Infinite Regress HQ wishes a Happy New 2022 to all those who celebrate.¹

Everyone loves Ted Lasso, both the character and the show, in great part because he manages to be funny without being sarcastic. It reminds me of what made Frasier so good: that the writers never took the easy jokes. Smart humor is hard, smart humor without sarcasm is even harder.¹

The past few years have made me sarcarsm-intolerant. I can still appreciate professionally done satire — Stephen Colbert of the Colbert Report years comes to mind — but you, my Twitter friend, are no Stephen Colbert. Good satire takes some effort to create, but is easily understood. Casual sarcasm is the opposite: it is easy to say or write what you don’t mean, but recognizing sarcasm requires knowledge of the context, the author’s prior writings, the subject in question, and even then, often, it is missed. Queue the author’s indignation and musings on how the Twitter sheeple can’t recognize a joke, though sometimes the indignation itself can be self-consciously funny.

Uh oh, I guess I better be able to prove real fast that I was doing work on bats a few years back…. pic.twitter.com/abkBX2z0Xl

— Vinay Prasad MD MPH (@VPrasadMDMPH) May 17, 2020

The exchange above was notable for erecting a barrier between people who some time ago would have considered themselves part of the same ingroup.² If there is one thing sarcasm does well, it is to erect barriers between smaller and smaller groups until everyone is at a war of wits with everyone else. It turns a tool of communication capable of spreading great knowledge quickly into a French court-style spectacle for the masses, fueled by the algorithm.

Dropping sarcasm would not make the internet excruciatingly boring. Note @10kdiver of the Markov chain thread from the paragraph above, or @wrathofgnon, @Gwern, @craigmod, @BCiechaowski… all brilliant, not an ounce of sarcasm between them (half an ounce from Gwern, perhaps). There is in fact an infinite number of ways to be interesting online without being sarcastic, and sarcasm itself permeates the online life so much that it is, well, boring.

Offline, the distinction blurs between being sarcastic and having plausible deniability. Sarcasm may be the highest form of intellect in teenage years, where plausible deniability helps save face, but before the end of adolescence saving face quickly turns into gaslighting. Small wonder that the most sarcastic character on Friends was also the one to catfish a woman.³ So if there ever was a quick and easy litmus test, it is this: after the horrible year we’ve had, and a decade that was not much better, whom would you rather hang out with and who would you rather be: Ted Lasso or Chandler Bing.

• Social media
• Gmail
• Richard Dawkins and his “New Atheism”
• Ayn Rand’s two books

There must be more, but I am good at suppressing.

See also: Things I heard were good but was holding out for reasons unknown then wondered why I haven’t tried them sooner.

Residency application season has just started. Many of the applicants, a few of whom I know in person, will be foreign medical graduates, or FMGs, meaning that they are doctors who want to work in the US but are not US citizens. Most FMGs, but not all, will also be international medical graduates — IMGs — meaning that they have graduated from a non-US medical schools. Something called the Education Commision for Foreign Medical Graduates, or ECFMG, acts as their medical school when interacting with most of the sprawling US bureaucracy. These are our personae dramatis, if you will.

Disclosure: I am both an FMG and an IMG, and first began working in the US on an ECFMG-sponsored J1 visa.

America is a net importer of physicians, that much should obvious to anyone who’s ever been in an American hospital. The country depends on FMGs to keep the system running, get the less lucrative specialties, work in underserved areas, etc. Not so obvious is that most FMGs get to America by lying; ICE-approved, foreign-government sponsored lying for sure, but lying nonetheless.

Here are the lies FMGs tell when they come in: that their country has a need for doctors of such-and-such specialty, and/or that their government is sending them to the US for training in the said specialty, and/or that at the end of training they will go back to their country of origin to work in the (sub)specialty they came in to obtain. Those are the three postulates of the J1 physician exchange visa, the very name of which is also a lie as there is no exchange taking place: foreign doctors do come in, but no American doctors come out.

The postulates are incompatible with reality, and imply foreign government competence that just isn’t there in second and third-world countries¹. Because over there, no one is keeping statistics on specialist needs, and if they are there is actually a surplus, and if there isn’t they wouldn’t be able to afford the (sub)specialists once they come back, and if they could then they would be chosen by party or family lines, and you wouldn’t want them in your hospitals anyway.

So to get a J1 visa FMGs need to obtain a letter from their Ministry of Health or equivalent stating the above (the postulates, not the actual truth; I’m sure that in some of those countries people have gone to prison for saying the truth). But is there a functioning Ministry of Health? Does anyone there know that the letter they are supposed to provide about lending a medical graduate and wanting them back is a piece of kabuki theater, and not a commitment to employ that person if and when they come back? And because this letter is supposed to come in a sealed envelope directly from the Ministry to ECFMG: does anyone there speak English? So here are all those FMGs whose main reason to emigrate to America may have been to escape their kleptocratic governments, being dragged into a game of Whom do I bribe next? and Which newspaper do I threaten them with?² by the rules of the country they were hoping was less crooked than their own.

Which is fine for America, because it doesn’t care as long as it gets its steady stream of MDs one way or another. Only it should care because 1) the amount of person-hours wasted is on par with if not greater than the amount spent writing grants, and that one’s a whopper, 2) it relinquishes control over a part of its healthcare to foreign governments, and 3) it introduces an air of subterfuge and deceit at the very beginning of the FMG-USA relationship. I would like to think this is an aberration to be fixed, and not a preview of things to come in other areas of governance.

The process was probably fine 50 years ago, when both demands of the medical system and the influx of foreign doctors were but a fraction of the current monstrosity, when USMLE was taken on paper if you had to take it at all, when it wasn’t so obvious to a non-aligned physician whether they should go to the US or USSR (or Yugoslavia, for that matter) to get more training. But healthcare has changed and so has the world: it’s time do drop the pretense of an exchange, America, and be honest about what’s going on here.

Twitter brings out the worst in people. If your worst is not that bad then power to you, madam, but most of us need to spend an extraordinary amount of energy not to look like sociopaths, or should just stay away. More often than not I choose the latter.

There are good arguments for why you should be on Twitter from both doctors and civilians. On the opposite end there is a whole book dedicated to why you shouldn’t (full disclosure: I haven’t read the book, but did read two accompanying NYT Opinion pieces back before I realized NYT Opinion pieces weren’t worth my time). So clearly there are two opposing points of view, and while I’m sympathetic to the Twitter cheerleaders and their cause, my own experience makes me take pause. Here’s why:

1. No nuance

Note the “madam” reference in the opening paragraph. Here, I have space to explain what I meant: that a well-behaved user on Twitter was more likely to be a woman. An outrage-primed stranger on Twitter just glancing at the post could instead interpret it as an attempt to emasculate the well-behaved male readers. And I forget, is it still kosher to use madam to refer to women? Or is “females” the appropriate term now, never mind that it’s an adjective? At least using “kosher” is not considered cultural appropriation yet. Right?

I don’t like this lack of nuance for two reasons: because I recognize it in myself when I overreact to a tweet and have to stop myself from writing a snarky reply and because writing down short thoughts that are still coherent is much more time-consuming than writing run-on sentences like this one.

2. Ill will

Recall Justine Sacco and the delight with which a Twitter mob tracked her WiFi-less flight across the Atlantic. Twitter mobs are pure minority rule, wherein the minority has a high follower count with an incentive to mobilize them. It is vexing to see someone with 10,000+ followers retweeting — with a snarky comment, of course — a poorly worded tweet that had thus far garnered three likes and no other retweets. No matter the content of the original tweet, and often they’re deranged rantings of an anti-vaccer, doing it to a person with a hundred-fold lower followe count and a thousand-fold lower reach is unethical at best, and dare I say immoral too when the intent of the retweet is nothing more than virtue signaling.

Again, this kills my enthusiasm for Twitter in two ways: the time I spend self-censoring my Eastern European spent-a-decade-under-US-sanctions tendency towards sarcasm, and the time I spend reading, digesting, and ultimately dismissing these worthless posts.

3. Poisoned stream

But isn’t the great benefit of Twitter over mainstream media the ability to choose whom you follow? Yes, but: Twitter the company is doing its best to ruin that by showing you not only retweets, but also those tweets that people you are following liked, and a random tweet here or there that’s been getting attention (as in: a lot of replies, as in: this is probably controversial) which it thinks may cause you to engage (as in: join the conversation, as in: enter the fray). I am not making this up.

So even if you try to keep your time line completely professional and only follow other MDs who post only their high thoughts on the latest randomized trials in the area you’re interested in… Well, you can’t stop them from liking political posts, and you can’t stop Twitter from foisting its algorithm on you.

4. No country for slow thinkers

So what? Just ignore the noise. Cull your follow list to manage input, write quickly and don’t look back to speed up your output. I suspect that’s what many people who are good at Twitter do, and if you can do it too then power to you. What kills it for me is 1) the opportunity cost (as in: I’d rather spend time with my family, and 2) (and this is the main one) I. cannot. write. like. that. This was supposed to be a two-paragraph post written in the subway. Well clearly it’s not.

As I finish writing this, a scientist I’m following has retweeted the FCC chairman’s gripe about the latest Twitter redesign. An MD is retweeting pointless videos. Random biotech factoids fly by my screen, unwanted and uncared for.

The world in general, and the US in particular, is spending too much on goal-directed, targeted biomedical research while undervaluing both applied and theoretical physics. Picture Leonardo da Vinci drawing helicopters: that’s the modern-day cancer researcher. The universal cure for cancer — and there should be one, if humanity survives long enough to create it — will not come from an NIH grant. If grants are involved at all, it will be something initially funded by the National Science Foundation. The current system of funding (government, non-profit, biotech, you name it) is broken, and if you account for the opportunity cost it is a complete disaster. Each of these statements deserves at least a paragraph, but I am saving my carpal tunnels for a manuscript, an LOI, and a couple of protocols (oh, the irony).

In the meantime, a few things physician-scientists should do for the overall good: * find causes and create better prevention strategies, because a look at the SEER database will tell you that it’s not just bad luck; * eliminate barriers for administration of known curative therapies world-wide (do we really want to leave this to politicians and economists?); * ensure rapid and honest evaluation of the many new treatments, procedures, and diagnostic/prognostic methods coming out of the biomedical behemoth.

How beneficial any of this would be for one’s career is a different question altogether, but let’s not get into incentives because RSI. I am also very open to opposing opinions, since my being wrong would make my life easier.

For better or worse, the American system of government is strong. Those who say otherwise have a financial interest in people thinking the opposite.

Culturally, US has more similarities with Iran than with Saudi Arabia, even if you count religion and religiosity as part of culture. The Christian right is working hard to make them even more similar.

Though still quite hard, it’s easier for a high-skilled immigrant to come to America than to any other country in the world. Comparison is even more favorable for low-skilled and unskilled immigrants. For all of them, quality of life, acceptance, and protection they get are better than anywhere else.

The randomness of the Green Card lottery process is a feature not a bug.

Reading the non-fiction sections of The New Yorker, The Atlantic, and whatever their conservative equivalents are, is good for generating fake insight but ultimately pointless. The Economist is useful for a tiny segment of the population but lets be real: if you’re reading this you are not it.

The only useful section in the daily newspapers is Local. Maybe Sports, if you are into that sort of thing, but professional and college sports are a scam so stick with the amateur leagues.

TSA agents and airline personnel are nice people but some passengers check out their brains at the curb and make everyone’s lives less pleasant.

Apple hardware products are underpriced for what you get but do you actually need what they offer? This doesn’t include the AirPods, which are the best thing Apple has made in the last 20 years and still underpriced; though they unfortunately resemble in both name and appearance a mind control method from Doctor Who S2 and paired with a smart phone are not far from it.

The world doesn’t need another IPA. America needs more tripels.

This is all coming from a non-immigrant resident alien with no expertise in politics, international law, transportation, or technology. I do know beer though.

Two years ago, I haplessly expressed excitement about my task list manager of choice being updated soon.

Speaking of @culturedcode, looks like Things 3 is progressing nicely. Hope “more structure” is code for dependencies. pic.twitter.com/ctwycDyL1e

— Miloš Miljković (@Miljko) February 2, 2014

It hasn’t yet. Two iterations of iOS and an Apple Watch later, Things 3 is still not available, and I am becoming increasingly annoyed. Inside my mind, two kinds of costs—Ms. Sunken and Mr. Opportunity—are battling it out.

Mr. O has me thinking about time wasted on not being able to turn a next action into a project; or having to make too many taps to edit anything in the iOS app. And then I stress out even more contemplating all the features I don’t even know I’m missing out on—not wanting to find out about those is why I not dare read reviews of the competition.

Ms. S, meanwhile, is raising dread whenever I thinking about moving to Omnifocus, Taskpaper, or whatever the GTD app du jour is—knowing that I would be trading a set of known deficiencies for a potentially grater set of unfamiliar ones.

The mister and missus are irrational beings—even though Things 3 remains vaporware, there have been a few 2.x updates that iOS7-fied the experience—from going flat to adding extensions and notification center widgets. All that considered, I should not spend so much time thinking about an app.

And yet, it is 6pm on January 2, 2016, and instead of writing about getting back to the lab, finally finishing the PhD thesis, or being a haughty gastro-tourist in unseasonably warm New Orleans, I am being much too first-worldly for my Balkano-Serbian comfort.

Which I will add to the pile of absurd reasons for why I dislike Cultured Code.

John Siracusa is a programmer. Merlin Man is a lifehack guru-cum-internet personality. If you are in a medical field, there is no particular reason you would know them.

They co-host a podcast that modestly has themselves as the subject matter. It is one of the best new podcasts this year, second only to CGP Grey’s (though with Road Work coming out this week, it may be a three-way tie). In this week’s episode, Siracusa had this to say about programmers (link to the audio here—it sounds better than it reads):

Plenty of people can espouse information telling some younger programmer “make sure you always call ‘srand’ before you call ‘rand’”, and they can easily tell you “don’t listen to that guy, you should not call ‘srand’ before you call ‘rand’”.

Neither one of them really understands it, because they can’t explain it. If that young programmer is saying “But why? But why? Why? How do these things work together? Explain it to me.” and they realize “Oh, I can’t explain it. All I have is this…”—it’s not a cargo cult, but it’s more like—”I have this practice that I’ve learned through supposed bitter experience that if I didn’t do this one time and something didn’t work, then I did do it, then it did work.” Very often in programming you can sort of learn that way where basically “I tried this one thing and it didn’t work, or this bug happened, then (I did) this other thing, and the bug was fixed”, and come away from that with a rule, or a heuristic, or something you think is an unwritten law without actually understanding the underlying…

Remind you of anything? In medicine, “cargo cult” is exactly
the term I would use. Programming’s saving grace is that it is a finite system created by humans, and—at least in theory—knowable. The human body is as black a box as it ever was—the only difference between now and the 1800s being a stronger flashlight.

So, programming clearly shares this with medicine: most of its practitioners don’t have a firm grasp of what they are doing, and don’t understand the underlying principles of their craft. Why, then, do we fool ourselves that adding programmers’ idiosyncracies to physicians’ by the way of electronic medical records, clinical decision support systems, and ultimately AI-run e-doctors, will somehow “fix” medicine instead of making it bad in a different way?

There are many misnomers in American medical English. Patients walk into your clinic (from Greek kline, bed) to learn whether their scan was negative (good) or positive (bad). Those who have severe chronic pain may ask for their pain medicine (that relieve pain, not cause it), usually opioids. Some physicians would call them pain-seeking (though what they are seeking is relief). If they don’t get a prescription, they may rate their doctor poorly on a patient satisfaction survey, which is a big thing if you are into quality improvement. Quality improvement. There’s a misnomer.

Quality improvement in medicine is by definition limited to improving things you can measure, i.e. quantify, i.e. judge by criteria that are the ying to quality’s yang. Those measures may be valid or not, and may improve patients’ lives, longevity, etc. (or not) but they are not quality. Because they are measures. Numbers. You know, quantities.

The movement is dangerous in at least three ways. Firstly and most obviously, many of the things being measured haven’t been validated in prospective trials. They are either (poor) conjecture—like tight glycemic control for type II diabetics assumed to help because of good outcomes in type ones (since, you know, a skinny teenager and a morbidly obese 60-year-old are similar that way.) Or they came out of a corporate think-tank cocaine-fueled outside-the-box brainstorming session, like patient satisfaction scores¹.

Secondly, even if they were the best measures in the world, tying them to promotion and compensation would have the unintended consequence of having practitioners loose sight of all other aspects of medicine, including the patient. There are many accounts of how it can happen—this one from Dr. Centor comes readily to mind—but since (1) identifying and (2) addressing the patient’s actual problem is difficult to measure objectively, it is not one of the benchmarks.

And finally, wherever there are numbers and money, techniques will evolve to game the system. David Simon’s account of how this happens in law enforcement is applicable. Want fewer central line infections? Enact a policy not to draw blood cultures from central lines! Too many nosocomial urinary tract infections? Urinalyses on admission for everyone! Hospitals create teams with dozens of people whose only job is to find new and better ways to do this. And they have to—because everyone else is doing it. A depressing amount of time, money, and effort wasted because of pointless exercises of anonymous pencil-pushers.

This is how you get to a near 3000% increase in the number of hospital administrators over 30 years. I am sure they are all good people, with good salaries, but they are, for the most part, insignificant. An epiphenomenon induced by someone’s desire to turn healthcare into an industry, forgetting that the six sigma ideology that works so well for toaster ovens can’t be forced onto moist, squishy, and fragile humans.

Which is also a good working definition of quality improvement.