• The only reason I bought and read this book was the excerpt published in the Atlantic which noted some parallels between 1990s' Balkans and 2010s', well, the world, which I was already mulling in my head. Turns out that's the best part of the book.
• The rest is uneven. Holbrooke was a slime ball of a human and his accomplishments were nil, yet Packer still manages to make the book into a hagiography. Which I guess is an accomplishment.
• Did Holbrooke truly think that his memos would change the world? In the Gervais Principle hierarchy, he was a clueless posing as a sociopath.
• Packer’s account of the Dayton negotiations confirms that the only reason a deal was made was that Milošević wanted it at any cost. The agreement was for Holbrooke to mess up, and he almost did, multiple times.
• There is mention of HBO buying rights to make a show out of Holbrooke's account of the Bosnian was. I haven't read "To End a War", but I like the idea of the Dayton negotiations being the centerpiece of a mini-series, with flash backs to each individual warlord's (and Dick's) messy history. Someone please give the idea to Damon Lindelof after he's done with Watchmen.

Written by George Packer, 2019

I started the decade childless and am ending it with three, so I have missed most of the 2010s’ pop culture. This includes the entire Transformers franchise and most of the Marvel Cinematic Universe (so, not much missed then?)

• Film: “Get Out”
• Blockbuster/action film: “Spider-Man: Into the Spider-Verse”
• Album: “Hamilton”
• Single: “Rolling in the Deep”
• TV Show: “Veep”
• Single Season: “The Leftovers” season 2
• Book Fiction: “The Dark Forest” (or “Death’s End” if you count the publication of the first Chinese edition, but TDF is superior)
• Book Non Fiction: “Antifragile”
• Athlete of the Decade: The Đoković-Federer-Nadal trio, but if I had to pick one then obviously Đoković.

Movies and music were better in the 2000s, but oh what time to watch TV and follow tennis. It’s too early to judge the books (though it’s telling that my favorite was originally written in 2008).

1. Malcolm Gladwell tries to explain the death of Sandra Bland by the way of the Hitler-Chamberlain meetings, Cuban double-agents, college student alcohol culture, an episode of Friends, and Sylvia Plath’s suicide by gas oven. Huh?
2. The pieces actually fit, and — a few abrupt interludes aside — the story flows nicely. His previous books were also stories and not scientific review articles, which people tend to forget, but this one more so than others. Which is good, since people tend to misunderstood him for a Pinkeresque academic with pop culture pretensions rather than a journalist having fun.
3. A single point of disagreement: his portrayal of Ferguson, MO police as misapplies of hot spot policing rather than racketeers rang false to my layman ears.
4. Gladwell has become a podcaster, and it shows in how the book is structured: it reads like a podcast script. I haven’t listened to the audio version, but this may be the one case of a non-fiction book that is better listened than read.
5. But if you don’t have the actual book, you won’t get to read the extensive notes, on of which directly refutes a whole chapter of Blink. Another is an excellent parallel between indiscriminate police searches and cancer screening tests. Too bad he didn’t use actual footnotes (but then people would also complain, see no.2).

Written by Malcolm Gladwell, 2019

Things I found to be scarier than this movie:

• “Cabin in the Woods”
• “Coraline”
• “Toy Story 3”
• My father upgrading his Windows PC
• My 2-year-old’s diaper
• The thought that I have spent almost two hours watching this drek

That this was co-written and produced by Guillermo del Toro and directed by the same person who did The Autopsy of Jane Doe is not exactly mind-boggling, but certainly disappointing. I wonder what went wrong.

Directed by André Øvredal, 2019

A collection of essays from the man who wrote Infinite Jest, also known as the 20th century’s best 21st century book. Each one is near-to-completely brilliant and worthy of more thought than a one-line in an inconsequential blog post, but that won’t stop me:

• Big red son is the one where he attends the AVN awards as a magazine correspondent. The more absurd things become, the more encyclopedic he gets. Yes it’s funny, but also existentialist and sad as only pornography can be.
• Certainly the end of something or other, one would have to thing is long title to a short-ish review of a supposedly science fiction book by John Updike. He didn’t like it.

• Some remarks on Kafka’s funnies from which probably not enough has been removed is exactly what it says it is. Having only high-school literature class-level acquaintance with Kafka, I can’t comment.

• Authority and American usage is a review of a dictionary but also the 20th century’s (written in 1999) best 21st century essay, covering issues of political correctness, identity politics, race, alienation, and a brief history of the battle between prescriptivism and descriptivism for the hearts and minds of I don’t know who exactly, but what an exciting battle it is.

• The view from Mrs. Thompson’s is about where he was on 9/11 (spoiler alert: he was at Mrs. Thompson’s).

• How Tracey Austin broke my heart is the reason I’m even sadder than I should be about DFW not still being around, because an essay about the Federer-Đoković-Nadal tennis trio in general and the mental gymnastics going on in Novak Đoković’s head in particular would have been spectacular to read (although there has been a fairly successful attempt). Oh, and it’s also a review of a reasonably bad autobiography of the titular Ms. Austin, who is also a tennis player.
• Up, Simba is DFW following McCaine’s failed 2000 attempt in the Republican primaries, wherein he shows just how walled away from the “real” world candidates were back then, how big of a gatekeeper the media world, and just why Twitter could have made all the difference.
• Consider the lobster is where a travel essay for a cooking magazine from a food festival in Maine turns into an existential crisis and a call for veganism. It’s good
• Host is so messed up by its formatting of footnotes (fortunately there is now a web version which more than makes up for it, and the original article published in The Atlantic was also easier to read, apparently, say people who were able to find it, and yes this should also have been a footnote) that it’s hard at first to appreciate how good of a story interspersed with thoughts on infotainment and talk radio it really is, and even though it was written more than a decade ago you can sort of see what it’s protagonist will eventually become in these troubling times.

Written by David Foster Wallace, 2007

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:

1. No nuance

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.

2. Ill will

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.

3. Poisoned stream

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.

4. No country for slow thinkers

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.