September 21, 2023

The best thing about fall is that if you do fall there are always fall leaves to soften your landing. Also, its versatility as a word.

At Kenilworth Park, October 2020.

Photo of a girl in a forest standing on a tree stump surrounded by fall leaves.

Drug price shenanigans

A recent podcast episode and a recent blog post show how screwed up the American drug market is, and in how many different ways.

In his Healthcare Unfiltered interview focused on generic drug shortages, the FDA Commissioner Robert Califf blamed Group Purchasing Organizations for driving down the cost of generic drugs to below what’s economically feasible. The manufacturers don’t have an incentive to shore up their process, the fragile production line fails, and presto, you have a shortage. Which is fine if you are manufacturing a placebo, but in recent years the FDA’s Drug Shortages Database has been ever-growing, and as of today includes potentially currative cancer drugs like cisplatin and carboplatin, many antibiotics, and even some formulations of sugar-water. Not to be confused with placebo.

This all reminds me a bit of my childhood in Serbia back in the mid-1990s, when bread was dirt cheap and never available. But that was too much price regulation. Here, we have too efficient of a market leading to a shortage. Only, I am sure there will be hands raised wanting to tell me that — well, actually — this was a clear example of over regulation, since new factories can’t just pop up too meet the demand and make use of the temporary market inefficiency, being dependent as they are on pesky FDA regulations — like the ones about drugs being safe. If only we could price in the risk of death by sepsis, we’d be in great shape!

So, on one end we have Medicare/Medicaid paying through the nose for brand name drugs because it is forbidden by law from negotiating for a better price, and on the other private GPOs negotiating too well for generics, to the point of extinction, forcing payers to get those expensive brand name drugs. Heads, brand-name pharmaceutical industry wins, tails, payers loose.

It was encouraging to see some movement in the price negotiation area: the comically misnamed Inflation Reduction Act allows for CMS to negotiate the price of some drugs, and the list of those drugs was recently made availalbe. Ideal? Far from it — in an ideal world the federal government would not be involved in any of this; but it’s not the world we live in. This is where the blog post comes in: from Alex Tabarrok, about how we are bad at pricing drugs because of unknown externalities (true!) but also with a side-comment reframing measures the IRA takes allowing nogiation as “price controls”, linking to [a policy paper][10] which suggests yet another set of measure to mitigate the adverse effects of IRA’s proposed solutions to the drug pricing problem. Efficient markets for me, but not for thee, as Tabarrok’s writing partner would quip. And so the measures pile up from both the pro- and anti-regulation side. Ad infinitum, I suppose.

See also: better drugs don’t cost more, and a list of a few earnest but misguided attempts at cost control.

September 20, 2023

Disruption as a concept is Lindy. Each particular manifestation of disruption, on the other hand…

From the The Car and Carriage Caravan Museum at the Luray Caverns.

Photo of an 1898 Benz horseless carriage, as a museum exhibit.

After more than a month, I wrote something in Serbian. It is about my disdain for Serbian journalists and the only (let’s hope) TV appearance there, from a few years ago. The disdain would probably apply to many other countries, seeing as the profession revolves around online lurking and email exchange at best, manufacturing consent at worst. Though there are, of course, exceptions.

September 19, 2023

Move over, Batman. This is what true living on the edge looks like, as seen at a Library of Congress exhibit.

Margaret Bourke-White on the job, photograph by Oscar Graubner, 1930.

Photo of a black and white photograph of a woman perched on a gargoyle of the NYC Chrysler Building while holding an old-fashioned camera.

September 18, 2023

🍿 Barbie (2023) turned out to be I ♥︎ Huckabees (2004) with a higher budget and a feminist bent, which isn’t the worst thing in the world. Like its partner, it relies more on moods and vibes than narrative coherence, particularly in the third act which required so much mind-squinting to make sense on any level that my brain shrunk by two sizes. Still, it was better at being an existentialist comedy than Oppenheimer was at being a biopic, so pink for the win!

From the Frist Art Museum in Nashville: some very old silk fabric.

Photo of a small gold-yellow robe with embroidered dragons.

Re-capitalizing the i̶Internet

Laments about the glory days of the internet are popping up in my field of view with increasing frequency. This is mostly a sign that people of a certain generation are reaching middle age, but since that generation is my own, I am in full agreement!

Just this weekend, Trishank was praising Geocities, and Rachel Kwon wanted to make the internet fun again. Not only that: she started a collection of like-minded articles which doubles as a most excellent blogroll.

On the margin of [a book review] I noted that, some time in 2016 — Year Zero of the New Era — most house manuals of style dropped the capital “I” from the internet, acknowledging something that people have been doing in their minds for at least a decade prior. The lower-case “i” internet has become a fish stew that we can’t unboil, but any quixotic attempt to fight the second law of thermodynamics in this regard has my full support.

September 17, 2023

The Georgetown waterfront is great for airplane watching, although the residents may not be too happy about that. I don’t think this one would have turned out as well as it did had the glare not been so intense.

Photo of birds and an airplane flying above the Potomac, silhouetted against a cloudy sky.

Why AI can't replace health care workers just yet

To convince myself that I am not completely clueless in the ways of medicine, I occasionally turn to my few diagnostic successes. To be clear: this is cherry-picking, and I make no claim for being a master diagnostician. Yes, a bunch of my colleagues had missed the first patient’s friction rub that was to me so evident; but say “friction rub” to a third-year medical student and they will know immediately the differential diagnosis and the treatment. How many friction rubs have I missed actually hearing? Plenty, I am sure! Like this one time when a 20-something year old man who languished in the hospital for days with severe but mysterious chest pain. Our first encounter was on a Saturday, when I saw him as the covering weekend resident; he was discharged Sunday, 24 hours after I started treatment for the acute pericarditis he so obviously had.

Once, during a mandatory ER rotation, I figured out that a patient who came in complaining of nausea and vomiting actually had an eye problem: bilateral acute angle closure glaucoma. I pestered the skeptical ophthalmology resident to come in on a Sunday afternoon, confirm the diagnosis, treat the glaucoma, likely save the patient’s vision, and get a case report for a conference out of it.

And I will never forget the case of the patient who was in the steaming hospital room shower whenever I saw him; he had come in for kidney failure from severe vomiting and insisted he never used drugs, illicit or otherwise. Still, it was obvious with anyone with a sense of smell that he had cannabinoid hyperemesis syndrome and would have to quit.

Superficial commonalities aside — all three were men with an acute health problem — what ties these together is that I had to use senses other than sight to figure them out: This being the 21st century taste is no longer allowed, but I will leave to your imagination how doctors of old could tell apart the “sweet” diabetes (mellitus) from the “flavorless” one (insipidus). hearing the friction rub, feeling the rock-hard eyeballs, smelling the pungent aroma of cannabis. And all three cases came to mind when I read a tweet an X about ChatGPT’s great diagnostic acument.

I can’t embed it — and wouldn’t even if I could — but the gist of Luca Dellanna’s extended post is that he:

  1. Had a “bump” on the inside of his eyelid that was misdiagnosed by three different doctors.
  2. Saw the fourth doctor, who made the correct diagnosis of conjunctival lymphoma.
  3. Got the same, correct diagnosis from ChatGPT on his/its first try.

A slam-dunk case for LLMs replacing doctors, right? Well, not quite: the words Luca used to describe the lesion, “a salmon-pink mass on the conjunctiva”, will give you the correct response even when using a plain old search engine. And he only got those words from the fourth doctor, who was able to convert what they saw into something they could search for, whether in their own mind palace or online.

Our mind’s ability to have seamless two-way interactions with the environment is taken for granted so much that it has become our water. This is the link to the complete audio and full text of David Foster Wallace’s commencement speech that became the “This is Water” essay, and if you haven’t read it yet, please do so now. But it is an incredibly high hurdle to jump over, and one that is in no danger of being passed just yet. It is the biggest reason I am skeptical of any high proclamations that “AI” will replace doctors, and why I question the critical reasoning skills and/or medical knowledge of the people who make them.

In fact, the last two years of American medical education could be seen as simply a way of honing this skill: to convert the physical exam findings into a recognizable pattern. A course in shark tooth-finding, if you will. This is, alarmingly, also the part of medical education that is most in danger of being replaced by courses on fine arts, behavioral psychology, business administration, medical billing, paper-pushing, box-checking, etc. But I digress.

Which is not to say that LLMs could not be a wonderful tool in the physician’s arsenal, a spellcheck for the mind. But you know what? Between UpToDate, PubMed, and just plain online search doctors already have plenty of tools. What they don’t have is time to use them, overburdened as they are with administrative BS. And that is a problem where LLMs can and will do more harm than good.