Ben White

Paying for COVID-19

04.24.20 // Finance, Miscellany

Morgan Housel, describing how we’ll hopefully “pay” for the truly massive bailouts we’ll need to get through the Covid-19 pandemic:

I’ve heard many people ask recently, “How are we going to pay for that?”

With debt, of course. Enormous, hard-to-fathom, piles of debt.

But the question is really asking, “How will we get out from underneath that debt?”

How do we pay it off?

Three things are important here:
1. We won’t ever pay it off.
2. That’s fine.
3. We’re lucky to have a fascinating history of how this works.

The analogy here is with World War II. It’s a great read.

I think Housel is right that high bracket tax increases will be inevitable. They’re almost comically low now compared with other countries as well as our own history, and this country was far more functional when they were higher. There are plenty of important reasons to do so even before tacking on several trillion dollars in additional debt and now presumably precipitously less political tailwind to preserving the top 0.1% than there has been in decades.

Private Equity and Healthcare, a Marriage in Crisis

04.23.20 // Finance, Medicine, Miscellany

“Is Private Equity Having Its Minsky Moment?” is another excellent article from Matt Stoller’s BIG newsletter, something that anyone who is interested in PE and corporate finance should be reading (I referenced a couple of his newsletters previously).

You’ve probably been hearing about salary cuts, furloughed employees, and big losses in health systems around the country. I myself am currently experiencing a sizable pay cut. You may have even heard about the possible impending bankruptcy of healthcare megacorp, Envision. Envision is now drowning because they grew to massive size by buying companies using tons of debt. Because of that massive leverage, if those businesses do poorly, they can’t meet their debt obligations. To give you an idea of how Envision operates, they have less than $500 million in deployable cash on hand to cover $7.5 billion of debt.

Stoller gives a nice summary of why these highly-leveraged private equity companies (and other companies using the same toolbox) are ripe for failure when credit markets collapse.

Private equity is undergoing what the great theorist Hyman Minsky pointed out is the Ponzi stage of the credit cycle financial systems. This is the final stage before a blow-up. As Minsky observed, a period of placidity starts with firms borrowing money but being able to cover their borrowing with cash flow. Eventually, there’s more risk-taking until there’s a speculative frenzy, and firms can’t cover their debts with cash flow. They keep rolling over loans, and just hope that their assets keep going up in value so that they can sell assets to cover loans if necessary. To give an analogy, in 2006, when people in Las Vegas were flipping homes with no income, assuming that home values always went up, that was the Ponzi stage.

Now, what happens with Ponzi financing is that at some point, nicknamed a “Minsky Moment,” the bubble pops, and there’s mass distress as asset values fall and credit is withdrawn. Selling assets isn’t enough to pay back loans, because asset prices have collapsed and there’s not enough cash flow to service the debt. Mass bankruptcies or bailouts, which are really both a restructuring of capital structures, are the result.

I think you can see where I’m going with this. PE portfolio companies are heavily indebted, and they aren’t generating enough cash to service debts. The steady increase in asset values since 2009 has enabled funds to make tremendous gains because of the use of borrowed money. But now they are exposed to tremendous losses should there be any sort of disruption. And oh has this ever been a disruption. The coronavirus has exposed the entire sector.

Everyone wants to make the easy money in a bull market. It makes finance professionals seem competent in running multiple businesses across multiple industries even though their performance often has more to do with the amount of money in the pot driving valuations up. Rolling up companies in high-growth industries by paying top dollar? Piece of cake. But what do you do when the hard times hit? How can your businesses survive when you’ve saddled them to barely function in the best of times?

The business model of the 1980s has been institutionalized in ways that are hard to conceptualize. Sycamore Partners’ takeover of Staples was a recent legendary leveraged buy-out that shows how PE really works. Sycamore Partners is a private equity firm that specializes in buying retailers. Sycamore bought Staples for roughly $1.6 billion in 2017, immediately had Staples take out $5.4 billion of loans, acquired another company, and then paid itself a $300 million payment and then a $1 billion special dividend. Then, Sycamore had Staples gift its $150 million headquarters in the suburbans of Boston for free, after which Staples signed a $135 million ten year lease with Sycamore to lease back its own building.

Healthcare is different because the biggest cost center of most healthcare practices is personnel. And those providers are also typically the only source of profit. This limits the shenanigans you can pull, limits how you can grow, limits the cost floor, and—because of Medicare and agreements with other insurers—limits your profit ceiling. Taking care of people is not a software company or a tech business that can achieve limitless scale at near-zero marginal cost. And what seemed like an easy positive cash flow business isn’t as simple as selling toner.

Tens of millions of people no longer have income, and even those who do are afraid to go back to their old lifestyles. The Fed can’t ultimately can’t print a functional economy. And at the end of the day, no matter how many games you play with debt loads and capital structures, firms have to have customers, and people can only be customers if they have income.

We’re currently in process of bailing out a lot of companies, and low-interest rates will let some of these folks continue borrowing money trying to bide time until they can raise more capital or potentially grow out of their debt. That may not be feasible for long enough to outlast this downturn, especially if the money spigots shut off.

But the issue with bailouts in situations like these is that in recent history they’ve perpetuated a private-profit public-loss business model where PE firms are rewarded for taking on absurd risk because that risk is really on the shoulders of the American people. And without meaningful regulation, this perpetuates the growth of the industry instead of reining in its excesses. Our historically “strong” economy crumbled within about two weeks of the shutdown. That’s overleverage at work.

The actual underlying businesses within these organizations are often still sound once you remove the onerous debt obligations, leasebacks, and other financial machinations. A tiny silver lining of this horrible scenario may be getting some of the rent-seekers out of polluting healthcare.

The ABR’s New “Agreements”

04.22.20 // Radiology

Update: Two days after this post was written, the ABR announced they were essentially following the recommendations at the bottom of this post including removing all the problematic language from the agreement and extending a new less onerous version to all diplomates, including those who had already signed the version I’ve outlined below. I have not yet seen this new version, but the ABR states it now just focuses on outlining the terms of MOC and not stealing the ABR’s copyrighted intellectual property. If this pans out as promised, it would be by far the most responsive the ABR has been to any stakeholder concern for at least the past decade.

You’ve signed dozens if not hundreds of EULAs over the years. Those are the “end-user licensing agreements” that pop up whenever you install software on your computer or start using a new service. They’re usually filled with pages of legalese, and no one reads them.

Presumably as a response to last year’s lawsuit, the ABR has foisted a mandatory draconian agreement on all of its candidates and diplomates. The difference between the usual EULA and this is that a real EULA is a choice.

You should read this one–even when you inevitably sign it–because it’s yet another stellar example of the ABR’s heavy-handed tone-deaf approach to just about everything within its tiny little purview.

The two versions (one for “candidates and diplomates” and one for MOC) are almost identical, so we’ll just break down the best parts of the MOC agreement.

Findings

By entering into this Agreement for Diplomates (hereinafter the “Agreement”), I pledge myself to the highest ethical standards in the practice of my discipline.

So far so good.

I agree to disqualification from examination or from renewal of a certificate in the event that any of the statements herein made by me are false, or if I violate any of the policies, rules and regulations, or the Bylaws of the Board.

You’re the one really making statements for me in this, but okay, I get it. On a related note, everyone should really read the ABR bylaws.

I recognize the trustees of the Board as the sole and only judge of my qualifications to receive and to retain a certificate issued by the Board. I understand and agree that as a diplomate of the Board, I have the responsibility to supply the Board with information adequate for the Board’s proper evaluation of my character and my credentials.

I take the first sentence to mean that we promise not to try to have any other competing board or entity do MOC, as it has recently been argued in court that initial certification and maintenance of certification are actually separate products and should be untied, freeing other entities such as the NBPAS to provide competing MOC products. Signing this is essentially saying you agree with the court that the ABR’s monopoly is totally okay.

Additionally, I hereby request and authorize any hospital or medical or professional organization of which I am a member, have been a member, or to which I have applied for membership, and any person who may have information which is deemed by the Board to be material to its evaluation of my registration or certification, to provide such information to representatives of the Board upon their request. I agree that communication of any nature made to the Board regarding my registration or certification may be made in confidence and shall not be made available to me under any circumstances. I hereby release from liability any hospital, medical staff, medical or professional organization or person, and the Board and its trustees and other representatives, from liability for acts performed in good faith and without malice in connection with the provision, collection, or evaluation of information or opinions, whether or not requested or solicited by the Board in connection with my registration or certification.

You agree that anyone you have ever or will ever meet should spy on you for the board’s pleasure, and the board will never tell you who. Despite dramatic verbiage, this is actually how state medical boards and lots of other certifying organizations function. That said, it’s not hard to imagine a world where the ABR goes digging for dirt on people it doesn’t like.

I understand and agree that in consideration of my registration, my moral, ethical and professional standing will be reviewed and assessed by the Board; that the Board may make inquiry of the persons named in my registration form and of such other persons and entities as the Board deems appropriate with respect to my moral, ethical and professional standing; that if information is received which would adversely affect my registration, I will be so advised and given an opportunity to rebut such allegations, but I will not be advised as to the identity of any individual or entity who has furnished adverse information concerning me; and that all statements and other information furnished to the Board in connection with such inquiry shall be confidential, and not subject to examination by me or by anyone acting on my behalf.

Due process, presumably. But I will point out that people are scared of the ABR. One anonymous complaint and your livelihood could be dragged in the mud. What’s the threshold when it comes to moral and professional behavior? Is mocking the ABR on Twitter still okay?

I agree that I will not use any litigation process, subpoena or other means to cause or attempt to cause any disclosure of the contents of any registration form, including my own, or any proceedings of any committee’s evaluation of such registration form or of my certification, whether such disclosure is by operation of law or otherwise.

What about litigation to end a monopoly? Oh, that’s a separate paragraph.

This one is a little confusing at first but seems to suggest that any deliberation of the ABR behind closed doors will always be confidential. You agree, for example, that even if the ABR were to opaquely and perhaps unfairly take away your certification, that you have no legal means to find out the real reason why, fight back, or obtain recompense.

I accept that the Board determines admissibility to all MOC examinations, and that each examination is supervised by proctors who are responsible to the Board and are empowered by the Board to ensure that the examination is conducted ethically and in accordance with the rules of the Board. I understand that I must bring government-issued photo identification to any examination that I attend. Such government-issued photo identification includes one of the following: state-issued driver’s license, military ID, passport, or state-issued ID.

This is a little odd because most diplomates now have to do OLA and no longer take MOC exams, but a similar passage is in the agreement for residents/fellows for the initial certification exams. This does suggest that any dissemination of the ABR’s exams (a topic I will be returning to in the near future) would require an amendment to this agreement.

I agree that the Board is not liable for information provided to the medical community or to the public regarding my certification status, and I further agree that I will promptly notify the Board of any error or omissions in such information.

It’s not the ABR’s fault for making mistakes in its core functions.

I understand and agree that the continued validity of my certificate will be contingent upon my meeting the requirements of the Maintenance of Certification Program (ABR-MOC) administered by the Board, as amended from time to time. I understand that the ABR-MOC program is designed to monitor my professional standing, lifelong learning and self-assessment, cognitive expertise, and practice quality improvement, each an MOC component for which I am responsible.

This is a tough one because stating that I “understand” that MOC is “designed” to monitor “cognitive expertise” is a false statement, which we agreed not to do at the beginning of the agreement. We all know that MOC in its current form is revenue generation thinly veiled in trivial box-checking.

I agree to participate in ABR-MOC in accordance with and subject to stated policies, rules and regulations, as amended from time to time, including timely payment of fees. The Board does not undertake any responsibility to provide individual diplomates with notice of changes to MOC policies. I further understand it is my responsibility to stay informed regarding all aspects of the MOC program and my progress therein, through my personal database and the ABR website. I will keep truthful and accurate records of my participation in the MOC program, and I will promptly advise the Board of any change of my current contact information.

The ABR of interviews and “the Beam” newsletter and the ABR of constant defensive legal posturing are not the same organization. I will quote ABR president Brent Wagner: “One of the fundamentals I’ve been encouraging is to take ownership of flawed or incomplete communications.”

So, it’s the ABR’s responsibility to do that, except not really, because we want to be able to blame you if we do a bad job.

I understand that it may be necessary to revise and update this Agreement at a later date, and that as a condition of continued certification and/or participation in MOC, that I may be required to execute and return to the Board a revised Agreement, which shall replace and supersede the terms of this Agreement.

Necessary and required. Gives you the warm fuzzies.

I waive and release and shall indemnify and hold harmless the Board and its trustees, directors, members, officers, committee members, employees, and agents from, against and with respect to any and all claims, losses, costs, expenses, damages, and judgments (including reasonable attorneys fees) alleged to have arisen from, out of, with respect to or in connection with any action which they, or any of them, take or fail to take as a result of or in connection with this Agreement, any examination conducted by the Board which I apply to take or take, the grade or grades given me on the examination and, if applicable, the failure of the Board to issue me a certificate or qualification or the Board’s revocation, suspension or probation of any certificate or qualification previously issued to me and/or the Board’s notification of any interested parties of its actions.

As in, I promise I will never sue the ABR no matter what.

That is one extremely long almost unreadable sentence (with 21 commas!), but, of course, that’s the point.

Impression

In summary, this is pathetic.

As a non-lawyer, I’m not even sure this kind of nonsense is legally enforceable. One could at least make the argument that these contracts are signed under duress (e.g. excessive economic pressure) and are thus null and void. “Voluntarily” signing a non-negotiable contract in order to be board-certified, which is a functional requirement to practice, certainly seems like at least a gray area to me.

I am under the impression, however, that duress defenses for contract breaches are not trivial to prove, and this agreement is certainly intended first and foremost as a way to discourage any further lawsuits.

While there is new fierce opposition within the radiology community about these agreements, they are actually largely unchanged dating back to at least 2013 for candidates (with the main addition that we’re also now also waiving our FERPA rights). It would appear the main change is spreading the love to diplomates. However, that the ABR conveniently waited until after the most recent amended complaint was filed in the recent lawsuit before rolling out this iteration is likely no coincidence. I look forward to seeing how much the ABR spent on legal fees in 2019 that resulted in them having their lawyers cook this up.

It’s easy to forget when dealing with the ABR that board certification is supposed to be a form of physician self-governance. Doesn’t feel that way, does it? Reading all this, it’s easy to lose sight of the fact that this organization’s primary function is converting multiple choice questions written by volunteers into money.

As I mentioned in a recent post, ABR president and soon to be highly-compensated Executive Director Brent Wagner has described his goal to increase communication and transparency. If he means that, and I have no reason to believe otherwise, then this is a perfect opportunity to follow through on that promise. Unilaterally dropping a compulsory heavy-handed one-sided agreement upon which every radiologist’s ability to practice in their field is predicated is exactly the kind of opaque aloofness that the ABR has been promising it doesn’t want to employ anymore.

The ABR has plenty of staff and several dedicated executives, including a head of external relations with a six-figure salary. From a communications perspective, these are unnecessary and objectively bad choices of the ABR’s own making and the organizational equivalent of scoring on your own goal.

Here’s what the ABR should do

  1. Say mea culpa for completely blowing, as per usual, a PR opportunity by simply dropping this bullshit in everyone’s myABR account without warning and then immediately breaking the OLA site functionality to coerce you to sign it without explanation or discussion.
  2. Flush this steaming turd back where it came from, including for those who already signed it, and then create a new reasonable agreement, preferably with stakeholder involvement. Even if this “agreement” is largely unchanged from years past, it’s still garbage, and it says a lot about the current level of trust in the ABR that people are this disgusted by a reiteration of what is traditionally a meaningless form.

At the very least, they should do with sincerity what I’ve done sarcastically above, translating paragraph by paragraph the obtuse legalese into plain English and then providing the rationale and background for imposing such one-sided legal powerplays.

It’s not that I can’t guess. It’s that I shouldn’t have to.

 

 

The ABR Defines the Intent of the Core Exam

04.16.20 // Radiology

Radiographics hosted a Twitter chat this week to discuss a recent op-ed, “Have We Done Radiology Trainees a Disservice by Eliminating the Oral Board Examination.” I was asked to participate.

ABR President and soon to be highly-compensated Executive Director Brent Wagner was also set to throw down and managed to fire off a couple of tweets at the beginning before disappearing. He answered the first of five pre-shared discussion questions and only responded to one direct question. You can read the full thread collected here if you’re interested.

The first question: “Does the ABR Core Exam test radiology competence?”

That sounds like doublespeak to me, but I think this is probably as straightforward an answer as the ABR can provide. It also makes the unfortunate admission that we are essentially testing for a simile.

Per the ABR, its mission is “to certify that our diplomates demonstrate the requisite knowledge, skill, and understanding of their disciplines to the benefit of patients.” We are testing for #1, but we can and should also be testing directly for #2.

The Core Exam is a knowledge assessment, and knowledge assessments based on multiple-choice questions are reductive and intellectually lazy. Knowledge in isolation is likely one of the least significant measurables in determining if a radiology trainee is safe to practice for the “benefit of patients,” especially in a world with easy access to electronic resources. So despite purporting to assess for skill in its mission statement, we are testing for knowledge and pretending that the correlation between knowledge and competence is so high that it can stand alone as the sole determinant of minimal competence.

We could, however, directly test for competence and critical thinking by designing a test where the diagnostic portion simulates actual radiology practice and not an artificial multiple-choice single-best-answer format.

Leaving aside the other parts of the exam that are irrelevant to practice, the issue that Wagner sidesteps (and that made up a large fraction of the discussion on Twitter) is that choosing a single likely diagnosis from a list is an unnecessary artificial construct being used for psychometric convenience. An MCQ test is cheap to create, easy to administer, and easy to validate. The ABR once said it was creating “the test of the future,” but it really just replaced two smaller MCQ tests and an oral exam with one longer MCQ test. It was only the “future” in the sense that it was announced before it happened. I don’t get primed by answer choices in real life, and that’s the difference between knowing the correct answer and merely recognizing it.

Today, a recent interview with Wagner was included in this Radiology Business article:

One of the fundamentals I’ve been encouraging is to take ownership of flawed or incomplete communications. In other words, if an ABR stakeholder doesn’t understand something, that’s our problem, not theirs, and we have the responsibility to do whatever it takes to fix it.”

So, fix it.

Stockdale’s Reality Confrontation

04.15.20 // Miscellany

Jim Collins, quoting Admiral Jim Stockdale, who called spending seven years in a Vietnamese prison camp “the defining event of my life that would make me a stronger and better person.”

This is what I learned from those years in the prison camp, where all those constraints just were oppressive. You must never ever ever confuse, on the one hand, the need for absolute, unwavering faith that you can prevail despite those constraints with, on the other hand, the need for the discipline to begin by confronting the brutal facts, whatever they are. We’re not getting out of here by Christmas.

Like a good Stoic, you should believe in yourself and focus on the things within your valence of control and stop–as much as possible–hinging your mental, physical, and even economic health on the things you cannot.

Painfully good advice for the world right now.

Anticipatory Grief, Anxiety, and—of course—COVID-19

04.06.20 // Miscellany

David Kessler, co-author of one of the classic books with Kübler-Ross detailing the 5 stages of grief, interviewed in the Harvard Business Review:

Understanding the stages of grief is a start. But whenever I talk about the stages of grief, I have to remind people that the stages aren’t linear and may not happen in this order. It’s not a map but it provides some scaffolding for this unknown world. There’s denial, which we say a lot of early on: This virus won’t affect us. There’s anger: You’re making me stay home and taking away my activities. There’s bargaining: Okay, if I social distance for two weeks everything will be better, right? There’s sadness: I don’t know when this will end. And finally there’s acceptance. This is happening; I have to figure out how to proceed.

He goes on to discuss ways to manage pandemic anxiety, including focusing on the present, mindfulness, etc.

And then the bombshell: He’s adding a sixth stage (Finding Meaning) to the classic five.

And, I believe we will find meaning in it. I’ve been honored that Elisabeth Kübler-Ross’s family has given me permission to add a sixth stage to grief: Meaning. I had talked to Elisabeth quite a bit about what came after acceptance. I did not want to stop at acceptance when I experienced some personal grief. I wanted meaning in those darkest hours. And I do believe we find light in those times. Even now people are realizing they can connect through technology. They are not as remote as they thought. They are realizing they can use their phones for long conversations. They’re appreciating walks. I believe we will continue to find meaning now and when this is over.

There will be a pre-COVID and post-COVID world, and they will not be the same. The question is how much of this tragedy can act as a hard reset, enabling us to stop the distraction, infighting, and isolation and start making progress on the things that really matter to us as individuals, as a society, and as a species.

Student Loans & The CARES Act

04.01.20 // Finance

The new CARES act pauses student loans for six months without interest. A few important facts:

  • This is a pause (administrative forbearance) until September 30, not a typical forbearance. No capitalization will occur.
  • You don’t need to do anything. It’s automatic for those currently in IDR.
  • These $0 “payments” count for PSLF and long-term IDR loan forgiveness.
  • You can call your servicer to request a refund for any payments made on March 13 or after.

There are a bunch of folks going for PSLF asking if they should pause their auto-payments to avoid making an extra unnecessary payment. Yes, it’s possible you could get charged and then subsequently reimbursed if you have an early April payment as the servicers try to rapidly implement the law. Folks are already reporting that their payment due amounts are now showing $0, and the servicers have until April 10 to implement the new law. It’s also already been stated that all benefits will be applied retroactively, so delays will not impact you in the long term–but you being impatient and foolhardy could.

Personally, if going for PSLF, I would absolutely not make any active changes to save money upfront unless you absolutely need to cashflow-wise. I am deeply suspicious in situations like these that the more you mess with the more likely it is for something bad to happen, requiring more work on the tail end. PSLF requires on-time monthly payments; if you call and get placed on a forbearance due to trying to pause payments, then you will not be in repayment status and these months may not count. Or, trying to manually pause autopay and then make a manual payment at the last second if you don’t see an account update is a massive hassle and places an additional burden on a company that was already strained by its day to day operations before the pandemic. I would just wait and let the servicer do their job.

Outside of the CARES act itself, if you’re PSLF bound and your income has fallen substantially, consider recertifying your income now with pay stubs to lock-in lower payments for when the $0 period expires.

What is the impact?

For most of the non-PSLF-bound, it’s just a pause. You can choose to not make payments for six months (or more, it could always be lengthened later), and there will be no penalty at all. Nice flexibility, but it doesn’t really change the natural history of your loans unless you choose to continue making payments during the pause. If you are fresh off of a capitalization step like consolidation or the end-of-grace period, then you have no unpaid accrued interest and so any optional payments you make will go straight to the principal, which is neat.

For PSLF, how much this will save you in the long run depends on where you are in the repayment process.

For graduating medical students:

Many folks consolidating at the end of school will earn $0 payments for their first year, so your monthly payments will not change. There will be no interest accruing for a while, but this will only be relevant should you eventually take a non-qualifying job. So, basically, it’s quite possible this will have literally no impact on you. For anyone considering PSLF, it’s just another reason to consolidate ASAP, because a full six month grace period could be an even bigger waste.

For those certain they don’t want PSLF, there is now a potential reason to wait to consolidate. A 6-month grace period after graduation will be longer than the CARES act 0% period (at least for now), so waiting until the very end will result in a token amount of increased accrued interest during the last couple of months that will then capitalize. But if you wait you can eek out extra months of $0 payments if you wait to consolidate because you’ll start your IDR cycle later and get a full year of low payments based on last year’s taxes (stacked after the CARES act instead of overlapping it). Ultimately that would result in a full year of the optimal unpaid interest subsidy in REPAYE, likely saving you real money. While waiting does make sense outside of loan forgiveness, I ultimately caution most residents with average or high debt to simply rule out PSLF early in residency.

For residents:

You will save a small amount of money because your monthly payments are generally low to begin with. Certainly not going to hurt, and it’s a good chance to take that extra cash and pay down any high-interest (e.g. credit card) debt you may have previously been unable to make progress on.

For attendings:

Attendings in PSLF will save a lot of money. An average physician debt holder capped at the 10-year-standard could easily save $12-18k thanks to six $0 qualifying payments during their high-paying attending years.

Unintended Consequences

As always, the macro and micro don’t match the way politicians or most people would intend or anticipate. Payment pauses are just the minimum viable cashflow bandaid, a step that will ultimately do little for most borrowers nationwide, who already struggle with student loans at baseline with a 10%+ delinquency/default rate.

Meanwhile, while physicians and other high-earners are certainly not immune to job loss from the COVID pandemic, the actual monetary benefits of this policy disproportionately benefit those with large loans and large incomes.

It’s just not enough.

It’s not enough to prevent an absolute economic crush on young Americans, especially if they are largely left behind in the recovery like they were in 2008.

Student loans–like so many other critical issues from our infrastructure and healthcare system to campaign finance and legislative reform–are crying out for a cohesive, coherent, and complete overhaul, and the developing public health and economic disaster should be a wake-up call.

WCI’s Continuing Financial Education 2020

03.31.20 // Finance

I was very much looking forward to traveling to Las Vegas to speak at WCICON20 earlier this month but ended up unable to because of the whole devastating pandemic thing, but Jim and crew have released the conference e-course today. I and several other folks who couldn’t make it in person recorded our talks for inclusion after the fact, so there are over 34 hours of lecture worth 10 hours of CME.

Due to horrific computer glitch, I lost audio during my original recording and had to the majority of it again a second time while juggling my infant and 4-year-old, so I welcome you to check it out and see if you can feel the undercurrent of my electronically induced suffering. The struggle is real.

The course is included in the conference fee, so even if you went in person you should still check it out and hear the extra talks. I already enjoyed the talk from Morgan Housel (author of the upcoming The Psychology of Money) earlier today.

For everyone else, the cost is $100 off through April 21 with code CFEINTRO (which is already embedded in this totally monetized affiliate link).

Coronavirus: The Hammer and the Dance

03.23.20 // Medicine

Another excellent follow-up from Tomas Pueyo about the need to stop doing half-assed mitigation measures.

On one side, countries can go the mitigation route: create a massive epidemic, overwhelm the healthcare system, drive the death of millions of people, and release new mutations of this virus in the wild.

On the other, countries can fight. They can lock down for a few weeks to buy us time, create an educated action plan, and control this virus until we have a vaccine [ed: or treatment].

Governments around the world today, including some such as the US, the UK or Switzerland have so far chosen the mitigation path.

That means they’re giving up without a fight. They see other countries having successfully fought this, but they say: “We can’t do that!”

We can do better together with decisive action and cohesive government intervention/support.

Humans are a communal species. While we need to be alone, right now, we should act together.

Maxims for Academic Medicine

03.17.20 // Medicine

Highlights from Joseph V. Simone’s “Understanding Academic Medical Centers,” published way back in 1999 (hat tip @RichDuszak):

  • Institutions Don’t Love You Back.

A wise colleague once told me that job security was the ability to move to another job (because of professional independence).

  • Institutions Have Infinite Time Horizons to Attain Goals, But an Individual Has a Relatively Short Productive Period.

There is little incentive for an institution to rapidly cut through the bureaucratic morass. An institution will always outlast a dissenting individual, regardless of the merit of the case.

  • Members of Most Institutional Committees Consist of About 30% Who Will Work at It, Despite Other Pressures, and 20% Who Are Idiots, Status Seekers, or Troublemakers.

Generous.

  • Institutional Incompetents and Troublemakers Are Often Transferred to Another Area, Where They Continue to Be Incompetent or Troublemakers.

They force others to pick up the slack or repair their mistakes, reducing everyone’s efficiency. If this continues for long, those who are consistently unproductive may become the majority because the competent learn that the institution sees no virtue in hard work and collaboration.

  • Leaders Are Often Chosen Primarily for Characteristics That Have Little or No Correlation with a Successful Tenure as Leader.

Examples of such criteria include a long bibliography, scientific eminence, institutional longevity, ready availability, a willingness to not rock the boat, or to accept inadequate resources. Choosing leaders is not a science, but it is surprising how often management skills, interpersonal skills, and experience are undervalued.

See: Academic Medicine & The Peter Principle.

  • In Recruiting, First-Class People Recruit First-Class People; Second-Class People Recruit Third-Class People.

Some hesitate to recruit a person who is smart enough and ambitious enough to compete with them. Others want a position filled at any cost because of “desperate” clinical need or other institutional pressures. If that approach continues for long, the third-class people will eventually dominate in numbers and influence and ultimately chase away any first-rate people that remain.

  • In Academic Institutions, Muck Flows Uphill.

Leaders often try to ignore or deflect the unpleasant mess, but the longer it incubates, the harder it will be to sanitize.

See: the dropped balls nationwide with current COVID-19 pandemic.

  • Personal Attitude and Team Compatibility Is Grossly Underrated in Faculty Recruiting.

A faculty member may be very productive personally but create an atmosphere that reduces the productivity of everyone else.

Annoying people are the black holes of camaraderie and joy.