On the heels of the recent announcement that the NIH will increase post-doc salaries, an article suggested that the proposed increase doesn’t go far enough. Leading the charge was a scientist in Boston who has been a post-doc for seven years. Maybe I was a bit of a troll for sending that Dr. Isis’s way. Seven years is too long for a post-doc, she posted, a post-doc should be no more than four years and a few people on line lost their minds at this suggestion. No way! Everyone is an individual! Different fields demand more time! Science doesn’t work on a schedule! You’re making our shakras come unaligned! Came the retorts. (I may have made that last one up.) Differences of opinion between intelligent people are fascinating, and I enjoy contemplating the roots of a disagreement. I don’t pretend to know the right answer, but I noticed a parallel with something apparently unrelated and I love making weird connections:
Extending your post-doc past four years is like going into debt. And I believe debt is a bad thing. “The borrower is the slave to the lender.”There is a fundamental disagreement amongst us about whether a post-doc is an employee and deserves a stable fair wage to send their kids to summer camp and have a nice place to live in a nice neighborhood with all the other fancy people. Or is it slavery*? I respect my post-docs tremendously and their professional and personal success is important to me. But they are more like slaves than employees. They are not paid enough for the work they do and that is as it should be because they a) receive training; and b) should be motivated to conclude their post-doc as soon as possible. We have staff scientist and technician positions that are straight-up get paid for the work of science, but a post-doctoral fellowship is not that.
Sure, some people spend 7 years and do just great. So do some people take on debt and pay it off without problems. But the hard nosed anti-debt philosophy is justified because the vast majority of people are victims while they are being swindled into believing they are the beneficiaries. Post-docs, like debtors, are victims in subtle ways like lost opportunities and a failure to build wealth. But more concretely, what post-docs are not facing hard enough is the reality of risk. Optimism is essential in science and in life and it’s difficult to put my own optimism on hold and contemplate the reality that things don’t always go as planned. Just like Dave Ramsey counsels “gazelle intensity” to get out of debt as fast as possible, post-docs should not get comfortable or chart an extended course, but should focus on getting their work done as soon as possible, like they were in a burning building. Because they are. There is the very real risk that the paper won’t work out, or the PI’s grant gets cut, or the imagined job opportunity won’t materialize, and this risk is real. Having debt assumes a rosey future path, that life will continue on without major interruption, but in the event of a crisis, the bank will be fine, but debtor is screwed. As a PI, I’m going to be fine. The primary job of the post-doc, for their own good, is to find a permanent job.
PS. The four years limit is of course arbitrary, but the number works because it is within the working span of many grants. A post-doc fellowship that extends beyond the scope of a single grant is also indirectly a violation of a promise to the granting organization.
* Addendum: Friends on line have expressed dismay and offense at the use of slavery in any way shape or form here. I know the missing and critical ingredient that differentiates slavery is consent. I agree wholeheartedly that post-docs are not slaves and it’s offensive to suggest that.
Saying that I should call post-docs “underpaid employees”or “exploited workers,” misses my point though, which was that it is not helpful to suggest we need a fix so post-docs can be contented workers. Post-docs are intentionally and consensually exploited workers and the fix is to wrap things up and get out ASAP.
For the past six months, I’ve been on a David Ramsey and @drisis-inspired mission to rid myself of debt. My grandmother instilled in me her Depression-era distrust of debt, but I lived in a way that forgave and demanded borrowing for years. I was told that her lessons were old-fashioned and tried to ignore the pains in my gut and the sleepless nights that debt gave me. In vain. I felt dread and a constant feeling of limitation imposed by what I owed. Sweet Sweet Dave, as we call him, gave me permission to pay off my debt with missionary zeal, and at the end of this month, I will have paid off all my debts (except my mortgage). It feels amazing, like lead weights being lifted off me. More than that, like a hot poker being removed from my guts. It’s been a philosophical journey too, more than I would have expected. Ramsey was right. My family thinks I’m weird (and that’s being charitable). Rejecting the majority culture’s ends justifies the means view on debt has been challenging for a few of my relationships and better for others, but it feels very right.
The debt-free journey has also made me think differently about Obamacare. I watched the Democratic debate last night and was stunned by the disconnect between Hillary Clinton and Bernie Sanders on healthcare. Martin O’Malley is too level-headed to have any chance in this carnival of a race. Michael Cannon is the exception to the rule that intelligent libertarian is an oxymoron, and to my chagrin found myself agreeing with him:
Clinton came out as the voice of “Obamacare is a good start, let’s keep going,” while Sanders, the unapologetic socialist pitched his just-announced, multi-$ trillion with a T “Medicare for all” plan. Sanders’s goal is to get private insurance out of healthcare (while claiming to support Obamacare, an insurance regulatory framework, proving that even socialists can be slippery). Others have written about the economics of his proposal: I applaud Sanders for being realistic about the costs and that taxes would be required (h/t @mikethemadbiol) to pay for his plan. Conservative gun-for-hire Avik Roy estimates that Berniecare would increase federal spending $28 trillion using Sanders’s own estimates.
Yes, government-sponsored, universal healthcare, like the rest of the industrialized world has embraced, is a good idea, but one without the support of the majority of Americans. And opponents of single payer have a point. Americans don’t have the stomach for European-style limits on healthcare, so universal healthcare in the US would be stupendously expensive. Add to that the opposition of goliath capitalist interests, the insurance and pharmaceutical industries, and you are a few miles away from a feasible proposal. Americans’ worship of freedom, love of capitalism and distain for European socialism are the reasons we wound up with the hybrid conservative approach of Obamacare. Frankly, as a transplant from the East-Coast to the Midwest, Democrats giving life to the stereotype that “we know what’s best for you because we’re smarter and are going to ram it down your throat” makes me a bit ill.
Half of America thinks Obamacare doesn’t go nearly far enough, and and the other half thinks it goes way too far. That, plus the fact that there is no real Plan B, makes me conclude that this may be as good as it gets. The system is messy and imperfect and there’s no end in sight for the arguments over it.
To get the most out of our current healthcare system, it helps if you understand that it is fundamentally a conservative system. Ramsey’s advice on personal responsibility are a good approach to fixing healthcare. If you want Obamacare to work for you, you need to follow three steps:
- Have an emergency fund. Ramsey suggests 3-6 months of living expenses, and it should be modified to cover your medical deductible. Healthcare is expensive and Obamacare doesn’t fix that. Having healthcare insurance will shield you from having to sell your house or go bankrupt to pay for healthcare, but to keep your monthly premiums under control, you will be responsible for unavoidably hefty deductibles when you use the system.
- Do everything you can to avoid touching your emergency fund. Subsidies are available for many and preventative care services are free. Do your research. Getting sick is expensive. Diet, exercise, no smoking..boring but good investments.
- If you have to spend your emergency fund on healthcare, haggle. It may seem strange suggesting that you treat the healthcare system of the most prosperous nation on earth like a bazaar, but here we are.
Navigating the healthcare system, finding out how much healthcare services cost, and what procedures and medicines are “needed” is a major challenge. The idea of consumer-driven healthcare is not without its critics, but the current trends in medicine, including consumerism, is occurring with or without Obamacare. If enough of us can be prepared to pay deductibles and can be engaged in making cost-benefit decisions in healthcare, our medical system will be transformed. Time will tell about that. Staying out of debt and having an emergency fund is the best strategy you can take no matter what. Politicians want to tell you that voting for them means you won’t have to work so hard for things you “deserve.” Free “puppies and rainbows.” Don’t believe them.
For all my kids’ lives, I’ve sheltered them and tried to give them things that I never had. Getting out of debt (or staying out) and putting aside an emergency fund required hard work and sacrifice. Period. But I’m happier now and more peaceful than I have been in a long time. I hope they see that.
I’ve been tweeting lately about Theranos, a privately held lab testing company, and the troubles it’s been having after an expose came out in the Wall Street journal. When I first heard about Theranos and its superstar CEO Elizabeth Holmes, it bothered me that there was a gap between the over-the-moon accolades they were receiving and my ability to find out details about how the technology behind company was supposed to work. Will Theranos revolutionize medicine, or is it the Emperor’s New Lab Testing Company? I’ve become obsessed with the saga. I won’t do a detailed analysis of the company here, but will explain why the mixture of medical science, showmanship and journalism got under my skin.
Elizabeth Holmes founded Theranos after dropping out of Stanford at the age of 19, and it has made her the youngest self-made female billionaire in the world. At Stanford, she was mentored by the legendary chemical engineer Channing Robertson. Dr. Robertson has a number of claims to fame, including bringing Big Tobacco to its knees. Robertson noted that tobacco companies were the largest consumers of ammonia, and he deduced and demonstrated to the courts that the reason was to increase the pH of the tobacco in cigarettes causing more rapid cellular uptake of nicotine when inhaled. Robertson’s expert testimony demonstrated that tobacco companies intentionally increased the addictiveness of their products, and it cost the four major companies billions of dollars and restricted their activities in the largest class action settlement of its kind. Bravo Channing Robertson! When Holmes approached Professor Robertson with her start up idea, at first he tried to convince her to complete her degree, but then supported her decision to drop out when he realized that he could be looking at the next Steve Jobs– high praise from a high place indeed. There is little doubt that Ms. Holmes is brilliant and there is still a part of me that wants to see her rise triumphant from the specter of suspicion that has arisen recently.
We all admire genius. So…what is her billion dollar idea? To collect tiny amounts of blood from a finger stick rather than traditional phlebotomy and running hundreds of tests using a few drops of blood in “nanotainer” tubes. Thernos technology, it is claimed, will change the face of medicine as we know it because it can be employed not just in the doctor’s office, but anywhere. At Walgreens or the grocery store for example. And for a fraction of the price of standard laboratory tests. And not just by doctors, patients can check their own labs! Bam. Industry upended. How exactly would Theranos run many tests on tiny amounts of blood quickly and accurately? Holmes’ answer was, essentially, “we could tell you, but then we’d have to kill you.” Venture capitalists in Silicon Valley and then the business press ate this stuff up. “Of course..*secret* technology is exactly what’s needed to transform healthcare!” But science geeks and transparency geeks were bothered by the secrecy– no peer reviewed publications, no public demonstrations of any kind. I was born and raised in New York City and my bullshit meter is always set to 11. I couldn’t find any information to convince me that the entire enterprise wasn’t a sham. A colleague recently told me one of his trainees went to work for Theranos on the technical side for a time, and left the company with no idea of how it was supposed to work. It didn’t help that Holmes responded to criticisms by adamantly attributing critical questioning to a lab testing industry conspiracy. Conscientious business reporters continue to give Holmes the benefit of the doubt, but have strongly suggested that she needs to stop bobbing and weaving in response to questions and start revealing. I have a sinking feeling that this has been a con.
What does this have to do with grants? I admire Holmes’ ability to convince people of the brilliance of her ideas–it’s exactly the skill needed to write a good grant. Significance 1, innovation 1. Once upon a time, I assumed that excellent work would transcend the need for clever marketing and charismatic presentation to sell it to the proper audience, but the longer I work in science, the more I see examples of necessary hard work labeled as incremental and dismissed and attention lavished on the well constructed story. The veracity of which appears secondary, or is assumed. I no longer think scientists have a special ability to see past hype and pressures for time make it difficult to tell the difference between working productively and spinning the zeitgeist, but I don’t think this is the case.
Don’t worry about people stealing an idea. If it’s original, you will have to ram it down their throats. – Howard Aiken
In communicating about science we say, “it’s important to tell a story,” and Elizabeth Holmes has demonstrated the power of a story unmoored from underlying reality. As Americans, we love the maverick genius who comes from nowhere to upend a field or industry, and there is desperation in our society obsessed with growth and paradigm shifts to see this narrative fulfilled. But someone should have actually changed the world before getting credit for doing so.
This story would not get under my skin if science funding were not a zero sum game, but it is. It angers me to see hard working scientists be denied money and resources because they aren’t flashy or charismatic enough to spin a fantastical tale. Holmes has some time and millions of dollars to make some magic happen. Not everyone is so lucky.
The University of Missouri (Mizzou) just gave its graduate students one hell of a surprise quiz: go find your own health insurance, we’re done helping. This broadside reduction in benefits left hundreds of students without healthcare insurance and was swiftly billed as another “outrageous” effect of Obamacare. The university acted as the victim of a surprise attack by the IRS.
One strategy the students came up with dismayed me: to petition the IRS to amend it’s rule. This strategy lets Mizzou off the hook for its negligent lack of planning and more importantly will very likely fail. The students have swallowed Mizzou’s lie that this IRS rule was a surprise that they could not avoid.
Here’s why: the writing was on the wall for Mizzou long before July 1. The lay business press was aware of this issue, and the Department of Labor was crystal clear that reimbursements like Mizzou provided were in violation of the ACA and would be severely penalized. From the Department of Labor’s web site November 6, 2014:
Q1: My employer offers employees cash to reimburse the purchase of an individual market policy. Does this arrangement comply with the market reforms?
No. [it goes on the explain in detail]
I strongly suspect that the Mizzou administration fervently believed the sturm und drang of the King v Burwell case would cripple Obamacare and somehow rescue them from this provision of the act. From the chancellor:
Why did you wait until the last minute to tell us?
We became aware of this issue on July 21, 2015. We hoped the national groups lobbying on our behalf would motivate the IRS to issue an alternate ruling or exception for graduate employees. At the same time, we were working very hard to create an alternative plan to ensure all current and new eligible student employees would have additional resources at the start of the year for such additional expenses. We knew we absolutely had to have this in place by Aug. 15. [emphasis added]
Mizzou was most certainly aware of this issue prior to July 21, 2015. What they mean perhaps is that in July their lawyers told them that wishful thinking was no longer going to help and compliance with the law was unavoidable.
A petition to the IRS will likely not work because the rule is not an accident of some kind or an unintended consequence of Obamacare. The IRS is deliberately putting an end to the practice of employer subsidies. Why? The Congressional Budget Office explains, “The favorable tax treatment of employment-based health insurance is the largest single tax expenditure by the federal government.” And secondly, “..the open-ended nature of the tax exclusions has increased health care spending..”
Some students have expressed confusion. What is Obamacare demanding of them and their university? It’s confusing because Obamacare is not dictating one solution, it’s forcing a decision. The university can decide to save money and let students fend for themselves or they can step up and provide health insurance for their employees. But reaping the benefits of the old tax structure is no longer an option.
Mizzou has the chance to step up and pay graduate students a wage that allows them to buy insurance on the exchange, or they can provide healthcare coverage outright, or they can throw the students out into the street. Frankly, the best option would be to throw the students out in the street…but only if the stone age Missouri legislature can be convinced to expand Medicaid. The Obamacare plan in this situation was to provide a broad net via Medicaid expansion for people like graduate students unable to afford health insurance. This would be much cheaper for Mizzou because some students are still eligible to be on their parent’s insurance and there would be no penalty at all for the university not to provide them insurance. But MO has adamantly refused the Medicaid deal, and so the graduate students are screwed.
I support the students planned walk out to protest the administration, as does some MU faculty. The law makers in Jefferson City have been spending their time recently worrying about what their interns are wearing, and they could certainly help students here if they wanted to. There are millions of federal dollars available to solve the students’ healthcare problem if the MO legislature would allow Medicaid expansion. I’d like encourage the students to view this debacle as a team screw up between the University and Missouri lawmakers and keep protesting until they are satisfied that Mizzou is a good place to learn and work.
Additional link: The Chronicle of Higher Education published a good piece on this situation here.
Ron Germain’s “people not projects” solution to fix the NIH funding scheme has been praised, apparently by people I don’t know, and roundly criticized by my friends and colleagues on line. In my med school applications, I wrote that having been an East Asian Studies major, I had the experience of having my world-view challenged and that this might be useful in science and medicine. It’s clear to me that the current reformers (let’s throw in ASBMB President Steve McKnight’s latest essay about how the NIH peer review process works) are working under some different cultural assumptions about how science works, as Physioprof has noted and I’d like to extend on that point. I’d go further and say that as brilliant as Germain and McKnight may be, their approach to science policy is flawed because they apparently do not understand the theory of natural selection.
Herbert Spencer’s phrase “survival of the fittest,” used by Darwin has promulgated the view that evolution proceeds when an individual survives because it is “better.” Evolutionary biologists dislike the phrase because it fails to encompass the diversity of reproductive strategies, but “survival of the fittest” has also shackled our understanding by putting too great an emphasis on the individual. I am a physician and cancer researcher, not an evolutionary biologist, and my understanding of this topic is rudimentary, but I think a lot about cancer cell growth as a Darwinian process, and it would be better if the phrase were “survival of the best fit.” For decades, cancer researchers have been trying to understand “the cancer cell,” and we certainly have learned volumes of molecular and cellular biology. Yet we remain baffled. In the case of the cancer I study, multiple myeloma, we have analyzed cancer cells with all available technologies including whole genome sequencing, and yet we are unable explain how these cells are different from pre-malignant versions that fail to grow and do not kill patients. Many of us feel the answer to how myeloma cells grow rests just as much in the environment around the tumor cells as in the cancer cell itself. The individual is not determinative, the environment plays a central role.
With that in mind, it becomes clear why the fixation that Germain and McKnight share of finding “the best” scientists is misguided. It fails to take into consideration that the “fittest” scientists are those that have been fortunate enough to find a suitable environment. It also fails to consider how terrifying it is for non-traditional scientists to be judged by their CVs alone. I know many outstanding scientists that have leveraged their stable upbringings and supportive environments to achieve great success. Germain’s own description of his career is one where his brilliance was recognized early and he was ushered into the club where he continued to thrive. I have done pretty well myself. But I know without a doubt that being a white dude has helped me immensely. I have great sympathy for people who have been kept out of the boys club because they just weren’t quite the right fit. Not everyone blooms early, and what motivates me is the possibility that hard work and creativity will pay off in the future. Any plan that fails to account for the fact that amazing contributions can be made by people with unassuming backgrounds is flawed.
That outstanding scientists may be diverse and thrive in unique niches. Basically that the tree of life is not linear but multi-dimensional. Even smart people are terrible at predicting the success of project ideas, but “people not projects” is only palatable when examined from within the cloistered environment of the NIH and HHMI. Successful people fall into two traps: they take personal credit and discount the role of the environment, or they think their environment was objectively the best for anyone’s success. Evolution happens from completely unexpected matches between diverse environments and diverse individuals. I like simple solutions, but by setting up a narrow criteria of success you will select for those that match your criteria but you will lose creative individuals without ever having realized what you have missed. Life thrives in diverse environments with unexpected solutions. Any single environment, or selection criteria, is an arbitrary one and we should provide an array of different paths to success so we allow people the opportunity to find one that fits them.
Germain’s proposal is a useful starting point for reforming the NIH. It captures very well the ideas of some very successful insiders. The monoculture produced a document, but there should be a little humility regarding the stink of nepotism that hangs over it. While the proposal represents a change from business as usual, it risks further perpetuating a monoculture or making it even less diverse. The challenge is how to get a counter-proposal from outside the gates from a group that does not believe there is a single best strategy for success.
Yesterday, on twitter Mark Cuban revealed that he has his blood checked quarterly to keep tabs on his own health and there was backlash from the medical cognoscenti. The exchange revealed an interesting disconnect between where health care is now–those tests are a waste of money, and where healthcare is heading– they won’t be. My own knee jerk response was that the tests were silly, but the more I reflected, the more I thought it would be a bad idea to bet against the owner of the Dallas Mavericks.
The kerfuffle actually highlights two schisms in the medical firmament: healthcare costs and the role of prevention. Why not check your blood every 3 months? Because it’s expensive (more so if we consider offering this to large numbers of people), and we don’t know if it will be helpful. But Cuban can easily afford the cost of these tests and the bald fact is that despite the long-held notion that Americans don’t want “two tiered” medicine, we should admit that we already have tiers in our current system. I believe that acknowledging different tiers might make our healthcare system more efficient. Every US citizen is entitled to basic healthcare and that it is ridiculous that many states, by not expanding Medicaid, are failing to provide basic care to it’s poorest citizens. But at the same time, there is a huge pile of medical tests and procedures that are not cost effective, not basic, but hell, if folks like Cuban wants to spend their money on “doing everything,” then why the hell not. This is where the cutting edge belongs. He didn’t say this, but given Cuban’s proximity to high performance athletes, I strongly suspect that his quarterly tests might involve hormone assays and therapeutic adjustments. Testosterone and other hormones can be adjusted in a personalized manner to optimize performance. Multiple medical societies have made clear there is no evidence for benefit of this practice, but it seems dishonest to dismiss it totally while the same establishment is going crazy over the idea of “personalized medicine.”
In the Forbes piece and elsewhere, there is discussion about the failures of preventive medicine which are real (e.g PSA screening for prostate cancer, as Otis Brawley has eloquently told) and the idea of over-medicalization of our lives. Obama’s Precision Medicine Initiative has been sold as the way forward for finding “the cure” for diseases. In cancer, I’m getting a bit tired of hearing the molecular studies that reveal horrifying complexity of cancer, as a key to individualized treatments. I certainly don’t want to interfere with the ability of my colleagues to raise money, but just between you and me, it’s marketing. But what this technology will allow us to do is to improve and individualize disease prevention. PSA is an early generation screening test. One day it is perfectly reasonable to assume, yearly blood tests will be able to scan for cancer-causing mutations allowing treatment at the earliest possible point in cancer development.
The idea that Cuban would evangelize for his type of screening horrified some healthcare professionals, and I understand why–there are no data that these tests will do anything but waste money and generate false positive worries. But you know what? Understanding and treating cancer when it is advanced is hard. And by hard, I mean it may be impossible. Cancer sequencing data show us that the genome of a cancer cell is shattered like Humpty Dumpty*. Right now, we are putting tremendous resources into trying to put Humpty Dumpty back together again, but some of the best cancer researchers feel that genome data will be much more effective in the setting of prevention.
“Don’t encourage people to do what we don’t understand,” seems hypocritical to me given the history of US healthcare. “Spend money on what you want to,” seems about as American as apple pie, and in healthcare, just may be the stimulus to get our technology in line, eventually, with health needs of more people. Many companies are pushing big data in healthcare, I see no reason why Cuban can’t push too in his own way. Maybe quarterly is too frequent. Maybe we don’t agree on what tests are needed. But if the richest among us are willing to provide data and enthusiasm for high tech precision medicine, that’s a good thing. If something really useful comes out of these experiments, those of us with more limited means will likely benefit in the long run.
So yeah, ha ha, that Mark Cuban is a silly rich dude who doesn’t understand healthcare. Personally, I think he has the right idea.
* Actually, whole genome sequencing of cancer biopsies show that most cancers are made up of multiple distinct sub-clones with unique mutation profiles–a dozen Humpty Dumptys shattered in different ways. So all the king’s horses and all the king’s men had it easy!!