Should Disney World offer a ride educating kindergartners on sexual orientation and gender identity?

by philg

“Disney pledges to help repeal Florida’s ‘Don’t Say Gay’ bill” (The Hill):

Disney has pledged to help repeal Florida’s “Don’t Say Gay” bill, which was signed into law on Monday by Gov. Ron DeSantis (R).

The Walt Disney Company issued a statement shortly after the bill was signed on Monday that said, “Florida’s HB 1557, also known as the ‘Don’t Say Gay’ bill, should never have passed and should never have been signed into law.”

“Our goal as a company is for this law to be repealed by the legislature or struck down in the courts, and we remain committed to supporting the national and state organizations working to achieve that,” the spokesperson said.

“We are dedicated to standing up for the rights and safety of LGBTQ+ members of the Disney family, as well as the LGBTQ+ community in Florida and across the country,” the spokesperson added.

The bill is set to go into effect on July 1 and will prohibit primary school teachers from classroom instruction related to sexual orientation and gender identity, while educators of all grade levels will be prohibited from instruction on those topics that is not “age appropriate or developmentally appropriate” for their students.

Note that public elementary schools are not prohibited from providing classroom instruction related to sexual orientation and gender identity. The prohibition is only for kindergarten through third grade. Starting in 4th grade, a student could receive 2 hours per day of instruction on these topics, which would prepare him/her/zir/them to “earn salaries ranging from $329,000 to $430,000” as a diversity, equity, and inclusion administrator in a state university (source: the dreaded Fox News, which seems to have pulled public salary data) and, perhaps, even more at an elite private college.

The question for today is why Disney can’t act directly, rather than trying to overturn the law passed by the Florida Legislature? Disney has announced an official corporate policy in favor of sexual orientation and gender identity instruction for K-3 children. Millions of K-3-age children visit Disney World every year. Many of them are from Florida and thus, due to this new law, are at risk of being denied “classroom instruction related to sexual orientation and gender identity”. Why can’t Disney step in to fill the gap? In the photo below, a (masked outdoors) Disney employee (maybe in California?) holds a sign reading “Help us teach our children kindness and inclusion”. But, with a captive audience of millions, Disney shouldn’t need any help to teach whatever it wants to teach.

How about a dark ride along the lines of It’s a Small World? Children of all ages, including K-3, could travel in a vehicle shaped like a Mazda Miata and learn about myriad options for sexual orientation and gender identity. By including video screens, the ride could be kept continuously updated with the latest Science and, e.g., newly developed gender IDs.

You might say that sexual orientation and gender identity isn’t as much fun as some other topics, but if Disney isn’t passionate enough about 2SLGBTQQIA+ to offer this to the children who are already on site, can we accept their passion for 2SLGBTQQIA+ in the public schools as sincere?

Readers: What should the scenes of the sexual orientation and gender identity dark ride include? I can start with the cisgender heterosexual section. A “man” and a “woman” (Kentaji will bring in a biologist to assist with these terms) are alternately bored to death by each other’s company and annoyed to death by their biological children. A banner overhead reads “Marriage means that we solve problems together… problems that we wouldn’t have if we had stayed single.” The second scene is family court where the plaintiff asks for “permanent alimony” under Florida family law. The third scene is a pickleball court in The Villages where the now-leathery heteros congregate in single-gender groups while their adult children are ignoring them from 1,000 miles away.

A separate idea: Because Americans don’t have to work anymore, every Disney World ride requires waiting in line for 1-3 hours, even on weekdays. K-3-targeted sexual orientation and gender identity instruction could be provided to those waiting in line, a literal captive audience.

Potentially inspiring, scenes of African and Mexican life from It’s a Small World (September 2021):

Related:

  • Carousel of Social Progress for Disney World? (see image below)
  • “I got a ‘dress code’ violation at Disney World over my revealing top” (New York Post), in which K-3-age children were protected from seeing some portions of a 23-year-old’s body. Disney prohibits “clothing which, by nature, exposes excessive portions of the skin that may be viewed as inappropriate for a family environment.”
  • LGBT rights in Saudi Arabia (Wikipedia): “Both male and female same-sex sexual activity is illegal. LGBT rights are not recognized by the government of Saudi Arabia. … Homosexuality and being transgender are widely seen as immoral and indecent activities, and the law punishes acts of homosexuality or cross-dressing with capital punishment, fines, public whipping, beatings, vigilante attacks, vigilante executions, torture, chemical castrations, imprisonment up to life and deportation.” (Disney Plus operates cheerfully in Saudi Arabia and Disney has not suggested any changes to these laws and customs.)

Note that SeaWorld has a 2SLGBTQQIA+ section in the gift shop, but no rides specifically on the topic of 2SLGBTQQIA+. From earlier this month:

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The Disney World cathedral: perfect for astronomers

by philg

One of my favorite stops on a central Florida trip earlier this month was the Basilica of Mary, Queen of the Universe (see also Wikipedia). It is tough to conceive of a more dramatic contrast with the theme parks. For starters, it’s free and you don’t have to wait in line,

For folks who love astronomy, this is the ultimate chapel:

The approach from the parking lot….

Once inside,

The stained glass covers the good old days when everyone got along:

Life was simpler before the Covidocracy. Moses stopped at 10 rules and didn’t revise them every week. And, although these rules were downloaded from the cloud, Moses did not claim that they were determined by Science.

Reviewing these windows makes me wonder if churches in the Northeast, California, and Illinois should be updated with stained glass panels depicting the lives of the modern saints, i.e., public health officials and governors who kept people safe via lockdown, mask, and school closure orders.

When you’re done with the cathedral, there is another church next door devoted to the god that most Americans worship, i.e., an outlet mall.

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Medical School 2020, Year 4, Week 9 (Urology Week 2)

by philg

I am in the OR with Coach K on Monday and his partner Comedian Tom on Tuesday. I see three TURPs (transurethral resection of the prostate) on each OR day. After the patient is under general anesthesia (anesthesiologist chooses between endotracheal tube versus LMA) and draped, Coach K inserts the rigid cystoscope into the urethra. He points out several anatomical landmarks in the urethra and bladder on the screen. He points on the screen to the verumontanum, a subtle elevation of tissue identifying where the ejaculatory ducts enter. “As long as we remove tissue distal to the verumontanum, the patient should recover full control of the bladder. The external urethral sphincter and levator ani (pelvic floor) are just proximal to this landmark.”

He inspects the bladder, there are trabeculations and several indentations into the bladder surface. I ask why they’re there. “The bladder, like any muscle, hypertrophies from the increased pressure trying to push urine through the prostate obstruction.” The diverticula look exactly the same as a patient with diverticula of the colon. He withdraws the scope to the prostatic urethra, inserts an electrocautery device, and uses its 5mm-diameter semicircular wire to cut through the urethra and prostate to open the channel.  As he shaves the prostate, a few bleeders are seen piercing through the clear water. He cauterizes the bleeding vessels. “The prostate is a poorly perfused organ so there isn’t that much bleeding when you cut into it; these bleeders are perforators.”

The nurse periodically hangs another bag of 7.5 percent glycine on a post near the OR table. A tube flows down to the scope to keep the bladder distended so we can see the entire prostate. Coach K explains that we use glycine because the electrocautery device would not work in saline. “The current would not be discharged to the local targeted tissue, but instead be conducted through the salt water. Glycine does not conduct so the path of least resistance is to whatever tissue is touching the wire. If we are just scoping the patient we use saline. Pure water would work, but it would kill cells from the osmotic pressure gradient. There is a small risk of hyponatremia [low blood sodium] after these procedures which is why we try to keep the irrigation time under 1 hour.”

There was a noticeable contrast between Coach K’s technical skills in the TURP versus Comedian Tom. Coach K carved out the prostate creating an elegant circular channel that was all cauterized with no bleeders. I felt Tom struggled to get good visualization during the procedure because he couldn’t completely coagulate off the bleeders distorting the picture. He didn’t “butcher” the patient, but it wasn’t as technically satisfying. I couldn’t tell if the channel was circular or how much he removed at the end. His patients still get benefits but I wonder if they have different 10-year outcomes. Coach K:  “90 percent of patients at 10 years after TURP do not have any obstructive symptoms. 10 percent get regrowth that requires either medical management or re-operation.”

Although these doctors operate at our hospital, they are partners in their own practice. “Private practice is hard. There is a reason it’s a dying breed,” Coach K explains. “We are clinging to paper charts for as long as we can. EMRs are so expensive for a small practice such as ours, but we also get penalized by Medicare for not having meaningful use.”  He picks up a patient’s folder. “This patient was admitted for an obstructing stone. I was called in and removed the stone. Here is the fax from the stay. Is this meaningful?” He hands me a 25-page print out from our hospital’s Epic EMR for the two day admission. The first five pages are demographic information, mostly blank (e.g., address 1 filled in, addresses 2 and 3 unfilled). There are numerous nursing notes, a CT report with paragraphs describing how radiation exposure was minimized, and his operative note. “This is all checking boxes. You cannot find actionable information.” When patients come to his private office for a follow-up after hospitalization he ends up throwing nearly their entire hospital record into the protected health information (PHI) shredder bin.

Another assault on his income is that our hospital has gradually bought up clinics and practices to form a regional health system in which providers are encouraged to refer to specialists within the system. The private practice doctors end up with the worst parts of working for the hospital, e.g., taking call, and none of the benefits. The private partners are also at a disadvantage when purchasing supplies, sometimes resorting to Amazon for scarce items.

[Editor: this was before the “supply chain” catastrophes that started in 2020]

Our last patient is a 73-year-old self-deprecating truck driver who walks in with a USA 45 hat. He has classic symptoms for BPH and an elevated PSA. He introduces himself, “I’m all healthy doc, except for my pee-pee.” The nurse measures a post void residual of 490 mL (this is pretty close to what would be considered full in a healthy individual; less than 50 mL is considered normal). He explains to me that he drinks 2 jugs of coffee to stay awake on his daily 8-hour drive. He sleeps with one of the cups due to fear of urgency and leakage. We start him on tamsulosin, and schedule a one-month follow up appointment.

One of our classmates just matched into urology. Coach K helped mentor him so is quite proud. My classmates meet at Buff Bri’s house for a penis celebration. Sarcastic Sally gets decorations from a bachelorette party store, including penis hats and straws. Mischievous Mary brings assorted nuts for snacking. We reflect on senioritis. Pinterest Penelope summarizes: “I have instagram and snap chat to deal with. I can’t be at the hospital.” Mary shares her latest experience: “I was doing an APR (abdominal peritoneal resection, removal of the rectum and anus) with a jewish colorectal surgeon and a resident. The Poop Doc was across from me, while the resident was in between the legs struggling to remove the rectum through the anus with all his might. Poop Doc: ‘You can help the resident  by pushing on the abdomen from above.’ As I do this, the rectum shoots out with liquid poop, which seeps down the resident’s gown. The resident exclaims, ‘It’s in my socks!’ Poop Doc, ‘Oy vey.'”

Statistics for the week… Study: 4 hours. Sleep: 7 hours/night; Fun: 1 night. Penis party.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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A $1.4 billion stadium for Afghans, Iraqis, and Somalis to watch American football

by philg

“After decades of decline, Buffalo boasts a ‘Refugee Renaissance.’ Can it last?” (Democrat and Chronicle, January 2022):

After reinventing itself as a haven for refugees, Buffalo seems poised for renewal. But with success comes higher rents.

Across the nation, the results of the 2020 census were the source of hand-wringing and political debate. But in Western New York, they were cause for unbridled celebration.

For the first time in 70 years, the city of Buffalo had grown.

The city’s modest 6% growth was trumpeted by officials as a pivotal triumph for a Rust Belt city that had become synonymous with loss. Hollowed out first by suburban flight and then the loss of manufacturing jobs, the onetime steel and iron powerhouse had hemorrhaged more than 50% of its population in the half-century since 1950. By the turn of the millennium, it also ranked among the most poverty-stricken in the nation.

The city’s turnaround came from a perhaps unlikely source: refugees from some of the most conflict-riven places in the world. After welcoming fewer immigrants than any city its size in the 2000 census, Buffalo has since re-imagined itself as a haven for new Americans from countries such as Myanmar (Burma), Somalia and Iraq.

Over the past two decades, more than a quarter of the refugees who came to the state of New York arrived in Buffalo’s Erie County, even as native Buffalonians continued to flee to greener economic pastures. Since 2002, more than 16,000 refugees have resettled in Buffalo.

Higher rents as the price of prosperity

West Side homes that used to sell for $40,000 might now go for hundreds of thousands, said Beehag at the International Institute, straining the resources of agencies trying to find housing for refugees who may need months to find jobs. To house the around 500 incoming Afghan evacuees, agencies are relying in part on churches and universities for short-term housing.

Poverty rates in Buffalo have barely budged even as other economic indicators trend upward — leaving both refugees and longtime residents alike in danger of displacement, according to a 2019 analysis led by Adelman.

What do impoverished refugees “from countries such as Myanmar (Burma), Somalia and Iraq [and Afghanistan]” need from taxpayers? “Buffalo Bills Strike Deal for Taxpayer-Funded $1.4 Billion Stadium” (New York Times, March 28, 2022):

New York State officials have reached a deal with the Buffalo Bills to use $850 million in public funds to help the team build a $1.4 billion stadium — the largest taxpayer contribution ever for a pro football facility.

Under the deal, the state would finance $600 million of the construction costs, while Erie County, where the stadium will be built adjacent to its current home, would cover $250 million. The remainder would be financed through a $200 million loan from the N.F.L. that was approved on Monday, plus $350 million from the team’s owners.

“Taxpayers To Be Billed a Billion Dollars for Buffalo Bills’ New Stadium” (reason.com):

as Field of Schemes blogger Neil deMause parses in his detailed rundown of the stadium deal, the actual public subsidies probably exceed $1 billion—and that doesn’t account for things like interest payments on the borrowing that the state and county will likely have to do to finance the agreement. The fine print of Monday’s announcement, deMause notes, puts the public on the hook for $6 million annually for the next 30 years to fund upgrades to the stadium and another $6.6 million for the next 15 years to fund “maintenance and repair.” All told, that’s an extra $160 million in taxpayer funds pledged to the project beyond the $850 million price tag.

Related:

  • “Sports, Jobs, & Taxes: Are New Stadiums Worth the Cost?” (classic 1997 paper from Brookings)
  • “Sacking Taxpayers: How NFL Stadium Subsidies Waste Money And Fall Short On Their Promises Of Economic Development” (Heartland 2015): “Taxpayers funded more than half the construction cost of 12 stadiums from 1995-2013,” TPA says. “During that time, national median household income rose 0.3 percent across the United States, adjusted for inflation. In the dozen counties in which an NFL stadium was built using more than 50 percent public funds, however, median household income plummeted 5.7 percent during the same time. Twenty-six counties in America are home to an NFL stadium that received tax dollars between 1995 and 2013. In an astonishing 17 of those 26 counties, the median household income actually decreased in constant dollars after the stadium received public money for construction or renovation. Taxpayer-financed NFL stadiums didn’t just appear to decrease median income, they also apparently contributed to increasing the number of people living in poverty.”
  • “NFL owners approve sale of Bills to Pegulas” (2014): That payment would be for $1.4 billion. (i.e., if we don’t adjust for inflation, the cost to taxpayers, who will get nothing in return, will in the same ballpark (so to speak), as the cost to the owners)
  • “Celebrating Women’s History Month” (BuffaloBills.com), from a team that refuses to hire anyone identifying as a “woman” to be a player
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Bubble in the Sun book: even those with the best information can’t predict a crash

by philg

Bubble in the Sun: The Florida Boom of the 1920s and How It Brought on the Great Depression (Christopher Knowlton) explains how Miami Beach was essentially the vision of a single individual, Carl Fisher (a pioneer in automobile headlights, highway development, and co-founder of the Indy 500).

Jane believed the project would be an expensive mistake. When Fisher took her to inspect the property by boat, they entered from the bay side, rowing up a channel lined with dense mangroves. “Mosquitos blackened our clothing,” she wrote. “Jungle flies, as large as horse flies, waited for our blood.… Other creatures that made me shudder were lying in wait in the slimy paths or on the branches of overhanging trees. The jungle itself was as hot and steamy as a conservatory.… What on earth could Carl possibly see in such a place?” But Fisher insisted that he knew what he was doing. Standing with her on the soft sand on the ocean side of the long neck, the surf breaking toward them in slow, white rollers, he sketched out his vision for the area. It would be half beach resort and half playground. “In that moment, Carl’s imagination saw Miami Beach in its entirety, blazing like a jewel with hibiscus, oleander, poinsettia, bougainvillea, and orchids, feathered with palms and lifting proud white towers against the sky,” Jane recalled. “But I looked at that rooted and evil-smelling morass and had nothing to say. There was nothing a devoted wife could say.”

As 1919 unfolded, Carl Fisher made two final and critical changes to his business strategy. The first was to switch his target audience, which had always been the elderly and the retired rich, most of whom still favored Palm Beach over Miami, and always would. As he told Business magazine a few years later, “I was on the wrong track. I had been trying to reach the dead ones. I had been going after the old folks. I saw that what I needed to do was go after the live wires. And the live wires don’t want to rest.” He would concede the superrich and the old money to Palm Beach. Instead, Miami Beach would be for the nouveau riche; for men like Fisher himself, especially those from the industrial Midwest; men who were younger, still making their fortunes, and looking for fun ways to spend their new wealth. He would appeal to them with the sort of activities that appealed to him: contests, races, and other events that featured sports celebrities. Henceforth, Miami Beach would become “a youthful city of indeterminate social standing,” in the words of social historian Charlotte Curtis. Fisher’s second change in tactics was equally radical: he raised his land prices by 10 percent, in part to give the appearance that his lots were appreciating rapidly in value. And to further promote that perception, he offered a return guarantee of 6 percent “to any customer in Miami or elsewhere who purchased lots from us and are not well pleased with their investment.” He assured his buyers that, from then on, he would be raising prices by 10 percent every year. Ten percent was an exceptionally attractive rate of return; 10 percent that seemed virtually guaranteed was even more attractive. Fisher, in trying to stoke a small fire, was about to fuel a conflagration. Behind the scenes, other factors had contributed to the marked improvement in sales. Chief among these was the wide proliferation of the automobile. The machines that Fisher had raced, sold, and promoted back in Indiana had evolved into bona fide consumer products, viable and cost-effective substitutes for the horse and buggy. The automobile, more than the railroad, the streetcar, or any other factor, turned the American landscape from raw land into real estate. It did so by making the land accessible and thus developable: its value could be easily established, enhanced, and commodified. Land then became a far more salable product, one that benefited landlords, lenders, contractors, and real estate agents, to say nothing of the purchasers and renters of that property. Nowhere was this truer than in Florida. And nowhere in Florida was it truer than in Miami Beach, where the road built over the Collins Bridge and the new County Causeway (renamed MacArthur Causeway in 1942) at last made the resort developments there commercially viable—by making them accessible to cars. Miami Beach was on its way to becoming the most widely publicized and most famous resort destination in the country. Fisher was now forty-three years old but still full of vitality. “This is only the beginning,” he announced presciently in an ad that appeared in the Miami Metropolis newspaper late in 1919, adding that he planned to further enhance Alton Beach the following year with “a polo club house, a church, theater, schoolhouse, six store buildings, and ten Italian villas ranging from $10,000 to $35,000 each.”

By the mid-1920s, Fisher’s vision was more or less realized:

In her memoirs, Fabulous Hoosier, Carl’s first wife, Jane, captures the surreal nature of the late boom years and how the clientele of their once sleepy resort town had changed: “Pouring into Miami Beach they came, fantastic visitors to a fantastic city. The gold diggers and the sugar daddies, the gigolos, the ‘butter and egg men,’ the playboys and the gilded heiresses, the professional huntresses, the tired businessmen who never grew tired, the gentlemen who preferred blonds. Miami Beach was the playground of millionaires and the happy hunting ground of predatory women.”

Then he tried to do it all over again in Montauk, Long Island and, due to leverage, blew up. The book chronicles the fate of other folks who became billionaires (in today’s debased money) from their efforts in Florida real estate, e.g., George E. Merrick who planned and built Coral Gables and Addison Mizner who is responsible for the Spanish-style architecture that we now see all over Florida. Essentially all of them went bust after staking their fabulous riches on yet more expansion.

What’s the worst that can happen in our current real estate and stock market boom? A retired hedge fund manager friend says that he wouldn’t be shocked to see a 90 percent crash. I think that this is excessive given that Manhattan real estate crashed by only 67 percent from 1929 to 1932 (HBS) and this was much steeper than the nationwide decline.

The book should be an inspiration for more diversification, though 2008 showed how tough that can be to achieve. Here are some $5-12 million houses (Jupiter Inlet Colony) to enjoy while the good times last…

Related:

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12 Hours of Sebring, a perfect Florida fly-in destination

by philg

Since small aircraft are generally inferior to a 2009 Honda Accord as a transportation tool, it is worth celebrating the situations in which it make sense to fly. The Sebring, Florida race track is actually built on part of what was once a vast military airport and is now a medium-sized civilian airport. Therefore, if you are landing on Runway 1 you’ll see the race before even getting out of the plane. You’ll hear the race as soon as you’re on the ramp (remember to pack earplugs, though they also sell them at the race). After walking through the beautiful modern GA terminal you’re a 20-minute walk from the event entrance, but the kind folks at the airport run a shuttle so you’ll be there almost immediately.

The true fans, either of beer or racing, show up on Wednesday and camp:

Imagine Burning Man with no philosophy…

Here are a Corvette and Lamborghini in 1st and 2nd place (within their class) after about 2 hours. They ultimately finished in the same positions. General Motors (Cadillac) also won all three top spots in the fastest “DPi” class.

A Ferrari appears to chase a McLaren (but they’re actually in different classes):

There is a modest midway of manufacturers’ booths and food. You can develop some new respect for your neighbor with the Hyundai Elantra:

Feel better about your job… there is an actual human zipped into this outfit in the 90-degree Florida sunshine:

Although there don’t seem to have been any drivers who identified as “female”, there apparently was a competition that may have featured some who identified as “women”:

(With the kids in tow, I was unable to stay for this important event and therefore cannot supply photos.)

Chevy’s contestants in the mechanical beauty contest… a flat-plane crank engine and a cutaway Z06 Corvette:

If you’re coming down from Maskachusetts or New York and are anxious to fit in, you might want to take the Hillary, Biden/Harris, Black Lives Matter, #StopAsianHate, and “In this plane we believe…” stickers off the Bonanza.

See you there in March 2023! (the kids are already preparing!)

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What kind of paintings should Stormy Daniels create?

by philg

“Stormy Daniels must pay $300k to Donald Trump after losing defamation case appeal” (NBC):

Adult film star Stormy Daniels has lost her appeal in her failed defamation suit against Donald Trump — leaving her owing almost $300,000 in legal fees to the former president.

“I will go to jail before I pay a penny,” Daniels tweeted Monday after the 9th U.S. Circuit Court of Appeals ruled against her in the long-running case.

Trump hailed the ruling by the appeals court, which he often bashed as president, calling it “a total and complete victory and vindication for, and of me.”

Michael Avenatti filed the defamation suit against Trump in 2018, when he was Daniels’ lawyer. Daniels, whose real name is Stephanie Clifford, said in a statement Tuesday that Avenatti had filed the suit “without my permission and against my wishes.”

“Once it was filed, Trump’s lawyers overwhelmed Avenatti and I was left the victim of an attorney’s fee award,” she added, calling it a “sad reality” that a “predator” like Trump “can openly brag about assaulting women and become president and be awarded money for his bad behavior.”

(Michael Avenatti was too busy running for President to be an effective lawyer; see “‘When They Go Low, We Hit Harder,’ Michael Avenatti Tells N.H. Democrats” (NHPR, 2018))

At 44, Stormy Daniels might be a little old to make money in the ways that she used to. But if she needs $300,000 from for her service to the cause of anti-Trumpism, why not create some artwork that loyal Democrats can hang next to their original Hunter Bidens (between $100,000 and $500,000 each, according to the NYT)? It shouldn’t take long to recover $300,000 after gallery fees and taxes.

What should Stormy’s medium be? Oils? Acrylics? Watercolor? And should the works be abstract or representational?

One idea, given the likely market: Stormy Daniels could paint portraits of Hunter Biden.

Related:

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How are American non-profits able to get donations while the war in Ukraine rages?

by philg

A money manager friend recently attended a charity fund-raising dinner in Palm Beach. The beneficiary is a liberal arts college in the Northeast. If they reach their goals, the Second Assistant Dean for Diversity, Equity, and Inclusion will be able to hire a second assistant and the Office of 2SLGBTQQIA+ Allyship can get some gender-neutral Steelcase chairs. No doubt these are worthy objectives, but why are donors giving anything all when there are millions of Ukrainian refugees who need assistance? (One of our loyal readers is housing 7 Ukrainian relatives in his house in France, for example; they can get health care and education, but “no hope for housing, they go into the general multi-year queue for social housing.” (as in the U.S., the French think that housing is a human right, which is why some people get taxpayer-funded houses, but it is not enough of a human right that the French are motivated to tax themselves sufficiently to build sufficient taxpayer-funded housing).)

Speaking of Palm Beach, here are some photos from a recent trip to The Breakers where a friend was paying $2,000 per night for “a tiny room” that afforded “glimpses of the ocean.” It seems that $2,000 is the new $500 because that was the room cost in all previous years.

At the entrance we learn that if you tip the valets sufficiently, even the simplest rental Chevy can occupy pole position:

The beach in Palm Beach is crummy compared to what we enjoy in Jupiter, with heaps of rocks dumped on the sand to prevent erosion:

A cold front with thunderstorms had just rolled through, so the beach and pool were mostly empty:

Although there are no homeless encampments, visitors from San Francisco should still feel right at home:

For $2,500 extra per day, you can rent a pool-side day-use room with attached bathroom:

Back inside the hotel, a wedding takes shape:

(Note that, statistically, the more money that is spent on a wedding, the higher the probability of a subsequent divorce lawsuit.) The other big event in the hotel that night was a black tie ball raising funds for a nearby hospital (already on the 20-percent-of-GDP gravy train).

I wasn’t sorry to leave. Palm Beach is a nice island (literally), but almost any path in or out goes through some depressingly impoverished neighborhoods. In Jupiter, by contrast, you can go from the ocean to Interstate 95 and beyond without encountering anyone unable to pay $1,500 per month for an apartment. It’s presumably nice to be rich enough to afford a $50-100 million house (“brokers fear they may run out of mansions to sell”; “We’re now seeing $50 million transactions on almost a weekly basis.”) that is occupied only 2 months per year, but I wouldn’t want to be regularly reminded of How the Other Half Lives. Maybe the answer is that the residents of Palm Beach never actually leave the island (until it is time to catch the G650 at KPBI), but send servants out for supplies that are available only in West Palm.

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Medical School 2020, Year 4, Week 8 (Urology elective Week 1)

by philg

I meet my attending, Coach K, in the four-urologist private practice at 8:30 am. The radio is tuned to the sports channel as he signs paperwork before the first patients are ready. “If I can get you to not consult urology when you cannot pass a Foley, you have had a successful rotation.”  (A Foley catheter drains urine directly from the bladder.) His new nurse is a friendly 63-year-old. Nancy retired after working 25 years in a family practice office, but returned to work because “my husband was driving me crazy with us both sitting at home with our kids out of the house.”

Nurse Nancy explains that Coach K likes to stay busy. He usually double- or triple-books each 15-minute appointment slot. This is plenty of time if Nancy is able to get a urine sample and the post-void residual bladder scan in a timely manner because most visits take less than five minutes. For example, if following a patient for elevated prostate specific antigen (PSA), Coach K will ask if there are any changes since the last visit, and then recount the options of biopsy versus active surveillance (PSA every three to six months). He says farewell, while Nancy draws blood for a lab company rep to pick up at the end of the day. 

Urologists see a wide spectrum of ages. Most patients are between 50 and 75 years old referred for either elevated prostate-specific antigen (PSA) or difficult-to-manage benign prostate hypertrophy (BPH). We see patients of all ages for kidney stone management. Young couples come in for vasectomy referrals. A vasectomy is a 10-minute office procedure done under local anesthetic. Coach K offers a valium to take beforehand in which the patient has to have someone to drive him home. I see a 29-year-old male accompanied by his wife and the mother of their five children. Coach K asks if they are sure they do not want any more children. When they learn that he could come in alone, the wife responds, “Oh no, I’ll be here. I have to make sure he goes through with it!” Coach K explains, “You will need to use protection for three months. After that he will drop a semen sample off here so we can test it to ensure there are no sperm present.”

[Editor: See also “Hamptons bachelors are getting vasectomies so gold diggers can’t trap them” (New York Post, May 27, 2017). “‘There’s a spike in single guys’ who get the procedure in spring and early summer, said Dr. David Shusterman, a urologist in Midtown. ‘This extortion happens all the time. Women come after them. [They get pregnant and] want a ransom payment,’ said Shusterman. ‘Some guys do an analysis of the cost — for three days of discomfort [after a vasectomy], it’s worth millions of dollars to them.'”]

We see roughly eight benign prostate hypertrophy (BPH) patients per day. Coach K: “10 percent of men at 50 will have obstructive symptoms, 100 percent by 80.” When asked about symptoms of obstruction, patients lights up as if saying with their face, “Finally, someone understands what I am feeling!” Obstructive urinary symptoms include: sensation of incomplete emptying, double voiding, dribbling, and decreased force of stream. A lot of men report having to get up in the evening. I learn that this is more related to irritative symptoms or excess urine production from mobilizing fluid while laying flat. Coach K explains, “Put your feet up 30 minutes before bed so you can pee off this fluid before getting into bed.” Most men’s BPH can be managed with medicine, either an alpha-1 blocker and, if needed, finasteride. Finasteride takes 3-6 months to have an effect as it lowers DHT levels that drive the growth of the prostate. Coach K explains, “The main side effect of finasteride is decreased libido, but most people are fine.”

[Editor: Reduced male libido may not be a problem: “Only 48% of married women want regular sex after four years.” (Good Housekeeping)]

My attending continues, “One controversial topic is whether finasteride increases the incidence of aggressive prostate cancer. The jury is still out.” If these medicines do not control the symptoms, Coach K discusses surgical options including transurethral resection of the prostate (TURP, pronounced “terp”) or a green light ablation. In theory, a primary care provider should be able to manage BPH, but several patients report it is easier to schedule an appointment with a specialist. “The earliest appointment was in four months for my PCP,” states a 62-year-old.

Patients are cheerful during their one-week post-op visits after TURP. “Doc, I feel like a teenager again!” exclaims an 80-year-old man. “Doc, one more question. Do our balls sag when we get old? Every time I sit on the toilet they touch the bowl!” His wife slams her hand on her face. Coach K responds: “Everything sags when we get older.” Another post-TURP patient exclaims, “Finally, I can go on my dream trip to the Canadian Rockies.”

A common complaint during office visits is the cost of erectile dysfunction medications. Although generics have been available since 2017, our older patients can’t figure out how to avoid being charged $300. Coach K: “I tell patients to always ask for the cash price and use GoodRx. In a study of the five most commonly-prescribed urologic medications, CVS was by far the most expensive. Walmart and Kroger were in the middle of the pack. Mom and pop pharmacies were the cheapest.” What about the Aetna-CVS merger? “It’s been terrible. Our office gets called by Aetna all the damn time telling us to switch a patient’s medication [to a cheaper generic-available drug]. The patient could be on the med for the past 15 years.” He is adamant. “No, I am not switching them, there is no medical reason.”

We see a 62-year-old patient whom I cared for six months earlier in the surgical ICU. A tractor rolled over him and fractured his pelvis. It was nice to get to know him as a person since he’d been delirious for his week-long ICU stay. Since discharge, he has been working with physical therapy, and is now able to use a walker. His wife asks if there is anything to help with control of his bladder. When he does any activity, e.g., rises from sitting, coughs, or laughs, he leaks urine. For two months he also had fecal incontinence, but this has slowly resolved. Coach K instructs me to perform a digital rectal exam (DRE). He has no rectal tone, and no bulbocavernosus reflex (squeezing head of the penis should lead to squeezing anus). He has damage to his pelvic floor muscles. “This might get better, time will tell and there is really nothing for us to do to make it go quicker.” We prescribe him Sudafed, a stimulant that can improve urethral sphincter tone. “It’ll make you feel jittery, but take it 30 minutes before you work with PT. It should help with leakage.” We also see several bed-bound patients that need a Foley exchange. 

Twice a day we see a child for bedwetting. Coach K explains that secondary nocturnal enuresis, in which the patient at one point did not wet the bed, is almost always a result of trauma, e.g., sexual abuse or parental divorce. “There is nothing we can do for them except try to reduce their stress level,” he says.  Most of the time this is for primary nocturnal enuresis (bedwetting since birth), for which Coach K explains that we are also without medical interventions.

[Editor: But not without an ICD-10 code and an insurance reimbursement!]

A 7-year-old female who has been potty-trained since 2.5 is brought in for bedwetting. “You’ll hear the same spiel as last time,” says Coach K. He explains to the family that this is a common issue due to immaturity of the connections between the brain and the bladder. The condition is strongly heritable and usually at least one parent recalls having been a bedwetter. Deep sleepers are more vulnerable to this condition. Do you have trouble waking her up in the morning? “Oh yes, she is such a deep sleeper. She won’t wake up from anything.” Coach K explains, “Bedwetting gets better with time. Only one percent of 18-year-olds are still wetting the bed, but the improvement will be gradual, coming down from 4-5 times per week to 2, to once per week to once per month.” Behavioral modifications, such as decreasing fluid intake between dinner and bedtime and restricting caffeine, will decrease the amount of urine produced at night, but won’t reduce the number of events per week. He hands the family a small pamphlet for a bed alarm. The bed alarm senses fluid and wakes the patient up. “It won’t stop the bedwetting,” Coach K explains, “but will make it more manageable for motivated children.”

Why not offer them medications? Coach K later explains to me that the success rate of DDAVP (desmopressin) is so low that parents get more discouraged when it fails. 

Later, I see a one-percenter: a fit 19-year-old freshman sporting a well-groomed large beard followed for primary nocturnal enuresis for over a decade.  Coach K asks how college is going. “I’m studying construction engineering. Math was always easy for me in high school, but I am struggling to stay afloat for some of these classes.” He’s in a “Live and Learn” community that should be supportive. In high school he tried imipramine, an antidepressant (TCA) that has side effects of bladder retention, which did the trick. He went from 5 events per week to 1 per week. He gave up the drug due to its side effects and now wets the bed 3 times per week. “I am sure this is a killer to your social life,” says Coach K. The patient asks to go back on the medicine and Coach K prescribes him a half-dose, emphasizing, “Keep in mind alcohol will make this worse. It puts you into a much deeper sleep.”

We see five bladder cancer surveillance patients per day, all of whom are former or current smokers (a big risk factor due to irritation of the mucosa). Bladder tumors are mostly diagnosed after gross hematuria (visible blood in urine) or persistent microscopic hematuria on urine dipstick testing. As long as the tumor is superficial, and does not invade the smooth muscle, treatment is removing it in the OR through cystoscopy (fiber optic scope with a cutter at the end). After the initial diagnosis, the patient is screened for recurrence every three months for one year, followed by six months for four more years, and then yearly. “I have patients that I find a recurrence every six months, and I have patients that are clear for a decade, and one pops up.” The first cystoscopy is alarming for both men and females. The patient is prepped in the procedure room with a drape over their exposed genitalia. Coach K inserts numbing gel into the urethra, followed by a flexible scope. When he sees an interesting finding, he signals me over to look into the scope.

[Editor: Bladder cancer patients seem to generate annuities for urologists. In 2012, Forbes noted that “These specialists earn an average of $461,000, not including production bonuses or benefits.”]

Statistics for the week… Study: 3 hours. Sleep: 9 hours/night; Fun: 2 nights. Taco and tequila bar with Straight-Shooter Sally and her boyfriend, an engineer for a green energy design firm.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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The Science of abortion

by philg

“What Quantum Mechanics Can Teach Us about Abortion” (Scientific American):

As light can exist as both a particle and a wave, an abortion provider can honor birth and fight for a person’s right to give birth when it’s right for them

Quantum mechanics, a discipline within physics, has demonstrated that both are true. Sometimes light acts like a particle, sometimes a wave. This duality explains all the characteristics of light that have been observed experimentally, and has allowed scientists to explore the cosmos in previously unimaginable ways. That these two seemingly irreconcilable beliefs could come together gives me hope that similar harmony could be achieved in the discussion of other deeply polarizing topics, including abortion.

Instead of either/or, imagine both/and. We recognize the value placed on a desired and loved pregnancy by families and understand that ending a pregnancy is the right decision for some people some of the time. Individuals may have ethical objections to abortion and recognize that anti-choice laws can harm people. We can value human life and recognize the complexities of reproductive decision making. Attending thousands of births has been a great joy in my career and has cemented my belief that forcing a person to give birth against their will is a fundamental violation of their human rights.

Generally, the article takes the scientifically correct position that those who identify as “men” are just as likely to get pregnant and give birth as those who identify as “women”. But then the author and editors for some reason slip into distinctly unscientific (and hateful) language:

Given that one quarter of women in the U.S. have an abortion, many Americans have benefitted directly or indirectly from abortion care. I implore readers to emulate previous generations of scientists who changed our understanding of the universe by their willingness to consider seemingly opposite empirical truths: Particle and wave, abortion providers and ethical physicians, pro-life and pro-choice.

Scientific American says that correct political and moral decision regarding abortion (legal right through 37 or 39 weeks in Maskachusetts so long as one doctor thinks it will help the birthing person) can be established scientifically, in other words, and therefore anyone who has a different opinion is factually and scientifically incorrect.

Is this idea new? A Duke econ professor‘s 2007 introduction to Nobel-winner F.A. Hayek’s The Road to Serfdom:

The British were not Continental socialists, but still, the danger signs were there. Clearly, the nearly universal sentiment among the intelligentsia in the 1930s that a planned system represented “the middle way” between a failed capitalism and totalitarianisms of the left and right was worrisome. The writings of what Hayek called the “men (and women!) of science” could not be ignored. Look at this message from the weekly magazine Nature, taken from an editorial that carried the title “Science and the National War Effort”:

“The contribution of science to the war effort should be a major one, for which the Scientific Advisory Committee may well be largely responsible. Moreover, the work must not cease with the end of the war. It does not follow that an organization which is satisfactory under the stress of modern warfare will serve equally well in time of peace; but the principle of the immediate concern of science in formulating policy and in other ways exerting a direct and sufficient influence on the course of government is one to which we must hold fast. Science must seize the opportunity to show that it can lead mankind onward to a better form of society.”

The very next week readers of Nature would find similar sentiments echoed in Barbara Wootton’s review of a book on Marxism: “The whole approach to social and political questions is still pre-scientific. Until we have renounced tribal magic in favour of the detached and relentless accuracy characteristic of science the unconquered social environment will continue to make useless and dangerous our astonishing conquest of the material environment.” Progressive opinion was united behind the idea that science was to be enlisted to reconstruct society along more rational lines.

From the same 2007 intro, potentially of interest now that we’re in Year 3 of a “National Emergency” (see “Notice on the Continuation of the National Emergency Concerning the Coronavirus Disease 2019 (COVID-⁠19) Pandemic” (whitehouse.gov, February 18, 2022))

Another theme, evident perhaps more explicitly in this introduction than in specific passages in Hayek’s own text, but nonetheless very much a part of his underlying motivation in writing the book, is Hayek’s warning concerning the dangers that times of war pose for established civil societies—for it is during such times when hard-won civil liberties are most likely to be all-too-easily given up. Even more troubling, politicians instinctively recognize the seductive power of war. Times of national emergency permit the invocation of a common cause and a common purpose. War enables leaders to ask for sacrifices. It presents an enemy against which all segments of society may unite. This is true of real war, but because of its ability to unify disparate groups, savvy politicians from all parties find it effective to invoke war metaphors in a host of contexts. The war on drugs, the war on poverty, and the war on terror are but three examples from recent times. What makes these examples even more worrisome than true wars is that none has a logical endpoint; each may be invoked forever. Hayek’s message was to be wary of such martial invocations. His specific fear was that, for a war to be fought effectively, the power and size of the state must grow. No matter what rhetoric they employ, politicians and the bureaucracies over which they preside love power, and power is never easily surrendered once the danger, if there ever was one, has passed. Though eternal vigilance is sage advice, surely “wartime” (or when politicians would try to convince us that it is such a time) is when those who value the preservation of individual liberty must be most on guard.

Related:

  • “Governor Newsom Signs Legislation to Eliminate Out-of-Pocket Costs for Abortion Services” (gov.ca.gov, 3/22/2022): “In the face of nationwide attacks on reproductive rights, California has taken action to improve access to reproductive care by removing financial barriers to this essential health care,” said First Partner Jennifer Siebel Newsom. “In the Golden State, we value women and recognize all they shoulder in their dual roles as caregivers and breadwinners. California will continue to lead by example and ensure all women and pregnant people have autonomy over their bodies and the ability to control their own destinies.” SB 245 prohibits health plans and insurers from imposing a co-pay, deductible, or other cost-sharing requirement for abortion and abortion-related services. The legislation also prohibits health plans and insurers from imposing utilization management practices on covered abortion and abortion-related services. California is one of six states that require health insurance plans to cover abortion services, but out-of-pocket costs for patients can exceed a thousand dollars.
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