Texas power outages demonstrate enduring human faith in hindsight?

by philg

Texans are suffering with cold weather, power failure, and water supply failure. (In other words, they’re learning what it is like to live in the Northeast; see, for example, the 2011 storm that took out power for 3.2 million people, many of whom went a week without power. In the Boston suburbs it is typical to lose power 4-6 times per year, e.g., due to a fallen tree or a storm, and for durations of up to 48 hours. Also 2013 and 1978 events, in the latter of which more than 100 people died.)

(That we’re calling this the “Texas power outage” might be an artifact of how our media presents things. “Widespread Power Outages Continue in Texas” is the caption the New York Times editors have placed over a map showing that the worst outages are in Louisiana and Mississippi:

)

The media can find an unlimited number of folks who describe this as a trivially foreseeable event, e.g., “Why Texas’ energy grid is unable to handle the winter storms” (NBC):

The crisis has made the state’s energy grid the focus of fresh scrutiny, primarily due to its independence from the rest of the U.S. Critics say that allowed its infrastructure to shirk federal regulations that require cold-weather capabilities.

Heroic regulators could have prevented this from happening? The governor agrees! “‘Massive failure’: Why are millions of people in Texas still without power?” (USA Today):

At the most basic level, the outages have been caused because demand amid the bitter cold has outpaced the supply of energy used to heat and power homes, said Daniel Cohan, an associate professor of civil and environmental engineering at Rice University.

Gov. Greg Abbott called the situation “unacceptable” and said he would add an emergency item to the state’s legislative session on reforming ERCOT. The nonprofit corporation is subject to oversight from the Public Utility Commission of Texas and the Legislature.

There were similar events in 1989 and 2011… “Five things to know about Texas’s strained electric grid” (The Hill):

The 1989 blackouts came amid a cold snap in December, while the 2011 blackouts took place during the first week of February when wind and unseasonably cold temperatures hit Texas and neighboring New Mexico.

In total, approximately 1.3 million electric customers were out of service at the peak of the 2011 event on Feb. 2, and a total of 4.4 million were affected from Feb. 2 to Feb. 4.

In a report following the 2011 blackouts, FERC and the North American Electric Reliability Corporation recommended steps including increasing winterization measures.

The report said electricity generating companies operating within the ERCOT system “failed to adequately prepare for winter,” citing inadequate insulation and a failure to train operators and maintenance personnel on winter preparations.

If this was easy to foresee (and maybe it should have been, given what happened in 1989 and 2011), why weren’t these newspapers and interview subjects out there at least since 2011 beating the drum for more power plants and more winterization of infrastructure?

Could there be a general principle in operation here? After a hurricane hits, it is obvious that we should have put vastly more resources into being prepared for the hurricane. After a bad respiratory virus pandemic, it is obvious that we should have put vastly more resources into stockpiling PPE and ventilators (see Paper titled “Stockpiling Ventilators for Influenza Pandemics” (2017)).

Here in the Northeast we know that we could eliminate nearly all of our outages via putting power lines underground, but nobody wants to pay for it. This utility explains:

The main reason why undergrounding hasn’t been fully adopted in the U.S. is the overwhelmingly high cost of installing underground power lines. Estimates place the cost of undergrounding power lines at roughly $750 per foot, compared with $70 per foot to install power lines the way we do today. At over ten times the cost, this would become expensive very quickly.

Take North Carolina, for example. In 2002, the state looked into undergrounding for their three major power companies after a particularly bad power outage that left 2 million people losing power. After it was priced out, North Carolina found that their project would cost $41 billion (six times the net value of those three companies’ distribution assets) and would require 25 years to complete!

People are regularly killed during power outages. Should we pay any price, bear any burden to save lives via underground power lines? Apparently not. (Even though $41 billion rounds to zero in coronanomics!)

Why can’t people see that (1) we don’t have infinite money and time and therefore can’t be prepared for everything bad that might happen, and (2) they’re using hindsight when they talk about how we should have put more resources into preparing against something bad that actually did happen?

As of yesterday, 4 percent of total customers (poweroutage.us), but I am pretty sure that this figure will never appear in a headline (since Texas has such a huge population the outage will appear as the total number of customers who are out).

I asked a California Democrat (and tenured physics professor), who was expressing outrage that the Texas grid wasn’t subject to federal regulation, what he thought the number would be, if not 4 percent, if Texas had been federally regulated. He answered “0 percent”. Let’s have a look at Mississippi, which has federal regulation and has suffered from a similar cold snap. 13.5 percent of customers in MS are out as of the same time as the above map:

How about Louisiana?

Across the three states, it looks as though the outages line up with the USDA Zone 8b (Austin, Texas being included in this zone).

In other words, a cold snap in Zone 8b results in power failures whether the grid is regulated by the feds or the state. (The failures were slightly different in character, with Texas knocked out by high demand while MS and LA suffered from both excess demand and power lines downed by the ice and snow. Both could have been avoided, however, with additional $$ invested in preparation.)

Update, Feb 20, 11:00 am: 6 percent of folks in Mississippi are still without power, mostly in Zone 8b and some in Zone 8a.

(Texas, where the outages started earlier, is 99.4% powered (0.6% without power).)

Related:

  • Austin and Lockhart, Texas: 10 barbecue restaurants in 72 hours (fortunately, the smokers will continue to operate without power)
  • “The Texas Freeze: Why the Power Grid Failed” (WSJ) sounds like a great analysis. Companies that generate power aren’t paid to sit on standby, so there is an undersupply of standby power, especially during cold snaps when it would be expensive to prep a plant to keep operating. A big nuclear plant tripped off due to a water supply freeze. The authors attribute the problems to the way Texas set up its market for electric power, e.g., paying only for power delivered and not for being ready. But they never look at why the grid failures were nearly as bad in Louisiana and Mississippi. Maybe this is like coronascience and it is only necessary to tell a good story after data are received?
  • February 2013 North American blizzard (Wikipedia), in which 18 people died, the power failed, and it was both illegal and impractical to travel by road here in Maskachusetts.
  • Northeastern United States blizzard of 1978 (Wikipedia) in which 100 people died.

Very loosely related…

From a 2018 business trip to Dallas, extended due to 50-knot winds in the Northeast and the cancellation of airline flights back home, the George W. Bush Presidential Library (closed for a year now due to coronapanic):

And from the art museum, an unfortunately timely painting, Frederic Edwin Church’s The Icebergs:

Full post, including comments

Life in the suburbs of Austin, Texas right now

by philg

I caught up with a friend in the hills just west of Austin, Texas today. He was spared from the power failures that have made the news, but life at 0 degrees F was not comfortable. “Even with the heat pumps going full blast and the extra resistive heater that is supposed to be used only occasionally, the temperature inside the house still fell to 55 degrees.” Better now that it has warmed up a bit? “The house has come up to 66, but the water system has been shut down. The treatment plants are back online, but there is simply no water in the reservoirs for pressure. It all leaked out when pipes burst.” If the power hadn’t failed, would these pipes still have burst? “I think so. Our neighborhood did not lose power, but neighbors have still reported on the mailing list that they had pipes burst.”

Earliest this week, I suggested the following to a friend who lives in Austin:

Wouldn’t the best stunt be “drive to Monterrey”? 67F and sunny tomorrow there.

I offered this same suggestion to my friend on the phone. It is only a 6-hour drive. Why not follow his senator and go to Mexico? “I can’t leave my neighborhood,” he replied. “Remember that you come up a hill to get to this house and it is still a sheet of ice. They might have one or two salt trucks for the entire city. I said that I would never need AWD now that I’d moved down here.”

T-shirt weather in Austin almost exactly two years ago, February 20, 2019:

(instead of running, I was doing research for Austin and Lockhart, Texas: 10 barbecue restaurants in 72 hours)

Full post, including comments

Did 10 percent inflation happen during 2020 without us noticing?

by philg

One of the miracles of 2020 was that the U.S. government could borrow/print money like crazy in response to coronapanic and yet inflation, as calculated by the U.S. government, did not go up.

But what if inflation did happen and we just didn’t notice because we were locked down and prevented from leaving the U.S.?

Here’s the USD versus the Euro:

A dollar was worth 0.92 euro a year ago. As of February 15, 2021 it is worth 11 percent less, 0.82 euro.

How about versus the yen?

The USD is down from 110 to 105 in yen.

The USD is down against gold and silver. On February 15, 2020 they cost $1583 and $18. On February 15, 2021 it took $1819 to buy the same ounce of gold and $28 to buy the same ounce of silver.

Is it fair to say that we’ve had 10 percent inflation over the last 12 months?

Full post, including comments

Flush toilets in New York City for $60 per hour

by philg

Our mole inside the New York real estate industry told us about a newly available career path: toilet flusher. “The office towers are empty and if you don’t have someone go in and flush toilets and run sinks, you’ll get Legionnaires’ disease. Even when the sinks and toilets are electronically controlled, nobody ever envisioned a time when buildings would be vacant for months or years. So there is no way to program them to run themselves automatically every few days. We’re paying people $60 per hour to go in and flush toilets.”

Why isn’t it $20 per hour? “There’s government funding for this so it has to be prevailing wage,” he replied. “Union wages start at $60 per hour.”

Full post, including comments

Life expectancy scientists never expected a pandemic

by philg

“A Grim Measure of Covid’s Toll: Life Expectancy Drops Sharply in U.S.” (NYT):

American life expectancy fell by one year, to 77.8 years, in the first half of 2020.

Thursday’s data gives the first full picture of the pandemic’s effect on American expected life spans, which dropped to 77.8 years from 78.8 years in 2019. It also showed a deepening of racial and ethnic disparities: Life expectancy of the Black population declined by 2.7 years in the first half of 2020, slicing away 20 years of gains. The life expectancy gap between Black and white Americans, which had been narrowing, is now at six years, the widest it has been since 1998.

“I knew it was going to be large but when I saw those numbers, I was like, ‘Oh my God,’” Elizabeth Arias, the federal researcher who produced the report, said of the racial disparity. Of the drop for the full population, she said, “We haven’t seen a decline of that magnitude in decades.”

The last time a pandemic caused a major decline in life expectancy was 1918, when hundreds of thousands of Americans died from the flu pandemic. Life expectancy declined by a whopping 11.8 years from 1917 to 1918, Dr. Arias said, bringing average life spans down to 39 years.

So… coronavirus was nowhere near as deadly as the last truly bad flu, yet the “scientists” in charge of life expectancy calculations apparently did not budget for even a moderately bad flu pandemic, such as 1957. They assumed that human population could be expanded from 2 billion (1920) to 8 billion (2020) without any virus evolving to take advantage of this expansion in hosts (and the hosts clustering themselves together in cities). They assumed this against a continuous stream of publications from the WHO and others that a pandemic was likely. (See Paper titled “Stockpiling Ventilators for Influenza Pandemics” for example; also Pandemic Influenza Preparedness And Response (WHO, 2009, which incidentally tells governments to do the opposite of what governments have done in response to COVID-19: don’t close borders unless you’re an island and don’t tell the general public to wear masks))

Is it possible to make these scientific conclusions, one about life expectancy and one about the likelihood of future respiratory virus pandemics, consistent somehow?

Full post, including comments

Medical School 2020, Year 3, Week 8 (Pediatrics)

by philg

Second week of outpatient pediatrics. My job for 80 percent of the visits is to differentiate between viral and bacterial upper respiratory infections (“URIs”). I take the history and physical for each cold and respond to questions about medication dosing. Then it is time to present the patient for two minutes while the attending fills out a SmartText in the clinic’s Epic system. Mother Mabel: “Once we realize you know how to conduct a basic exam, we want to see if you can parse the relevant findings from the ordinary.”

We see an 5-year-old who has red macules and patches all over her body. She’s not scratching and doesn’t even notice them. The rash started on her leg, and spread over her entire body. I have no idea what the rash is because it does not fit the standard viral exanthems (rashes) of childhood that we learned in medical school. As I am describing the case to Mother Mabel, she starts smiling. “I know exactly what this is.” Pityriasis Rosea. We tell the patient there is nothing to do but wait. “We believe it is caused by the immune system’s reaction to various viruses.”

We see a 13-year-old patient with Addison’s disease for a URI and dizziness. She and her mother knew a huge amount about managing her disease, including about the need to take extra stress dosing. Addison’s disease is an autoimmune attack destroying the adrenal glands. Without any cortisol, the body can become hypoglycemic in times of stress. During an infection, the patient is instructed to take an additional “stress” dose over her daily hydrocortisone level.

Mabel also gets excited by this one. We check her blood glucose to rule out hypoglycemia and prescribe antibiotics for a sinus infection: high dose amoxicillin. I talk to Busy Belle, the patient’s regular pediatrician, about management of Addison’s disease such as stress dosing and risk of other endocrine gland destruction. “I’m not sure, my N is 1.” Last year, Busy Belle saw the patient at the office in hypoglycemic shock. Her blood sugar was in the 30s, blood pressure was 80/35. She gave her some pedialyte solution and sent her to the hospital in an ambulance where she was diagnosed with Addison’s disease. Her most recent labs in the chart show a slightly elevated TSH (thyroid stimulating hormone) at her last visit with the pediatric endocrinologist, with whom she has an appointment next week. It seems that all the exciting management is done by the specialist.

A similar experience occurred on Wednesday with Mercedes Mike. He has accumulated several patients with congenital heart defects. I see an adorable 4-year-old with hypoplastic left heart syndrome who came down with the sniffles. The mother brought her in to ensure she didn’t need immediate intervention. Her oxygen saturations were fine, so we sent her home until her F/U (“follow up”) with the cardiologist in a week. We talked afterwards about the various surgical management of hypoplastic left heart syndrome. Once again, all the interesting management, e.g., echocardiograms, CT surgery referrals, EKG evaluation, etc., is performed by the specialist.

Patterns emerge around risk factors by age group. Every girl with a chief complaint of back pain is going to be either a dancer or cheerleader. An 8-year-old who presented for a typical URI tells us that she dances competitively five days a week. I asked if she has back pain. The mother lights up: “Oh yes, tell him honey.” The expected five minute visit, turns into a complicated 20 minute neurological exam. Afterwards, Mercedes Mike asks: “What’s the elephant in the room you have to rule out in these patients?” I don’t know. I look it up and get back to him. Spondylolisthesis, where one vertebra slips forward from the one below. This can cause serious spinal cord injury if not treated.

My next patient stumbled and hit her head on the gym floor during cheer practice. My presentation: “A CT is not indicated. She has a benign neurological exam, no LOC [loss of consciousness], and only mild headaches. My assessment is she has a mild concussion from the fall and should return to practice only after she feels comfortable at school for a few days.” He responds: “I agree with you, but it’s better to not use your gut when there are evidence-based protocols. Look up the indications for a CT scan.” After 10 minutes of googling I find the PECARN (Pediatric Head/Injuries Trauma Algorithm) guidelines and summarize: “As long as there is not prolonged LOC, signs of basilar skull fracture and no altered mental status, it is unlikely to have a significant TBI requiring further intervention.” Mike responds, “Yep, look above your screen.” Taped to the wall above the nurse’s station is the algorithm figure from the original PECARN paper. According to the these guidelines, there is less than a one percent chance of a clinically-important TBI as long as there are no signs of LOC > 5s, Glascow Coma Score < 14 (GCS, standard metric to assess neurological status) or palpable non-frontal skull fracture. Mercedes Mike: “I’m a new attending, so if I were talking with a more experienced doctor about a patient with suspected TBI, I would definitely mention PECARN just so they know that I am familiar with the guidelines. As a new attending, you need to build trust with other doctors.”

[Later, to Jane: “If we ever have kids, they are not doing dance or cheer.”]

A middle-class white 16-year-old girl is next. Mom wants to increase her ADHD medication dose because of bad behavior at home. Instead of acquiescing, Mercedes Mike asked, “Why are you poorly behaved at home?” Teenager mumbles: “I just get mad when my mom and sister ask me to repeat myself.” Mike: “Well neither of you are perfect, but she’s in charge right now until you pay the bills. So try not to mumble” Teen: “I’m going to be working at Taco Bell soon.” Mike: “You’re not paying the bills yet.” Decision: no change in meds.

[Busy Belle suggests skepticism regarding schools’ recommendations for ADHD evaluation. “We always get teacher and coach evaluations as well as a parent evaluation of each kid. The symptoms need to be occurring in at least two different environments. I started to notice a lot of kids at one school were being recommended for ADHD medication. It turned out that the evaluations were the exact same letter with the names substituted. Boy, did they regret that. I contacted the county superintendent and the principal’s secretary was fired with a stern warning to the principal.” (Editor: the stern warning to the bureaucrat was softened only by a monthly paycheck, lifetime health insurance, and lifetime pension.)]

Outpatient pediatrics is helpful for understanding why diagnoses take a long time. A common reason for patients to come in is non-specific abdominal pain without any diarrhea, constipation, or vomiting. It’s not reasonable to get a full work up (CT, CBC, CMP, inflammatory markers) for a one-week history of GI pain. Patients arrive with only a vague story of off-and-on symptoms rather than a precise timeline. One of our common responses is handing out a symptom diary. Mother Mabel: “As a new attending I keep a slightly closer eye on my patients. Instead of telling them to come back in a month with a symptom diary, I’ll have them come back in two weeks for a follow up visit.”

The best part so far is playing with the adorable 4-8 month olds. However, most of what a pediatrician does is educate parents or tell students to get their act together and listen to mom (our typical patient lives primarily with a “single mom” and is well-behaved every other weekend with dad, but out of control in the mom’s house). Should seven years of training be required for this? A successful parent of four could do most of this job. A pediatrician is involved in the “interesting” kids only to manage common illnesses that pop up in between their visits to specialists.

Mike delivers a mid-clinic eval. “You’re doing fine. Use a template when you interview patients to not forget anything, but overall good job.”

Jane on pediatric hematology/oncology, an elective rotation, and has been bored because one of the hematologists is on vacation. Jane’s typical day: arrives at 8:30 am, her first two patients are (Medicaid) no-shows so her attending fills out paperwork in the office. She sits around waiting until her lecture at 12:30 for a journal club on the use of antibiotics and reflux medications in childhood leading to allergies. She waits all day to see two patients at 3 and 4:30 pm. She returns home: “I wanted to strangle a 7 year old today.” Strangle a kid with cancer? “He wouldn’t shut up, and he was in remission.” 

Statistics for the week… Study: 8 hours. Sleep: 8 hours/night; Fun: 1 night. Meet classmates downtown for happy hour margaritas. Pinterest Penelope, also in pediatrics but in a different clinic: :”What I hate about third year so far is that you cannot plan anything. I rescheduled my own doctor’s appointment today so that I could be there for all the patients. The last two were no-shows. It’s just so much waiting, yet no free time.” (Penelope’s clinic serves an all-Medicaid population and there are no charges for failing to show up.)

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

Full post, including comments

Wealth migration from New York measured by K-1s

by philg

A friend of a friend runs a real estate business in Manhattan: “We have 18 limited partners,” he said. “Ten years ago, we mailed 18 K-1s to New York addresses. This year it was 0.” Where did the rich limiteds migrate to? “Two went overseas, one to Switzerland. Most of the rest went to states with no income tax. Florida, South Dakota.”

Full post, including comments

Clubhouse is a greenfield for whitesplaining

by philg

In the department of what’s old is new and what’s new is old, I’ve used Clubhouse a bit more. It is hard to explain how it is different from old-school talk radio other than not being limited by spectrum and therefore able to handle an infinite number of channels. However, the same could be said about Zello, an app from 2007 that supports public channels. Clubhouse has a Follow button so it is easy to get into the same channel as your friends. Maybe Zello never had that?

Here’s a conversation that I couldn’t resist joining (as an audience member), “Black Voices for Trump 2024”:

It was fascinating to hear how a substantial sized group of Black Americans process the messages being sent to them by the white elites with BLM signs on their lawns.

Some excerpts:

  • “If you’re Black in America and put your mind to it, you can be whatever you want to be.”
  • On how she talks to Black Democrat friends: “If Trump were impeached, how would it help your community?”
  • “Biden has been issuing executive orders at a furious rate. What has he done for the Black community?”
  • “Why are they trying to feminize all our men?”
  • “Once all of the illegal immigrants are naturalized, the Democrats will never talk to us again. We will be behind Hispanics and Asians and won’t be relevant.”
  • “Biden is cut from the same cloth as Strom Thurmond. Why would you vote for someone like that?”
  • “Obama set off five proxy wars in Africa”
  • “I’m finishing a PhD on the War on Drugs.”
  • To a white participant: “You will never know what it’s like to be Black and I will never know what it’s like to be white. We just have to find common ground.”
  • Woman: “I tell my white friends not to apologize to me for white supremacy because that makes me feel that they’re saying they are superior to me. I grew up in Alabama and my father had a third rate education, but he was able to raise us without my mother having to work and we never felt that there was something we couldn’t do.”
  • Woman from Texas: Trump stopped the revolving door of illegal immigrants who would get deported and come back a few days later. Despite this, the Black neighborhoods of Texas continue to be wiped out via population replacement with Hispanic migrants.

I posted these in real time to a Facebook post. In an aside, I noted “I am waiting for a platoon of white Democrats from San Francisco to set these folks straight regarding the proper way to be Black!” Right on cue…

  • White-looking guy named Arjun: “I’m a multi-Ethnic person.” [But if you saw his profile photo you would likely say that he is white.] He thanks the group for their respect and humanity. Says he comes from a different place politically. Disproves the idea that white liberals offer Blacks empty words by speaking for about 2 minutes and saying nothing.

A bit later….

  • Arjun is back. Talking about working at a farmer’s market in the Tenderloin and “genuinely perplexed” by the fact that only 10% of the customers at this farmer’s market are Black. “A true travesty”. He posits that maybe Black people don’t know how to cook.

(Arjun was right about one thing: when Trump haters showed up they were heard out in full, not interrupted, and responded to respectfully.)

The meeting continues…

  • 35-year-old:: “I didn’t vote for Trump in 2016. Everything Trump was doing once in office was creating opportunity for me. So I voted for him in 2020.”
  • Guy who went door to door in a white liberal neighborhood recounts all of the whites that told him that he shouldn’t be supporting Trump because he was Black. “Do you really need to know what Joe Biden’s policies are to vote Donald Trump out?” asked a white say-gooder. “Yes, ma’am, that’s what politics is about.”
  • “White women are getting all of the contracts, jobs, and minority preferences set aside for Black people to make up for Jim Crow.” (Nobody chimes in to point out how difficult it is to be a white woman in North America.)
  • LBJ’s welfare policies were a Trojan Horse because the welfare system’s incentives destroyed the two-parent Black family. We were rats in an experiment for the white liberals of the 1960s.
  • “Didn’t nobody rob my mom’s liquor store in the ‘hood because she had a cross around her neck and her right hand on a Glock.” (What would Mom think about Uncle Joe’s latest call for commonsense gun control?)

Arjun can’t be in every room 24/7, so I think that means Clubhouse needs (nay, demands) an army of well-meaning white folks who can explain to these conservatives why they ain’t Black.

(Separately, one aspect of the room that was interesting was how much better informed and thoughtful regarding policy these folks were than my friends who are in the credentialed elite (tenured professors, management consultants, etc.). Where the credentialed elite expresses hatred for Trump either for personal reasons or because Trump does not give the credentialed elite sufficient respect, the Black conservatives were interested in the Trump administration’s policies, not in the personality of Trump-the-person.)

Related:

  • First impressions of Clubhouse?
  • Interview excerpts with Denzel Washington, who is in sync to some extent with the above folks.
  • A Massachusetts Democrat on hearing about the above room: “Reminds me of the old (old) joke: The Massachusetts republican party will be meeting in the phone booth at the corner of Tremont and Clarendon this afternoon at 3 sharp.” When I told that there are 2,300 followers of the Black Conservatives club on Clubhouse, that hundreds were connected to the discussion for the 2+ hours that I listened, and that dozens spoke… “Ok, I wish them all well. I suppose it challenges the idea that blacks (et al) all think in one stereotypical way.” (who had this all-think-same “idea” other than him?)
Full post, including comments

Medical School 2020, Year 3, Week 7 (Pediatrics)

by philg

Work starts at 8:00 am at an outpatient pediatric clinic that is a one-hour drive from the hospital. I’m the only student in the clinic. I meet the three attendings, one advanced care provider (“ACP,” typically a PA or NP), and lactation consultant) before the first scheduled office visits at 8:30 am. Two of the attendings are hot off the press, having finished their residencies a year ago. Momma Mabel had a baby in December and is back after three months off [Editor: fully paid thanks to the extra work put in by the childless.]. Her husband is a stay-at-home dad who brings the baby in during lunch. Mercedes Mike, the other new attending who drives a new SLC Roadster, and Busy Belle, a divorced pediatrician in her 50s who is booked weeks out except for two unscheduled daily sick slots. 

They have fifteen 15-minute well-child-checks (“WCC”) scheduled each day, thirteen 10-minute scheduled sick visits, and two open 10-minute sick-visit slots at the end of the day. A complicated patient, e.g., chronic headache, may be allocated two 10-minute slots. Five minutes out of the 15 are allotted for rooming. The nurse will get vitals while the physician writes up notes from the previous encounter. The physician then has either 5 or 10 minutes to see the patient without falling behind. I go in with Mabel for a 4-month-old WCC. Mabel invites me to listen to the patient’s heart and I hear an early systolic murmur. When I tell Mabel about that, after the encounter, she says “Yep, good job. That’s called a Still’s murmur. It classically is described as having a musical quality. I didn’t tell the parents because it is a benign murmur of childhood.” Mabel pumps during the one-hour lunch break as I head over to the other side of the office for lunch with Busy Belle.

Belle explains the different pay structures for primary care. Some health systems use a flat salary. “You are required to see a minimum number of patients.” Many health systems are transitioning to a relative value unit (RVU) reimbursement structure. Mercedes Mike stops by and adds: “I  considered working for another system that is completely based on RVUs. I’d get paid more per patient, but if I decided to go on vacation for two, I would get nothing. I felt this was a little nerve-wracking for me just starting out with a young family.” Another factor emerging is scorecard evaluation. “We get evaluated based upon peer performance across selected metrics, e.g., smoking cessation, weight loss.”

I shadow Belle for the remainder of the day and we’re done with patients at 4:30 and out the door at 5.

Tuesday I graduate from mere shadowing and begin to interview patients alone prior to the attending coming in. My first  interview is with the mother of a 2-year-old presenting for a two-day history of sore throat, fever, and runny nose.The kid just started daycare, and the parents took an ear temperature at 100 degrees, which means she’s technically afebrile because fever starts at 100.4. I complete a physical exam before presenting the findings to Mabel while she fills out an Epic SmartText template. Students are allowed to write notes for surgery, but not for pediatrics due to concerns about insurance reimbursement. We then both go into the room. Either I got the history wrong or the mother has changed her story. The sore throat began three days ago, not two and nasal saline rinse has been used, contradicting my report of no medications. Afterwards, Mabel completes her own physical. We send them home and recommend symptomatic management with Tylenol and ibuprofen if needed.

Our next four patients come in with sniffles or sore throat. I can’t find signs of bacterial infection. “What is your assessment?” asks Mabel.  “She has a viral pharyngitis that can be managed symptomatically. Let’s tell them to keep hydrated and make sure there are 3 or 4 wet diapers per day. Return in case of fever.” In the afternoon, I see a 6-month-old with conjunctivitis, bilateral otitis media, and pharyngitis caused by a suspected adenovirus infection. Mabel: “Notice the difference? Treatment is symptomatic, but these kids can get really sick. Tell me the serious complications of adenovirus?” She goes into the next patient while I look at UpToDate. I report that the main complication of adenovirus is pneumonia. Fifteen percent of childhood pneumonias are caused by adenovirus and myocarditis (a rare heart infection) is usually caused by certain strains of adenovirus. Finally, I report an outbreak of serotype 7 that caused a serious outbreak in 2014 with 136 (69 percent) of 198 persons with adenovirus-positive respiratory tract specimens were hospitalized, out of which 18 percent required mechanical ventilation, and 5 patients died (“Human Adenovirus Associated with Severe Respiratory Infection, Oregon, USA, 2013-2014”, Emerg Infect Dis. 2016)

After I finish a 17 year-old WCC and sports physical, my attending grabs me to come take a listen to 9-month-old twins with bronchiolitis. “Could my medical student listen?” she asks the parents. These are the sickest patients I’ve seen today and show classic signs of adenovirus: conjunctivitis, runny nose, cough and pharyngitis. I listen to their lungs and hear inspiratory crackles with an expiratory wheeze. There are no signs of dehydration, such as lack of tears while crying, poor capillary refill, poor urine output. They are not in respiratory distress, e.g., nose flaring, intercostal retractions, abdominal muscle use. We sent the family home with instructions regarding what would merit a follow-up visit.

I’m learning that most of a pediatrician’s job is educating parents on the basics: when to brush teeth, how often to breastfeed, what car seat should the child be in, how much should the baby drink, when to stop using the bottle. The format of a well child check is standardized for each age. Despite the hundreds of millions of dollars spent to install Epic, it doesn’t default to the practice’s preferred form for, e.g., a 10-year-old, when a 10-year-old patient is being seen. The efficient physician populates a custom-made SmartText for a 10 year old, and then fills out certain milestones that were filled out by the parents on paper.

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: best friend from college visits this weekend. He is an M3 at a different school who has already been on rotations for six months: “Third year sucks. Physicians claim that they remember third year as the best. Bullshit. It is mostly waiting around doing nothing, and yet you have no free time.” He adds: “Scary to think this is all the training we have in some areas. For example, if you don’t want to be a surgeon, you will be a practicing physician with only a few weeks of surgery experience. It wouldn’t surprise me if some physicians don’t even know how to start an IV anymore.” He is looking forward to psychiatry: “You talk to each patient for 30 minutes, chart a note during the interview. Pay for psychiatrists grew 15 percent last year. If this continues for 5 years, a psychiatrist will get paid as much as an orthopedist and get out every day at 2:00 pm.”

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

Full post, including comments

Shutdown favors bigger enterprises: car registration example

by philg

Here in Maskachusetts, our year-old state of emergency means that the Registry of Motor Vehicles (RMV) will see people in person only by appointment. Appointments are seldom available, however, and typically a Boston-area resident who needs to do business with the RMV will have to drive to Pittsfield, Massachusetts, more than 5 hours round trip.

While swapping our 2018 Honda Odyssey for a 2021 Honda Odyssey, the salesman told us about his recent trip to Pittsfield. He had purchased a car privately and there was no way to register it without an in-person trip. “Why don’t we have to go to Pittsfield to register this new Odyssey?” we asked. “Dealers are able to do everything online,” he explained.

Full post, including comments