disruptive companies that will prevent them from being stagnant once they have become the kings of the hill.

This also lets us make some predictions in medicine. In this age of hospital consolidation, there are several companies, such as Kaiser and UPMC, which have local monopolies. By virtue of their location in consolidation, they basically have a lock on the medical care of patients in their geographic region. However, crucially, they can’t actually make a great deal more money by being better hospitals. Even if they came up with a new kind of robotic surgery, or reduce hospital infections in half, there’s only a limited extent to which patients would come specifically to them. And so, while I think it’s possible to see some process innovations from economies of scale, we wouldn’t expect explosive medical innovation to take root in these monopolies. On the other hand, there are some companies that are creating the market as they go along. This includes concierge physicians, which are trying to disruptively grab market share from established healthcare systems, as well as services like 23andme and Foundation Medicine, which are premised on creating entirely new markets for genomics and cancer diagnostics. Of course, we can’t predict whether or not these companies will succeed, but this model does predict that they have the incentives to make a valiant effort.

Personal finance for new residents

As a new resident, I was recently put in the funny position of going from negative income to positive income for the first time.  And so, just before the start of residency, I took some time to set up a personal finance system from the ground up.  Since starting residency, I’ve helped a few fellow interns sort out bits and pieces of their financial infrastructure, so I thought I’d write up my system, in case it’s helpful to future interns.

As a note, this is not a fantastic path to riches, just a simple system that works.  My philosophy in setting all this up is to set it and forget it – finding the optimal tool for each function, and then leaving it alone to work its magic.  After all, as busy residents, we don’t have time to keep tweaking and adjusting.  So it makes sense to do the homework upfront, set it up right, and set it on autopilot.

  1. Bank

The purpose of a bank is not a holding area for savings (that comes later).  The purpose is for it to be a simple funnel between paychecks coming in and payments (for bills, credit cards, and savings) going out.

For that purpose, online banks are significantly better than brick and mortar banks.  They let you write and deposit checks and have ATMs, all the functionality that I actually use, and they’re equally FDIC insured, so your money is equally safe.  But because they don’t have to pay for all the physical locations and staff, they have lower costs and can pass along some of these savings to you.  This means two things: slightly higher interest rates, and more importantly, no hidden fees.  Many other banks have minimum deposits or hidden fees; online banks tend not to, which makes them less of a headache to deal with.

I use Capital One 360 as main banking account; there are other good options as well, such as Ally and GE Capital.  I direct deposit my pay there, and set up auto bill pay for everything possible, including rent, utilities, and credit cards.  It’s possible to supplement this with a local bank or credit union account if you want some of the old-school banking services; in practice I haven’t found that necessary.

  1. Credit cards

As long as you pay off your balance every month, credit cards can be a useful convenience.  They also provide a tiny slice of rewards back, which is a nice bonus.  Since we’re not carrying a balance, the main thing to look at is the rewards.  I ended up using the Sallie Mae Mastercard, which offers by far the best rewards among non-fee cards – effectively 5% back for groceries, gas, and Amazon purchases, albeit with a cap on each category.  There are cards with annual fees that offer a greater percent back, and if you spend a lot more than I do (you can do the math yourself; it generally runs around $15-20k/year) it may make sense to get a fee credit card with even better rewards.  It’s possible to get super nerdy with getting multiple different credit cards for different spending, but I haven’t gone to those lengths, keeping in mind that the difference will likely be less than $100/yr.

  1. Investments

If you have money left over, it’s worth thinking about where to put it.  Depending on your situation, it may be worth it to pay off loans quickly.  But it’s also well worth thinking about investing some of the surplus.

Before you even think about stocks versus bonds, think about taxes.  “Retirement savings” may not sound exciting, but there are two categories of retirement savings that are tax-exempt, which is a pretty big deal.  At a resident’s salary, that means an instant 25% bonus on your savings, which is well above what even the smartest Wall Street jockey can get you.  Briefly, in normal taxable accounts, you pay taxes when you receive the income, and you pay capital gains taxes when you withdraw it in the future.  With a Roth IRA, you pay taxes on your income, but you don’t pay taxes when you withdraw it.  With a 401k, you don’t pay taxes now, but you pay taxes when you withdraw it in the future.  Many hospitals offer a match to your 401k contributions; this is free money you’d be a fool to turn down.  So at the minimum you should set your contribution to your 401k such that you get the full employee match.  (For people working at nonprofits, which includes most hospitals, you have a 403b rather than a 401k; they work the same way.)

As residents, we’re in a unique position where we’re making fairly small amounts of money now, but have a solid expectation of making an attending’s salary in the future, which also means paying an attending’s tax rate.  So it makes sense to prioritize the Roth IRA, and pay the taxes now, while we’re poor and the taxes are lower, rather than in the future.  But both tax-deferred savings accounts are pretty good, and overall I’m maxing out my contribution limits in this order: Roth IRA ($5,500 limit) > 401k ($18,000 limit) > ordinary savings, after accumulating a small rainy-day buffer in my ordinary savings account.

It’s important to note that for the Roth and 401k, there are severe penalties for withdrawing funds early.  These savings are for retirement, not a buffer for immediate spending.  It’s possible to use the 401k money as backing for a loan for a mortgage, so you still get some value from the money stored in there, but it’s not meant to be touched until retirement.

Money in the retirement accounts can be invested, just like ordinary savings.  I won’t get too much into portfolio theory; I generally believe the efficient market hypothesis that it’s very difficult to consistently beat the market.  So, I’m a fan of low cost, broad-based index funds, such as those offered by Vanguard.  (The “low-cost” aspect is worth emphasizing.  Some funds have expense ratios of 1% per year or more, which can add up to enormous savings lost over a lifetime, even if the market is otherwise doing well.)  For early savings, a Vanguard target date retirement fund is a good option – it automatically rebalances a broad portfolio of stocks and bonds and shifts from aggressive to conservative as you get older.  Furthermore, and this is important for first-timers, it has a low minimum contribution; $1,000 compared to $3,000 or more for other funds.   From there, it’s worth exploring further and diversifying into things like international markets and REITs (real estate), but this is a good way to get started.

You’ll have noticed that I haven’t mentioned a savings account in this section.  That’s because in practice, it makes more sense to keep your rainy day fund in a taxable investment account, where it’s working for you at a much higher rate than your bank can offer.  You can still sell off some stocks in the account to cover your expenses if an emergency arises.

  1. Mint

Mint is a great piece of software.  You can link it to your credit card and bank accounts, and it passively reads your activity and compiles a snapshot of all the money you spend each month.  This lets you really see where all your money is going, and what you’ve been spending on.  Over time, you can develop a sense of where it makes sense to cut back, and where it’s okay to spend more money.

  1. Profit!

And that’s pretty much it.  With all this set up, your monthly pay is deposited into your (online) checking account, and your bills and credit cards are automatically paid off.  Your investment savings are also automatically funneled off, and the rest is yours to spend as you like.  With that, you can have your finances mostly set on autopilot, and just worry about getting through residency.

Weaponized reductionism

One of the fun parts of Neal Stephenson’s Anathem is the way the book forces the reader into a sort of reverse culture shock, understanding the full strangeness of a post-industrial society through the eyes of his cloistered scholars.  He describes familiar things in this world with such care and attention to detail that they become strange again:

“Before leaving town we stopped, or rather slowed down, at a place where we could get food without spending a lot of time.  I remembered this kind of restaurant from my childhood but it was new to the Hundreders.  I couldn’t help seeing it as they did: the ambiguous conversation with the unseen serving-wench, the bags of hot-grease-scented food hurtling in through the window, condiments in packets, attempting to eat while lurching down a highway, volumes of messy litter that seemed to fill all the empty space in the mobe, a smell that outstayed its welcome.”

I’ve been reading Marcus Aurelius’s Meditations recently, and one of the things that really jumped out at me was the extent to which this Roman emperor deliberately used the same reductionist technique to not to let the pomp and luxury of his office make him proud or put on airs.  He wrote:

“[Cultivate] disgust at what things are made of… marble as hardened dirt, gold and silver as residues, clothes as hair, purple dye as shellfish blood.”

He applies this sort of reductionism throughout his book, and uses it to try to see through the social conventions of his day, and arrive an objective view of what in his life was worth valuing.  Instead of living in a resplendent palace, emperor of the known world, he forced himself to see it as living in an artificial cave, ornamented with bits of shiny stuff dug out of the earth, and instead of lording it over senators he simply saw himself as dealing with other humans who happened to wear hairs dyed in purple shellfish extract.  “Latch onto things and pierce through them, so we see what they truly are.  That’s what we need to do all the time…to lay them bare and see how pointless they are, to strip away the legend encrusts them.  Pride is a master of deception.”  Without saying a single tendentious or untrue thing, he manages to transform these luxuries and totems into the mundane and frankly bizarre.

Elsewhere, he performs the exact opposite trick, turning a mundanity into a transcendent purpose:

“What’s left for us to do?  I think it’s this: to do (and not do) what we were designed for.  That’s the goal of all trades, all arts, and what each of them aims at: that the thing they create should do what it was designed to do.  The nurseryman who cares for the vines, the horse trainer, the dog breeder – this is what they aim at…I do what is mine to do; the rest doesn’t disturb me.”

And what was this telos that we were designed for?

“Revere the gods; watch over human beings.  Our lives are short.  The only rewards of our existence here are an unstained character and unselfish acts.”

So he uses reductionism to tear down temptations, while telling grand, non-reductionistic narratives to encourage himself to virtues.  And his book is really powerful in changing perspective because of this selective use of reductionism.

Now, you could imagine the opposite: a situation where people explain away virtue as just old-fashioned twaddle – or worse, nothing more than the deceptions of an entrenched power structure or an emergent property of Darwinian selfishness.  At the same time, they might tell really compelling, teleological stories about the importance of success at short-term things, whether being a business titan, winning a political debate, or dating someone really attractive.  Of course this would be pretty crazy and I don’t know why anyone would do this.