Sleep-Deprivation is no way to run medical residency

Came across this in my tweetstream the other day. 

Father of modern surgery, William Halstead, invented the overnight call system. He thought it toughened the character. What we learned later was that his method for staying awake was cocaine. The entire on-call system for medical trainees is premised on cocaine dependence.

I have always thought the inhuman work hours expected of medical residents is mad folly. It is well-known that sleep deprivation drastically reduces performance. To the point where for some tasks even moderate sleep deprivation is equivalent to being over the (U.S.) limit for drunk driving. Why on earth would you want someone in that condition making medical decisions?

Oh, I know there are elaborate justifications. But the whole system reeks of a combination of self-interest (addicted to cheap labor), plus its-always-been-this-way-ism (accepting the clinical justifications as self-evident, my generation went through it, so why shouldn't yours). As in many questions of policy, it is useful to turn to empiricism. What do other places do? Studies suggest there are good alternatives.

For inspiration, consider working remotely. Many organizations and managers were against it, until they were forced, at the figurative point of a gun, to rely on it. Now, I think the large majority thinks it is viable, and many think remote work can be even more productive. Of course I'm not claiming that automatically proves a change of comparable magnitude would work for medical residency, but it is one more good argument for considering and experimenting with improvements.

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Postscript: I have my doubts whether the tweet is entirely accurate. The part about inventing the system is true, and so is the cocaine addiction. But it isn't clear that they go together. This Quora post claims they were not related. I generally would not like to rely on a Quora post for the final word in anything. But the original tweet contained no link, and in 10 minutes of searching, I found very little that make the cocaine-sleep deprivation-enabling connection. The one thing I found looked the likely source of the tweet. Nothing else made the link. Including this very detailed article of apparent first-rate provenance. None of which changes the fact that the US Medical Residency system is surely due for an overhaul.

Excellent Retirement Drawdown Calculator, Factors in Social Security and Pension

This calculator is fantastic. It takes care of a really hard part, which is factoring in years between "early" retirement, and time you start receiving Social Security and/or a pension. Also factors in inflation. For what it's worth, my investment rate of return assumptions are:

• Middle/Mildly Optimistic: 7% return, 2% inflation
• Moderately Conservative: 6% return, 2% inflation

Very important note--this assumes 100% equities. If you take a route that involves less market risk and lower volatility, you will likely have substantially lower inflation-adjusted returns. It also assumes that your savings are tax-sheltered; either retirement accounts (fully tax sheltered) or long-term investments (mostly tax-sheltered).

Assumed returns are over the very long term, mind you. Any time horizon under 10 years may well be less predictable (not that there are any guarantees of predictability--this is a build-your-own annuity). Also, as I write this (Feb 2021) the market has been so strong for so long, that I make a near-term adjustment. I assume zero market returns for the next 4 years. That could come either as a near-term correction, and then a return to more normal returns; or it could come as 4 years of stagnation. (DISCLAIMERS: these are just my own uninformed guesses that I bake into my model. Nothing magic about 4 years, either, just my guess/model.)

So to use the calculator, you need to have an idea of how much income you need/want in retirement, and also how much pension and Social Security income you will have (the latter can be looked up online). For instance, here is a model run using some nice round numbers:

This model is for someone who retires today at age 60, and waits until they are 67 to begin drawing Social Security. Here are the results (some intervening years omitted for brevity):

They will run out of money in 20 years, at age 80. 

A crucial aspect of the model is that it factors in inflation. This is absolutely essential. Even with the very low inflation we have been experiencing for many years now, over a decadal timescale inflation  has a huge impact. (Again, the model is only going to be good as your wild guess on inflation, but that is much, much better than ignoring inflation.)

Also crucial to remember: the calculator does not factor in income tax. So that $7000 monthly income could translate to more like $5400 post-federal and state income taxes.

For modeling how much savings you will have at point of retirement, there is another calculator in the family. As for determining your budget, that's an exercise for the reader, but I will offer a few things to consider:

• Don't forget, since you don't pay Social Security taxes from retirement income, your monthly income need is effectively ~7.5% smaller.
• Likewise, in retirement you obviously no longer need to save for retirement, so that is another chunk of your monthly budget to the good.
• If you have significant after-tax savings, the tax rate will be lower. In the case of Roth, tax rate is zero. In the case of regular, non-retirement-account savings, the LTCG is 15%, instead of your 22-24% federal income tax bracket (though I wouldn't be shocked to see that differential eliminated in the future).

Finally, a limitation of the model is that it doesn't factor in cost of health insurance, prior to being Medicare-eligible. And we all know that can be well into double-digits. It also doesn't factor in when you are done paying off a mortgage, which would also be very helpful.

PSA: Upgrade Your Under-Microwave Bulb

I recall a Blondie comic strip decades ago, where the punchline revolved around Dagwood falling prey to a door-to-door salesman, who convinced him to "stock up" on refrigerator lightbulbs, in order to get a big volume discount on a pack of a dozen. Being a youngster of perhaps 8 years, and having recently absorbed the concept of "volume discount" when shopping, I asked my Dad why that was, apparently, an idiot move on Dagwood's part. My father of course explained that refrigerator lightbulbs, only being in use for minutes per day, tend to last for years*. So Dagwood had just purchased a lifetime supply, and then some.

I myself have replaced a few refrigerator bulbs over the years, though I expect never to do it again, now that they have converted to LEDs. And on that note, microwaves. The typical suburban over-the-stove microwave includes a little 40W bulb, to shed light on the stovetop. Setting aside the silliness of measuring light in watts, 40W is really quite dim.

Until a week ago, I had never given the bulb or its replacement much thought, beyond mentally deploring its dimness. I can't recall ever having needed to replace one (just lucky timing, with moves and microwave replacements, I don't think we have ever had a microwave longer than 8 years). Until last week, when I finally experienced a burned-out microwave bulb.

I automatically went down the path of looking for a compatible LED. That wasn't hard, search yielded many 4W LEDs advertised as equivalent to a 40W incandescent. BUT--why settle for equally dim? Why not find a compatible form factor with higher lumens (brightness)? A little more searching turned up 7W equivalent replacement bulbs--so more like 70W. Still far from really good lighting, but a big step up from 40W dimness.

When they arrived, though, I immediately spotted accursed Murphy hovering in the vicinity: the new bulbs had the same base size, but they were about 1cm longer. Uh-oh. My initial attempt to fit it in was like a square peg in a round hole. While there would be (barely) enough clearance for the fully-screwed-in bulb, there was no room to maneuver to get it to the screwed-in state.

I really thought I was done for, but I persisted. And eventually managed a rare and surprising triumph over Murphy. What I discovered is that, like a semi backing into a seemingly impossible space, if I made just the right combination of moves, I could get it to fit. Those moves were:

• Turn the bulb sideways (perpendicular to the receptacle).
• Raise it all the way to the top of the enclosure--higher than the receptacle.
• Then rotate it 90 degrees, so base is lined up with receptacle.
• Finally, ease it into the receptacle, using every micron of space to get the first thread to take.

I have no idea if other microwaves will have this problem, nor if the solution will work with other microwaves. Just sharing in case it helps. The replacement bulbs are so cheap, it is worth trying just for the 75% increase in lumens.

Here is what I bought, for $13. Slight ironic coda: it's a two-pack.

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*We are talking the old, pre-LED, pre-CFL incandescent bulbs that generate lots of heat, and fail regularly, with typical usage lives of about 1000 hours. I suspect the cold operating temperature may have contributed to perception of long bulb life, in equal part as infrequent use.