Personal philosophy

What if doctors were tenured?

Posted on October 31, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Personal philosophy, Self-deception |

Reason is the unique path to knowledge. This is the credo of rationalism. Existence as a pure rationalist may be a highly-prized state, but getting there certainly is not “half the fun”. There is a lot of pain involved in recognizing and discarding long-held positions when they do not pass the rationality test. On the lead page of this site, I state that retired urologist has launched a quest for knowledge about Artificial Intelligence, extended life, and the issues inside the health-care industry. The sticky point in the quest is the concept of knowledge, a goal that can be approached only along the path of reason, yet, as Robin Hanson has pointed out, doctors are “lousy at abstract reasoning”. I have agreed with him profusely in this earlier post, yet I still had a knee-jerk defensive response to it’s reiteration recently on his Overcoming Bias blog. I, and you, are wired that way.

It seems like a quid pro quo thing going on. “If I’m going to go through the pain of admitting my long-practiced deficiencies, those who so readily identify them for me should do likewise,” or something like that. But no. Not going to happen. Actually, can’t happen may be a more appropriate description. I have become convinced that the human brain is hard-wired to ignore certain of one’s own biases, while readily identifying those same biases in others. It’s not a new concept, nor original. Long before neuroscience was a word, the Biblical writer of the gospel of Matthew asked, “Why behold you the mote that is in your brother’s eye, but consider not the beam that is in your own eye?” Why indeed? Perhaps because it’s unavoidable. It bears repeating that those gifted with more intelligence are more likely than those with pedestrian IQ’s to exhibit this defect (skill?). Via intellectual attribution bias, smart people are about nine times more likely to attribute their own position on a given subject to rational reasons than they are the position of others, which they will attribute to emotional reasons, even if that position is the same as theirs (Michael Shermer). Via confirmation bias, smart people tend to seek or interpret evidence favorable to their already existing beliefs, and/or to ignore or reinterpret evidence unfavorable to their beliefs. Hanson considers confirmation bias to be a major contributor to ideological fanaticism, the greatest threat to the world, yet he employs it frequently. He can’t help it: he’s very smart.

In fact, he’s so smart that he has tenure. Now, there’s an interesting concept for a libertarian supporter of free markets, idea futures, and outcome-mediated health care plans! Tenure is, at best, an arbitrary system which may or may not reflect effectiveness, yet which virtually guarantees employment and facilitation. Hanson’s espoused ideas revolve around the establishment of “betting markets on controversial issues, in which the real experts (maybe you), would then be rewarded for their contributions, while clueless pundits would learn to stay away.” (quoted here) Yet his own job doesn’t work that way. One would think that when offered tenure, such a person would have turned it down, on philosophical grounds. Ah, but there is the consideration of responsibility to one’s family. Intellectual attribution bias facilitates just such paradoxical behavior, not just in Hanson, but in humans generally.

So comes the question: what if doctors were tenured? Immediately, it comes to mind that all the things Hanson finds wrong with doctors, and the health care system in general, would be magnified. Doctor arrogance, a frequent topic of Hanson’s concern, would soar, perhaps approaching the level of university professors. Health outcomes, as bemoaned in Hanson’s analysis of the Rand Experiment, would surely, and predictably, worsen, as there would be no correlation between quality of work and job security. If there were a doctor agency similar to the insulating university, one could predict soaring rates of malpractice among tenured doctors, since the consequences would be borne by their institution. On the positive side, doctor-related felonies, such as Hanson documents here, would likely decrease, since commission of a felony would be grounds for revocation of tenure. Doctor supply would surely increase, as would the average age of doctors, since, once tenured, there would be no reason to retire and no pressure to perform effectively. In summation, it seems that university professors would view tenure as an excellent idea for university professors, but a very bad idea for doctors. Personally, I agree with the free markets that Hanson talks about, as opposed to the closed market in which he participates.

I am trying to learn how to think differently (more effectively), since my education and profession actually did not include any courses, or even any experience, in clear thinking, sad to say. I know there is a strong bias about the arrogance of doctors, especially given their rather well-documented failure to make a positive impact on *overall* health care in the USA. I abhor the “doctor arrogance” as well. Any arrogance seen in my posts is (usually) unintentional, and comes not from being a “arrogant doctor”, but from the failing of being an “arrogant person”, a quality that seems widespread among intellectuals. The more I learn about how such “ninja-brained” people think, the less I have to be arrogant about. I’m here to learn.

 


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Do you know the way to San Jose?

Posted on October 24, 2008. Filed under: Layman's AI, Personal philosophy, Self-deception, The Singularity |

Long-time reader, first-time visitor to Silicon Valley. I just arrived for the Singularity Summit. It will be interesting to see how out-of-place a redneck sex doctor will be in this sea of geniuses. More to follow.

Add-On: see today’s Summit summary.

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Nude Banzai

Posted on October 20, 2008. Filed under: Everything you wanted to know about doctors, Good ol' days, Personal philosophy |

Today’s post is a chapter from my not-yet-published book, Chasing a Light Beam. If you actually read it, please let me have your criticism.


 

NUDE BANZAI

Many men go fishing all of their lives without knowing that it is not fish they are after. 

                                                                                                        -Henry David Thoreau                                              

 

The man shifted a little in his chair. He thumped the edge of the crystal martini glass; it made a musical tone. With his foot propped, he could stay comfortable like this for quite a while.

I was single again, and I called my cousin Punky in Jacksonville to see if he wanted to go on a guy-trip. He was nine years younger and had no wife to convince. I knew his dad way before he did. Big Punky wasn’t a blood relative, but after Mom moved us to Jacksonville, he was the closest thing I had to a father. Just like Daddy, he liked to fish, and he liked to take me along.

Big Punky was the one who taught me to catch sheepshead with fiddlers. The first thing you had to do was find a bank on a tidal river when the tide was out. The fiddler crabs would be cruisin’ around on the mud and oyster shells in droves, each waving his larger claw. If they saw you coming, they’d crab-walk faster than a light beam – that’s not really possible, like I said in the beginning, but whatever – back to their burrows and disappear. You had to sneak up on them, and you had to get between them and their holes. Then you ran out with a bucket and used your free hand to scoop up as many as you could. You grabbed them, and they grabbed you, but it wasn’t true pain. Most of them would get away, but if you were good at it, several dozen would go in the bucket. As to the actual fishing, I never understood how sheepshead could use those human-looking teeth to get the meat out of a fiddler shell without sending any vibrations at all up the line. At least, that’s the way it seemed to me; Big Punky could feel the slightest twitch, and we usually came home with plenty to eat.

Punky was only six when his father died. When he was older, he’d get me to tell him about the times I spent with his dad. His favorite was the day Daddy took Big Punky and me to a little lake in the Ocala National Forest. We were after largemouth bass, and the bait was wild shiners, hooked through the lips. Daddy had a flat-bottomed plywood boat with a three-horse Champion outboard. We trolled the shiners behind the boat, slow enough to let them swim. One line was out each side, and Daddy’s line was out the back. When the bass would hit, the click on the reel would scream. You’d count to ten, and then jerk, to set the hook. The limit was eight bass in those days, and there was no such thing as catch-and-release; it was catch-and-eat. We caught twenty-four bass that afternoon. Big Punky had one that went nine pounds, two ounces, and another that weighed eight pounds, fifteen ounces. I know that, because Daddy always stopped at a little roadside store on the way home to weigh any “lunkers” on their certified meat scales. ‘Til the day he died, Big Punky said that was the greatest fishing trip of his life.

I figured Punky might like to try to find that pond with me; he’d never been there. When Daddy was alive, he tried to keep that fishin’ hole a secret; you could drive right by it on the two-rut forest road, and never know it was there. His effort succeeded until the day he took the preacher of the First Baptist Church out for a chance at a big bass. He made him swear to secrecy, and the preacher caught an eight-pounder. The next time Daddy went there, the preacher and two other boatloads were on the lake. It wasn’t a secret after that.

(more…)

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Bias on the hoof: Hanson and RU continued

Posted on October 5, 2008. Filed under: Everything you wanted to know about doctors, Personal philosophy, Self-deception |

Today’s post is a study of bias in the intellectually gifted (at least as pertains to one of the parties; I’ll let you guess which one). 🙂

In my October 4 post on Disagreements, I used a disagreement between Robin Hanson and me as subject matter for a set of disagreement analysis questions Hanson had requested readers of his blog to use. To refresh the particulars, we disagreed on the suitability and veracity of this anecdote in an article he posted called “Doctors Kill”:

A colleague of my wife was a nurse at a local hospital, and was assigned to see if doctors were washing their hands enough.  She identified and reported the worst offender, whose patients were suffering as a result.  That doctor had her fired; he still works there not washing his hands. Presumably other nurses assigned afterward learned their lesson. 

A reader (not me) saw coverage of the post on the blog of Seth Roberts, and asked Hanson “whether you actually ever met and talked to the fired nurse, how strong her evidence was that she was fired for the reason in the story, etc.? Did your wife actually know her, or know someone who knows her (who might turn out to be someone who knows someone who knows someone), that sort of thing? ” Hanson replied: ” the nurse was a close co-worker of my wife, who I’ve met.” (Nothing more.)  

I contacted Hanson privately to express all the factors mentioned in yesterday’s post, as well as the fact that the article quoted was not evidence against doctors so much as against other hospital employees. In addition, I told him:

I cannot imagine a hospital administrator telling a nurse, “We are firing you because a doctor you reported has requested your dismissal”. If that statement were not made, the nurse could not know that it was the reason for her dismissal.

Hanson replied, making no mention of any of my evidence of inaccuracy, lack of veracity, and bias, save this:

If you think no one in a work place can know anything other than what people say through official channels, you don’t know much about ordinary workplaces.  

According to his curriculum vitae, Hanson has never spent time in an “ordinary workplace”. I, on the other hand, have been a printer, electrician’s helper, warehouseman, assistant to television repairman, gasoline station employee, yardman, laborer in an asphalt plant, infantryman in Army (PFC), university information employee, delivery-man, ER doctor, breath-spray franchisee, computer technician for a beer/whiskey distributor, employee in a medical practice, owner/director of a medical practice, owner-partner of a hospital, chief of surgery at two hospitals, and laboratory research assistant in a psychiatric hospital (that I can recall; never fired, by the way, even though none involved tenure). I am particularly experienced at job relations and administration in hospitals, and especially at doctor-nurse relations. This would, if nothing else, seem to give some credence to my claim that Hanson should take another look at the value (truth?) of the story. (more…)

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Disagreements

Posted on October 4, 2008. Filed under: Everything you wanted to know about doctors, Personal philosophy, Self-deception |

Prologue:

Robin Hanson and I had a disagreement about the accuracy of an anecdote he used to illustrate doctor arrogance. I was dissatisfied with the lack of resolution to the disagreement, unless one considers “no change at all in either party’s postion” to be a “resolution”. He titled his piece “Doctors Kill“; it’s subject is nosocomial (hospital-acquired) infections. The anecdote:

A colleague of my wife was a nurse at a local hospital, and was assigned to see if doctors were washing their hands enough.  She identified and reported the worst offender, whose patients were suffering as a result.  That doctor had her fired; he still works there not washing his hands. Presumably other nurses assigned afterward learned their lesson.  

I objected that this anecdote was based on a third-party uncorroborated snippet amounting to gossip, and certainly in the category of ad hominem criticism. The statement “he still works there not washing his hands” is indicative of the inflammatory intent of the anecdote, since Hanson had no way to know what the doctor may have been doing subsequently. I pointed out that the anecdote added nothing to the statistical presentation of evidence, and as such was egregious expression (and strong evidence) of personal bias. I expected that Hanson, an extreme advocate for eliminating personal bias, would have seen that his personal bias against doctors had crept into his writing. Instead, Hanson replied that the nurse was also a a personal acquaintance of his, so the story must be true, and that his readers had found it to be valuable.

Analysis of Disagreement:

Recently I have come across Dr. Hanson’s post on “disagreement case studies“. Today, I will use his questions for analyzing our disagreement. (more…)

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What, me worry?

Posted on October 1, 2008. Filed under: Layman's AI, Personal philosophy |

Today, on Less Wrong, one of the commenters used the word “sinecure”, sending me rushing to the dictionary: an office or position that requires little or no work and usually provides an income. How did I reach this stage of life without benefit of this marvelous word?! It’s Latin roots suggest an even deeper meaning: sine cura, “without cure”, referring to a Middle-Ages ecclesiastical appointment, but without the power to “cure souls”. In my part of the US, we’d say it was someone who was “all hat and no cattle”. And, it is easily rearranged to “insecure”. Significantly, the commenter was referring to the position of “Research Fellow” at the Singularity Institute for Artificial Intelligence, I presume tongue-in-cheek. This Fellow has identified a threat to mankind of which few others (mankindly-speaking) are aware: unfriendly general artificial intelligence. The perceived level of the threat is absolute: total annihilation of humanity and the world as we have come to know it. The timing of the threat is soon: perhaps three decades or less. The perceived likelihood is 100%, save some intervention from a ninja code-writer. To make it a story easily publishable, and on the fast-track to moviedom, there’s this twist: the Fellow is the (potential) ninja code-writer, and only he can save us. His version of friendly general artificial intelligence would not only prevent annihilation, but also provide a paradisiacal existence for all. His position is funded by donations. He hasn’t produced anything so far, but he thinks about it (and writes about it) all the time.

Sounds like this is going to be a Fellow Roast, eh? It’s not. I’m one of his admirers (at least of what he represents), albeit a Johnny-come-lately. I’ve written positively about him before in this blog, as well as having been inspired to cover the fictionalized human aftershock of his ideas in a short novel. No, it’s no roast. Instead, a reality check. For the past year or so, I’ve spent perhaps several hours of each retired day reading and ruminating about the technological Singularity. There’s the media-friendly version (see The Singularity is Near by Ray Kurzweil), which is all happy and inspiring, but weak on nuts and bolts. Then there’s the blog and mailing-lists version, full of competition, snarking, and predictions of doom, complete with such-high-level-that-only-they-can-understand-it nerdism arguments apparently confirming both the enormity of the task and the misconceptions of everyone save him who is doing the writing. Beneath it all, I am fascinated that a topic of such perceived enormity, described as the greatest event since the appearance of the first replicating chemicals (read:life), is almost unknown to the public, especially since no one is atempting to keep it a secret. To the contrary, fund-raising and publicity efforts are in full swing, as evidenced by the upcoming Singularity Summit.

Suppose the Deep Impact scenario occurred, but starting now, with 30 years warning. In the movie, the US government’s first reaction was to maintain secrecy while beginning survival measures. Once outed, what would be mankind’s reaction? In general, that scenario has been playing for millennia, with the time-frame being less predictable, and the comet being Death. Under those circumstances, there has been little extravagant reaction at all, other than to live until it happens. But death-as-a-part-of-life has always been around, and mankind is accustomed to it. True comet-type death (or on the flip side, elimination of death) is a different animal.  So what is the US government’s response to the possibility (inevitability?) of a mankind-altering Singularity, be it friendly or unfriendly? A well-placed employee at the Department of Defense says here: “I don’t know a *soul* in DoD or any of the services off the top of my head that has any *inkling* of the very existence of trans-H (trans-humanism) or of the various technical/scientific lanes of approach that are leading to a trans/post-human future of some sort. Zip. Zero. Nada.” OK, assume there are no world-class AGI (artificial general intelligence) experts, unknown to the rest of the AGI community, in cahoots with our government, or that of other nations, with a near-solution leading to the Singularity. And suppose that these AGI guys, in all nations, all know one another, and are familiar with one another’s skills. And suppose that none of them has any idea how to write code for a Friendly AGI, and our Fellow stands alone thinking he may be able to do it, eventually. Now, throw in the kicker that a significant number of AI experts think they can write code for AGI soon, leaving the “friendliness” aspect aside. If they are right, and if “undesignated” AGI becomes “unfriendly” AGI (as the Fellow assures us it will), it seems nearly inevitable that the comet is on the way.

There is another, perhaps much larger, community of experts who do not give any type of AGI much hope for existence. These mostly claim either that mankind will destroy itself before the Singularity, or that the possibility of the Singularity is exaggerated. That may be why AGI is a fairly well-kept secret (or just ignored?). Let’s set this group aside as we look at the strength of the AGI group’s convictions. They know the Singularity is coming. They assign various time-frames and modes to it, but their conviction is compelling. There is apparently a common belief among them that those over the age of forty years are unlikely either to have or to retain the math and other technical intellectual skills to be partner to the project, so almost all the go-getters are in their twenties and thirties. I have a few questions for them:

  • Are you enrolled in a financial retirement plan, assuming you need 30 years of service to qualify?
  • Are you saving any money for the future, or are you spending as you go, enjoying life to the fullest?
  • Are you planning to educate your children with the goal of them having a career?
  • Would you buy a 30-year bond at the right price that has no redemption value before 30 years ?
  • Lots of other long-term considerations, perhaps more subtle than I can readily identify

I suppose any answers of “yes” could fall into the category of “wearing a belt and suspenders”, “erring on the cautious side”, “go by what I tell you, not by what I do”, et cetera. For those not familiar with the advantages of the “good” Singularity: none of the things listed would have value post-Singularity. In the case of the “bad” Singularity, no one will be around to worry about it. Either way, it is a list of useless activities. Unless, of course, there either is not going to be a Singularity, or it’s not going to happen for at least two generations.

Without some remarkable non-Singularity breakthroughs, I won’t be here to judge, as the optimistic time-frames put me well into my nineties. What should I do? I’ve got lots of spare time. Hopefully, I have enough money. I’m smart enough to realize that the problem is one of dire importance, and I read enough to detect the urgency in the messages of those involved. One solution is a classic approach when encountering difficult problems, as Bluto advised Flounder: drink heavily. Unless one was dealt the required one-in-a-million brainage, and has subsequently used it to develop the appropriate technical, mathematical, and philosophical skills to approach friendly AGI, heavy drinking (or whatever hedonistic pursuit appeals) seems reasonable. The solution is out of my hands, and most likely out of yours as well. One thing for sure: I’m not going to worry about it.

Cheers!

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Vanity, thy name is “expert”

Posted on September 29, 2008. Filed under: Everything you wanted to know about doctors, Layman's AI, Personal philosophy, Self-deception |

As my medical school years drew to a close, each of us faced the choice of residency that would determine how we spent our professional lives. A close friend and member of AOA, the medical honor society comparable to Phi Beta Kappa or Law Review, declared that he had chosen OB/GYN. He and I had shared what I felt was a miserable experience as “acting interns” on the obstetrics service our senior year, so his choice astounded me.

“Why?”

His answer was seminal: “Have you noticed the size of the textbook?” Indeed, the OB/GYN text was far smaller than that of any other subject we studied. “I think it’s possible to learn everything there is to know about OB/GYN. I can be an expert.” Perhaps he was citing the mental comfort associated with mastery of a skill, and the unlikelihood that he would find himself in a situation beyond his capabilities, akin to a world-class martial arts expert walking alone at night. I suspect the knowledge that one’s work was done as well as could be done would provide substantial comfort, especially if one were well-paid, and the importance of that work were protected and promoted by a guild system. [NOTE: in those days, there was little concept of medical malpractice, a scourge which subsequently would hit the OB/GYN specialty harder than any other.]

Yet, I think his answer (and his career choice) may have been more instinctive, and perhaps outside his conscious awareness: the possibility of being an expert may have been subsumed by the possibility of being recognized as an expert. Dr. Robin Hanson, on the Overcoming Bias blog, initiated a discussion of a similar concept, referring to “expert at” versus “expert on, in which the former could perform successfully and the latter could talk about it successfully. I’m referring to a third entity: an expert on a topic who also is an expert at that topic. He is an expert by all practical considerations, and he is well-remunerated. Is that enough? Perhaps not.

I have observed a distinct change in attitude when the expert-aspirant is exposed to his peers. In my own field, I wanted to be, planned to be, and worked to be the best in the world. In my own mind, I achieved that (male surgical sexual medicine is a very small pond for any size frog), and I was compensated financially in adequate fashion. I want to be satisfied with the knowledge that my work was of superior technical and ethical quality. But it’s a self-edited summary; often (not always) at the highest levels of anything, self-satisfaction seems overrated, and inadequate. At a conference of IPP (inflatable penile prosthesis) technical experts, early in my career, I was seated at dinner next to a surgeon who was prolific in numbers of successful operations. In fact, studying his methods had caused me to take a number of steps that benefitted both my technical skills and my practice success. Because of his influence, and my subsequent personal experience, he and I both used the same brand of IPP in our patients. Neither of us was in academics, so our “fame” came only from our patients and from the recognition of the manufacturer. He mentioned that he had performed “3- or 4-hundred” procedures that year. Unlike some areas of surgery, the number of IPP surgeons who ever perform more than 100 procedures in a year can be counted on two hands. My pride was piqued, and I replied, “I did 201, and Mr. X (the manufacturer CEO) told me that was tops in the world.” When I was just starting, this same surgeon had asked me to join his practice; after the dinner encounter, he was never friendly to me again. It was vanity versus vanity. Of note, I am very unpopular with the “experts on” in my field, those I call the “thought leaders”, none of whom are “experts at”. It’s the recognition, stupid.

Lest you think that the self-satisfied expert at/expert on doctor is immune to this vanity, give him a chance for recognition. Pharmaceutical and device manufacturers have caught on to this weakness in spades. The opportunity to be the star at doctor-to-peer lectures and presentations has changed the attitude of many a current physician, and strongly influenced his practice habits. Even when one has reached the pinnacle of both actual and recognized expertise, the vanity drive remains strong. Dr. Michael DeBakey gave the AOA visiting professor lecture during my junior year. I don’t remember much of what he said, but one quote has stayed with me: “I could make a career simply correcting the mistakes of other vascular surgeons.” Probably a true statement, especially at the time, but of what value was this knowledge to junior medical students? Could there be any doubt that recognition was the driving force?

Recently on Overcoming Bias, the smartest of the smart have shown not only are they are not immune to the vanity of the experts, they actually are as pedestrian as the rest of us when it comes to this human frailty. In the posts and discussions here, here, and here, it’s all about who is the smartest, who is the best qualified, and who is the leading expert. One would think pride in one’s intelligence is severely misplaced. As one of the main posters, Eliezer Yudkowsky, has said, “We are the cards we are dealt, and intelligence is the unfairest of all those cards.” Yet note the ego-involvement. One would think that accomplishment was a far better source of pride. And if that accomplishment has not yet occurred? Such encounters as this are the result. I choose Mr. Yudknowsky as an example only because he is a dedicated student of the human thought process, and one of two main writers on a blog dedicated to eradicating bias. If it can happen to such as him, perhaps it’s innate.

*Pro tip*:The ultimate goal is not only that I succeed, but also that you fail.

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The truth will set you free… but first, it will piss you off.

Posted on September 25, 2008. Filed under: Everything you wanted to know about doctors, Medical marketing, Personal philosophy, Self-deception |

David J. Balan, on Overcoming Bias, writes about the difficulty of responding honestly when people say, “Give it to me straight.” Generally, it’s such a bad idea that the Cajuns in my neighborhood have a story to illustrate:

Boudreaux was a widower whose most valued possession was his cat, Felix. Boudreaux won a trip to Europe, and he asked his friend Thibodeaux to look after the cat in his absence. “Thib,” he said, “I’ll call you from England to check on Felix.” Three days into the trip, Boudreaux indeed called Thibodeaux and asked, “How’s my cat doin’?” Thibodeaux replied, “Mai, Boudreaux, your cat died.” Boudreaux was beside himself, first with grief, then with anger. “Thib,” he wailed, “You don’t just tell somebody flat out that their cat died. You got no sensitivity. You should ease into it. Like, you should say, ‘Boudreaux, your cat’s on the roof, but I’m pretty sure we can get him down.’ Then when I call the next day, you say, ‘We got your cat down, but he caught pneumonia. The vet’s pretty sure he’ll be OK.’ Then on the next call, you say, ‘The cat took a turn for the worse, but the vet’s giving him some powerful medicine.’ Then the next day, you finally say,’Boudreaux, we did all we could, but your cat passed on.’ That’s the way you handle bad news like this.”

Thibodeaux expressed his remorse for his insensitivity and vowed to be more thoughtful. Two days later, Boudreaux called again. “Thib, how’s my mother?” Thibodeaux replied in his kindest voice, “Boudreaux, your mother’s on the roof.” (more…)

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    About

    The director of the Sexual Medicine Center leaves penile implants behind, and launches a quest for knowledge about Artificial Intelligence, extended life, and the issues inside the health-care industry.

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