Merry Christmas to all who celebrate!

For some Sunday pre-holiday week reading, here is a detailed analysis of what went wrong in Valencia from the Financial Times that shows both the human and technical side of the flooding there earlier this year. It is excellent throughout, and really got my blood boiling near the end with this series of paragraphs:

Cutting the risk of flash floods is not impossible. After the 1957 disaster, generalísimo Francisco Franco oversaw a vast engineering project to reroute the Turia river away from Valencia’s city centre. It is the reason why the capital was largely unscathed on October 29. But dictators do not have to consult stakeholders and such poured-concrete solutions are out of fashion today.

Still, Spain has not lacked modern proposals to stop the Poyo ravine flooding. But its slow-moving state has failed to implement them. The Júcar river basin authority put forward a risk reduction plan in 1994. Three of its four parts were blocked on environmental grounds, so it only stabilised the walls of the ravine from Paiporta to the coast — a job finished in 2005.

By then the basin authority had commissioned work on an alternative plan, which was authorised by the central government in 2009. It involved restoring forests to improve soil water absorption and building a “safety” channel to siphon water from the ravine to Franco’s rerouted river.

By the time it won environmental approval in 2011, Spain was heading into austerity. A new conservative government then shelved the plan. When the socialists returned to power in 2018, the environmental approval had expired. Pedro Sánchez’s government concluded a new plan was needed, but cost-benefit studies and new environmental demands at regional level threw up fresh obstacles. On the ground, nothing was done.

Valencia is a beautiful city as I saw for myself not long ago, and big part of it was the dry river bed-turned-park going straight down the center, orange groves and all. To think that what enabled it was a fascist dictator’s big project, when he probably didn’t care an iota about the park. And the people who care about the parks are clearly not capable of doing these large-scale projects. It’s the yin and yang of humanity.

The one thing to read this weekend is this NYT interview with Rick Steves. His answer to “what you would do if you couldn’t travel any more” was pitch-perfect:

I would welcome the day, strangely, when I could not travel anymore, because it would open a gate of things that I’ve not done because of my love for travel.

Which is my feeling as well. You can love what you are doing and still be OK not doing it any more because, and this is Rick again, “[t]his world is such a beautiful place to experience, and there are dimensions of experiencing this world that I have yet to try.”

As Nassim Taleb likes to say, no rumor is true until officially denied. Godspeed.

And in even bigger news for clinical medicine:

Brian Thompson, the CEO of United Healthcare, was shot and killed by a masked man near a Midtown Manhattan hotel early Wednesday, according to police sources.

United Healthcare is, of course, the Big Bad for-profit healthcare hydra gobbling up hospitals all over the country. On an unrelated note, this seems to have been a hired hit.

Faber est suae quisque fortunae.

Big news for academic medicine yesterday:

Dr. Brian Druker, CEO of the Knight Cancer Institute at Oregon Health & Science University and developer of a drug that revolutionized cancer treatment, said he was stepping down in part because OHSU had “forgotten our mission” and is no longer a place to do cutting-edge research.

The problem with academic medicine is that it is still part of American medicine, and an MD’s worth is measured in RVUs they can generate. This is easier to calculate and cross-compare with non-academic docs, so it wins out over any other activity in an MBA’s spreadsheet.

I am at ACR Convergence all weekend, but here are some quick shots:

• How it went
• Epistemic hygiene
• Maybe Bluesky has “won” (ᔥDave Winer)
• I hated Dubai until I learned about it

Here is a brief anecdote that may help contextualize some recent developments, in particular why anyone black, or brown, or uneducated, or poor may have preferred Trump over Harris.

Two apartments ago, a bit before Covid, we were living in a 2-bedroom apartment in Northwest DC that was absolutely gargantuan by European standards but must have seemed cramped for a family of five-plus-a-house-guest to our neighbors. One neighbor in particular, let’s call her Alice, seemed unusually interested in the goings on of our household: the foreign accents, the visiting grandparents, so many children. So she made a point to, whenever we bumped into each other in the hallway, gather as much information as possible, and give a few bits about herself in return.

Alice worked for a federal agency, you see, and as a hard-core democrat was trying to minimize the chaos that the orange man — this was during the first Trump administration — and his peons spewed on the people. Now the agency in question was healthcare-adjacent so my wife and I, both being physicians, knew that the problems ran deeper than the president and his appointees, but that is not the point of the story.

The point is this: with every interaction, Alice would highlight that we were not US citizens, then highlight some more that we had visiting family members who also were not citizens and who may or may not be in the country legally (they were all, of course, visiting on a tourist visa as they have been in more than a decade since we moved from Serbia), then apologize for what Trump was doing to the immigrants and aren’t we all lucky that DC is a town of welcoming democrats and can you please let her know if we needed any help with anything, at which point Alice would — unironically — wink.

It’s hard for me to say what felt more insulting, the sly and not so sly insinuations that we were there illegally, the entitlement that we must be best of friends because we were immigrants, or the expectation of gratitude to all the democrats for “fighting on our behalf” when there was no fighting to be had. And this is before we even had our green cards, staying on a combination of work and (this is my favorite name for a bureaucratic invention) Alien of extraordinary ability visas. I can only imagine how much worse the feeling would have been if we were citizens with the unfortunate property of having an unusual accent or unconventional (for upper-middle-class-non-hispanic-whites) housing arrangements.

To be clear, I have no idea what Alice’s intentions were. I am pretty sure she didn’t want to insult anyone, and that her thoughts and feelings were true. And it is often the case that someone can feel insulted for reasons completely within their control: a slight sense of shame that you weren’t living up to someone’s arbitrary standards, annoyance that you are spending hours on immigration paperwork when others don’t have to yet feel as welcome, outrage that anyone would give even a hint of a suggestion that you are a family of Anne Franks looking for an attic. All internal and within your own control, but not any less true. Humans being humans.

This was all before Covid-19. After March 2020 our hallway conversations turned into talks about masks, vaccines, and how everyone was grateful to have doctors in the building. About a year into the pandemic another neighbor ran out of their antipsychotic medications and started setting small fires and hitting random hallway doors with baseballs bats so we were soon out — the benefits of renting — but we stayed on good terms with Alice. Still, those first few impressions stuck, and majority of our interactions are only first impressions without the benefit of a pandemic to deepen a relationship.

One of the defining properties of America is, I’ve learned over the years, the tendency to go all-in. People don’t just go on a hike or two a year, they buy hiking gear, download hiking apps, plan out routes and become hikers. They don’t go out for a jog when the weather is nice and they feel like it, they train for a marathon. They don’t enjoy a night out at a restaurant, they rate and review and call themselves “foodies”. They don’t just like their work, they do it on evenings and weekends and holidays too. That is how you get to the highest GDP of any developed country, I guess, but there is also some subtlety lost and the democrats who were all-in on immigration have lost that subtlety and unintentionally — I hope — fanned the flames of indignation across the board. So not only were those pro-immigration efforts insufficient to overcome the feelings about the economy, they may have even hurt.

1. It won’t be close. Most pollsters are hacks who commit even greater statistics crimes than physicians so their 50/50 is most likely to mean a landslide either way.
2. That link above is to Nate Silver’s Substack post, but please remember that he is also a hack who builds prediction models from the polling garbage he describes above while knowing it is garbage. That is even worse than what the pollsters are doing because shouldn’t he know better?
3. Worse yet are economists who excuse the pollster behavior: they see crimes being committed and think yep, that’s how it should be. This is a University of Michigan professor of economics and a senior fellow of some pretty serious Think Tanks who doesn’t realize that fiddling with your results after you’ve collected them in order to better align with the aggregate of other people’s results is scientifically unsound. I’d send all of his papers to Retraction Watch for a close inspection.
4. From 538 to the NYT to Nate, every poll aggregator has for months been fed back its own bullshit. Little wonder then that they all converged to a 50/50: complete ignorance.
5. Prediction “markets” are no better than equity markets in reflecting reality. Which is to say, they reflect the reality of vibes and wishful thinking, not the ground truth. They are best ignored.
6. Sátántangó (2019) by the Hungarian director Béla Tarr is a 7-hour masterpiece shot in black and white; perfect for watching on a crisp autumn evening like tonight’s, no other screens allowed.

A Wall Street Journal article on physician work-life balance prompted lots of online chatter, including people remembering their parents' dedication to the calling. But times have changed. The choice now isn’t between spending time with family and patients, it’s between spending it with family and corporations. If practicing medicine were more meaningful, there would be less of a retreat to family life by people who self-selected for delayed gratification and frank masochism.