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Before starting the publication of Medical School 2020, Year 2 entries, here are some Year 1 wrap-up thoughts from our anonymous insider:

Nearly every answer in medical school spurred another question until finally the answer wasn’t known or wasn’t answerable in the limited time for each subject. I eventually got used to the frustration that the system at-hand was too complex for a simple generalization. The every-two-month exam cycle gives students a sprint mentality, but I came to realize that it was okay to not know everything. Medical school is a marathon, not a sprint.

One year done and I’m more excited about working in healthcare, but disillusioned about the trajectory of American health. Diabetes, drug abuse, premature heart disease, psychosis. These are not typically driven by genetics, but rather symptoms of the society that we’ve built. Americans expect the healthcare system to clean up the mess, but seldom are doctors able to provide a complete cure for these ills of modern society.

I have also become disillusioned about our ability to formulate health care policy. We learned about ongoing clinical trials that pay diabetics to exercise and eat better, similar to the classic “A behavioral approach to achieving initial cocaine abstinence” (Higgins, et al. Am J Psychiatry, 1991), in which patients were given $1,000 to stay clean for 12 weeks rather than being put into rehab ($1,000 per day?). This could be much cheaper than Medicaid and Medicare paying to treat the inevitable complications. Politicians make beautiful speeches taking credit for providing insurance to millions of Americans, but where are these people who have purportedly been helped? Some of the hardest working people I met in the clinic made too much to qualify for Medicaid, but not enough to afford an Obamacare policy. They eventually have to stop work and show up in clinic with a far worse prognosis, e.g., half a foot that needs to be amputated, and the bill is paid by Medicaid or absorbed by the hospital’s charity care fund.

At least in our university-run, mostly Medicaid/Medicare-funded, health care system, I didn’t see obvious examples of what Jack Wennberg, the founder of clinical evaluative sciences, called “supplier-induced demand.” However, my attendings would nearly always refer patients to specialists out of fear of “missing something,” and every stubbed toe got an X-ray. Perhaps Wennberg’s estimate that 30 percent of healthcare expenditures are unnecessary or harmful is correct, but it wasn’t obvious which 30 percent we should have cut.

As a child I associated healthcare with doctors and nurses. One trip to the most popular restaurant across from the hospital campus and Jane and I realized that it was really more about administrators, lawyers, IT, and Human Resources staffers. I’m no longer surprised to see a hospital employee badge reading “business development officer” pinned to a business suit.

Classmates often wonder “Why does medical school cost so much?” Our conclusion is that the enemy may be us. Administrators and deans have proliferated along with LCME requirements in the name of creating an fair and equitable learning environment. Is it helpful to have lectures recorded? Yes, but it requires a huge IT department and expensive software. Our gym was just upgraded, which seems to have been a marketing decision because most classmates didn’t know that we had an in-school gym within the school in addition to the membership at a comprehensive fitness center (with pool!) that is covered by our tuition. The Wellness Committee and the Office of Inclusion and Diversity, led by a Ph.D. psychologist, seem to have unlimited funding to hold seminars on self-defense and microaggressions (I try never to miss one due to the great catering from local restaurants); funding for student-organized events on medical topics, such as a suture workshop, is limited to $2.50 per attendee and can be challenging to obtain. Waste is noted, but seldom criticized, due to the free-flowing Federal spigot of student loan funds.

I conducted an informal survey of classmates towards the end of the year. Some of their responses are below.

What has surprised you?

“The amount of independence. You hear about all these learning environment resources, different subjects, supplemental materials for purchase like Anki and Firecracker. It is pretty overwhelming at first. I eventually realized that if I just study the exact the same way [as in undergraduate courses] then I do well. It is just school.” [Jane]

“That I could actually be interested in surgery.” [Disinterested Dorothy, originally planning to follow her father into internal medicine]

“People like talking about their health problems.” [He obviously hadn’t met my grandfather!]

Is it more or less studying than you expected?

“Less overall but exam week is brutal. It’s the way it is, not the way it should be. I regret not being as organized and dedicated as some students. I would study more spread out instead of cramming before.” [Jane]

What did you wish you knew about healthcare that you know now?

“I always thought doctors were unquestionable. Doctors are human. Ask them questions. If they are not explaining the reason, they are not doing their job right. I now know there are good doctors and bad doctors.” [let’s hope that she doesn’t practice these sorting skills at home; she’s the daughter of a physician]

“Healthcare is challenging but it is more accessible than people would think. I approach healthcare as a field in which if you work hard enough or study long enough you can succeed. Compare this to, for example, computer programming or engineering. No matter how hard I worked at that, I just could not do it.” [she majored in biology as an undergrad]

What do you like about the class and what do you not like about the class?

“I like how our class is fun and likes to hang out with each other. We have a good sense of humor. What do I not like? Our class will complain about anything. They can also be quite disrespectful.” [Jane]

Do you wish you took time off before medical school. Gap year or no?

“No stigma either way. Straight in or five years out doesn’t matter. Once you are here, you are here.” [Youngest classmate]

“It took me three application cycles to get into a school.” [Straight-Shooter Sally]

“I am glad I took a gap year. I don’t think I was intellectually mature enough to go straight through. I think I would have fooled around with all the free time in medical school if I didn’t learn some discipline working in the real world.” [Male classmate who worked for pharmaceutical company]

“I am glad I am here, but certain specialities are off the table for me. I’m too old!” [Upperclassman who started medical school at 35]

What do you think about our teachers?

“Passion is infectious. When someone is passionate you can’t help but listen to them. M.D.s are more fun than Ph.D.s. Teachers talk about what they know. They know their patients. That’s why we are here.” [undergraduate physicist major known as the class gunner]

“About a third of the instructors are great. I give an instructor one chance. If I don’t like them, I no longer show up for lecture.” [Classmate notoriously late for the few lectures he does attend. If the class gives him the heads up it was worthwhile, he might watch the recorded lecture online.]

What do you think about anatomy?

“I liked MSK (musculocutaneous) dissections. It was satisfying using your hands to isolate muscle and fascia layers. Reproductive was pretty cool too. I literally cut a penis in half and took the fascia layers apart. Not many people can say that! Oh, and that bone saw was sick!” [Disinterested Dorothy]

“I hate anatomy. You cannot see anything in a cadaver. So excited to be done with it.” [Pinterest Penelope apparently has better things to do]

“Anatomy is the best part of medical school. It is the unique topic for medical school. All the other material a lot of us have have been to exposed to in various undergraduate majors. No one gets exposed to anatomy, at least at this level.”

Anatomy Advice for M1?

“Get in there to get over. Thinking about it is bigger issue. I never had issue. Doesn’t feel real because the cadavers are cold.”

“It is pretty rare to have surgeons take time out of their day to spend two hours helping you dissect. Take advantage of it. You get out what you put in. Be interested in what you are doing. It looks bad when half the class leaves early from lab.” [Jane]

“Buy a pair of scrubs. You look badass and that way you won’t get your normal clothes smelling like the lab.” [Class Orthopod]

What are you excited about?

“Being a doctor allows you to make a decent living wherever you want to live. You don’t have to live in a big city where all the jobs are for young people.” [Classmate from Kansas]

“All my friends and family ask me about their health problems. It is fun to play doctor. We can now understand what is wrong with them. Ask us what to do about it? We are no better than the internet. Patient care comes from experience, not from education. I’m excited to eventually be able to answer their questions with action.”

What is something you would change?

“Administration treats us as kids, not adults. There is a resource for everything.” [Classmate who juggles a newborn and toddler with medical school studies]

“The cost of tuition. The founding of for-profit medical schools tells you all you need to know.” [Classmate with PA-student wife]

“Just tell me what is going to be on Step I. I do not have time nor the brain space for anything else.” [Type-A Anita…]

“Residency match. If you want to do a speciality, it has become so competitive. The Match is in a death spiral.” [Class Orthopod]

---

Following the curriculum isn’t enough if you want to be a good doctor. Friends at other schools, a few classmates, and a physician mentor agree that the focus of medical school is ensuring that the lowest denominator passes, not challenging each student to reach his or her highest potential. The resources are there for anyone who wants to take the initiative, but peer pressure works in the opposite direction. The most vocal students echo each other’s complaints that the curriculum isn’t sufficiently test-focused.

First year for most students serves a reminder that not all of us are special. Most medical students were near the top of their undergraduate class, but that was partly because their fear of failure (failure = less than an A) was so great they didn’t take challenging courses. Classmates’ first reaction to getting a question wrong may be to assert that the question was unfair, poorly worded, or that the answer was not worth cramming into our already crammed brains. We expect to be the discoverer of a new drug or the manager of a big project. One of my bosses during my gap year said, “What we really need are great employees. Leadership comes afterwards.” The more that I shed the entitlement mentality, the more I was able to focus on my strengths.

One thing that I learned is that medical students don’t relax until a few months prior to graduation. Classmates traded their fear of not getting into their first-choice medical school for three years of anxiety of not doing well enough on Step I (end of second year) and in rotations (third year) to get into their first-choice residency. One of our clerkship directors sent us an article about the surgery residency match process: “This leaves the 163 orthopedic residencies that participate in the Match in the unenviable position of having to sort through 88,169 applications for 717 total positions from just over 1,000 total applicants.” (Scott E. Porter, JAAOS, 2017) I.e., a typical applicant applied to 88 programs, more than half of the total programs nationwide.

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One of my neighbors (no longer a Millionaire for Obama; now a Millionaire Against Trump) posted the following on Facebook:

Thanks for your service and your leadership Senator McCain.

One of his female friends responded with

Amen. Always a hero, again and again and again!

Another friend, whose profile picture shows an overweight woman past middle age:

Thank God he has a heart.

Another older woman:

He’s a good man

I think that they’re all excited because McCain opposed an ostensible Obamacare repeal (I don’t bother to read the details on these anymore since the last “repeal” that I looked at was almost exactly the same as Obamacare).

It doesn’t surprise me that Massachusetts Democrats like this particular position that McCain has taken. But the unqualified love for McCain from these middle-aged-and-older women baffles me. Why would these women celebrate a guy who divorced his crippled-by-a-car-accident wife to marry a rich woman 18 years his junior?

(McCain sued his wife in 1980, which made him a relatively early adopter of the no-fault divorce law in Arizona (1973). The rich young intended protected herself from a potential second lawsuit by McCain with a prenuptial agreement (NPR) and continued residence in a jurisdiction where prenups will be enforced (see Arizona family law).)

Related:

• “The wife U.S. Republican John McCain callously left behind” (Daily Mail 2008)

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I just finished a couple of interesting books on Amazon Kindle Unlimited:

• D DAY Through German Eyes – The Hidden Story of June 6th 1944
• D DAY Through German Eyes – Book 2

These books are transcripts of interviews conducted 10 years after D-Day. One question that they answer is “Why were German soldiers fighting?” If they saw the war in the same way that we did, for example, why not simply surrender and walk over to the side with both Might and Right?

Here’s one example:

Helmut Voigt was a Grenadier (Rifleman) with the 716th Static Infantry Division, based in the Saint Aubin area, inland of Juno Beach.

My father, being in the banking profession, had affected my thinking about the war completely. My father was very sympathetic to the National Socialist (Nazi Party) view of the world. In this view, a United Europe was trying to assert its independence and its very right to exist, against certain powerful international forces. America and the English were in an unholy alliance with the Bolsheviks, and it was these Russians who were orchestrating world events from Moscow. Moscow –that word! During the war, so many bad things were explained by saying that ‘Moscow arranged it’ or ‘Moscow has done this to us.’ Even when the Americans and the English bombed our cities, when they began destroying whole towns, the newspapers would often say this was done ‘at the command of Moscow.’

Russia actually was responsible for the German defense strategy, according to one interviewee:

Gert Hoffmann was a Festungswerkmeister (Fortification Development Officer) attached to the 352nd Artillery Regiment, 352nd Infantry Division, in the sector of Carentan on the Southern Cotentin peninsula, inland from the American Omaha beach.

I must first clarify that the phrase ‘Atlantic Wall’ is itself rather misleading. There certainly was a ‘wall’ along the North East coast of France, around the Pas de Calais, where there were enormous concrete bunkers and gun emplacements, … But the further West you went, the less substantial the fortifications became, because the Western area, including Normandy and Brittany, was not originally considered a likely site for an invasion. Up until the autumn of 1943, the Normandy defences were quite simple, being mostly small bunkers, minefields, anti-tank barricades and so on, with a few larger concrete emplacements. Many of the smaller bunkers were actually civilian stone barns or houses, which had been reinforced and fortified, not at all like those massive concrete blockhouses of the Pas de Calais zone. It was when General Rommel was put in charge of the Atlantic Wall that the Normandy area began to be more heavily reinforced with more barricades, anti-tank ditches, much bigger bunker structures and so on. But this process was not finished when the invasion came, which was very fortunate for the Allies. We had many other plans for the Normandy coast which were only just coming to fruition.

I was a Fortress Officer of the Divisional artillery. Our role was vitally important, although today it is largely forgotten. We humble Wehrmacht engineers and builders have been eclipsed by the panzer men and the infantry and all the rest.

My role was in the creation of zones of fire on a large scale. This meant that we found ways of altering the landscape of the battlefield, using mounds, ditches and other means, in order to influence the way that an enemy attack, especially an armoured attack, would progress inland. We have to be honest today and say that the function of the coastal defences, I mean the emplacements on the shoreline itself, on the sea wall, was only to slow down an attack and give time for the alert to be sounded and a counterattack to be implemented. Of course, the infantry men inside those sea wall emplacements didn’t know this! On the contrary, they were told repeatedly that their mission was to drive the enemy back into the sea, to prevent them moving off the beaches, that not one enemy boot must step past the shore line, and so on. But this was purely to motivate them. We could hardly tell those boys on the sand, ‘You’re only there to slow the Allies down.’ It was expected that, at least in the first few hours, a determined Allied attack using armour would progress inland. In fact, it would be better if it did progress some small distance: this would bring large volumes of troops and armour into a prepared zone where they could be surrounded and ground down. This would destroy the enemy’s capability and also, very importantly, deter future attacks.

this was a bitter lesson which we learned in several places, but above all at the battle of Kursk in Russia in 1943. You may know the story of Kursk? Well, at Kursk we made the dreadful mistake of allowing the Soviets enough time to prepare a defence in depth against our panzer formations. Those Russian engineers took over a zone of ten thousand square kilometres, and they built a huge series of traps for our armour, with endless ditches, forts, traps, minefields and so on. None of these defences was insurmountable by itself, and over several days they were finally overcome, but the cumulative effect was to bog down our panzers, and turn them from a thrusting attack force into a slow or static target. The Russians showed us how to defeat an armoured attack properly! Not with a single line of fortifications, as the French tried to do with their absurd Maginot Line in 1940, but by taking a whole geographic zone and making it into a swamp for panzer forces, a swamp for men and vehicles. Making the entire landscape into a swamp for the invaders. That was what we planned to do in Normandy, in the absence of a true shoreline ‘Atlantic Wall.’

an example would be the landscape we created around the base of the Cotentin Peninsula. There, we opened the canal sluices and we flooded a wide area of fields to a depth of two metres, which panzers cannot cope with. Then, we placed a series of incendiary barges along one side; these were river craft fitted with burning material which would explode as the enemy approached, deterring them from trying to ford the water. We created a lane around one side which could be used to cross the floods, defended lightly so that the enemy would think they were fighting their way through. As the enemy came out of this, they would be faced with an anti-tank ramp system camouflaged by nets, which would hold up their panzers as they broke through. Onto this zone, we had Nebelwerfer (rocket mortar) batteries calibrated to fire on the stranded vehicles. Any panzers that finally crossed the ramps would become caught up in a system of bunkers armed with PAK guns, firing down a slope. And so on, and so on. The enemy would find himself with a long, thinly spread spearhead of armour which grew less powerful with each phase, very vulnerable to being isolated and ground down. This was all very closely based on what the Russians had done to us at Kursk.

Related:

• “Fake Russian Facebook Accounts Bought $100,000 in Political Ads” (nytimes on how Russians spent enough to reach one third of Americans for 0.6 seconds via a Super Bowl ad)

More: Read

• D DAY Through German Eyes – The Hidden Story of June 6th 1944
• D DAY Through German Eyes – Book 2

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The Pilatus PC-12 has a single engine and therefore in theory it is worth practicing what to do when the engine quits. Harrison Ford’s landing on a golf course shortly after taking off from Santa Monica is a good example of the value of proficiency. In practice, though, the PC-12’s engine is extremely unlikely to quit. This is a PT-6A turboprop (jet engine that spins a propeller), which is statistically far more reliable than piston engines or human pilots.

This investigation into the crash of an Air Force PC-12 shows that the training cure can be worse than the engine failure disease. Two Air Force pilots, presumably both more proficient than the average civilian pilot, wrecked a perfectly functional PC-12 while practicing getting back to the runway in the event of an engine failure shortly after takeoff. This is confusing because the PC-12 has a stick pusher to prevent pilots from aerodynamically stalling the plane. It is sad because FlightSafety has built Level D simulators in which this maneuver can be practiced without risk to any body part other than ego.

Fellow instructors and pilots: What do we take away from this?

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I saw a bike accident (arrived too late to know if it had been a car-bike accident, but probably). People were already gathered around the cyclist, who seemed to be mostly okay.

What if I’d had to call the police?

With the fragments of cell network coverage that are left to those of us who live among the towerphobic Millionaires Who Hate Trump (formerly the “Millionaires for Obama”), I’m not sure that I would have been able to sustain a voice call to 911. If I had called 911 successfully would the Enhanced 911 system have worked to give the operator my location? If not, it might have been challenging to specify a location in Massachusetts due to the lack of street signs for the bigger streets (i.e., most intersections have street signs for just one of the two streets).

It would have been way easier to get an Uber to my precise location since Uber is typically able to function with poor coverage. And certainly it would have been a lot more likely to get a text message out. https://www.fcc.gov/consumers/guides/text-911-quick-facts-faqs says “Today most consumers cannot reach 911 by sending a text message from their wireless phone.”

Given that our local governments have invested vastly more in communications infrastructure than Uber has in software and server hardware, why is it easier to get an Uber than police or fire department assistance?

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On August 26 I wrote The End Times in Texas: media portrayal versus reality about the contrast between the tone of at least some media stories regarding Hurricane Harvey and what Houston-based friends were saying in email or on Facebook. My post sought to avoid the selection bias of typical media reports by seeking on-the-ground accounts from non-journalists.

Within about 40 hours of that post it became apparent that the scale of damage was close to the worst-case scenarios that had been painted. None of my on-the-scene friends had been prepared for it. Now I’m wondering if the media’s generally hysterical tone is partly responsible for folks discounting the likelihood of the worst-case scenarios.

In the not-so-glorious-as-remembered days of my youth, newspapers didn’t have to work desperately to capture readers and advertisers. More or less every family in a city would subscribe to that city’s principal newspaper. There was a steady stream of subscription and advertising revenue even during “slow news” periods. An editor could run a quiet “human interest” story on the front page if there were nothing sufficiently dramatic happening to justify a big headline.

Today, however, newspapers have to compete for attention with other online diversions, streaming video, video games, etc. So even the most irrelevant information is characterized as having the potential to change readers’ lives, the smallest issues debated in Congress become life-or-death, and the most ineffectual action taken by a president is the next step toward tyranny.

As an example, here’s a front-page expose from the New York Times on the same day, August 26, as my Hurricane Harvey post: “Late Wages for Migrant Workers at a Trump Golf Course in Dubai”:

“Trump is not the owner or developer of Trump International Golf Club Dubai nor does it oversee construction or employ or supervise any of the companies or individuals who have been retained to work on the building of the project,” said a company spokeswoman, Amanda Miller, in an emailed statement.

The Pakistani driver who works at the Trump course arrived three years ago, seeking to support his wife and two boys. He took a job driving a pickup, earning over $800 a month, or more than twice his pay at home. He is supposed to be paid within the first five days of the month. Frequently, a week or more passes without the money arriving.

In other words, after reading about 15 screens of text one learns that the subcontractor of the subcontractor of the Trump partner does eventually pay workers in full. This merited “top of the home page” placement on the same day as stories about one of our largest cities being potentially flooded.

Readers: What do you think? When everything is presented as a crisis do we lose our ability to perceive the true potential crises?

Related:

• What can we do to help Houstonians?

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Marc Ginsberg, who was Bill Clinton’s ambassador to Morocco, was a speaker on our recent cruise to that country. It seems that, subsequent to this position in Morocco he has done a lot of work with Asian countries and thus he gave a talk about North Korea and stressed the rationality of the ruling Kim Dynasty. It has not escaped the Kim family’s notice that dictators who gave up their nuclear weapons programs eventually lost their lives (see Saddam Hussein, for example, and Muammar Qaddafi). Thus the media description of the Kim leaders as “crazy” is inaccurate. In Ginsberg’s view, the correct way to think about North Korea is that it is a successful family business for the Kims.

What to do about a nuclear-capable North Korea? In Ginsberg’s view the Obama Administration’s policy of “strategic patience” (i.e., doing nothing for 8 years) has unfortunately left us with no good options. The North Koreans are so heavily armed at this point and Seoul is so close (about 20 miles) from the DMZ that any kind of military assault on North Korea presents an intolerable risk to South Koreans. Basically we will have to admit that China is the only real power in that corner of the world and humbly beg them to help us out.

(After the talk I asked Ginsberg “If it is a business, why not offer them $20 billion per year to live comfortably in Switzerland? That’s nothing compared to what we’re spending on our military response.” He said that it wouldn’t work because the Kims were having too much fun being at the head of a cult of personality, but I still think it is worth a try! Switzerland is a lot nicer than North Korea and $20 billion is probably more than they’re extracting for personal use from the North Korean economy.)

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Get What’s Yours: The Secrets to Maxing Out Your Social Security has a chapter on America’s favorite program: SSDI. Here are some excerpts:

Just as Social Security has become the dominant source of income for most older Americans, so has it become the nation’s default welfare program. Neither role was part of the agency’s founding mission, which envisioned Social Security as a modest source of income to augment people’s savings and pensions. Yet here the program finds itself, some 80 years later, paying out benefits under two programs to more than 20 million disabled Americans. That’s a huge number in its own right and even more so considering how many additional lives and livelihoods are affected by the $200 billion in annual benefits the disabled receive.

The rules for disability benefit eligibility are quite demanding. They are less strict if you are younger, however. For example, someone who is disabled prior to age 25 can collect disability benefits with only 6 quarters of covered earnings.

Another key point (which applies to the non-disabled as well): you can obtain up to 4 quarters of coverage in a given quarter simply by earning enough money in that quarter.

So perhaps the optimum SSDI strategy for a lot of Americans is to work for about 6 months at a reasonably high salary and then become disabled prior to age 25? Maybe not:

We’ve had several people with disabled children ask us how their child could collect child benefits while they themselves are still alive, and child survivor benefits after they die. Just as we were about to tell them they only needed to apply for their child to receive them if that child was disabled prior to age 22, they stopped us dead in our tracks. They did so by telling us either (1) their child was working or (2) their child was receiving disability benefits on the child’s own work record. In both cases, this meant the child may have disqualified himself or herself, forever , for both disabled child and child survivor benefits. The reason is that for disabled children to collect on their parents’ work records, they not only have to have been disabled before age 22, but they have to stay disabled. And if your child earns too much money in even one year, Social Security will view the child as not having remained disabled. For 2016, the limit was $13,560, with some adjustment for work expenses. That’s not a lot of money. In one case, a parent told us they had employed their disabled child themselves for one year to make the child feel he played a meaningful role in society. (In fact, the child had not earned his pay and had not been able to continue coming to work.) When we asked how much the child had been paid, we winced. It was about $1,000 more than the annual limit, meaning the parent may well have disqualified the child for the rest of the child’s life from collecting benefits on the parent’s work record.

Readers: Please read Get What’s Yours: The Secrets to Maxing Out Your Social Security and figure this out and then give us the answer in the comments section!

Related:

• Who funded America’s opiate epidemic? You did.

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“This Is How Sexism Works in Silicon Valley My lawsuit failed. Others won’t.” is an excerpt from Ellen Pao’s Reset: My Fight for Inclusion and Lasting Change, a book released today.

One part of the Ellen Pao lawsuit that never made sense to me was “Why would the Kleiner partners want to make themselves poorer by pushing out a high performing junior partner?”

The excerpt explains some of this. First, it seems that Pao was essentially hired as a secretary, not as an investor:

When I first got the three pages of specs for a chief-of-staff position at Kleiner Perkins in 2005, it was almost as if someone had copied my résumé. … John Doerr wanted his new chief of staff to “leverage his time,” which he valued at $200,000 per hour. [actually worth a lot more under the California child support formula]

It was fun having sex with a married guy at work:

[Ajit Nazre and I] started seeing each other and had what eventually amounted to a short-lived, sporadic fling. It was fun bonding over work. Ajit told me the history of the firm and gave me the scoop on departed partners, and I felt like I was at last being let in on company secrets. Finally I had someone who was willing to talk about the dysfunction we saw in our workplace, and to be honest about how decisions were really made.

You know that you’re with a homophobe if your female partner objects to you having sex with other men:

During our first date in New York, he told me during hours of conversation that he had previously been with men, something I never had a problem with but which would later be used in the press as evidence that our marriage was a sham. We got engaged just six weeks after we met.

Here’s the most interesting part, though…

One secret of the venture-capital world is that many firms run on vote trading. A person might offer to vote in favor of investing in another partner’s investment so that partner will support his upcoming investment. Many firms, including Kleiner, also had a veto rule: Any one person could veto another member’s investment. No one ever exercised a veto while I was there, but fear of it motivated us to practice the California art of superficial collegiality, where everything seems tan and shiny on the outside but behind closed doors, people would trash your investment, block it, or send you on unending “rock fetches” — time-consuming, unproductive tasks to stall you until you gave up.

Venture capital’s underbelly of competitiveness exists in part because the more I invest, the less money for you, my partner, to make your investments. And we’re all trying to make as many investments as possible because chances are low that any one investment is going to be successful. Partners can increase their own odds by excluding all of your investments. And as a junior partner you faced another dilemma: Your investments could be poached by senior partners. You wanted to pitch your venture so it would be supported but not so much that it would be stolen. Once a senior partner laid claim to a venture you were driving, you were better off just keeping quiet.

In other words, it may be that Kleiner wasn’t a pure partnership and therefore Pao’s allegations might not have required each Kleiner partner to act against his or her self-interest. (Though, even in a state where a jury was willing to award $417 million to a woman who used talcum powder (USA Today), Pao’s lawyers couldn’t convince her jury.)

I’ll be interested to hear from readers who decide to invest in Ms. Pao’s book.

Related:

• Ellen Pao’s new job?
• Global douchebag circuit: Aspen Institute, Ellen Pao, and Buddy Fletcher
• What should Ellen Pao’s forthcoming book be titled?
• Litigious Minds Think Alike: Divorce litigators react to the Ellen Pao v. Kleiner Perkins lawsuit
• Ellen Pao v. Kleiner Perkins wrap-up

 

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Given that the only one who can accurately estimate the true cost of paying Social Security benefits is God (since only God knows exactly how long each of us, including the yet-to-be-born, will live), it isn’t surprising that people would differ on whether or not Social Security is solvent.

What is kind of interesting is that we can find this difference of opinion within one book: Get What’s Yours: The Secrets to Maxing Out Your Social Security.

The book has three authors. One is a professor of economics at Boston University. He says that the system is broken and bankrupt:

Our Social Security system is a disgrace, not in its objectives or in the tremendous help it has provided older people over the years, but in the way it’s been designed and the way it’s been financed. Its complexity is beyond belief. The formula for the Social Security benefits of a married spouse involves ten complex mathematical functions, one of which is in four dimensions! It leads all kinds of people to make all kinds of mistakes in deciding when to take benefits and what benefits to take. And the good folks at Social Security will far too often tell you things that are one hundred percent untrue with one hundred and fifty percent conviction.

Democracy is collective choice by the people. But having indecipherable institutions, be they our Social Security system, our tax system, our health-care system, or our financial system, deprives the people of the knowledge they need to make choices. Instead it leaves social choice not to the people but to the bureaucrats, who get to decide what’s best. The way the new Social Security law was passed is about as good an example as one can have of the incredibly nondemocratic processes that suffuse “America’s democracy.” I say bureaucrats rather than elected officials because our representatives are also at the mercy of the bureaucrats. Indeed, there is, I’d wager, not a single member of Congress with detailed knowledge of Social Security’s 2,728 rules or its tens of thousands of rules about those rules. And when it comes to Social Security, the big picture is the sum of all the small pictures.

Radical change in our Social Security system is inevitable for the simple reason that the system is broke—indeed, in worse fiscal shape than Detroit’s pensions when that city declared bankruptcy. My evidence for this? It’s the $26 trillion infinite-horizon fiscal gap shown in table IVF1 of the 2015 Social Security Trustees Report. This present value shortfall is net of the system’s trust fund and is almost $1 trillion larger than the system’s fiscal gap reported in 2014. The table shows that Social Security is 31 percent underfunded.

The economics labeling problem is the reason that the Inform Act has been endorsed by more than 1,200 economists, including 17 Nobel laureates (see www.theinformact.org ). The Inform Act mandates infinite-horizon fiscal gap accounting by government agencies for the entire fiscal enterprise. My own estimate based on the Congressional Budget Office’s Alternative Fiscal Scenario Projections puts the country’s overall fiscal gap at $199 trillion for 2015. This is 53 percent of the present value of all future federal taxes, so our federal government, taken as a whole, is 53 percent underfunded. Stated differently, we need a 53 percent hike in all federal taxes to permit our federal government to meet all its expenditure commitments. And if one focuses just on Social Security, the requisite immediate and permanent Social Security FICA tax hike to ensure that Social Security pays all scheduled benefits is 31 percent!

The less our generation pays, the more your kids and grandkids will have to pay; mine, too. And we are moving full speed ahead to leave our kids and grandkids with fiscal bills that are far, far beyond their capacity to pay.

The other two authors are journalists and they are quite sanguine about the system; it just needs a couple of tweaks:

even the darkest official forecast still assures people as young as 18 today something like 75 percent of the paychecks their elders are currently receiving. Official forecasts, however, are deeply misleading. That’s because they rely on the notion that there’s a Social Security “trust fund” that is running out of money; that a so-called Social Security lockbox has been “raided” to pay for other expenditures. Such palaver is misleading, if not arrant nonsense. First of all, the so-called trust fund is an accounting fiction: the money supposedly stashed away for future generations is nearly $ 3 trillion worth of U.S. government bonds— Uncle’s Sam’s IOUs that he gives as a legal promise to pay back what he’s borrowed.

Many of us will give a little. Some will give more than others— presumably Americans who earn enough not to need Social Security’s checks. There will be a huge outcry, as there always is when people are asked to pay more or get less.

if we changed, starting in 2021, the way in which benefits are indexed— from using average wage growth to using inflation as the basis— the actuary reports that we would not only wipe out the entire Social Security deficit over the next 75 years but in fact build a substantial surplus. Indeed, even over the infinite time horizon Larry favors, 89 percent of the deficit would be eliminated by this one change alone.

Alternatively, according to the actuary, we could increase the normal retirement age three months per year starting for those aged 62 in 2017 until it reaches 70 in 2032 and increase it one month every two years thereafter. Deficit reduction? Sixty percent over 75 years; 48 percent, infinite horizon.

Larry has interesting ideas for replacing Social Security with a fairer and better program. They’re never going to happen. We’re not going to replace an eighty-year-old program that has become an enormous bureaucracy, with rules to match, and that touches the lives of virtually every American.

 

Only someone with a crystal ball can say who is right, of course. Certainly Detroit had plenty of actuaries who signed off on its fiscal vitality. The last word from the economist:

Yes, Paul, I know you and Phil feel this will never happen and that small adjustments will be made and that all will be fine. This is Panglossian in the extreme, as a quick glance at Argentina’s century-long economic decline confirms. Yes, things that can’t go on will stop. But they will stop too late. The fact that the Social Security actuaries raised their, not my, measure of the system’s unfunded liability by almost $1 trillion in one year shows how quickly things are changing and why small, slow changes won’t work any better for Social Security than they did for Detroit.

More: Read Get What’s Yours: The Secrets to Maxing Out Your Social Security.

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