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“Extreme poverty in America: read the UN special monitor’s report” (Guardian):

The proposed tax reform package stakes out America’s bid to become the most unequal society in the world, and will greatly increase the already high levels of wealth and income inequality between the richest 1% and the poorest 50% of Americans. The dramatic cuts in welfare, foreshadowed by Donald Trump and speaker Ryan, and already beginning to be implemented by the administration, will essentially shred crucial dimensions of a safety net that is already full of holes. It is against this background that my report is presented.

The United States is one of the world’s richest and most powerful and technologically innovative countries; but neither its wealth nor its power nor its technology is being harnessed to address the situation in which 40 million people continue to live in poverty.

The Federal War on Poverty began 54 years ago (Wikipedia). As a percentage of GDP, the U.S. spends more on its welfare state than any other country on Planet Earth other than France (Forbes). Thus, due to our larger population, we actually run the world’s largest welfare state. Is it thus fair for the Guardian to say that our wealth isn’t being harnessed for poverty relief? What about the fact that the evil Donald Trump might assist Congress in changing the way some of this money is spent? If tens of millions of Americans are desperately poor despite the river of poverty relief cash that has been flowing for 54 years, what is bad about change? Is it too early to declare that the old methods have failed? It is plain that we were just about the turn the corner on poverty?

Unless these folks were suggesting that currently poor Americans were actually doing great prior to Donald Trump’s election, I think the only logical inference that one can draw from the above is that War on Poverty hasn’t been given a fair chance. That seems also to be the general feeling among New York Times readers. See, for example, “The U.S. Can No Longer Hide From Its Deep Poverty Problem” (nytimes), by a Nobel-ish economist:

it is precisely the cost and difficulty of housing that makes for so much misery for so many Americans, and it is precisely these costs that are missed in the World Bank’s global counts.

(So if we already have too much demand for too few houses and apartments, how is population growth via immigration supposed to make low-income Americans better off?)

The readers respond to this with comments demanding that we double-down on the Big Welfare State:

(the very top-rated-by-readers comment) Nancy Parker, Englewood, FL: … we should tax the rich until they yell out loud, because they are privileged, not entitled to the chunk of wealth they lay claim to. Not until every poor person has the basics can they live the lives of excess and extreme that they do.

(the next one, which 951 people recommended) Susan Sheeley, Salem, MO: … Poverty isn’t the result of immigration. It is the result of the very wealthy leaving the rest of America behind.

flyoverprogressive, Michigan: The 1.5 trillion that will mainly stuff the coffers of the wealthy should have been used to provide universal healthcare, affordable college, daycare for working moms and immediately infrastructure repair. Where I live, the roads, bridges, water and sewer systems are little better than the ‘shithole’ countries of Africa.

alan haigh, carmel, NY: … Americans are sold a mythological identity of a self reliant, individualistic people always capable of pulling themselves up by the bootstraps when sufficiently motivated. If this was true, poverty would not so stubbornly pass from generation to generation here. Poverty breeds poverty, not a lack of motivation- any lack of motivation is a symptom. [i.e., he is denying the science of heritability of success!]

T.A.S. Milwaukee, WI: … If the minimum wage were a living wage, so many fewer would be on welfare. If we had reasonable public transportation, people could get to work. Etc.

Among the highly-rated comments there is only one that shows some evidence of thoughtcrime:

Don P, New Hampshire: … During the past 50 years there has been tremendous action at the federal, state and local level to address poverty and many programs yet the number of Americans in poverty still grow.

The one glaring area that no one has attempted to address and certainly no politician will even speak about is the high birth rate. In 2015 the birth rate for women with income less than $10k was 64.7 as compared to 52 for women earning $50-76k, 46 for women earning $100-140k, and 43.1 for women earning $200 k.

The clear fact is that those with the least financial means are having the most children who are being born into poverty and are opportunistically disadvantaged from they day they are born. And far too often being born into poverty results in a lifetime of poverty.

(But of course he is not enough of a thought criminal to ask “Why would people who get paid by taxpayers to have kids have a lot of kids?” or “Is it possible that when a child is born to two parents who have never worked the child will be less likely than average to seek a job?” (See The Son Also Rises: Policy Implications and The Son Also Rises: economics history with everyday applications))

Readers: Why do Americans, after having spent so many trillions of dollars over so many decades, and observing the continued presence of tens of millions of their fellow citizens still “in poverty,” still have faith that the stuff that hasn’t worked for 54 years will suddenly start working?

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From our anonymous insider…

Heart failure week begins Sunday evening. Jane and I watch (at 1.75x speed) three hour-long lectures on hypertension and ischemic heart disease (due to obstructed arteries the heart is starved for oxygen causing chest pain d). The lecturer is a 35-year-old cardiologist who comes in Monday morning for a two-hour case workshop. “I get excited when I see 30-year-olds with hypertension. I can change their lives. When I see a 70-year-old patient with three decades of uncontrolled hypertension, the damage is already done.”

Hypertension is categorized by disease acuity. Malignant hypertension is a severe acute elevation of blood pressure that causes end organ damage, particularly in organs with dense capillaries, e.g., the kidneys and retina. Benign hypertension, over 95 percent of cases, is a progressive mild elevation of blood pressure. Our lecturer explained that Amazonian tribes with no exposure to Western diet typically show blood pressures of 80/50. Normal blood pressure for an occasional McDonald’s customer is 120/80. Greater than 140/90 mmHg constitutes benign hypertension. Over 200/120 mmHg is malignant.

“The vast majority of benign hypertension is simply caused by chronic excess of salt intake,” said the cardiologist. “Our bodies have evolved complex mechanisms to retain fluid by holding onto salt. Recommended salt intake is about 4 grams; most Americans consume about 10 grams per day.” About 30 percent of the US adult population has hypertension compared to 45 percent of the Japanese adult population with their salt-heavy fish diet.

He explained that, although salt intake is a serious driver, “there are many risk factors that interplay with this volume overload state. It is well-established that African Americans have an increased risk of hypertension. The current theory is that there was an evolutionary adaptation to holding onto salt in Sub-Saharan Africa. These adaptations helped individuals survive as young children in a dry environment with little access to salt.” He continued, “The unintended consequences of chronic hypertension that develop when you are 50 do not really matter from an evolutionary standpoint. Our genetics are most adapted to getting to reproductive age.” There is nothing that humans can do after age 50 to increase their genetic success? “I would like to think there is some selection that occurs during your 50s as you take care of your child, perhaps even into grandchildren-rearing age.”

Why is hypertension bad? “A misconception about hypertension is that the heart is at fault. Hypertension is not a disease of the heart, but a disease of the vasculature and kidneys. Cardiologists get stuck dealing with many of the serious complications.” The endothelial cells and smooth muscle cells of vessels do not respond well to chronically elevated hypertension. Over time, the increased pressure within the vessels hardens and narrows both large and small arteries (atherosclerosis and arteriosclerosis, respectively). The increased resistance decreases perfusion to tissues and increases the risk for thrombus (clot) formation leading to embolic events such as heart attack and stroke. Further, the left ventricle undergoes hypertrophy (thickening) as it struggles to pump against an increased total peripheral resistance.

“For most of my patients, losing weight is the most effective method,” said the cardiologist. “Unfortunately, only six percent of patients told to lose weight actually keep weight off at one year. I give HTN medications first and tell them that they can get off them once they lose the weight.” What about reducing salt? “Americans are so far to the extreme that taking away the salt shaker will do nothing. Shake away. Chronic benign hypertension needs antihypertensive medications.”

Where is HTN treatment going? “We are in the dark ages of hypertensive treatment and pharmacology in general. Most of us hope that in twenty years we will have a renaissance in pharmacogenetics to personalize treatment. Right now it is just black or white.” (White patients may respond to single drugs, but certain monotherapies are contraindicated in African Americans due to poor response rates. Black patients will be started on lisinopril in combination with a diuretic.)

The cardiologist concluded: “On a brighter note, we are at a unique point in human history that we are no longer dying from microbes and predators. Instead, we are eating, drinking and smoking our way to death. Not bad.”

The rest of the week was dedicated to the diagnosis and management of heart failure. First we learned multiple classifications:

• Diastolic v. systolic (relaxation versus contraction)
• Ischemic versus non-ischemic (oxygen supply to the heart muscle)
• Preserved versus decreased ejection fraction (percentage of blood pumped out of heart)
• Hypertrophic cardiomyopathy versus dilated cardiomyopathy

Retired Navy Physician: “Cardiology is not rocket science. It is just common sense.”

We were prepared for our patient case with a lecture on dilated cardiomyopathy, a systolic non-ischemic problem. The heart is enlarged due to growth of muscle cells, but the resulting thin-walled muscle is unable to pump enough blood. This can be caused by genetic defects, viruses (Coxsackie B), parasites (Trypanosoma cruzi causing Chagas disease), alcohol abuse, cocaine, and poorly understood autoimmune mechanisms.

For the most part, we’re not working with cadavers this year, However, this week we go into the anatomy lab to dissect the preserved hearts that we removed from our cadavers last year. Several students expressed frustration that they had to resurrect their anatomy outfits. Pinterest Penelope: “I thought we were done with anatomy lab. Another pair of scrubs will be tossed.” Our favorite trauma surgeon and an M4 helped with the dissection. We first weighed each heart and found that two-thirds weighed more than the normal 500 grams. The trauma surgeon attributed this to “pervasive hypertension”.

We used a scalpel to open the right atrium. We used angled probes to identify the veins draining the body: inferior vena cava, superior vena cava, and the barely visible coronary sinus. We then opened the left atrium with its four pulmonary veins draining oxygenated blood from the lungs. One student found a patent foramen ovale (PFO) type of atrial septal defect (ASD). You could see a hole connecting the left atrium to the right atrium. (The trauma surgeon expected more: “I would expect to have several PFOs. It is expected to be present in 25 percent of the population. Look closer!” We then opened the left and right ventricles to observe the heart strings connecting to the valves. Afterwards we went over to the “Tray of Horrors,” collected over multiple years. We looked at the severely dilated thin walls of dilated cardiomyopathy, a bicuspid aortic valve, and a heart with several stents in the left anterior descending coronary artery. “Good haul!, I am very impressed,” said our trauma surgeon. She suggested that our class contribute to the school’s archive: “Put the mechanical aortic valve and aortic dissection on the tray.”

Our patient case: Jonathan, 53-year-old construction manager and father of two, presents to the ED for progressive shortness of breath and swelling in his legs associated with a 15-pound weight gain over two weeks. Lung auscultation (listening with a stethoscope) reveals bibasilar (base of both lungs) crackles. Heart auscultation reveals a S3 gallop, an extra heart sound that sounds like a horse’s gallop, suggestive of rapid ventricular filling.

Feeling for the location of the heart under Jonathan’s left nipple revealed a laterally displacement. Chest xrays showed an enlarged cardiac silhouette and bilateral infiltrates (pathy whiteness at the base of the lungs) with accentuated vasculature at the hilum (connective tissue where the pulmonary artery, pulmonary vein and bronchi pierce through the pleura). EKG shows sinus rhythm with a left bundle branch block, left ventricular hypertrophy, and biatrial enlargement. An echocardiogram (ultrasound of the heart) shows dilation with a 30 percent ejection fraction (normal > 55 percent). Jonathan is diagnosed with dilated cardiomyopathy secondary to viral myocarditis (infection of heart). (“Viral myocarditis and dilated cardiomyopathy,” Kearney, et al. Post-Graduate Medical Journal, 2001 ).

Jonathan, his wife, and their 25-year-old son were joined by his cardiologist. Jonathan and the son rarely spoke; the wife, a middle school teacher, led the conversation. “We did not know what hit us. It came out of nowhere,” explained the wife. “I did not know what to say to my children or husband for weeks.” The son was clearly uncomfortable. When asked about his perspective on two separate occasions, he repeated: “I try to stay optimistic, and hope for the best. I just have to believe my father will pull through this.”

Jonathan’s symptoms rapidly deteriorated at the hospital to a point he underwent a LVAD (left ventricular assist device) implantation to improve his cardiac output while he waits for a heart transplant. “We would have liked to do the surgery at a larger hospital that does maybe 100 per year. There was just no time, he was on his deathbed,” explained the wife. “The surgeon had done maybe two in his life. We put our faith in him, and it fortunately went great.”

Jonathan has been on the heart transplant list for five years. He appears tired, worn out, although he still looks imposing in his burly 6’5″ frame. “It is hard to find a heart that fits his size,” added the cardiologist. His wife is convinced he will get one soon. She recounted the scariest day in her life: “I got a phone call from my husband telling me he got in a car accident. A truck veered into his lane, striking the car in front of him. He swerved off the road hitting a tree. “I believe God has a plan for him. He wouldn’t have come out of that car accident without any scars.” Jonathan: “I am realistic. I have lowered my expectations.” There is clearly a disconnect.

Jonathan’s symptoms have improved remarkably from his deathbed with the LVAD. His progress has pushed him down in the transplant list for more urgent cases. He is maintained on diuretics and antihypertensive medications. He quickly gets out of breath from walking. He has had to retire on disability, while his wife has picked up hours working at Starbucks after her job.

A student directly asked Jonathan, “Are you depressed?” “I feel like a failure. My whole life I provided for my family. Now I just sit and wait.” Several students went up afterwards to thank the family and look at the numerous batteries and charging devices for the LVAD. Mary asked to listen to his LVAD. “It sounded like a fish-tank pump.”

Our ethics lecturer and facilitator returned this week to introduce the topics of beneficence and nonmaleficence (do no harm). Lecture opened with the classic ethics train dilemma. “There are five people on the track who will die unless you pull the lever to divert it to the side track where one person will die. Would you pull the lever?” Most students responded via the iClickers, “Yes”. “Now you have five patients that need a transplant and a healthy tourist comes to town? Should you harvest the tourist’s organs to save your five patients?” The class responded “No”. Asked to justify the different answers, one student responded “The guy on the track got into his unfortunate situation, the tourist did not.” Lanky Luke: “Is that victim blaming?”

In our small groups, we went over the Jesica Santillan case. Jesica Santillan was treated for anemia in her hometown of Guadalajara, Mexico with iron supplements, but over the years her conditioned worsened and a heart murmur was found. She was diagnosed with restrictive cardiomyopathy, a genetic disorder requiring heart transplant. She crossed the border illegally to stay with a family member living in North Carolina and sought treatment at Duke. After she was denied Medicaid coverage, a local business owner and the community donated $500,000 to pay for a transplant. A heart and lung transplant was performed at Duke in February 2003. Unfortunately, she probably would have been better off getting the transplant in her native Mexico. The American transplant surgeon, James Jaggers, assumed that the organ program would not have contacted him unless the donor and Jesica were a match. Her body rejected the new

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My Facebook friends are still outraged that the current U.S. President used some undiplomatic words to characterize living conditions in some foreign countries. (“undiplomatic” = saying what you think!)

I think that I’ve found a young foreigner who can replace this old native-born American worker. This is from an au pair “host mom” discussion forum:

In response to question about being an AP with a single mom family, AP says “yes.” In response to question about a single father family, AP says “No. I don’t think it would be appropriate. Depending on why the father is a single parent, I don’t want to have the expectation to take on a role larger than being an au pair.” What sort of role does she think she’d take on??

If the Constitution permitted foreigners to run for President, I would vote for this young lady to be our Wordsmith in Chief!

Here’s some more fun stuff from the same list…

interestingly we know there is a single mom that hooked up with her AP Lol

I am really struck by the number of APs who don’t want to live with same sex families. Although I am straight, I use this question as a screen bc I don’t want someone living in my home who isn’t open and accepting to all my friends and family members, and who would potentially bring an anti-gay POV to my children.

I just think it’s their level of comfort not necessarily anti gay.

I am sorry but not sure I understand how that is different. Not homophobic just dont want to live [for a year] with a gay couple.

I also use the willingness to live with same-sex couples (and people of other races and religions) as a screening tool. I don’t want to live with someone who isn’t comfortable around all kinds of people.

we had some candidates who said they didn’t care about religion until they found out we were Jewish. We were shocked as one was from the UK and another from Sweden I think.

Drives me nuts when I find a good candidate who otherwise fits what I’m looking for but says they aren’t ok with LGBTQ. We have gay friends and Seattle is a supportive city for LGBTQ community and so I can’t take anything less.

I understand why young women don’t want to live with single dads. … I do not judge their discomfort with it though. I am very judgy on the other hand with APs who put a “no” to same sex couples, or have a preference for a particular sex. You are not comfortable with living with same sex, I’m not comfortable with you. Your age, where you’re from etc, doesn’t matter to me in that case. I only interview APs who would work with same sex couples. And what is it with APs not wanting to work with female couples? Do they think these women will make them googly eyes?? [Maybe the AP doesn’t want to work with statistically unhappy children?]

We also screened out boys as at first DH and I were not comfortable and later DS only wanted girl AP. Did that make us sexist I guess the answer would be yes for childcare. Do I love my husband, son, nephews, guy friends etc yes I am not a man hater but I never hired a male childcare provider.

I swear the AP life is a soap opera in our area–mom was getting high AP supervised visits of mom with kids, dad who walked into AP room drunk in middle of the night and tried to get into bed with her, AP and host mom hooking up, AP who knew mom was having an affair…

we had one who was privy to mom’s affair too. It was a disaster.

Separately, when did Americans become too lazy to type “my son” or “my husband” and need to use DH and DS?

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One of my Bay Area friends was engaged in a typical California activity: talking trash about other states. In particular, he was decrying Kentucky’s attempt to try to get “able-bodied adults without dependents to work at least 20 hours a week to qualify for [Medicaid] coverage.” (The Hill) [Note that producing or getting hold of a baby would continue to guarantee welfare benefits, such as free housing, health care, and food, for 18 years (there may be better ways to cash in a baby, though, albeit not in Kentucky where child support revenue for a parent is capped at about $15,000 per year per child).]

I pointed out that, rather than complain about the unfairness of what Kentucky offers to welfare recipients, why not simply invite these folks to come to California?

friend: if people are fleeing your state, because of your government policies — you suck at governance.

me: Californians are generous and warm-hearted, right? Why is it a problem if people in Kentucky who can’t get welfare there anymore move to California?

friend: Who said it was a problem for us? They come here, and get work, because we have a functioning economy It’s a problem for the people of KY that they’d have to do that.

[California has a higher unemployment rate and a lower labor force participation rate than the U.S. average (stats); adjusted for demographics, California has the worst schools in the U.S. (nytimes); California has one of the highest tax burdens (Tax Foundation).]

me: if they are on welfare in Kentucky and can be enjoying the satisfaction of gainful employment in California, isn’t this a good situation? If California is an awesome place to work AND has the correct/fair level of welfare services, why shouldn’t everyone who is failing to prosper in Kentucky move to California? Donald Trump won both the Republican primary and then the 2016 Presidential election in Kentucky. Do you mean to suggest that people are better off in a Trump-supporting state than in California?

friend: It does NOT fix the problem in KY! How is that NOT a bandaid? If they can make it here, but not in KY, how is that not a problem?

me: If everyone who needs welfare in Kentucky moves to California, the problem of the inadequate (in your view) Kentucky welfare system is fixed, by definition. There will be nobody collecting welfare in Kentucky and therefore it won’t matter what the rules are.

friend: What, it’s not a problem that if you live in KY, and you become disabled, you have to leave? That’s … insane. A special kind of insanity. The kind that says “It can’t happen to me.” It can happen in an instant.

me: A one-way ticket from Louisville to San Francisco is $190. Just tell me how many you need! The ticket can be purchased in about 5 minutes. The disabled person will be at your house in California by the next day. You can then assist them with collecting fair welfare benefits in a state that rejects Donald Trump. How are they not better off?

friend: As long as people in KY fall on hard times, or suffer injuries or health problems that leave them disabled, the supply will be endless.

me: Kentucky has a population of only 4.4 million right now. Even if 100 percent of them need to come to California due to their inability to work, that’s only a 10 percent boost to the California population. You have a functioning economy, right? Surely you can easily expand your housing supply by 10 percent. After all, aren’t your friends there wearing “No Human Being is Illegal” T-shirts? If they support immigration from outside the U.S., why wouldn’t they be happy to have immigrants show up from Kentucky? (and, remember, that Kentucky does not have 100% of its population on welfare!)

The exchange went on until I had to get back to work. Summary: he didn’t want any refugees from Kentucky in his house or neighborhood, but he did want to be on Facebook criticizing the lack of generosity of voters and politicians in Kentucky. So far I have not had to purchase any plane tickets (but my offer remains open!).

I’m wondering if Donald Trump could do the same thing in the context of international migration. People in San Francisco, Santa Monica, Manhattan, Boston, etc. are criticizing Trump for voicing his opinion (wrong, by definition!) regarding living conditions in Haiti. They also criticize him for being unwelcoming toward low-skill immigrants from unsuccessful societies in general. What if Trump were to offer immigration proponents an unlimited supply of people, without any preference for those capable of working, on condition that immigration advocates use state and local tax dollars to pay for their housing, health care, food, and walking-around money? So if people in San Francisco want to build a 1000-unit apartment complex for Haitian immigrants, and folks will be permanently entitled to live there by paying a defined fraction of their income in rent ($0 in rent for those with $0 in income), and San Francisco commits to build additional apartment complexes in which any children or grandchildren of these immigrants can live, why should the Federal government stand in the way of their dreams? (Of course, the city and state would also have to pay 100 percent of the costs of Medicaid, food stamps, Obamaphones, and any other welfare services consumed by these immigrants or their descendants.)

If there were no numerical limits on immigration, but host communities had to pay for the guests whom they were welcoming, Trump wouldn’t have to be the bad guy anymore. If my friend is typical, the overall level of unskilled immigration to the U.S. would fall (maybe to zero!). In any case, whatever the level happened to be it would be one that Americans had agreed on and therefore would be more likely to accept as fair and appropriate.

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“World’s Largest Air Purifier Completes Successful Trial Run in Xi’an, China” (arch daily) is about a 100-meter-high air cleaner that the Chinese have put together. It seems to work! Whenever people complain that, due to our Plague of Trumpness, the U.S. has “lost its leadership position on climate change,” I respond with “Why were we ever considered leaders considering that we cannot build solar cells or infrastructure cost-effectively and we are not good at most kinds of engineering? Wouldn’t we expect it to be the Chinese, Germans, and Japanese who come up with engineered/infrastructural ways to reduce atmospheric CO2?”

Readers: What do you think? Can we now rest easy and drive around in circles in our pavement-melting SUVs?

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Antonio Garcia Martinez posted a fun item on Facebook. He was heading over to Google to give a talk and, that morning, they canceled. Someone at Google finally cracked open his book, Chaos Monkeys, and discovered an offensive paragraph:

Most women in the Bay Area are soft and weak, cosseted and naive despite their claims of worldliness, and generally full of shit. They have their self-regarding entitlement feminism, and ceaselessly vaunt their independence, but the reality is, come the epidemic plague or foreign invasion, they’d become precisely the sort of useless baggage you’d trade for a box of shotgun shells or a jerry can of diesel.

Who will volunteer to read If You Give a Mouse a Cookie to these tender coders?

Related:

• Casting out the heretic at Google
• No free lunch (at Google) for thought criminals
• Modest proposal for the Google all-hands meeting

 

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I found an interesting book the other day: Designing the Requirements: Building Applications that the User Wants and Needs. My Amazon review:

I found this in the MIT engineering library. Unfortunately the people who need to read it the most are probably too busy coding to read any book. But it is rewarding and basically sensible. The book is much more informed by the reality of designing and building software than the typical academic work or textbook for undergrads (just imagine the kid who goes straight from a lecture on classical “waterfall” methodology into a job at Google or Facebook!).

I guess one way to look at the competing literature is that it reflects the lessons of failure. Software projects that were years late and 300% over budget led to a genius sitting down and writing “Whoa. If we had only done X, Y, and Z that project could have been successful.” This book, by contrast, feels like a synthesis of general principles starting from lessons of practical success.

What do readers think? The most successful software projects don’t seem to generate neat methodologies to which book authors and/or academics can give names (Wikipedia contains a partial list). This whole genre started with The Mythical Man-Month, Fred Brooks’s attempt to understand why IBM’s OS/360 project had gone off the rails:

The effort cannot be called wholly successful, however. Any OS/360 user is quickly aware of how much better it should be. The flaws in design and execution pervade especially the control program, as distinguished from the language compilers. …. Furthermore, the product was late, it took more memory than planned, the costs were several times the estimate, and it did not perform very well until several releases after the first. (page xi)

Friends who work at the most successful software development enterprises, e.g., Google, Amazon, Facebook, Apple, don’t report the use of any special project management sauce.

I posed a question to a Silicon Valley insider (not quite as far inside as Ellen Pao, of course, since he merely produces hardware and software that hundreds of millions of people have used instead of lawsuits and discussion around gender equality):

Let’s say 5 programmers are going to spend 2 months coding something at Netflix, Google, or Apple. What would you expect to be the number of pages of requirements, specifications, system architecture documents, etc. to be written before the coding starts?

His answer:

At Netflix there would be no documentation and everybody would go and be a cowboy.

At Google there would be a 3-page half-assed document (Google Doc) that looks like crap and barely scratches the surface.

At Apple anything could happen: If it was between different groups there might be meticulous API specifications that people had to sign off on (that then became immutable), but if it’s internal it would depend on the group and there could be nothing.

Maybe it is worth asking if readers think that there is any value to the official methodologies compared to basic common sense (i.e., don’t compare Waterfall or Agile to flailing away in a disorganized fashion, but instead compare to a common sense “write down whatever seems useful to write down, use version control for the code, use a bug/task tracker for change requests, etc.”) and, if so, is there a One True Methodology?

Related:

• http://philip.greenspun.com/doc/chat (from 1999; answers at least the minimum questions that I like to see in a web-based application, such as “Why was this built at all?” and “Where is the code to be found?”_

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From our anonymous insider…

Cardiology week begins with a one-hour lecture and two-hour workshop focusing on interpreting electrocardiograms (ECG or EKG). An electrophysiologist with a Southern accent who is celebrating his 40th year reading EKGs implored us to “develop a systematic way to read EKGS. Don’t just jump into the details.” He commented on 30 slides of pathological EKGs. Afterwards, we broke up into seven-person groups and went through 20 example EKGs with a fellow. Straight-Shooter Sally was unimpressed with our fellow: “When asked why this is a LBB [left bundle branch], all she would say is, ‘That’s what a LBB looks like. It’s pattern recognition.’ That does not help us. Connect the physiology to the EKG.”

We next traveled to the clinical room to practice on Harvey, a cardiopulmonary patient simulator, with a soft-spoken retired Navy cardiologist who had become a class favorite last year. “Studies show that it requires hearing about 200 murmurs to get decent at identifying one on a patient.” Jane put her stethoscope on Harvey’s chest while the rest of the students listened to the simulated heart sounds on wireless stethoscopes. “Enter number 24”. The heart sound changes from a crescendo-decrescendo systolic ejection murmur of aortic stenosis to the holosystolic murmur of mitral regurgitation. Jane found it challenging to determine whether a murmur is systolic or diastolic. “It was really helpful to listen on Harvey while feeling for the pulse. If the murmur happens with the carotid upstroke, it is a systolic murmur.”

Each group also rotated through two patient volunteers. Patient #1: accommodating 40-year-old female recently diagnosed with pulmonary stenosis after an enlarged thymus was removed. We felt a thrill (vibration felt with hand) under her left clavicle and a loud systolic murmur that radiated to her back. Patient #2: genial 75-year-old male with mild mitral regurgitation, typically a benign finding due to the changes accompanying an aging heart. The murmur was barely audible after concentrating for 45 seconds. The cardiologist asked, “How could we bring out the murmur?” After several blank looks from the group, Gigolo Giorgio proposed, “Make him squat?” “Yes!!,” exclaimed the cardiologist. “Squatting would certainly work, but we’ll just ask him to flex his arms together.” With an increased afterload (blood vessel resistance), the left ventricle pushes more blood backwards through the mitral valve orifice. This accentuates the mitral valve regurgitation murmur. We asked the patient to stand up. The decreased preload (the total amount of blood returning to the heart) completely eliminated the murmur.

A pediatric cardiologist, recently retired from clinical practice, introduced congenital heart defects. She emphasized the cyanotic (“blue baby”) defects including Tetralogy of Fallot (four heart defects combined) , transposition of the great vessels (left/right reversal creating two nearly separate circuits), and tricuspid atresia (closure of the tricuspid valve orifice). She referred to current events while looking at the swirling color doppler field of flow through an obstructed aortic valve: “Looks like [Hurricane] Irma.” Fortunately for her, she’s already retired because Generation Politically Correct was gunning for her. Pinterest Penelope: “It is inappropriate to make light of the suffering of those who have gone through Harvey, Irma, and Maria.” Two classmates piled on.

The pediatric cardiologist continued regarding the importance of the ductus arteriosus in these “duct-dependent disorders.” The ductus arteriosus is a short connection (right to left) shunt between the left pulmonary artery (carrying deoxygenated blood from right ventricle to left lung) and descending aorta that allows oxygenated blood from the uterine vein (from the mother) to bypass the lungs and mix with the systemic circulation. Compared to normal oxygen saturation after birth, the fetus survives on a lower oxygen saturation in-utero.

When baby takes her first breaths, the pulmonary vasculature opens up. Usually the ductus arteriosus closes. However, if the ductus arteriosus fails to close (patent ductus arteriosus or PDA) the shunt reverses direction, causing oxygenated blood to overload the pulmonary circulation. A reverse-flowing shunt isn’t bad for everyone. Patients with an obstructed right ventricular outflow tract, such as babies with Tetralogy of Fallot or tricuspid atresia, require the right-to-left shunt PDA to get blood into their lungs. “A patent ductus is the only thing keeping the baby with Tetralogy of Fallot alive. Pump those prostaglandins. Do NOT let it close.”

Tetralogy of Fallot was a lethal disease until the 1940s when a surgical procedure was developed to connect the right subclavian vein (part of systemic circulation) to the right pulmonary artery for oxygenation. This procedure is front-and-center in the identity politics of medicine, having been developed by Alfred Blalock, a white male surgeon, Helen B. Taussig, a white female cardiologist, and Vivien Thomas, a black male lab technician. People fight about whether the procedure should be called “Blalock–Taussig” (BT) or Blalock–Thomas–Taussig (BTT) and also how much credit should be assigned to the three collaborators. The discussion regarding the race and gender identification of the creators has outlasted the original procedure. Today a synthetic dacron shunt is placed between the right subclavian vein and right pulmonary artery. “Eventually the child will grow out of the BT shunt,” said our pediatric cardiologist, However, the heart has grown enough so surgeons can perform a more complicated fix.”

Our patient case: Becca, a female neurotrauma nurse, age 27 at the time, returned to work two months after giving birth to her second child. “It was just a normal day. I had two great patients, which means it was somewhat boring — not stressful at all. I was pushing some meds to my patient when I had this odd sensation in my neck. It wasn’t a sharp pain, but a strong tingling sensation. I went over to the charge nurse who sat me down.” Becca’s heart rate was in the 50s (bradycardia). She felt a searing pain in her chest and was sweating profusely. “It felt like someone was stabbing me through the front of my chest all the way out the back.”

Becca recounted how she was hauled down to the ED in a gurney. “Let me tell you something: patients remember what they hear in the hospital. My scrubs were soaked with sweat by the time I got to the ED. I started taking off my scrubs and even sports bra. I am sure people saw me naked through the makeshift curtains in the ED. Some ED nurse blabbered, ‘What’s wrong with her?’ It was just rude.” Her cardiologist, the retired Navy doctor who taught our simulator session (above), commented, “A lot of residents make offhand jokes about patients. Try to do it in the resident lounge.”

The ED physician performed an EKG. “I turned my head to look at the screen. Those Tombstone T waves are still seared into my head.” [Tombstone T waves suggest a myocardial infarction (“heart attack”).] “This is when I was called down to the ED,” explained her cardiologist. She was taken to the Cath Lab while a nurse called her husband, at home with the 2-year-old and 2-month-old. Becca: “I’ve sent several patients to the Cath Lab, some don’t come back. I was freaking out all alone.”

“We inserted a catheter through Becca’s femoral artery up to her heart. Pretty quickly we realized we were not dealing with a typical MI caused by a thromboembolism,” explained the cardiologist. He showed several images of the catheterization. A student asked, “How could you tell this was not a thromboembolism?” The cardiologist responded, “This is why they pay me the big bucks.” [Interventional cardiology is one of the highest paid specialties, if not the best with explanations.]

Becca had spontaneous coronary arterial dissection (SCAD) of her left anterior descending artery, the main artery that supplies both ventricles. From Wikipedia: “a dissection is a tear within the wall of a blood vessel, which allows blood to separate the wall layers. By separating a portion of the wall of the artery (a layer of the tunica intima or tunica media), a dissection creates two lumens or passages within the vessel, the native or true lumen, and the ‘false lumen’ created by the new space within the wall of the artery.”

SCAD is a rare condition, accounting for fewer than 0.4 percent of heart attacks, but is more common during the postnatal period. This increased risk may be due to the the progesterone surge that weakens connective tissue to prepare for the baby traversing the vaginal canal. The progesterone also weakens connective tissue in blood vessels, thus enabling false lumens to develop.

Coronary dissections can be difficult to stent (putting a tube into the collapsed vessel, then inflating). “Sometimes it pays to be lucky instead of good.” The cardiologist got the catheter through the true lumen instead of the false lumen. “I’ve only dealt with two coronary dissections in my lifetime. I knew I did not have my catheter through the false lumen because I did not have to put much force on the catheter to move it through the left coronary artery. If it had been the false lumen, I would eventually have gotten stuck where the lumen ended.”

The cardiologist placed the first stent where the false lumen ended and worked his way back to where the dissection originated (working from distal to proximal). This required three stents total before perfusion normalized.

Becca’s rehab included a psychology consult. “It was hard for me to not think about how close I was to dying. I would lie awake scared that this could happen again. I still see my psychologist periodically.” The cardiologist: “Fifty percent of individuals experience depression during the first year post-MI.” Becca returned to work at the neurotrauma ICU after 1.5 years and exercises regularly. She gets an annual echocardiogram. “One thing [the cardiologist] told me is that I cannot have another child.”

During a brief intermission, our class joked about the weekly newsletter section on “How to Save Money”. Recommendations submitted by former students included (1) Make your own laundry detergent pods, and (2) Take up offers for food from friends. The cardiologist chimed in, “Does anyone have a part-time job?” One of our classmates drove Uber five times per month during M1 year, but he has stopped this year. The cardiologist commented that one of his classmates paid for medical school by working as a cab driver while another worked as a part-time cop. “Getting shot at was his stress relief from studying. He is now a trauma surgeon.” Classmates noted that tuition has gone up so much faster than wages that even paying for undergraduate tuition would be impossible today.

After the patient case concluded, the cardiologist summarized myocardial infarction complications. The danger of a MI does not end during the acute event. After the risk of cardiogenic shock or sudden cardiac death from an arrhythmia, there is significant remodeling of the necrotic tissue. Over the next few days, white blood cells infiltrate into the tissue to eat up the dead tissue. During this period there is a significant risk of ventricular wall rupture, in which blood flows from the heart into the pericardial sac. Blood filling the sac around the heart compresses the heart, preventing pumping (cardiac tamponade). “You die pretty quickly from a free wall rupture.” Weakened tissue can also cause a papillary muscle (“heart strings”) tear that holds the mitral valve from prolapsing during systolic contraction. Over months and years, remodeled scar tissue may develop arrhythmias and aneurysms. “An MI does not end after the two-week hospital stay. Patients need to be followed for life.”

Our ethical group met for a 1.5-hour discussion on patient autonomy and veracity. Nervous Nancy, an attractive, intelligent female who asks great questions at the speed of sound, worked as a CNA and scribe for a large health system in the ED and orthopedic unit before medical school. She recounted, “Patients would come in on lawyers’ directions to get a payday because they knew the hospital would settle rather go to court. We had this one woman purposefully fall off a bed that did not have the railing up.

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There is now apparently a debate about undocumented immigrants who came to the U.S. as “minors” and now want to stay permanently and/or become citizens. The Wikipedia page on the DREAM Act says “They were younger than 18 years old on the date of their initial entry to the United States” and, confusingly, “Have proof of having arrived in the United States before age 16.” There is also “Be between the ages of 12 and 35 at the time of bill enactment.”

My dumb question for today… if these folks are undocumented how would anyone be able to establish their ages? Why would they have birth certificates, for example?

[And why is 16 or 18 the cut-off for “minor”? Under New York family law, for example, a plaintiff parent can get “child support” revenue until the subject of the original lawsuit turns 21. In Massachusetts the cut-off age is 23. Why is someone a “child” when an adult plaintiff wants to get paid, but not a “minor” for purposes of immigration?]

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From our anonymous insider…

Classmates are enjoying the flipped classroom format, especially because class begins at 9:00 am instead of 8:00 am. Type-A Anita: “I do not even watch the online lectures. I prepare for lecture by watching the corresponding Pathoma videos. It solidifies the material when we go over cases in the workshops.”

A tall Russian-immigrant pulmonologist in his late 50s introduces diseases of the pleura. Pleura is a thin membrane that runs along the inside border of the chest wall and outside border of the lung forming an air-sealed fluid sac called the pleural space. (Embryologically, the lung bud from the esophagus actually grows into this pleural sac like a fist going into a balloon). The pleural space links chest wall expansion to lung expansion. Chest wall expansion produces a negative pleural pressure that expands the lungs.

A pneumothorax occurs when air gets into the pleural space, thus destroying the negative pressure gradient that holds the lung expanded (-5 cmH20). This can occur spontaneously, typically in “long and thin” men, when a small section of lung parenchyma ruptures the visceral pleura, creating a connection between small airways and the pleural sac. It can also happen from trauma when the parietal pleural membrane is punctured. Tension pneumothorax, a life-threatening complication of a pneumothorax, occurs during trauma when the punctured pleura forms a one-way valve allowing air in on inspiration but not on expiration. The pleural pressure can get so high that it displaces the heart in the thorax.

A pleural effusion is a buildup of fluid in the pleural space. This causes increased intrapleural pressure and displacement of the lungs and potentially heart in the thorax. The fluid can be composed of plasma ultrafiltrate (transudate) suggested of inflammation or exudate (“a pus filled mess”). Pneumonia (infection of lung parenchyma) frequently leads to a harmless transudative pleural effusion, but the bacteria can migrate into the pleural space causing an exudative empyema. “Never let the sun set on an empyema. This is a medical emergency.”

Mesothelioma, a rare complication of asbestos exposure, is cancer of the pleura. “Most of my asbestos-exposure patients were in the Navy, stationed either in shipyards or on ships. I ask them if they were exposed to asbestos. They respond, ‘Oh yeah. I would go to the engine room and particles would be falling down.'”

“All of the data on the risks of asbestos exposure is from studying construction workers during the 1960s skyscraper boom in New York City.” Asbestos exposure in the absence of smoking history is associated with a 6-fold increase in lung cancer. According to UpToDate, “asbestos exposure acts synergistically with cigarette smoking to increase the risk of developing lung cancer (not mesothelioma) 60 times over that of a similarly matched non-smoking, non-asbestos-exposed cohort.” The pulmonologist: “The Board loves to test that mesothelioma is far less common than lung cancer or pulmonary fibrosis from asbestos exposure.”

If lung cancer is a more common consequence of asbestos exposure, why so many commercials from plaintiffs’ lawyers looking for mesothelioma patients? “Lawyers salivate over a mesothelioma case because it is no work. There is a one-one causal relationship between mesothelioma and asbestos exposure. Smoking is not a risk factor for developing mesothelioma. The defense cannot say it was lifestyle choices or smoking that led to the disease.”

An invasive pulmonologist in her 50s discussed lung cancer for two hours. An invasive pulmonologist gets one to two years of training after a pulmonary fellowship and three-year internal medicine residency (i.e., there is no pulmonary residency, only the post-residency fellowship). With this additional training, an invasive pulmonologist can perform procedures such as a biopsy and bronchial thermoplasty (burning airway smooth muscle for non-responsive asthma). Symptoms of lung cancer are nonspecific. These include dyspnea, cough, cachexia (wasting, sudden weight loss), hemoptysis (coughing blood), and pleural effusion (from metastasis to pleura or to lymph nodes draining the pleura). “The most important aspect is to recognize the chronicity of the symptoms versus a more acute episode of pneumonia.”

Smoking is the most important risk factor for lung cancer. She defines a non-smoker as “someone who has had fewer than 100 cigarettes in his or her lifetime.” Smoking also causes the more aggressive forms of cancer: squamous cell carcinoma and small cell carcinoma (SCC). “SCC has a proclivity to metastasize to the brain. We treat SCC with prophylaxis brain radiation because by the time we can detect it in the brain it is too late.”

She then went over the staging system for lung cancers. “Staging is important to be able to give the patient an estimate of his or her life expectancy. I would expect my fellows to be able to give an accurate stage. I just expect you to know the different components that go into staging.” Staging incorporates the tumor size, nodal involvement, and presence of metastasis. “Lower stages are typically dealt with through surgical resection of a lung lobe and resection of any lymph nodes. Higher stages require chemotherapy.”

Gigolo Giorgio asked the pulmonologist her thoughts on e-cigarettes. “E-cigs are such a new product. Each tobacco company uses a different formula. A new FDA regulation requires tobacco companies to release the full set of ingredients used in the vapor. I will withhold judgement until this information is analyzed.” She did mention that she has noticed a rise in fungal pneumonia cases among e-cig smokers.

Gigolo Giorgio, true to his Los Angeles roots: What about pot? “That’s also a tough question. There are no studies that show an increased risk of lung cancer that I know. When my patients tell me they smoke pot, I cannot tell them to stop for fear of getting lung cancer. Cancer patients? I say go for it.”

She described how the second cause of lung cancer is radon exposure. Radon exposure increases the risk for adenocarcinoma, a less aggressive form of lung cancer compared to smoking-associated small cell and squamous cell carcinoma. “If you live in a high radon state, make sure you get a radon inspection. My house was off the charts. I had a radon mitigation system installed.”

Our patient case: Beth, a 45-year-old spunky sarcastic mother of three, presents to her physician for worsening shortness of breath and joint pain. A chest x-ray reveals hilar infiltrates (enlarged lymph nodes of the lung). She was referred to a tertiary hospital for follow-up.

“I was diagnosed for three years with asthma. When I finally was referred to the university hospital for biopsy I was almost relieved.” She drove three hours for her lung biopsy appointment. “When I was called back from the waiting room, the nurse grabbed my hand and started praying. I was like, ‘Damn, Woman, what are you doing?’ I did not realize I was in the OR. I did not sign up for this!” Her lung biopsy revealed non-caseating (no necrosis) granulomas diagnostic for sarcoidosis.

Sarcoidosis is a systemic inflammatory disorder that causes granulomas, a collection of immune cells formed in an attempt to wall off a substance. The soft-spoken Indian pulmonologist explained, “We have made incredible progress in understanding sarcoidosis. This mostly shows how little we knew ten years ago and how far we have to go. We still do not know what causes this immune response. It likely is an unknown substance that certain individual’s macrophages cannot deal with.” These granulomas can form anywhere in the body, but sarcoidosis almost always involves the lungs. “Patients are diagnosed due to shortness of breath from the pulmonary fibrosis or on incidental findings.”

Beth has a lot to say about her physicians. “I cannot stand when the doctor comes in and says, ‘So what brings you in today?’ Look at my damn chart. Spend two seconds getting to know me. I once told a physician, ‘Well I was learning to twerk on the kitchen table and fell. That’s what causing my joint pain, not my sarcoidosis on my chart.’.”

Beth is managed with glucocorticoids and methotrexate (folate synthesis inhibitor) to reduce her immune system response. These have greatly improved her joint pain and lung function, but have lead to significant weight gain. “Laugh all you want. Call me Fatso.” She explained how frustrating it is that people around her, both strangers and close family members, attribute her weight gain to laziness. “It does not matter how much I eat or exercise. I will just keep putting on weight. It makes me depressed. I cope with it with humor, by poking fun at myself. I would not wish this even on my worst enemy… my ex-husband. And I hate him.”

Beth has not had to increase her dosage for two years. Most patients will regress and require more intensive pharmacologic agents. “I am hopeful I can continue this lifestyle. I view my disease as that devil on your shoulder. He’s always there, and I hope I can keep him silent for a little longer.”

This week’s ethics session: “Distributive Justice”. Before the lecture and small group meeting, we read several papers and completed a quiz:

True or False: The Affordable Care Act can be viewed as an effort to mandate distributive justice in the United States? Lanky Luke had a field day: “I was going to put false. Then I remembered a liberal probably wrote it.” [Editor: sometimes justice is not fully distributed; more than 30 million Americans were without health insurance in mid-2017, seven years after Obamacare was enacted.]

True or False: Distributive justice refers to the fair and equitable distribution of goods and services.

Which of the following strategies for eliminating healthcare disparities is the most difficult to implement? Answer: Collection of standardized data on patient and provider race and ethnicity.

One required paper was “Ushering In The New Era Of Health Equity” by Joseph R. Betancourt: (Health Affairs Blog, October 31, 2016):

several promising opportunities are on the horizon … activities focused on diversity and inclusion, and especially new conversations about racism, implicit bias, and stereotyping as root causes for disparities, are bubbling up now more than ever before. This is likely a direct consequence of the coverage of police violence against Black citizens, the Black Lives Matter movement, and the current and toxic political climate around race relations.

Luke: “My problem is not that they are making us read these articles. It is important to keep an open mind to new information. My problem is that they state their opinions as fact. Their job is not to indoctrinate us, but to provide the tools and resources for us to make our own opinions.”

[Editor: Dr. Betancourt thought that the political climate was “toxic” in October 2016; imagine how he felt after Donald Trump was elected in November!]

Another article contained an interview with the physician president of a free clinic. He explained how they had planned to close down the clinic after the passage of the ACA. “Little did we know we would have more business than ever before from people with high-deductible plans not able to pay for small checkups and medications. Of the 4 million dollars in services we provide now, about 3 million go to the pharmacy.”

An endowed university professor of ethics and member of the ethics committee at the hospital introduced the topic with a 1.5-hour lecture. He proposed that people agree on two principles:: (1) a decent minimum access for all, and (2) better or faster care for those who can afford it. [Editor’s note: this is what most countries around the world, from Mexico to the U.K. to Russia, actually do provide. The public hospitals are free and can be reasonably good; private hospitals and doctors are available for the rich. They manage to do this while spending only a fraction of what U.S. society spends.]

He gave a personal story about Canada’s attempt to provide gold-plated service for all: “I used to teach in Canada. My daughter went to an ophthalmologist where she was told she may have brain cancer and needed an

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