I don’t hide my disdain for Eric Topol, and of course one has to wonder whether professional jealousy plays a role; he is, after all, a high-profile doctor with thoughts about technology. But this morning I found an excellent counterfactual in Peter Attia who is slightly closer to me in age, moves in high-profile circles, and spends time “creating content” about what I think is a bit of a time-waster for rich people: prolonging lifespan healthspan. In other words, he carries the perfect confluence of properties to create even more disdain on my part; and yet, I think that overall he is an upstanding guy who is smart, no-nonsense, and great at communicating complex ideas.

This was a long-winded intro to my recommendation for today’s episode of EconTalk, which has confirmed my priors and reminded me that it’s never too early in the week to call Topol a hack. Him and Attia are so similar on paper, so different in reality.

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.

I am reluctant to recommend long podcasts, but Joe Walker’s 3+ hour interview with Richard Rhodes, the octogenarian author of The Making of the Atomic Bomb, was so engrossing that I didn’t even realize it was that long until posting this very message. Between discussing the Manhattan project, nuclear energy, AI, and a sprinkling of geopolitics past and present, the conversation just flew by.

From the annals of I told myself so: against my better judgment I’ve listened to the first two episodes of How I write. The first one, with Tyler Cowen and Alex Tabarrok of the Marginal Revolution blog, was fine but unremarkable, especially compared to the duo’s 20th anniversary episode. The second one, with The Cultural Tutor, let it slip that the Areopagus author hates when people say they write as a hobby, and ended with a promotion for Perell’s writing course that will — and this is verbatim — “help you two-ex your potential”.

Well, this hobby writer is tuning out, content with his one X of potential.

My fellow NCI-trained oncologist, friend, and occasional co-author Vinay Prasad had another appearance on my favorite podcast, and I’m happy to say that the result is a contender for the best EconTalk episode of 2023. It is all about cancer screening, but also about decisions, paternalism, and regret. No mention of Covid — thankfully — and Russ Roberts mostly listens but then asks the most poignant questions that result in some spirited conversation.

The word not mentioned — a surprise since Russ likes to pull in Talebisms whenever there is a good opportunity — was ergodicity. Or rather, the non-ergodicity of medical interventions: there may only be a 0.01% chance of death with a procedure, but if it happens to you, you are 100%, not 0.01% dead. People I don’t do well with negative definitions and it would be nice if there were a separate word for non-ergodic processes, like there is for antifragility.

Another missed opportunity is to discuss efficacy — the outcome of a procedure in ideal settings — versus effectivness, which is how procedures behave when you let humans do their human things en masse. Even with that, it is a great episode, do listen, and maybe take some notes along the way.

How I Write is a new… podcast(?) from David Perell, who tweets posts Xs:

Imagine if all of your favorite writers recorded their own audio versions of Stephen King’s On Writing.

That’s what this show is about.

It’s like Chef’s Table for writers. We go behind the scenes to uncover the meta-mechanics of writing, the lifestyle behind it, and all the ways you can make money at your keyboard. By learning how your favorite writers work, you’ll see your own creative process with fresh eyes.

The emphasis is mine, and between how over-produced the show looks and Perell’s Monetize-It! ethos it could not have been less than a match for me. But then he got the Marginal Revolution duo as his first set of guests, so give it a chance I will.

By the way, at what point do we stop calling them podcasts and start calling them YouTube shows with an audio-only track?

My favorite podcast host, Russ Roberts, has just posted an interview with one of my favorite bloggers, Adam Mastroianni: on the Brain, the Ears, and How We Learn. This is their second conversation; the first was on Peer Review and the Academic Kitchen. Highly recommended!

The most fascinating aspect of Tyler Cowen’s interview with Paul Graham is how many times Graham admits to not knowing, in a way that makes you think he may know a bit more than he is letting on. I’d attribute it to his age, but I know many elder doctors and scientists who’d rather die than say there was something they didn’t know.

Incidentally, this is the first time in nine (!?) years that Overcast’s Suggestions for you section had something that was both new and noteworthy. There were a few more that look promising, so either the algorithm has changed or it has finally learned my tastes.

It isn’t every day that a podcast goes from my Testing to the Regular playlist, so I have to mark the moment. “Reason is Fun” by Lulie Tanett and David Deutsch is, well, fun and thought-provoking throughout, even if (because?) I often disagree with either or both of the hosts.