Category: Uncategorized

Anatomy lab was less than 30 minutes: we removed with blunt dissection the posterior muscles around the vertebral column to prepare for next week’s laminectomy (removal of the vertebral laminae to expose the spinal cord)! We went over spine anatomy and common spine disorders such as a herniated (“slipped”) disk (the gelatinous nucleus pulposus part of the intervertebral disk herniates through the outer fibrocartilage annulus fibrosus) and spondylolisthesis (anterior or posterior displacement of a vertebra). We discussed how aging causes loss of the elastic dampening capabilities of the nucleus pulposus.

Lectures detailed two sensory systems, the anterolateral and medial lemniscal tracts. The anterolateral tract conveys tissue damage (pain), whereas the medial lemniscal tract conveys fine touch and proprioception (vibration and positional awareness). Sensing vibration requires extremely responsive transducer elements in the skin to convert rapid changes in pressure into electrical signals. All these tracts end in the postcentral gyrus in the cerebrum, which forms the sensory homunculus. The medial part receives sensory input from the lower extremity. The genitalia neurons are adjacent to the foot neurons, a potential explanation for why some humans have a foot fetish. The lateral part of the brain receives sensory input from the upper extremities.

Doctor J called the tallest student up to the front. He grabbed a measuring tape and asked the student to step on one end of it. He then measured all the way up his back to the end of his neck — 5’6. “This is the length of a single neuron in your body.” The whole class was amazed. Neurons that sense fine touch and proprioception travel from the big toe up to the spinal cord, ascend the spinal cord in large bundles, and finally synapse in the medulla (part of the brainstem). One cell.

Our patient case: Sherry, a 50-year-old overweight female accountant with uncontrolled diabetes presents to her primary care physician with a foot ulcer. During tax season she is so busy that she forgets to take care of herself. She has not refilled her medications, including metformin, for several months. A neuromuscular exam, specifically using a 256 Hz tuning fork to test for vibration sensitivity, reveals diminished sensory ability in both extremities. She explains that her foot has felt numb for weeks. A cut on the foot went unnoticed, and got infected.

Sherry suffers from diabetic peripheral neuropathy. Uncontrolled glucose levels lead to non-enzymatic glycosylation (adding sugar groups) of proteins,lipids, and nucleic acids. These advanced-glycosylated products (AGEs) interfere with normal function and activate inflammatory pathways. A familiar complication of diabetes is vascular (arteries and veins) damage, which leads to increased risk of atherosclerosis, heart attack, and stroke. This inflammation also damages neurons and their companion Schwann cells (cells that myelinate peripheral nervous system axons). The longest axons are affected first. The neurological deficits such as numbness, loss of pain sensation and balance difficulty start in the foot and travel up the leg. By mid-calf, the sensation loss also begins in the hands. Fifty percent of diabetics have peripheral neuropathy (eighty percent after 15 years). Interestingly, the physician mentioned that twenty percent of prediabetics have some sign of developing nerve damage, suggesting that vibration tests should be used as a screening tool for diabetes.

Sherry had trouble simply walking. As is common among laypeople, classmates associate diabetes with laziness: failure to exercise, overeating. This case prompted us to ask “How could someone exercise if they cannot walk?” The physician concluded, “It is critical for diabetics to check their feet daily. They might not even realize they have a cut or foot ulcer. The infection can spread to the bone requiring hospitalization and, too commonly, amputation.” He reminded us that diabetes is the leading cause of amputations [73,000 in 2010]. Sherry described her diabetic foot ulcer, now cured, as a wake-up call. She was discharged from the hospital three months ago and has been taking her medications regularly.

A diagnostic radiologist and an interventional radiologist led a lunch session about their respective specialities. Diagnostic radiologists complete 5 years of training: an internship year typically on general surgery followed by a 4-year radiology residency. Interventional radiologists conventionally would complete a separate 2-year interventional radiology (IR) fellowship, making for a total of 7 years of post-MD training. There are now direct IR residencies that take just 5-6 years.

IR is a subspecialty of radiology. Interventional Radiologists perform minimally-invasive procedures using imaging guidance such as x-ray and ultrasound. These procedures include: central line placement, endovascular (e.g., stents and thrombectomy of blood clots) procedures, radiation treatment, and bile duct obstruction procedures. Other specialities overlap with many of these. Indeed, there is sometimes tension what specialty group performs a given procedure at different health systems. For example, stents can be placed by IR or interventional cardiology; strokes can be treated by neurosurgery or IR.

The interventional radiologist explained why he chose IR: “I loved anatomy. And I like working with my hands doing procedures.” The diagnostic radiologist explained why she choose radiology: “I had the worst internal medicine rotation fourth-year. Day after day, I would have a patient die on me. The worst was a 30-year-old cystic fibrosis patient, the exact same age I was. I was so miserable I considered quitting medical school or not completing a residency. A radiologist lived upstairs of me and noticed how miserable I was. He suggested I shadow radiology. Never looked back.”

She described radiology as the “experts’ expert.” Clinicians increasingly rely on imaging procedures as opposed to physical examination skills. “Do not go into radiology if you cannot wield responsibility. You decide if someone in the ED goes to the OR or gets sent home.” We learned that radiologists are highly compensated, but also have a higher liability profile: “Every radiologist will be sued several times.”

What will the role of machine learning play in radiology? “Computers will not replace radiologists. They will just make radiologists much better at their jobs.” The diagnostic radiologist elaborated, “Computer algorithms in some areas are just as good as radiologists in identifying if something is wrong with a patient [high sensitivity]. However, computers are terrible at ruling out issues [low specificity].” I attended a neurosurgery informal dinner where I asked a similar question about radiology. The neurosurgeon was shocked by the radiologist’s response, and exclaimed, “Radiologists are terrible at ruling things out. Every report is littered with: ‘cannot rule out x, y, or z’. Give me a break, they will be replaced.” (See “A.I. Versus M.D.,” New Yorker, April 3, 2017.)

I’ve been working on a personal project in the evenings. My favorite trauma surgeon comes in most Wednesdays at noon to evaluate my progress. She tidies up my dissection then sends me on another mission that our class did not have time to explore during formal anatomy lab. Examples: Find the annular ligament of the radius, the ulnar nerve, or the anterior humeral circumflex arteries. One thing that makes medical school different is that an after-hours project may involve a dead body. In this case, I have a whole cadaver to myself, unlike in anatomy lab where we switch bodies every few months. The cadaver was a black 60-year-old, mildly overweight female. I have developed a deep sense of appreciation for this woman who donated her body so that I could pursue this upper extremity (arms) project focused on nerve and blood vessel anatomy.

One evening around 9:30 pm there was a knock on the locked door. I took off my soaked gloves and opened the door to find the head dean escorting a fundraiser group of dressed-up bankers and business people. They wanted to see the wet lab. I forgot how quickly one adjusts to the sight of cadavers in a formaldehyde-scented room. As I was there by myself, the whole head was uncovered and several chunks of removed fat lay exposed. A few people approached the body, but most were hesitant and stayed at least several feet away. I showed them the nerves and vessels of the arm.

A visitor asked about the purpose of cadavers. I explained that cadavers give unparalleled understanding of human anatomy. Textbooks cannot replicate this experience, especially the geometric relations of anatomical structures. An important part of the learning experience is discovering how the individual died and what diseases he or she lived with. I mentioned that one cadaver had a heart attack, prompting a question from a gentleman in his late 50s regarding what the heart looks like after a heart attack. I explained the cadaver suffered a heart attack in his left anterior descending (LAD) artery, as evidenced by a small, hardened discoloration on the surface of his left ventricle (see previous post). He did not die from the myocardial infarction because hardened scar tissue replaced the infarcted region. If he did die from the MI, the infarcted region would have the same firmness as the rest of the myocardium. The gentleman thanked me, took a peek at the cadaver and left. The next day the dean told me that the wet lab had been the guests’ favorite part of the event.

Statistics for the week… Study: 8 hours. Sleep: 6 hours/night; Fun: 1 nights. Example fun: Two classmates and I attended this year’s SonoSlam in Orlando, Florida. SonoSlam is an ultrasound competition among medical schools held on a Saturday by the American Institute of Ultrasound in Medicine (AIUM). My favorite part was using the most advanced ultrasound machines. Several of machines were controlled via iPads. One bluetooth-enabled ultrasound probe was only slightly larger than a smartphone and could be controlled via an iPhone app. The competition ended around 6:00 pm. As first-year students without the pathology training of the fourth years, we had low expectations for the competition and we did not exceed them. However, we celebrated our failure with post-competition drinks at a local brewery and “Cutthroat” at a nearby billiards parlor.

More: http://fifthchance.com/MedicalSchool2020

Full post, including comments

Now that we’re sufficiently distant from the obligatory sentimentality around Mother’s Day, let’s look at Sheryl Sandberg’s Facebook posting on the subject:

Being a mother is the most rewarding – and hardest – job many of us will ever have. The day you become a mom, you also become a caregiver, teacher, nurse, and coach. It’s an all-in-one kind of role that comes with no training.

Apparently she and Bill Burr are destined to disagree regarding the difficulty of a job that can be done in pajamas.

For most moms, it’s only one of many jobs we have. Over 40% of mothers are the primary breadwinners for their families – and in many, the only breadwinner. We all have a responsibility to help mothers as well as fathers balance their responsibilities at work and home.

Celebrating the heroism of single mothers is a stock item for politicians so perhaps Sandberg will soon run for office? But can she be right about a significant number of single moms being the only breadwinner? If this is a low-income mating situation, the taxpayer will be providing the single mom and her children with a subsidized (or free) house, free health care, and free food. If this is a high-income mating situation, the child support defendant will be sending a stream of cash into the mother’s checking account.

Companies can do a lot to lead the charge, and I’m proud of the steps Facebook has taken. But not everyone has the opportunity to work for a company that supports working parents. It’s time for our public policies to catch up with what our families deserve and our values demand.

To start, it’s long past time to raise the federal minimum wage. Two-thirds of minimum wage workers are women. Raising the wage would reduce pay inequality and help millions of families living in or near poverty.

Sandberg is concerned about “pay inequality.” Her reported net worth is $1.6 billion. Thus we can estimate that she has been paid $2-3 billion pre-tax by Facebook, money (or the stock equivalent) that otherwise could have been paid to employees lower down in the bureaucracy. Why not reduce pay inequality at Facebook before asking for government intervention in the labor market for other employers (let’s assume that Facebook, being in Silicon Valley, is forced by the market to pay well above the minimum wage, so a change to this law will have no effect on Sandberg’s personal wealth).

We need paid leave. The United States is one of the only developed countries in the world that doesn’t guarantee paid family leave – and we’re the only developed country in the world without paid maternity leave. That means many moms are forced to return to work right after giving birth to keep their jobs. They deserve more support. So do dads, LGBTQ parents, adoptive parents — families of all kinds.

So those Americans who haven’t been fortunate enough to find a mate or have a child are going to be further disadvantaged by a forcible transfer of income to those who have been blessed with a mate (at least for a few hours) and children?

All of us will have times when we need to take care of ourselves and our relatives. We shouldn’t have to risk losing a job or being able to meet the basic needs of our families to do that.

And we need affordable child care. Child care for two children exceeds the median annual rent in all 50 states. How are parents supposed to work if they don’t have a safe and affordable place to leave their kids?

More wealth transfer from the childless will be required!

On this Mother’s Day, even more than ever, I feel deep gratitude for my amazing mom Adele Sandberg, who has given me her love and strength my whole life and these past two years especially. I am also grateful for the love and support of my mother-in-law Paula Goldberg who dedicates herself not only to her own family, but to families with children with disabilities through the PACER Center. For those for whom this day can be more painful than celebratory, I hope – as Connie Schultz would say – that it lands gently.
This is an emotional day for so many reasons – because we thank the mothers we have and remember the mothers and the children we’ve lost. I hope we can also use this day to commit to do more for all the mothers who have given so much and deserve even more.

Sandberg proposes to hit women who couldn’t find a mate and/or couldn’t have a child with higher tax rates to subsidize their sisters who were fortunate enough to become mothers. But Sandberg offers them some kind words in exchange for their higher tax payments!

Related:

• The inquisitive gender studies student and Sheryl Sandberg
• Sheryl Sandberg sweeps away sex discrimination at Facebook
• Sheryl Sandberg: Everyone is stupid compared to me
• Sheryl Sandberg: thinking small
• Sheryl Sandberg, Jane Austen, and the Queen of Versailles
• Lean In
• Lean In: Women can move up the career ladder as soon as men change

 

Full post, including comments

From our anonymous insider…

We had a week off. Several classmates visited girlfriends, boyfriends, and family. One went on a Caribbean cruise. A few stayed in town to recuperate and study this next block in advance (“gunners” is the class label for this behavior).

We’ll study neurology for the next two months, but class began with two deans reprimanding us. “It has come to our attention that several doctors and professors think you need to work on professionalism. Several of you are on Facebook, browsing Amazon, and checking Instagram during lecture while you sit next to a physician. SnapChatting in class is inexcusable. These physicians frequently volunteer their time to come in and speak to you. Treat them with respect. Every class gets a reputation. Don’t let this be yours.”

For eight weeks we will be taught almost exclusively by a 74-year-old neuroanatomist, “Doctor J”. He worked for several years as a physical therapist, then earned a Ph.D. in neuroscience. His first slide was a quote from Emerson Pugh: “‘If the human brain were so simple that we could understand it, we would be so simple that we couldn’t.” “We will do our best,” explained Doctor J. His second slide was a black and white photo of an old guy. “Neuroscientists bow before Cajal.” In the late 1800s there was no consensus on the anatomy of the nervous system. Two luminary anatomists, Camillo Golgi and Santiago Ramón y Cajal, supported opposing viewpoints. Golgi supported the reticular theory: nerves are a syncytium of several cells connected together. Cajal supported the neuron theory: each nerve is a single cell. Cajal used Golgi’s own staining method to disprove the reticular theory. This history lesson gave a human spin to the evolution of knowledge. These men worked in shoddy laboratories with microscopes that we could build today out of paper and tape.

We had to purchase several tools for the neurological exam, including a reflex hammer, pen light, and eye chart. Our white coat is filling up with gadgets! We will practice the exam in several workshops. Students complained to the dean about Doctor J not posting answers to the workshop questions. The neuroanatomist responded during lecture, “This is your fault. The first few years we did give out answers for the lab book. I put a copy in the library. Within a week, someone had photocopied it and send it as PDF to the whole class. The value of the workshops went down, no one attended, so I no longer give the answers out.” Apparently not all classmates were mollified by this explanation because enough students went back to the dean that he submitted a “formal grievance” against Doctor J.

Lecture began with an overview of the nervous system, divided into a central nervous system (CNS) and peripheral nervous system (PNS). The CNS is a tube with a hollow canal in the middle where cerebrospinal fluid flows. This tube is simple in the spinal cord but becomes suddenly more complicated at the top of the tube, which will become the brain. During fetal development (in utero), the cells of this part grow much faster than the surrounding skull causing bending and folding of the tube. The brain retains its lumen (inner membrane adjacent to canal) as the four ventricles of the brain that are continuous with the central canal of the spinal cord.

Unbeknownst to me, the spinal cord does not extend the whole length of the spine. Before birth, the spinal cord extends to each vertebrae. However, during childhood the vertebrae elongate faster than the the spinal cord, resulting in the spinal cord’s termination at the first or second lumbar vertebrae (above the hip bones). A lumbar puncture (“spinal tap”), a common procedure to sample cerebrospinal fluid, leverages this anatomy by sampling the cerebrospinal fluid at L4 without the risk of puncturing the spinal cord.

There are about 860 billion cells in the brain, only 10 percent of which are neurons. Ninety percent are supporting cells called glia and microglia. These cells perform various functions: astrocytes (a type of glia) maintain the blood-brain barrier by wrapping foot processes around ninety-five percent of the capillary surface area (it reminds me of the scintillating podocytes in the glomerulus of the kidney); oligodendrocytes (a type of glia) insulate the axon cable (wire to the next neuron(s)) by wrapping sheaths of their cytoplasm around the cable; microglia are specialized resident macrophages that get in the central nervous system in utero before the blood brain barrier is formed.

Myelination is essential for neuron function. The conduction velocity of the action potential (the nerve signal) decreases as the resistance of the axon cable increases. Organisms such as the giant squid without myelinating cells achieve high transmission speeds by having huge axon diameters. Myelination decreases the effective membrane capacitance, which reduces the amount of potential needed to charge up the axon, and decreases potential leakage. Myelination enables the preservation of high speed as more neuron connections are packed into a small volume. This is important because intelligence is related to the connectivity (or synapse density) of each neuron. A human brain is estimated to contain more than 100 trillion synapses for roughly 86 billion neurons.

We learned how the number of cells change during human development. Between the third week and twenty-eighth week after fertilization, 250,000 brain cells are produced every minute! Many of these neurons undergo apoptosis (cell suicide) during training of the neural network. Despite this amazing proliferation, the brain is only twenty-five percent of its adult size at birth; the brain reaches seventy-five percent of its adult size at one-year of age.

In my small group we discussed foundational neuroanatomy structures. The corpus callosum is a bridge for nerve fibers to cross between cerebral hemispheres. Someone mentioned the corpus callosum is thicker in females. A question “Is this why women are more emotional?” yielded chuckles from several male students and glares from Type-A Anita and straight-shooter Sally. Anita replied, “Yes, that is exactly why. It’s going to be a long two months with you guys.”

Anatomy held a dry lab in which we felt bone vertebrae. Dry vertebrae (just the bones) have spinous processes which look like something out of a Game of Thrones episode. The spikes you can feel on your back are these spinous processes. The vertebral body, the main weight-bearing part, lies deep to this on the anterior (front) side. The spinal cord sits between the vertebral body and the spinous process inside the vertebral foramen (hole). The spinal cord gives off spinal nerves through the small bilateral intervertebral foramen. We saw how the intervertebral facet joints differ among the cervical, thoracic, and lumbar (neck, chest, and lower back) regions. The cervical vertebrae have the joints in the axial (horizontal) plane facilitating rotation; the cervical have the joints in an oblique plane preventing significant movement here; and, the lumbar vertebrae have their joints in the sagittal (vertical side section) facilitating forward bending and extension.

Our patient case: Jonathan, 25-year-old male presents to the ED nine months ago for a three-minute seizure and worsening headaches in the morning for the past month. A neurological exam shows absence of venous pulsations, suggesting elevated intracranial pressure. Jonathan did not pay much attention to the headaches. He was busy at work, and his wife was due with a second child.

A CT (“CAT scan”) revealed a 3x3x3 cm (a little more than a cubic inch) tumor in the right temporal lobe of the brain. Surgery was scheduled immediately. The neurosurgery team debated removing the entire temporal lobe or just a “lesionectomy” where they remove the tumor with as good margins as possible. A lesionectomy was performed and a pathology analysis of some of the tumor removed revealed a grade III glioma. Jonathan’s neurosurgeon told us that “All grade III gliomas eventually become grade IV.” A death sentence. Jonathan is still alive, nine months after his first ED visit, but was unable to attend due to worsening health.

According to the neurosurgeon, a patient presenting to the ED with a headache will always get a head CT. However, it is unlikely the same patient’s primary care doctor will order a head CT for just a headache.

How many patients with advanced brain cancer elect not to get surgery? “Much more rare than you would expect,” responded the neurosurgeon. “Everyone hopes they will be the exception, the extreme outcome. We hope for a cure, so our treatment plan is very aggressive.” He has operated on a 86-year-old with grade IV glioma (the patient died; Medicare paid the bill). He recounted a troubling story of a 60-year-old late stage Huntington’s patient with glioblastoma. “His wife had a very difficult time letting go. We said we could get him back to baseline, but that baseline was late stage Huntington’s. They decided to not operate.”

What’s more important for neurosurgery, dexterity or knowledge? “We can teach a monkey to do surgery in seven years. Passion is the most important quality. I see senior residents get angry at newer residents because they work shorter hours than they did. They are bitter, and remorseful. Unless you have the passion, you will burn out.” He joked that sometimes beginners can be too passionate. “One of my residents got so excited about a successful shunt [apparently, a common neurosurgery procedure] he performed. It’s not that big a deal, we do shunts every damn day. I did not want to burst his bubble so I told him ‘Great job!’… Don’t tell him I said that!”

How did he cope with such depressing cases? “It is tough. I see cases like Jonathan’s every month,” he answered. “Everyone manages it differently. For me, as long as I feel like I treated my patient and their family like my family, I sleep fine. It is when I remember at night that I forgot to talk to that family member that it hits me.”

A seventy-year-old dermatologist with a strong southern accent held a lunch session to explain why his field is the best: “I cannot think of a single reason why you would not want to do Derm. It pays well. It has unbeatable hours. The patient population is generally quite motivated to get better.” He was in private solo practice for much of his career. “Many of my patients, such as lawyers, paid cash.” A classmate asked, “Did it get lonely working solo?” He responded, “No, we have nurses.” He described how there are just not many dermatologists, claiming this was the reason why there were so few dermatology residency slots. Dermatology is one of the most competitive residency programs.

Friday was Match Day, a slight misnomer because it is one day after fourth-year medical students hear where they will (or will not) be completing residency. Students and residency programs rank their top choices. Almost 36,000 domestic medical students and international doctors vied for about 29,000 residency slots. Fifty percent of applicants nationwide got their first choice.

The whole school attends the ceremony. Each student goes up to the podium and says something like “I will be will doing Internal Medicine at the University of Southern California.” Fifteen percent of the class couples matched. Two individuals need not be married or in the same specialty to couples match. An orthopedic surgeon sent an email out congratulating the class on their impressive Match Day results, but reminded the first through third year students not to slack off. He ended with a quote from Will Rogers: ” Even if you are on the right track, you will get run over if you just stand there.”

Statistics for the week… Study: 10 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: A good friend and former coworker visited for the weekend. We joined Match Day celebration at a pregame followed by a late bar night filled with plenty of Guinness for Saint Patrick’s Day. Jane and I saw Beauty and the Beast on

Full post, including comments

Right next to my hotel…

Full post, including comments

In some meetings in London regarding the helicopter market I noticed a big difference in how pleasant well-educated natives spoke about the people who might want to go from Point A to Point B within this cloud-plagued rain-soaked traffic-clogged land. Where an American might have said “executives” or “businesspeople,” the British consistently referred to potential helicopter users as “businessmen.” Nobody seemed surprise by this phrase, not even the female consultants at the global management consultancy conducting the meetings.

Readers: Is this just another example of the persistent inability of people in England to use the English language correctly? Or does the apparent sexism of the language reflect a society that is in fact more sexist than the U.S.?

Full post, including comments

Mark Zuckerberg showed up this year to give the commencement speech at Harvard. Let’s look at parts of the transcript:

graduates of the greatest university in the world

What better proof of the high quality of a university than that the most successful affiliates are those who dropped out? (See also Bill Gates, apparently too busy saving Africans (or “sharing the load” of housekeeping with his wife?) to give this year’s address.) Times Higher Education gives Harvard a solid #6 ranking, behind such schools as Oxford, Stanford, and Cambridge.

my best memory from Harvard was meeting Priscilla. But without Facemash I wouldn’t have met Priscilla, and she’s the most important person in my life

She faces some obstacles to becoming the most important plaintiff in Zuckerberg’s life, though, because the wedding was deferred until a day after the IPO (see “Zuckerberg’s post-IPO wedding is smart legal move” (Reuters) and our chapter on California family law).

Many of our parents had stable jobs throughout their careers. Now we’re all entrepreneurial, whether we’re starting projects or finding or role. And that’s great. Our culture of entrepreneurship is how we create so much progress.

Young people are better and more interesting than their boring parents. The Harvard graduate who goes to work for the government is an “entrepreneur.”

Millennials are already one of the most charitable generations in history. In one year, three of four US millennials made a donation and seven out of ten raised money for charity.

[Entrepreneur notes that “Despite being the largest U.S. demographic by age, the generation of 18-to-34 year-olds donates less and volunteers less for charitable causes than any other age group.” “Why Are Americans Less Charitable Than They Used to Be?” (Atlantic) says “The average American has grown more tight-fisted in recent years, donating a smaller portion of his or her income to charity than he or she did 10 years ago.” (Of course, the authors note that high-income Americans have become less charitable recently, but don’t consider the possibility that this could be due to higher tax rates, such as the Obamacare tax on investment income.)]

giving everyone the freedom to pursue purpose isn’t free. People like me should pay for it. Many of you will do well and you should too.

[… on average not as well as folks who chose to become California prison guards.]

We should have a society that measures progress not just by economic metrics like GDP, but by how many of us have a role we find meaningful.

Maybe Facebook can re-hire Chia Hong to measure the meaningfulness of jobs within the company? (See also “Underpaid and overburdened: the life of a Facebook moderator” (Guardian))

We should explore ideas like universal basic income to give everyone a cushion to try new things. … In a survey asking millennials around the world what defines our identity, the most popular answer wasn’t nationality, religion or ethnicity, it was “citizen of the world”. That’s a big deal. Every generation expands the circle of people we consider “one of us.” For us, it now encompasses the entire world.

UBI will enable everyone to start a company. Certainly no American would use his or her UBI to become an opiate addict, as has been common with SSDI and Medicaid.

[If you’re a citizen of the world and also support universal basic income (UBI), shouldn’t everyone on the planet get a handout? Why does someone who happens to be physically in the U.S. have a greater entitlement than a fellow citizen of the world in Bolivia, India, or China? We take the total wealth we’re going to hand out and divide by 7.5 billion? Or do we exclude citizens of the world who live in the richer-than-the-US countries from joining the check-of-the-month club?]

We’re going to change jobs many times, so we need affordable child care to get to work

Guy with a kid says that people with no kids should work harder and pay higher taxes to subsidize his child care costs.

We get that our greatest opportunities are now global—we can be the generation that ends poverty, that ends disease. … How about curing all diseases and asking volunteers to track their health data and share their genomes? Today we spend 50x more treating people who are sick than we spend finding cures so people don’t get sick in the first place.

There is no way that viruses will turn out to be smarter than humans. Certainly throwing money at a problem will solve it. Maybe a War on Cancer instead of these ongoing battles we’ve been funding?

How about stopping climate change before we destroy the planet

There is no better way to conserve the planet’s resources than tearing down four houses and rebuilding them in the same location.

Readers: What struck you about the dropout’s speech to the graduates?

Related:

• Christmas love from New Yorker magazine to Mark Zuckerberg, philanthropist
• Is the new Zuckerberg fake charity an estate tax avoidance scheme?
• Can a school system that wastes $1 billion per year waste another $200 million?
• More from Chaos Monkeys

Full post, including comments

Suppose that part of Berkshire Hathaway’s value is avoiding corporate income tax by combining insurance with conventional businesses. And part of the firm’s value is avoiding individual income tax by doing stock buybacks instead of dividends.

Warren Buffett says that Trump’s proposed federal corporate tax rate cut to 15 percent (don’t forget to add state taxes as well!) would help his investors (link). But if corporate and/or individual income tax rates are cut, would that devalue Berkshire Hathaway relative to other enterprises?

Full post, including comments

I met an expat for coffee in Moscow. He is British, but also has a U.S. passport because his mother is originally American. He runs a company that does business in Russia and the U.K. He has to file taxes both in the U.K. (because he works there) and in the U.S. (because he holds the passport). Much of the U.S. work is disclosure, e.g., of real estate owned or money withdrawn from a foreign bank account, e.g., to pay for an apartment. “It takes me one hour to do the U.K. taxes,” he said. “I use the government’s web site and it leads me through it step by step.” What about the U.S.? “That takes a week and it is the worst week of my year.”

Full post, including comments

Shortly before we sat down to a family dinner of chicken enchiladas, a moderately Deplorable friend emailed me “This Week in Appropriation: Kooks Burritos” (Portland Mercury):

This week in white nonsense, two white women—Kali Wilgus and Liz “LC” Connely—decided it would be cute to open a food truck after a fateful excursion to Mexico. There’s really nothing special about opening a Mexican restaurant—it’s probably something that happens everyday. [in Mexico?]

Week after week people of color in Portland bear witness to the hijacking of their cultures, and an identifiable pattern of appropriation has been created. Several of the most successful businesses in this town have been birthed as a result of curious white people going to a foreign country, or an international venture, and poaching as many trade secrets, customs, recipes as possible, and then coming back to Portland to claim it as their own and score a tidy profit.

Because of Portland’s underlying racism, the people who rightly own these traditions and cultures that exist are already treated poorly. These appropriating businesses are erasing and exploiting their already marginalized identities for the purpose of profit and praise.

People of color are nothing more than an afterthought when the white perpetrators of this tradition continue to do this on a regular basis.

I didn’t feel the need to read the masthead to infer that this is from Portland, Oregon rather than Portland, Maine…

Full post, including comments

Growing up in the 1970s I was told by American media that Russia was to blame for everything that wasn’t going well here in the U.S. This is apparently still true today. A one-day (May 16) sample from Facebook:

• “Trump Revealed Highly Classified Intelligence to Russia” (nytimes; referenced by a concerned Facebook friend)
• The guy under investigation for illegal ties to Russia leaks classified material to the…Russians! Yes, but she used email
• Another Russian Connected To Trump Has Turned Up Dead – That’s 8 So Far
• DEMAND A SPECIAL PROSECUTOR ON RUSSIA (ACLU)
• Trump’s business network reached alleged Russian mobsters
• “Top Senate Democrat Calls on White House to Release Trump-Russia Meeting Transcripts” (nytimes)

Our media portrays Russians as living under a cruel dictatorship. Vladimir Putin and his friends are stealing all of their money. Our go-to “look how they abuse their women” slam against enemies doesn’t work with Russians (since women obtained an equal role in their society 100 years ago) so we decry the cruel oppression of gay and transgender people by a heteronormative government.

What was it like on the ground? I visited Moscow, which I was told was the part of Russia least likely to support Putin. Nonetheless, I met Putin supporters and Russians of all political persuasions agreed that Putin would win 65-70 percent of the vote in a completely free election. Putin is credited with eliminating corruption and chaos at local and intermediate levels of government. Although Russians might be happy to live in an English- or German-style parliamentary democracy, they don’t see this as the alternative to Putin. Instead they envision pervasive corruption, violence, and looting. What about the fact that Putin and people close to the government seem to have become richer than typical civil servants? [Though let’s keep in mind that these folks haven’t made anywhere near as much money, in the aggregate, as cronies of the U.S. government! Consider the $182 billion A.I.G. bailout, for example, and all of the Wall Streeters protected from their own incompetence thereby.] “I look at Putin as a hedge fund manager,” said one Russian. “We have about $500 billion in foreign currency reserves and Putin should get a fee for managing that. At least he hasn’t buried us in debt the way that Bush and Obama buried the Americans.” (A Boston-based emerging markets bond fund manager confirmed Putin’s basic fiscal prudence: “When oil prices went up, Russia paid off a lot of its debt early. Compare that to Venezuela where they spent it on social programs and making Hugo Chavez’s daughter a billionaire.”)

Russia has a flat 13-percent individual income tax, a flat 20-percent corporate income tax, and a European-style value-added tax of 10-18 percent (PWC). They are suffering from more or less permanent “austerity” because the government spends only about what it takes in via revenue. I.e., they don’t have deficit spending.

Tyler Cowen said that the stagnation of the U.S. economy shouldn’t make us weep because we now have the option of same-sex marriage (and, fortunately for litigators, divorce). Russians certainly don’t have this option. Is the oppression of gays as bad as portrayed in the American media? “You can be as gay as you like here,” said one expat. From the Lonely Planet Moscow:

Moscow is the most cosmopolitan of Russian cities, and the active gay and lesbian scene reflects this attitude. Newspapers such as The Moscow Times feature articles about gay and lesbian issues, as well as listings of gay and lesbian clubs. Visit Gay.ru (http:// english.gay.ru) for up-to-date information, good links and a resource for putting you in touch with personal guides.

Students at the university that I visited had a much more diverse set of opinions regarding social and political issues than their American counterparts. On the issue of gay rights, for example, students at the same cafeteria table might range from someone actively interested in promoting LBGTQ issues (maybe not the Transgender part, though; I didn’t hear anyone mention gender ID) to someone who would openly say “It doesn’t bother me if people want to have sex in their apartments, but I don’t want to hear about it.” They could all go back to eating after discovering these differences, instead of one group trying to enforce political orthodoxy on the other! What do university students who don’t put energy into enforcing conformity do with all of their leftover time and energy? I met economics masters students who not only knew the names of a bunch of (Russian-language) poets, but actually had poems memorized!

As in Soviet times, though there is probably more freedom of expression in social and work situations than we have here in the Boston area (e.g., you can express your opposition to race-based hiring preferences at your employer, but you won’t have a job a day later!), running a mass-market TV network with 24/7 anti-government stories wouldn’t work. People thought that Putin would still win in totally free elections in a country with totally free media, so restrictions on media may not have any practical effect on the government.

What about something that corresponds to our obsession with Russians controlling important events here in the U.S.? Are there Russian stories about how various officials are being manipulated by Americans or the American government? There don’t seem to be. Government-influenced Russian media do seem to enjoy pointing out American hypocrisy and of course we give them plenty to choose from. The Land of Liberty (TM) has the world’s highest incarceration rate. The Land of Opportunity (TM) has a massive underclass. From those two contradictions alone the Russians can fill all of the pages that they want with stories that make us look ridiculous.

Full post, including comments