Residency application season has just started. Many of the applicants, a few of whom I know in person, will be foreign medical graduates, or FMGs, meaning that they are doctors who want to work in the US but are not US citizens. Most FMGs, but not all, will also be international medical graduates — IMGs — meaning that they have graduated from a non-US medical schools. Something called the Education Commision for Foreign Medical Graduates, or ECFMG, acts as their medical school when interacting with most of the sprawling US bureaucracy. These are our personae dramatis, if you will.
Disclosure: I am both an FMG and an IMG, and first began working in the US on an ECFMG-sponsored J1 visa.
America is a net importer of physicians, that much should obvious to anyone who’s ever been in an American hospital. The country depends on FMGs to keep the system running, get the less lucrative specialties, work in underserved areas, etc. Not so obvious is that most FMGs get to America by lying; ICE-approved, foreign-government sponsored lying for sure, but lying nonetheless.
Here are the lies FMGs tell when they come in: that their country has a need for doctors of such-and-such specialty, and/or that their government is sending them to the US for training in the said specialty, and/or that at the end of training they will go back to their country of origin to work in the (sub)specialty they came in to obtain. Those are the three postulates of the J1 physician exchange visa, the very name of which is also a lie as there is no exchange taking place: foreign doctors do come in, but no American doctors come out.
The postulates are incompatible with reality, and imply foreign government competence that just isn’t there in second and third-world countries. The transitioning and developing world, if you will. Because over there, no one is keeping statistics on specialist needs, and if they are there is actually a surplus, and if there isn’t they wouldn’t be able to afford the (sub)specialists once they come back, and if they could then they would be chosen by party or family lines, and you wouldn’t want them in your hospitals anyway.
So to get a J1 visa FMGs need to obtain a letter from their Ministry of Health or equivalent stating the above (the postulates, not the actual truth; I’m sure that in some of those countries people have gone to prison for saying the truth). But is there a functioning Ministry of Health? Does anyone there know that the letter they are supposed to provide about lending a medical graduate and wanting them back is a piece of kabuki theater, and not a commitment to employ that person if and when they come back? And because this letter is supposed to come in a sealed envelope directly from the Ministry to ECFMG: does anyone there speak English? So here are all those FMGs whose main reason to emigrate to America may have been to escape their kleptocratic governments, being dragged into a game of Whom do I bribe next? and Which newspaper do I threaten them with? In 2019 the correct answer is, for most countries of this sort, None. by the rules of the country they were hoping was less crooked than their own.
Which is fine for America, because it doesn’t care as long as it gets its steady stream of MDs one way or another. Only it should care because 1) the amount of person-hours wasted is on par with if not greater than the amount spent writing grants, and that one’s a whopper, 2) it relinquishes control over a part of its healthcare to foreign governments, and 3) it introduces an air of subterfuge and deceit at the very beginning of the FMG-USA relationship. I would like to think this is an aberration to be fixed, and not a preview of things to come in other areas of governance.
The process was probably fine 50 years ago, when both demands of the medical system and the influx of foreign doctors were but a fraction of the current monstrosity, when USMLE was taken on paper if you had to take it at all, when it wasn’t so obvious to a non-aligned physician whether they should go to the US or USSR (or Yugoslavia, for that matter) to get more training. But healthcare has changed and so has the world: it’s time do drop the pretense of an exchange, America, and be honest about what’s going on here.
“Diagnosis” is a Netflix reality show first, a comment on American healthcare second, and Lisa Sanders’ medical show on crowdsourcing the diagnostic process a distant third. If you wanted to see more of what made her book and column great, like I did, well, tough luck: this ain’t it. Because — and this isn’t a surprise — most people with access to a tertiary medical center do get an adequate diagnosis. Those who are undiagnosed either lack access, or have a functional-slash-undiagnosable condition that ultimately doesn’t change much in their management.
Realizing this, the producers add a spin: the crowdsourcing they bring is also there for emotional support, connecting with people, getting different treatment recommendations. As if Facebook didn’t exist. If this show were a clinical trial, it would be a phase II with an unimpressive response rate but hey look at those bio markers we hadn’t initially planned on doing!
Warning: spoilers for Episode 1 ahead. I may get to the other ones, eventually.
Only the first episode half-lives up to its promise. A young woman from Las Vegas has a problem. Her local doctors don’t know the cause; I certainly didn’t, but could make a ballpark guess as to which type of a disorder it was and which subspecialist she should see. However, instead of giving her a referral to the nearest university medical center, the doctors flood her medical bills, and sue her for non-payment to boot. Only in America!
Enter Sanders: her NYT article gets a bunch of people across the world sending video suggestions as to the possible diagnosis. A medical student from Turin, Italy, offers a free work-up. Netflix, bless their hearts, films the patient and her partner flying to Italy to get it done, marveling at the wonders of a single payer system. I can only presume travel and boarding were paid for by the production team. But why not pay for a trip to San Francisco instead? Well, the skyline isn’t as dramatic as that of Turin; and it would rob Dr. Sanders of the opportunity to marvel how crowdsourcing brought the answer from half way across the world, literally.
In a nutshell: Because of No Insurance and TV Drama Makes Better Ratings, woman from Nevada flies to Italy — instead of driving to California — to get diagnosed with a rare medical condition.
To be continued…
Twitter brings out the worst in people. If your worst is not that bad then power to you, madam, but most of us need to spend an extraordinary amount of energy not to look like sociopaths, or should just stay away. More often than not I choose the latter.
There are good arguments for why you should be on Twitter from both doctors and civilians. On the opposite end there is a whole book dedicated to why you shouldn’t (full disclosure: I haven’t read the book, but did read two accompanying NYT Opinion pieces back before I realized NYT Opinion pieces weren’t worth my time). So clearly there are two opposing points of view, and while I’m sympathetic to the Twitter cheerleaders and their cause, my own experience makes me take pause. Here’s why:
Note the “madam” reference in the opening paragraph. Here, I have space to explain what I meant: that a well-behaved user on Twitter was more likely to be a woman. An outrage-primed stranger on Twitter just glancing at the post could instead interpret it as an attempt to emasculate the well-behaved male readers. And I forget, is it still kosher to use madam to refer to women? Or is “females” the appropriate term now, never mind that it’s an adjective? At least using “kosher” is not considered cultural appropriation yet. Right?
I don’t like this lack of nuance for two reasons: because I recognize it in myself when I overreact to a tweet and have to stop myself from writing a snarky reply and because writing down short thoughts that are still coherent is much more time-consuming than writing run-on sentences like this one.
Recall Justine Sacco and the delight with which a Twitter mob tracked her WiFi-less flight across the Atlantic. Twitter mobs are pure minority rule, wherein the minority has a high follower count with an incentive to mobilize them. It is vexing to see someone with 10,000+ followers retweeting — with a snarky comment, of course — a poorly worded tweet that had thus far garnered three likes and no other retweets. No matter the content of the original tweet, and often they’re deranged rantings of an anti-vaccer, doing it to a person with a hundred-fold lower followe count and a thousand-fold lower reach is unethical at best, and dare I say immoral too when the intent of the retweet is nothing more than virtue signaling.
Again, this kills my enthusiasm for Twitter in two ways: the time I spend self-censoring my Eastern European spent-a-decade-under-US-sanctions tendency towards sarcasm, and the time I spend reading, digesting, and ultimately dismissing these worthless posts.
But isn’t the great benefit of Twitter over mainstream media the ability to choose whom you follow? Yes, but: Twitter the company is doing its best to ruin that by showing you not only retweets, but also those tweets that people you are following liked, and a random tweet here or there that’s been getting attention (as in: a lot of replies, as in: this is probably controversial) which it thinks may cause you to engage (as in: join the conversation, as in: enter the fray). I am not making this up.
So even if you try to keep your time line completely professional and only follow other MDs who post only their high thoughts on the latest randomized trials in the area you’re interested in… Well, you can’t stop them from liking political posts, and you can’t stop Twitter from foisting its algorithm on you.
So what? Just ignore the noise. Cull your follow list to manage input, write quickly and don’t look back to speed up your output. I suspect that’s what many people who are good at Twitter do, and if you can do it too then power to you. What kills it for me is 1) the opportunity cost (as in: I’d rather spend time with my family, and 2) (and this is the main one) I. cannot. write. like. that. This was supposed to be a two-paragraph post written in the subway. Well clearly it’s not.
As I finish writing this, a scientist I’m following has retweeted the FCC chairman’s gripe about the latest Twitter redesign. An MD is retweeting pointless videos. Random biotech factoids fly by my screen, unwanted and uncared for.
I’ve always assumed that much of the western scientific tradition is a series of That’ll-Do measures made by imperfect humans in imperfect circumstances. This monograph showed me just how imperfect were both the circumstances (the English civil war) and the humans (naive, vain, incestuous, sometimes all at once). And just how much like the present times was the whole scientific endeavor: even back then, with so much yet to be discovered, most published papers were trivialities, most scientists (and “scientists”) cared for status more than truth, and most research (and “research”) was left unheard and unread.
It’s not a mystery then why we have such a hard time changing the ways of the ancients when those ways were built out of sheep’s blood and luminescent meat. But then I realized: we don’t get the science we need, we get one that we deserve, and we’ve been deserving the same kind of science for centuries now.
Written by Adrian Tinniswood, 2019
Written by Francis S. Collins, 2007
There are so many wasted opportunities in this movie that I hesitate to recommend it. Here is the raw material in more-or-less chronological order: an atheist theoretical physicist studying time, black holes, and the beginning of the universe falls in love with a devout wife, develops a catastrophic neurological condition, gets married and has children, becomes world-famous, gets a tracheotomy and can’t talk any more, gets a robotic voice, falls out of love, divorces, marries his nurse, denies suspicions of domestic abuse by the said nurse, divorces the nurse, reconciles with the first wife, never wins a Nobel prize and never will because it will take too much time for his theories to be proven correct.
With so many intertwined plot lines and obsession with time you would think this would be non-linear story, or better yet a series of reverse-chronological set pieces that covers the highlights in depth. What we get instead is a shallow, lukewarm love story carried entirely by the walking-to-debilitated transformation of Eddie Redmayne whose best actor Oscar is one of the better deserved. If you want to tell such a complex life story beginning-to-end, make it into a mini-series and put it up on Netflix.
Directed by James Marsh, 2014
Jared Diamond’s Guns, Germs, and Steel is a book with a brilliant idea, adequately presented. Collapse is also presented adequately, for an undergrad ecology course textbook. The ideas aren’t lacking, but are dull, undefined, hard to follow, and boil down to this: it is hard for a society to survive in a harsh, isolated environment, and some places tend to become harsh and isolated once humans start overexploiting resources, so better be careful. He presents several past societies that thus failed (Easter Island, Anasazi, the Greenland Norse, etc.), several that survived, and gives some not entirely plausible accounts of current societies which may be on the brink of collapse (Montana, China, Rwanda).
Diamond likes to enumerate: there is a Five-point Framework for Societies’ Collapse, but also Ten (?) Reasons Why The Vikings Failed, Seven Ways the Hard Mining Industry is Ruining the Environment, and Fifteen Things to Do in Iceland. I made-up those last three numbers, because I couldn’t remember the actual ones — he likes to enumerate, but doesn’t like lists, so it doesn’t make for a very good textbook either.
Written by Jared Diamond, 2011
Directed by Jordan Peele, 2017
A cheap (estimated budget $5,000,000) sci-fi movie that doesn’t look cheap. Its looks are a blessing and a curse: yes, the camera work is good and the actors are photogenic but what are supposed to be gritty run-down inner cities of the utopian/dystopian near-future look instead like HD-bloomed props of a glossy magazine photoshoot.
The story features drones, self-driving cars, moments of gender ambiguity, and — the title gives it away — upgraded humans. It is timely, but also kind of lazy; I would have preferred more time dedicated to the huge inequalities between the different flesh-and-blood humans rather than the more obvious AI versus humanity plot line.
But I like where the movies are going much better than TV: the barrier to entry for both the makers (again, $5 mil) and consumers (90 minutes on the couch) is low, potential payoffs high (Upgrade’s gross was double its budget, a pretty good return on investment), and with word-of-mouth traveling more quickly and easily than ever before the good ones are more likely if not guaranteed to get awareness. Upgrade is not as good as it gets, but it’s pretty good.
Directed by Leigh Whannell, 2018