• As of this morning it has reached >17,000 signatures. Yay!
• The Healthcare Unfiltered podcast has two good interviews: the first is with Wes Fisher and his decades-long battle with ABIM; the second is a debate between Aaron Goodman — who started the petition — and Richard Baron, the President and CEO of ABIM
• The debate was a clear loss for Baron: his smooth baritone and even smoother sophistry could not help hide the fact that MOC is a pure money grab. I will lay out the 3rd grade math and 6th grade logic later this week.
• Aaron was too nice on Baron. There should be a second petition: for ABIM to start having accountability, or else shut down. Back in the 1930s when it was founded we may have been ABIM “diplomats” who pay for their certification once then never again. Once you start extracting yearly dues, you no longer have gentlemen diplomats, you have members.
• Richard Robber Baron.

Nassim Taleb has updated his essay against IQ, and I don’t know if Figure 1 there is new or I haven’t been paying attention before, but it is a true eye-opener. It shows how meaningless correlation is in the absence of symmetry, and medicine is full of asymmetries. I shudder to think how much medical literature consists entirely of physicians-cum-naïve statisticians pouring through medical charts gathering data to calculate such correlations. Counting the official and semi-official guidelines based on such flawed papers would be a nice side project.

Aaron Goodman’s petition to eliminate MOC requirements has 16,000 signatures and counting. That’s a lot, but still <10% of ABIM’s 220,000+ active certificate holders for internal medicine alone. So, please sign if you haven’t already!

And if you have no idea what any of these acronyms mean, ABIM’s home newspaper of record has a good overview.

“The American Board of Internal Medicine is under fire for a ‘maintenance of certification’ requirement. Their own tweet didn’t help.":

Frustration among physicians who feel they are being asked to do increasingly more to prove their competency has been building for years and in recent weeks, boiled over for many. At least 12,000 people have signed a Change.org petition, which is open to anyone. Many added their name after the petition’s organizer resurfaced a July tweet in which ABIM suggested their ongoing certification was so easy, doctors could do it while on vacation.

I have been meaning to write about ABIM’s train wreck ever since I signed the petition, but yet again my proscratination has been awarded: Philadelphia Inquirer says everything I wanted to, and then some. Ding-dong…

Economists do occasionally publish papers with which I agree: ⊕ For the other ones, look here.

…I find that vaccines saved 748,600 lives through June 2023. That is, without vaccines, cumulative mortality from COVID-19 would have been closer to 1.91 million over this time period. In answering the second question, I find that behavioral efforts to slow the transmission of the virus before vaccines became widely administered were critical to this positive impact of vaccines on cumulative mortality. For example, with a complete relaxation of these mitigation efforts, vaccines would have come too late to have saved a significant number of lives. Earlier deployment of vaccines would have saved many lives.

Which yet again shows that out of the two extremes, John Snow and GBD, Snow was the more correct one both ex ante and ex post. Yet instead of taking an “L”, GBD proponents keep saying that we should not have locked down. Yes, shutting down outdoor playgrounds for a full year was ridiculous, but stopping mass gatherings and any goings on in tight public spaces until we get a working vaccine? Absolutely! Only next time, Operation Warp Speed should be set at Warp 5, not 0.1.(ᔥTyler Cowen)

The Washington Post’s Andrew Van Dam on the average US doctors' salaries:

The average U.S. physician earns $350,000 a year. Top doctors pull in 10 times that.

I will write more about this later but for now I will just note how frustrating it is to read an article that has a premise and conclusion that I completely agree with (America doesn’t have enough doctors so the ones that it does have are compensated way above average) backed up by mishandled and misreported data (first the article doesn’t say whether the “average” is mean or median — it is the median, which is actually good — then doesn’t explicitly mention that the median in question is of the adjusted gross income at the household level, not of individual compensation: the median total individual income is $265,000).

At least the article linked to the NBER paper with all the data, which in turn completely validated my recent quip about economisits. Frustrating throughout, especially if you try reading the comments.

Economists are prone to making hypotheses about other fields that make perfect sense to them and others outside of the field, but that can be easily refuted to anyone with an iota of relevant field-specific knowledge. And not just economists. This very sentence is, in fact, one such hypothesis.

But to get to the point: Alex Tabarrok at Marginal Revolution wrote a post titled Left Digit Bias in Medicine which excerpted his WSJ review of Random Acts of Medicine which is a book about “The Hidden Forces That Sway Doctors, Impact Patients, and Shape Our Health”, which is, believe it or not, part of the title. ⊕ I hate, hate, hate what book titles have become. This is the literary equivalent of the Amazon product name trash recently discussed on ATP. SEO for books as an externality of Amazon’s dominance — who would have guessed?

Now, I haven’t read the book yet, and the WSJ is behind a paywall, so I only have the excerpt to go by, but it is long and it is sufficient. I won’t quote from it — 4th level of abstraction would be too much — but I will copy the figure and make a few comments. You should read the blog post itself, it is good.

1. This is the biggest and the most obvious regression discontinuity I have seen, and it has a reasonable explanation. Kudos.
2. Age is plotted as a continuous variable. This is not how doctors see the patient’s age in their medical record. It is shown as an integer, not a fraction, so someone who is a day shy of their 40th birthday will look just the same as someone who just turned 39. And if the guidelines say you should do something for a 40-year-old but not for a 39-year-old, that’s what most doctors — let’s hope — will do.
3. This is therefore not left-digit bias.
4. While the date of birth is also part of the medical record, it is rarely if ever looked at by MDs — except just prior to an invasive procedure that requires a timeout. It is often checked by nurses prior to administering medications, and they are often the ones who will note that an inpatient’s birthday is coming up.
5. Tabarrok has buried the lead in his blog post. Regardless of the cause, the discontinuity is there and can be used as pseudo-rendomization for a natural experiment of the effect of “testing for heart attacks” (I will guess by that the others meant an ECG and troponin levels) on outcomes. The entire last paragraph of the excerpt is about that, and I 100% endorse the idea.

Two things keep me logging back in to Twitter X: DMs from people who should know better, and all of my colleagues who insist using it. But how else was I supposed to learn of this petition for ABIM to eliminate their “maintenance of certification” grift?

Yesterday’s EconTalk was with Lydia Dugdale on the Lost Art of Dying, which is the title of Dr. Dugdale’s book but also a translation of Ars moriendi, a 15th century Latin text about the good death. The episode is in this year’s Top 5, and I wish I could dwell into this. Ars longa…, as they say.

Visiting Montauk beach at Calvert Cliffs, a family member had one mission: to find a shark tooth. Millions of years ago, this part of Chesapeake was warmer and mostly under water. Many a shark dropped a tooth or a hundred during that time; today, they tend to drift to the shore with some regularity.

Searching for a speck of black in a tapestry of white-gray brought to mind Annie Dillard’s Pilgrim at Tinker Creek, more specifically the chapter about learning to see, and yet even more specifically, her discovering praying mantis egg cases This is a longer blog post from The Examined Life about writers and insects; scroll down for the Pilgrim… excerpt. everywhere she looked, once she learned what one looks like.

My own learning-to-see training started with watching birds — not organized or consistent enough to be called birdwatching — and realizing in short order that not every brown-gray bird smaller than a robin is a sparrow, that blue jays, cardinals, and woodpeckers are actually quite abundant even in urban areas, and that those blue jays, as magnificent as they are, usually sound like nails on a chalkboard. The beach makes for even better training grounds. For novices like us there are mermaid’s purses and loggerhead turtle tracks — we saw both during our Outer Banks excursion — things alien enough to immediately be recognized as something. The mental exercise consists of discovering what that something is.

Not so with shark teeth, especially not with the small ones you are more likely to come across during a daytime summer stroll, as opposed to a planned break-of-dawn winter expedition. Is it a spiky piece of iron ore? A fossilized crab claw? Tooth of a mammal? Who knows!? Short of finding a 6-inch dental behemoth, casual beachgoers like us will come up with a million reasons why this black triangle isn’t an actual tooth, and why this other may be, without ever knowing if they are correct. Annie Dillard could put that insect egg casing in a jar and see dozens of tiny praying mantisses scuttle out and devour each other. I can put my black triangle in a dish and look at it until the Sun implodes, and it will continue being that same black triangle, possibly melted.

Unless, of course, we find an expert to tell us why these ridges here mean that it comes from a shark’s jaw, or why this dent over there means it is actually part of a crab. And, knowing that, we will know with certainty — conditional on us trusting the expert — what those two particular artifacts are, but could hardly extrapolate to other pieces of black material found on the beach, and most certainly not to those nestled on the forest floor, or buried in the desert sands, or hiding under the carpet of a 3-story walk-up.

This is in fact very much how medicine works: sometimes, the symptoms are clear enough and occur often enough that you may know as well as an MD that there is a urinary tract infection brewing. But too often — most of the time, in fact — the problems are subtle and chronic and may not develop into something recognizable until it is too late — in which case you better find an expert — or, maybe, never amount to much of anything — in which case you need that expert even more, the most valuable part of medical expertise consisting of the knowledge and experience needed to muster the confidence to say that something is just a piece of rock.

Update: Two months later, we went back and found some.