• Keller, Murray, Ivory & Cabreros for The NYT: The Deadly Rise of Giant Trucks and S.U.V.s. A beautifully-illustrated case for America’s king-sized vehicles being the main culprit for increased pedestrian deaths. The careful reader will remember that this “Big SUV hypothesis” was also highlighted by Brian Potter a while back, though it didn’t explain all of the increase. And of course my conspiracy theory may also be true, although if there are people who said a while back “hey, these big A-pillar will lead to more pedestrian deaths” and then there are more pedestrian deaths, well, there’s a conspiracy theory for you.
• Adam Cifu: Advice for Internship. July already? Seems like my last day of residency was but a few years ago, but now, it’s been a full dozen years as of today. And I’ve given up sharing tips almost as long ago.
• Casey Handmer: In Defense of the Marginal Baby. Handmer presents the case for having more babies, with which I agree wholeheartedly. I do not share his enthusiasm for a contraption some call a “Snoo”, a preposterous subscription-based baby rocker.
• Charlie Stross: The Golden Age Of (sic!) Bond Villains. Stross shares the afterword for a reprint of his book The Jennifer Morgue, which is about a billionaire who wants to unleash a Lovecraftian horror in order to rule the world. It was written in 2009 and yes, some idiot billionaire — probably one from the Dialog crowd — must have confused it for an instruction manual. Anyway, Stross’ “Interview with the Entrepreneur”, the entrepreneur in question being Bond arch-nemesis Ernst Stavro Blofeld, is a thing of beauty.
• Ian Finder: UHF X11. A beautifully pixelated window system built for visionOS and Apple Vision Pro. Due to my newfound aversion to Apple I haven’t touched my own AVP in almost a year. This has persuaded me to pick it up again, for the novelty if nothing else.

📺 Widow’s Bay is the best thing I have seen on TV all year, with good comedy, moments that are genuinely scary, callouts to many horror classics and a stellar cast. Will watch again.

The more I read about “Dialog” — a Peter Thiel-adjacent semi-secret society — from the likes of Andrew Gelman and Cory Doctorow, the firmer my belief is that America has zipped through its oligarchy phase to become a full-blown kakistocracy. These people are morons.

A quarterly update to my Now page is in. For more like it, check out Derek Sivers’ nownownow.com.

Yesterday, I received the strangest of emails. It was nominally from the founder of a physician services company, one of those that will, for an undisclosed “signature membership” fee, help doctors with contract negotiation, financial planning, estate management and such. Fine. Stylistically I doubt that the founder, or indeed any human, has had much input on the contents, which were this: sign up for a free 3-day online course and your host, an “expert on lead generation and trust-building” will teach you how to increase revenue and influence in order to get more patients to your clinic. He once, and I am quoting directly from the email here, “helped a little-known surgeon go viral, ⊕ [Note: This is most likely a reference to John P. Williams, a breast cancer surgeon and the creator of the YouTube channel Breast Cancer School for Patients. He was the chair for two and a half years. ] fill his waiting room, and become the White House–appointed chairman of the President’s Cancer Panel.”

Crikey.

This gave me flashbacks from October 2023 when the annual meeting of a medical society which looked more like a TED talk than a serious clinical conference shook me so much that I wrote about it. Yes, of course doctors should learn to become influencers, as well as entrepreneurs and art critics, and also counselors on the matters of faith, car safety and gun violence, everything — everything! — but experts in medicine, which up until 1986 encompassed “the science and practice of caring for patients and [various aspects of] their injury or disease”, but then in the 1970s and 80s, all diseases apparently eradicated and injuries no longer needing treatment, started to include health promotion. And who can possibly be against promoting health?

Something else lamentable happened a half-century ago: in 1975, “the Federal Trade Commission (FTC) accused the profession of ‘restraint of trade’ and legally persuaded doctors to permit advertising amongst their clan”, as noted in the Journal of Medical Ethics. Yes, you have read that right: under threat of legal action, doctors were persuaded to advertise. Up until then, the Code of Ethics of the American Medical Association explicitly forbade it, those 19th century idiots not knowing what was good for them. Or their business. Is there a difference?

Let me postulate that, prior to that faithful — or was it faithless? — decade, the medical profession was defined as sharply as a scalpel and doctors had a notably different status from other professions. Justifiably so, was it not, for people who asked you about bowel movements and sexual habits, and poked and prodded various bodily orifices. [Note: Ah, but I wrote this sentence in the past tense, for both probing questions and the actual probing are done less and less in doctor’s offices, unless it is probing with an intravenous needle to inject that expensive drug, or to insert a medical device. Note how more of the former probing would have led to less of the latter. ] With an increase in scope, the equation of medicine to a business like any other, and one grave of an old physician at a time, the profession has slowly been getting blurrier. So blurry, in fact, that one can exclaim how “there is nothing wrong with healthcare that getting rid of doctors won’t fix” at a tech summit keynoted by Tony Blair ⊕ [Note: ↬John Naughton ] and get applause instead of jeers. So blurry, are they not, that they are just asking to be rubbed out!

Was there a master plan to eliminate a profession and make it into an ordinary trade? I doubt it. It was, as ever with Americans, a pinch of short-term gain and a dash of performance artistry in the stew of unintended consequences. But how oh how to unstew it now?

• Sara Hendren (@ablerism on micro.blog): catechesis by camera. This is the first time I have encountered the case of Jesse and Ashley Ridgway, and Hendren’s article is a wonderful perspective on one aspect of the story. All I could think of, on the other hand, is our grandmothers’ wisdom: do not share pregnancy news with the outside world for the first 90 days. Sure, there may be some superstition there, but more than anything it saves you from a messy round of sharing any unfortunate updates — which happen more often than you would think — and keeping track of who knows what. So yes, it was completely expected that learning things about the baby in real time along with your YouTube followers may turn sour. May younger generations, who have long ago stopped listening to their parents let alone grandmothers, learn from the Ridgways — and there are many lessons to learn.
• Vinay Prasad: Shingles vaccine(s) and dementia: the only medical intervention to work faster than Tums. Unsurprisingly, Prasad is more sceptical about the effect of the shingles vaccine on dementia than Eric Topol. Be that as it may, it is not a bad vaccine to get if for nothing else than to prevent shingles. In the meantime, I am sure the four observational studies which all point to the same thing will fuel at least a decade’s worth of translational and basic science research to connect herpes zoster virus to dementia. Better than wasting it on the amyloid hypothesis!
• Andy Baio: The Wholesale Plagiarism of Obscure Sorrows. One good thing about this post is that I now know about the Dictionary of Obscure Sorrows, containing “made-up words for emotions that we all feel but don’t have the words to express.” The other is that I have even more reason to avoid obviously AI-slopped websites that look slick, professional, clearly have an agenda, but carry no byline, because they are not only stealing my attention from a more deserving human creator, they are also stealing that creator’s material, without attribution and with an ulterior motive.

In his latest essay, “How to Earn a Billion Dollars”, Paul Graham does his best impression of a condescending prick while trying to explain that it is possible to have a billion dollars without cheating. This was in response to Alexandra Ocasio-Cortez’s comment that:

There’s a certain level of wealth and accumulation that is unearned. You can’t earn a billion dollars. You just can’t earn that. You can get market power, you can break rules, you can abuse labor laws, you can pay people less than what they’re worth, but you can’t earn.

This is my interpretation of Ocasio-Cortez’s words: no one deserves to have one billion dollars of their own. You can get to them by ways both lawful — underpaying your workers, abusing labor laws, etc. — and, of course, unlawful, but you can’t earn them. Somewhere on your path to a billion, in fact in too many places to count, you will have broken a moral, ethical, personal or public standard, sold your soul piece by piece, through acts diabolical when written down and thought about for more than a moment but which tend to go down smoothly, like nothing at all, just doing regular business as taught and practiced by people like Graham. No one described it better than C.S. Lewis in his essay “The Inner Ring” and, more viscerally, in the third book of his space trilogy.

This is how Paul Graham seems to have interpreted those same words: it is impossible to have one billion dollar net worth without cheating. He then uses basic math — start with a few measly million, grow it at 93% per month, see magic happen — to show that no, it is mathematically impossible not to get to a billion with that kind of growth. The only reason you are not a billionaire is that you are not trying hard enough, not producing the magical technology that will get you to a 93% monthly growth rate. Left unsaid, for this was initially a talk he gave at the Oxford Union debate society, are the many assumptions that are to me unpalatable but to Graham either so common that they have become like water or equally unpalatable and therefore hidden deep in his hindbrain. I can’t tell which is worse.

Assumption one: growth is a universal good. Without even going into what it is that you are growing (gambling, recreational drugs, surveillance systems, etc) the easiest way to grow a thing good or bad is to provide more to the customer than what they are paying. If I gave people a dollar for every quarter they spend my growth would be through the roof! Normally you grow because the perceived value to the customer is greater than the monetary one, but we are long past that. Getting thousands of dollars worth of tokens for a $200 per month subscription is the latest iteration, but Uber did it before on wheels, as have many companies before and since. Welcome to step one of enshittification.

Assumption two: to the founder go the spoils. Well, not just the founder — spare the thought for the investor — but notice how it goes without saying that by getting the company to a billion dollar valuation it is the founder who would become the billionaire. You see in this kind of thinking one of the reasons why CEOs, board members and investors are so enthusiastic about AI: widespread implementation would absolve them of the moral injury they get by shafting their workers. Well, those who still have morals to be injured.

Assumption three: these are not, I repeat — not — shark-infested waters. The second assumption is that the workers should be happy with their salary and a few lottery-ticket options, and that only a handful of people, the founders, should get a lion’s share of the company. The third is that the financial ecosystem will let the founders keep the money. Alas, from banking and legal fees to business partners and investors claiming their share, our newly not poor founder may find herself in an Old Man and the Sea situation. This is much more common in biotech where the academic founders regularly get mere crumbs once they cede most business to people presenting themselves as the adults in the room.

Assumption four: all assets are equal when it comes to net worth. The Internet has been flush with graphic depictions of what one trillion dollars means in physical terms — even one of my favorite popular science outlets was in on it — without stopping to think whether Elon Musk actually has access to that kind of money. Founder shares are particularly susceptible to melting down once the founder starts liquidating them, so the answer is no, Musk would not be able to get his one trillion and lock them in a vault Scrooge McDuck-style. Which is fine, as long as you can buy, borrow, die, but then what have you “earned”, exactly? The right to cheap credit and no taxation?

Assumption five: to be a billionaire, you have to want it. This one is in fact the correct assumption! There are no accidental billionaires, though not for the reason you think. You can be purposeful and diligent in building a great business; alas this is not sufficient. Mr. Market won’t just hand you gobs of money after it sees what you have done, no, you have to absolutely want to be a billionaire, make those small sales of your soul, shaft the workers, avoid the sharks and buy into the lifestyle. Balk at any one of those steps and wham, even if the number of whatever tracker you use gets to ten figures you won’t stay there for long. Well, conditional on inflation being under control, or soon enough we will all be billionaires!

There are many, many people in the tech and biotech circles who could have become billionaires but haven’t, and kudos to them! They tend to be silent, but Jeff Atwood comes to mind as an exceedingly decent human being who is also unusually outspoken and kudos to him. Whether there are even more people who would desperately want to be billionaires but can’t — or aren’t yet — I cannot say for certain, though my brief exposure to the ecosystem tells me that the answer is sadly yes.

After ten… eventful years in DC, our family — which doubled in size since 2016 (and more than doubled if you include the cat, and why wouldn’t you) — is moving to Denver, Colorado! Next month. Less than three weeks from now. Gulp.

So anyway, here is a recent storm over Washington to set the mood.