Adam Mastroianni had another interview with Russ Roberts, and this one didn’t sit with me as well as his previous appearance. They talked about things we learn in school — higher education, for the most part — and what the point of it all was when most of what we cram in is forgotten.

They gave several examples of this, all of which I have quickly forgotten (ha!), but listing things we were made to learn in medical school never to use again was a popular past time on #medtwitter so I will list a few topics that come to mind first:

• Bernoulli’s equation
• the Krebs cycle
• names of all 12 branches of the maxillary artery
• formula for the independent two-sample t-test
• recommended step height and depth for elementary school stairwells

Though that last one was clearly a relic of Serbia’s socialist past, the first four weren’t, and are still being taught in pre-med courses and medical schools around the world. If the goal was to have every doctor know all of these throughout their careers, well, mission failed. But why would we even want that to happen?

Well, I have come around a bit since that 6-year-old tweet and came to appreciate the exposure to different concepts as the scaffolding to whatever career we end up in. No one cries out, after a skyscraper is complete, about all the money and time wasted putting up a scaffolding, setting up cranes, temporary elevators, and such. It is not a perfect analogy since most people in higher education don’t have a blueprint — not even medical students since a doctors' job can be anything from an artist (plastic surgery) to woodworking (orthopedics) to glorified administrative asssistant (general practitioners in most countries) — so it is like building a scaffolding to nowhere, parts of which ossify into the building proper, parts of which decay with time, and parts of which you dismantle as soon as it seems safe to do so, since you hate them from the bottom of your being.

“Why ever did I bother learning about the Krebs cycle five different times!?” ⊕ Twice in high school — biology and chemistry separately, and three times in medical school — chemistry proper, biochemistry, and physiology. I cry out now, as a hematologist/oncologist without a regular practice; but things could have taken a turn towards a career in organic chemistry, or genetics, or one of those specialties where the cycle is more relevant (though really oncology may very well be one of them!)

The poor Krebs cycle is notorious because it is repeated so often without practical use for most of medicine, but there are many more such concepts throughout life that went in one ear and out the other (Are viruses causing hemorrhagic fevers made of DNA or RNA? Well, I knew it for my USMLE Step 1 exam!) ⊕ RNA, says Wikipedia.

The scaffolding analogy puts a slightly different spin on grades as well, which could be a rather useful signal of where your construction should go and what kind of a building you want to make, and not your worth as a human being that most teachers and some students want it to be. But let’s not bring up grades again.

So I was surprised by Mastroianni’s and Roberts' surprise about us forgetting — because of course we do! And if the intent of the teachers was to instill knowledge that will last forever and ever, well, most of it is a miserable failure, except for that one sliver of insight that each of us carry for life. But the slivers are different for each of us, and to appreciate your unique sliver you may still need background knowledge that you will eventually forget — the more specialized the area, the more background knowledge needed, so good luck trying to untangle that web.

Today’s episode of Conversations with Tyler with the historian of the Renaissance Ada Palmer shoots straight to the top of this year’s best-of list for any podcast. Here is a long excerpt to whet your appetite:

Imagine for a moment that you are the French ambassador, and you’re on your way to Rome to meet with the pope because the French king always needs this. Now, if you’re an ambassador, you’re, at minimum, the son of a count because only aristocracy can be ambassadors. On your way south, you’re stopping off in different cities, including Florence.

Now, you already have a terrible opinion of Florence because Florence is a pit of merchants, scum, and villainy. Florence, in order to prevent noblemen from taking over the republic, literally executed everyone in this city who had a drop of royal blood or noble blood. So, it’s just commoners. There’s not a single person in this city who is of sufficient right to be worthy to talk to you. In addition, Florence has such a terrible reputation for sodomy, homosexuality, and perversion that the verb to Florentine is literally the word for anal sex in five different European countries, including in France.

So, you’re on your way to this city, and it’s full of merchant scum and they’re all perverts and there isn’t even anyone there who’s worthy to host you on the way. You’re going to stay with your dad’s banker because he’s the only Florentine whose address you’ve got. You show up in the city, and you reach the city, and suddenly, wait a minute, it’s full of these gorgeous ancient Roman bronzes. Wait a minute, they can’t be ancient Roman bronzes. They look like they’re new, but that technology doesn’t exist. That technology was lost centuries ago.

Then you go to the banker’s house, and he greets you humbly at the door saying, “I’m sorry, my house is unworthy to host your excellency,” and he invites you inside, and you look around the courtyard, and it’s like nothing you’ve ever seen before, with these round circular arches that let enormous amounts of light shine in on the gardens and the statues. You’ve never seen this before. Wait, you have seen this before. It looks like the ruins of the Roman villa in the backyard of your father’s castle where you grew up, but that doesn’t exist anymore. Those arts were lost.

In the middle of the courtyard, there’s a gorgeous statue, an ancient Roman statue of Bacchus or Dionysius, and next to it, there’s a brand-new statue that’s obviously new because it hasn’t even turned green yet. The bronze is still ruddy. But that technology, you know, doesn’t exist.

In the corner, there are some men dressed in strange robes speaking a language you’ve never heard, and you say, “What language are they speaking?” The banker says, “Oh, they’re speaking Ancient Greek. They’re Plato scholars.” And you say, “But Ancient Greek is lost, and Plato is lost. How do you have this?” “Oh, we have lots of Ancient Greek here. Look, here’s my grandson, Lorenzo. He’s just written a sonnet in Ancient Greek about the three parts of the soul.” And then, here’s a little boy reciting a sonnet to you about the nature of the soul in Ancient Greek.

You’re like, “Where am I? All of this stuff is impossible.” And that’s the moment that your host, Cosimo de’ Medici, turns to you and says, “Would France like to make an alliance with Florence?”

You should listen to any podcast with attention to get the most out of it, but this one actually does deserve your fullest attention. Pull to the side of the road if you have to, or else just read the transcript.

And she writes Hugo-nominated science fiction? Ada Palmer is the Renaissance woman.

Update: Of course that she would have a blog: Ex Urbe. Though points deducted for not having posted anything in almost a year.

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.