Category: Medical

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Culture Medical Politics

Day 945 and Secrets and Safetyism

Keeping secrets used to be a lot easier. Noble philosopher kings with priestly knowledge kept that shit under under lock and key so some uppity courtesan or eunuch didn’t get too clever.

Not that it was all that necessary. Nobody was accidentally misinterpreting the layers of mystical knowledge because illuminated manuscripts were expensive as fuck. And that was cheaper than the previous method which was memorizing oral histories. The expense of sharing information has acted as a control mechanism for centuries.

If you’ve got the money, you can store your sex toys and drugs in layered secret drawers behind a hidden bust of Socrates. But some asshole will post a primer online and your benzodiazepines and vibrator will be long gone.

The metaphor I’m working with on this silly desk is that humans love to horde secrets. We’ve got a lot of incentives to keep knowledge locked away. Drugs and sex in my joke mere proxies for ways we access altered states. Eve’s apple was a metaphor for forbidden knowledge so I’m not reinventing the wheel here.

So where are we today on secrets? Well, I think we are trying desperately to put the genie back in the bottle.

We think we’ve got an open internet but ten years ago Instagram stopped including the metadata tags to allow Twitter to display rich content embedded directly in a Tweet. Now Twitter and Reddit are taking the same approach as Instagram did as data ownership becomes a hot issue.

Closed gardens are meant to keep thieves out and Eve in. And depending on who you are it’s likely you will experience the fall from grace of Eve and the persecution of the thief. God clearly knew something as his conclusion was that once you’ve tasted the bitter fruit there is no point in protecting paradise.

Every time there is more access to information we have the same debate. Fundamentally you either believe people should have access to information and how they apply it to their lives (side effects included) or you don’t.

I’m happy for you to argue the nuances of it. Want a recent example that looks complex and might actually be deadly simply?

The clown meme format asks if it’s
a joke to conclude confident that “LLMs should not be used to give medical advice.”

I know it’s tempting to side with the well credentialed researcher over the convicted felon when faced with a debate over access to medical advice. But I don’t think it’s as simple as all that.

From Guttenberg to the current crop of centralized large language models, it’s just more complexity and friction on the same old story. It is dangerous to let the savages have access to the priestly secrets. I for one remain on team Reformation. Rest in power Aaron Schwartz.

To quote myself in my own investor letter last month.

Most builders remain deeply skeptical of Noble Lies, “for your own good” safetyism, regulatory capture, oligopoly control, and the centralized nation state control as the most effective methodology of innovation for a dynamic pluralistic human future. We are having cultural and financial reformations at a frightening speed. It’s beyond future shock now.

So if I have a gun to my head (and that day may come) I’d like to have it on record that I don’t think secrets have any inherent nobility. It’s just a control mechanism. Keeping people safe sounds noble. But you’d be wise to consider how you’d feel if your life depended on having access to medical data. How would you feel if the paternalism of a noble lie to keep you from it? It’s not great Bob.

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Medical

Day 928 and Season of No

I feel like I’ve been caught in a loop of shitty things that has me in a “fight or flight” pattern that I can’t find a way to release myself from.

I’m having a very “if it’s not one thing it’s a other” summer. And it has to stop here. If I don’t let it all go I’ll be miserable and it will have been my own choice. I’ve got a choice to prioritize the well being of myself and my family.

I’m writing this at the oral surgeon’s office as my husband’s wisdom teeth removal is today. I’ve been given several lectures on how challenging his recovery will be as he’s so much older than the ideal extraction age.

Teenagers have a lot better bounce back rates than even late thirty something apparently. Fingers crossed being fit and healthy counts for something.

I’m stressed by the prospect of prioritizing myself and family. I like being open and available to the universe.

So I’m just going to start saying no to more and more things until I feel like I’ve got myself out of this misery loop. My priorities will remain my family, my fund, my founders and myself. Probably not exactly in that order but pretty close.

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Biohacking Medical

Day 927 and Standard Operating Procedure

I’m going to be nursing my husband through oral surgery recovery this week. He’s run out the clock on wisdom teeth and they all need to be removed.

We will miss a few obligations this week but such is the nature of medical need. Necessity doesn’t always come when you want it. If we don’t do it this week we’d be waiting till November for the next appointment. Such is getting medical care in this day and age.

I’ve been in a bit of a frenzy preparing as I myself have some medical issues that are chronic so if we are both fucked up physically it gets a little tricky to manage routines. Particularly because we live a little bit country these days in Montana.

I’ve gone down a deep rabbit hole of procedures for surgical recovery. I looked up standard operating procedures for inflammation and surgical recovery from every source I could find. I consulted with our doctors. I looked at risk factors.

You’d be surprised at how optimal procedures differ from the standard median recommended ones. The fear of overprescribing pharmaceuticals runs pretty rampant even when it’s clear that some protocols would be beneficial like say post surgery prophylactic antibiotics. The NIH, Mayo and Cleveland Clinics agree it’s a effective way of preventing complications related dry socket. The condition can turn into a painful infection that is relatively dangerous if it gets out of hand given it’s proximity to your brain.

But we can’t make an antibiotic standard operating procedure as it’s not technically necessary. Especially since we have prioritized using less antibiotics overall as a public health policy for the wider social good of preventing antibiotic resistant strains of bacteria. Good of the many versus good of the one. I’ll admit I’d be inclined to say that my husband deserves the Spock treatment even if it is illogical.

I’ve written out an hourly schedule for the recovery procedure I intend to follow. I won’t post it all here as it’s obviously not in my best interest to disclose it. It’s involved and intended to reduce inflammation and have the maximum pain management that is responsible so that my husband’s body can recover quickly with no unnecessary stress.

Proteins powder, bone broth and soft foods

It seems as if a lot of recovery comes down to simply retaining adequate electrolytes balance with enough liquid calories. You have to meet a macronutrient balance that gives enough protein to knit the tissues and not make the body think it’s resource constrained. Which is harder than it sounds when you can’t chew or even suck on a straw.

I’ve got a number of techniques to leverage from lymphatic drainage massage to the woo woo options to reduce stress and promote recovery and I intend to use all of them. And yes I’m available for nursing.

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Emotional Work Medical

Day 896 and Watching Pain

Two of the people closest to me emotionally are having bad days. I’d like to discuss what it feels like to watch someone’s pain when you yourself are intimately familiar with pain yourself.

It hurts to watch someone else in pain when you yourself know how much it takes from your spirit and how little it gives. Because you see, I know now that pain simply is, just like nature, death, & grief. There is no moral valence to suffering. It is a lie that our culture loves to tell that pain is a good teacher. Ben Hunt of Epsilon Theory wrote beautifully about being in the grip of totalizing pain.

They say that pain is a teacher. This is a lie, at least when it comes to pain beyond understanding. suppose understandable pain could be used as a correction, as part of a causal learning process. Pain beyond understanding, though … pain beyond understanding teaches you nothing.

Ben Hunt

America is in a pain crisis. Most of it is chronic and challenging to treat. It’s worse for our most vulnerable who struggle to be treated because we see pain too often through the lens of shame, punishment & physical dependency. We only admitted to the problem because the opioid crisis brought into stark relief that the kinds of pain we are in are rich, varied, traumatic and systemic.

But it’s important to remember that pain is personal. Mine comes from a chronic spinal condition called ankylosing spondylitis. And it comes and goes. Other people have different pain. And it’s hard to articulate no matter who you are.

I forget the contours of pain when I’m not in its grip. Such is it’s overwhelming power that pain is the only thing you can focus on when you are in it, but it melts away from your consciousness like snow on a sunny day the moment it dissipates. Pain is both all encompassing and a ghost on whom it is impossible to keep a grasp.

Day 183 and Pain

Because pain is both absorbing and fleeting, we need our loved ones to witness it. Without the framing of someone outside your experience, it’s easy to become lost in the pain. The other side of this is we forget how to grapple with pain when it strikes unexpectedly as our memory kindly looks to remove it leaving us open to suffering when it reappears. Others bearing witness helps with both.

I won’t sugar coat how much of a challenge it is to watch someone suffer through pain. The first instinct is often to leap to solutions and caretaking. Which sometimes our loved ones may need. If they are lost in pain and unable to help themselves the saving grace can be someone pulling you out with reminders or rendering of treatments.

That being said, you must remember to ask before you care for someone. Simply going straight to your preferred solutions may not be what is needed. Be gentle in doing so being invasive can worsen the suffering. Respect the agency of those in pain by asking if they have a preference for how you engage with them in their pain.

A simple example from my own life today. I asked my loved one if they would prefer to rest rather than engage with me as I know when I am in pain my preference is to lay down. I framed my pain in relation to theirs.

But crucially I followed that relating assuring I did not presume this was their preferred outcome or experience but merely that it’s mine and that I’d like to know theirs. Do not presume that a preference you have is someone else’s. Always ask upfront.

Maybe they want company, or a medication, or a distraction or a myriad of other possibilities. There is no one cure for pain. But it is eased by the love of those we love in return.

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Medical Preparedness Travel

Day 884 and Who Hurts First

I spend time in Europe for professional reasons. Some of my founders are unable to reach the United States as our visa program has become untenable. So I spend time in places founders can reach me. Trade crossed all borders.

Just in the last two, I’ve had Nigerian, Indian, Albanian, and Russian Jewish founders years find themselves unable to secure visas to visit America, not even for professional conferences or tourism. It is much worse with HB1 or O1 visas. You may not think this problem doesn’t affect you, or may even benefit you, but can I assure you one day it will affect you negatively. American industry was built by immigrants.

At first I thought I could simply work around America’s travel restrictions. Capitalism will overcome the inequalities our states have wrongly thrown up to divide us.

But I am learning that climate change and failures in sustainable energy policy is making it much harder to travel with a disability or chronic medical condition. Heat is a strain some bodies can’t take. And mine is one of those bodies. Migraine sufferers are too. So are the elderly. It’s quite common.

Last year I briefly did that American thing where we pretend we the Mediterranean lifestyle is aspirational by spending two weeks on the Ioan Sea. Utter disaster. I am not calling White Lotus a liar, but I couldn’t possibly imagine how hell could be worse than a heatwave in Sicily in July.

Watching the Germans treat air conditioning use like some sort of criminal shameful behavior was a vivid reminder that society always chooses who we hurt first. A policy that is for the common good may find uncommon hurt delivered to those we didn’t consider. It’s not deliberate but it may as well be.

If you paid attention during the pandemic you probably learned a lot about how we treat the sick and weak. Now imagine yourself as an one of them. It’s almost enough to make you consider becoming a reader of Rawls.

The end result for me is that I don’t believe I’ll be traveling to Europe except in the winters going forward. I can’t risk the lost days of productivity to something stupid like a default hotel setting for 72 degrees. I feel a bit robbed by this. Grief even that even late May is too risky to be on the road.

It’s a small thing to have your travel be restricted in a world of bigger sorrows, but the feeling of having your opportunities narrowed hurts. I’m sad because a utilitarian neoliberal wonk decided that most people would be perfectly comfortable with slightly warmer rooms. The finance teams at the hotels agreed. It’s not so bad. It doesn’t bother them. I wonder what other decisions won’t bother them. And whether they will hurt me unintentionally.

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Medical

Day 845 and Fucked Fertility

A bit of discourse stirred up a lot of grief and sadness for me. Noah Smith did an analysis of the much discussed Atlantic piece “The Myth of the Broke Millennial.” His breakdown is excellent and I recommend the Twitter thread where several of my geriatric millennial friends weigh in on how late in life security has come for many of us and how precarious it still feels.

What jumped out at me most in Noah’s breakdown is whether millennials will feel financially secure enough to have kids if it’s indeed true that we are getting less precarious.

That matters as a question as having children appears to be a driving force towards conservative politics but also a general preference for less government involvement. Noah wondered if millennials will be less woke and less inclined to socialism if we don’t turn out to be downwardly mobile. The theory is we might be if, and it’s a big if, we feel secure enough to have children.

There is one age-related factor that appears to draw people to the right, however: having children. Fertility rates are down, and Twenge discusses some reasons for this in her article. But what really matters for politics is probably not the number of kids that get born, but the number of people who end up having any kids at all.

I’ve got bad news on this front as the first wave of elder millennials who haven’t already had kids probably can’t. Why? Our women are aging out of fertility before they find the security they feel they need to consider having kids.

By the time millennial women get to a place where it seems feasible we’ve long entered “geriatric pregnancy” territory. I froze my eggs right before it was considered a geriatric situation. Which is give or take 31-32 now as we redefine fertility. I am now 39.

Now that’s a longer story for me personally as freezing my eggs felt like a consumer decision, was marketed as insurance policy, and ended up being a life changing catastrophe. And I still don’t have kids.

The process of egg extraction triggered an inflammatory disease and I may never be able to carry to term. And I have complicated grief stricken emotions about the entire affair. And we spent a small fortune getting me healthy enough to go back work.

But my suspicion is that many millennials will learn that fertility isn’t as easy as they imagine if they try to deal with it past 35 let alone past 40.

And we simply cannot seem to discuss the issue in a way that is productive. The discourse is toxic as cultural warriors, often men weigh in with their complex emotions about what it means to have a family, support children and generally deal with women’s health.

Shaming and controlling women’s bodies doesn’t really do much for the cold hard reality that we failed many millennial women by assuring technology could solve for the hard questions on fertility. So we marketed these new medical options and sold it at premium. Silicon Valley mounted a whole campaign to freeze eggs for its female workforce.

I’m afraid we are too deeply entrenched in a culture war to discus this productively as most of the people I see with the message that fertility is complex tend to view things in a more traditional context.

I personally love playing a tradwife on Twitter because I’ve learned a lot about how reactionary feminists and baroque online misogyny views motherhood. They talk to me and I’ve listened.

But we need to get women of all politics and preferences and family structures involved in this conversation as a full decade of millennial women are going to need to consider their relationship to their own fertility and bodies in short order. And for many of us it’s too late.

Treatments like IVF and egg freezing & extraction are expensive and have considerably more risk than we are comfortable discussing. Surrogates are a quarter of a million dollar expense which disgustingly is for bureaucratic costs not the surrogate herself. If you want multiple children it’s not crazy to plan for a million dollars. And don’t get me started on how adoption plays into all of this.

A generation of fucked fertility with myriad corporate profit motives driving decision making sounds like the stuff of conspiracy and cranks but don’t be fooled by extremism. We’ve done a shitty job investing in women’s healthcare in America and it will have consequences.

I know it’s scary to look at head on. I regularly break down with my own grief on the matter. I’ve been looking at it for years. Having a serious health crisis brought on by family planning has been a blessing to my marriage but that blessing has enormous costs. I’d expect this process of addressing the fertility of a generation of women to be challenging for us all no matter your personal choices or politics.

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Medical

Day 836 and Medical Care & AI

I had a little bit of excitement in New York City when I encountered some type of gastrointestinal issue. We’d speculated it was food poisoning or norovirus with our doctor.

After getting it out of my system and speeding back to Montana; we’ve been pouring over the symptoms, timing, biometrics and medicines to see if we missed anything. It felt like an opportunity.

We had three doctors retire on us this year and after two years of rising premiums, we are naturally skittish about health care. Pandemic telehealth reimbursement being sunset is a hit to rural care as is the other policy roll backs as the of emergency winds down. Reciprocal licensing across all states sure seemed like it should have been a keeper. But alas American health care is a mess.

Thankfully we’ve got a doctor local to us in Montana who we’ve been slowly building up a relationship with over our first year here. After his star turn in this gastrointestinal saga, I am ready for a round of blood work and a look at the big picture with him.

We’ve even been dabbling in a few theories with our Large Language Model friends. While ChatGPT goes to a lot of trouble not to diagnose, we’ve been able to run down some leads on our own and bounce them off our doctor. I’m looking forward to getting a look at my liver panels and gallbladder. Maybe tweaking some of the pharmaceutical line up.

While it may seem a bit grim, I’m considering that with enough questions asked and enough clever inferences on our behalf from our new AI friends, maybe we can get further. Sure we are down 3 doctors and up 30% cost wise, but maybe these plucky kids can make do with a chatbot, a young doctor and a can do attitude.

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Medical

Day 834 and Inside Out

I had a really rough night last night. It’s entirely possible my original theory of industrial lettuce wasn’t the whole picture.

For a little timeline clarification. Yesterday, I woke up with stomach troubles after eating agribusiness salad chain for dinner on Wednesday. I had meetings on Thursday so I took some varied drug store tummy medicines and gutted it out. I even had a very fun time at my meetings. But then as the adrenaline of the day wained I was heading towards disaster. The nausea and had was getting worse.

I realized I couldn’t attended a dinner with some old friends but Alex was fine. I told him to pick up some Tums on the way home. As his dinner wore on my symptoms got worse and worse.

I felt like I was beach ball ready to pop. My stomach was distended so far I felt like I had back problems my stomach pushed out so far. I was tight Mike a drum. The pain and nausea consumed my focus. Around 7:30 or so I called Alex saying I needed a doctor or a visit to urgent care. I couldn’t tolerate it any longer.

Blessedly our doctor in Montana called back almost immediately. He had just personally had a case of stomach flu or norovirus himself and mentioned it was trending up nationwide. At that point I was mostly moaning and curled into a ball from the nausea and gas. He prescribed an antispasmodic called dicyclomine. It helps calm stomach cramping.

I had an hour of crying and praying waiting for it to kick in. I’m sure I scared the shit out of the other hotel guests with the moaning and crying. I was begging Alex to please fix it. To find something else I could take. To do literally anything to relieve me of this horror. Thankfully around 930pm or so it kicked in fully. How do I know?

I was able to vomit. A lot. Seven times over the course of half an hour. And then I was fine. My stomach deflated down to a normal size. The nausea abated. The pain and cramping subsided. Four hours of intense misery has passed with a drug that turned me inside out.

I spent all of Friday in bed sleeping it off. I missed all my meetings and couldn’t eat anything till dinner time came around. I’m having some soup and I suspect I’ll simply pass out. New York is an inside out kind of place sometimes and I’ll just have to live with it.

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Medical Travel

Day 833 and Industrial Romaine

I packed my day a little too full so I found myself ordering a salad from popular New York industrial salad chain Chopt at 8pm right as they closed.

The order was placed on an app so it was a crapshoot and I knew it. And sure enough I got something that wasn’t what I ordered but I’d been running around for 12 straight hours so I just said fuck it I’ll eat this weird burrito of industrial romaine and mayonnaise because I’d really rather be passed out.

Incredibly poor decision making on my part. I was up early and I was up often performing ablutions and praying to the gods of intestinal fortitude that this please pass swiftly.

I appear to have stopped with the worst of it and had about an hour or so before a meeting I really didn’t want to cancel. It’s not as if food poisoning is catching. So I groomed and put on something that would withstand the 88 degree heat of…checks notes… early April in Manhattan? And then I got on the subway.

Shockingly heat and the subway aren’t a great combination, but I was determined to gut it out. I’d left early so I could find my way to a drug store. Naturally nothing was available to purchase without someone unlocking a cabinet. Nothing more humiliating than asking if one could have a key to acquire GasEx, Tums and Imodium. A really stellar look all around.

I’m now comfortably in a lovely office of a venture capitalist hoping it all kicks in before I need to attempt socializing. Naturally I’m taking the time to write about it as I wait as it’s keeping my mind off the discomfort and misery of it all.

This isn’t the first run in I’ve had with agribusiness greens that’s gone awry for me. Many moons ago I got food poisoning from spinach I bought at a Trader Joe’s. A few blocks from where I am now. I had Gucci insurance (literally Gucci the luxury house I do not mean that it was particularly fancy) and spent the night in the emergency room. So maybe this is just a full circle experience. Ashes to ashes romaine lettuce to romaine lettuce to romaine lettuce.

I can feel the drugs kicking in and maybe I’m at the end of it. And hopefully this will just be an amusing anecdote that I recount on why we need to be more careful with food safety and industrial run off. But also I am loathe to cancel a commitment during a business trip. Showing up matters too.

Categories
Medical Politics

Day 776 and Informed Consent

I’d really like to write about informed consent and whether it is a convenient fallacy to obfuscate the harsh reality that medicine isn’t as black and white as we have been led to believe.

It’s a complex topic so consider this my notebook of scraps and gently judge it’s content as it’s not a full cohesive argument so much as a collection of thoughts I’m working through here. If you feel you are reacting to it strongly please work through why on your own time.

I am on this topic as I am reaching a point of frustration with the discourse around transgender issues and who is responsible for informed consent. We’ve got a spiraling culture war where everyone is ignoring basic facts like children are below the age of consent and thus their parents are responsible.

Our entire legal system is based on the premise that before 18 you have not reached the age of reason and are not fully responsible for your actions. Yes it’s flawed and doesn’t always work that way and we try minors all the time but the fact remains parents are the guardians of their children.

I am oddly both well read and well cited on issues related to informed consent and substituted judgement as I was a medical ethics research assistant at the University of Chicago. I got paid $10 an hour for my troubles so you know my credentials check out (in sarcasm font). Seriously go look I’m an author on a few papers.

Making a choice to engage in almost any medical procedure is risky in ways no one, not even doctors, can fully articulate. Bodies are complicated and abiding by a simple principle like “first do no harm” turns out to be hard calculus.

Sure you can get awfully close to the right answer but you will be pretty far down the calculating differential equations path once it dawns on you that we can get infinitely close to certainty but certainly itself cannot be reached. Turns out math is useful in daily life.

Patients have a right to chose their own risk parameters. Doctors do their best to inform. But the grey area is so wide it’s practically an abyss. Add in making decisions for a minor and it’s all best guesses and other people’s facts. Believe the science means you’ve got to do your own math and it appears most people are innumerate.

I am willing to make big criticism of the transgender panic crowd because they’d prefer to pick and chose convenient narratives like “think of the children” as a defense. I’ve heard that tune before in every other moral panic. And yet it’s still not the government’s job or the doctors job to make the call. It is the parent’s call because children require the substituted judgement of their parents for informed consent.

If this is annoying or unsatisfying to you well that’s a bummer for you. I’d encourage you to read up on how we’ve scapegoated populations in the past to make sure the in-group’s priorities and social mores are sustained. Every moral panic has one. I’d recommend René Girard’s work here.

When we fixate on a vulnerable population the story is always the same. And I believe anyone who is reading this blog is smart enough to grasp that in good faith. And we’ve got a long history of scapegoating people who don’t conform to our majority population’s comforts.

The transgender issue is no different and trying to wedge it into a “but the children” argument runs up against two issues. Most of our American historical moral panics have scapegoated in this exact way. And medicine is simply not so concrete that any treatment for any condition is risk free.