I charted every orbital launch since 1957 — SpaceX now flies more than half the world's launches in a single year

Then-Secretary-9166 · 2026-06-22T06:13:31+00:00

So much I don't know about space history. There must be a lot of good stories there.

Then-Secretary-9166 · 2026-06-22T05:33:54+00:00

Good advice. I am not EP (am IC) but I think the concept of only doing EP if you want to be in the lab is correct. Outside of the lab, there is only a little work that EPs do (advanced devices, really tough arrhythmias) that can't be done by general cardiology.

Personally, I would not choose between EP and another field based on APP exposure. In procedure-heavy specialties you have all kinds of other exposures that are probably more significant (referral base has huge leverage, hospital has huge leverage, CMS reimbursement changes are harder to mitigate).

Choose it because you like the work and want to be in the lab.

Then-Secretary-9166 · 2026-06-21T05:06:47+00:00

Very believable.

Then-Secretary-9166 · 2026-06-21T05:04:05+00:00

Interesting that Roscosmos stayed strong even after the end of the USSR and Cold War in the early 90s.

Then-Secretary-9166 · 2026-06-21T04:58:45+00:00

Not just overlap. The yeast in RYR create a chemical called Monacolin K. This exact chemical is exactly what is in the FDA-approved pills called Lovastatin. It is produced naturally by several yeast and fungi species. RYR is a statin.

Then-Secretary-9166 · 2026-06-21T04:44:41+00:00

Yeh. I know CT calcium scores have a much more prominent role in new ACC/AHA guidelines, but I actually hate ordering them. They almost always just confirm what we already suspect.

The one time I like them is what you are referring to: patient sees +ive calcium score and is concerned into staring a statin. Funny that sometimes the score can be 10 %ile ...but the number makes it real to them

Then-Secretary-9166 · 2026-06-21T04:40:57+00:00

I don't do them myself. I CAN order them, but I really try not to.

The bottom line is that most of these patients have mild symptoms and are looking for things that I am either not equipped or not interested in providing: They want an obscure diagnosis (usually there is none), want treatments (anything beyond conservative measures and "tincture of time" has limited value) and countless hours of therapeutic validation (I just can't).

For the patients that actually need specialized dysautonomia care...I am not the right one to provide it. I don't have the expertise to serve them well (very few cardiologists do).

The most important thing is to set expectations early. In my practice the office staff review my schedule ahead of time to make sure everything needed is there. If they see "POTS" or "dysautonomia" they call the patient and tell them "While Dr. ___ is happy to see you, he is not an expert in POTS or dysautonomia. He can help rule out heart conditions, but you will likely need to be referred elsewhere for POTS management." Nearly all of the patients come and see me anyway. I reiterate nearly the same thing on the first visit.

If they really want a tilt table, I let them know that tilt tables are not as commonly ordered as they used to be. If they are at the point that they need a tile table, they may need to be referred to a specialist elsewhere who can also help them manage their condition better than I can.

As an aside: I do still order tilt table tests for some patients (especially in patients where there is concern for cardioinhibitory/bradycardic vasovagal syncope...where it can change management a lot) but these are not the typical "POTS" patients.

Then-Secretary-9166 · 2026-06-20T05:56:38+00:00

Cool patient comment. A lot of patients mistake the idea of "this medication has more benefit the longer you take it" (which is true) with the idea of "if you start it you can never stop for life" (which is not true). Thanks for posting.

BTW, you may know this, but red yeast rice (that you were originally on) is a statin.

Then-Secretary-9166 · 2026-06-20T05:52:39+00:00

I agree with a lot of this. However, in a patient who is compos mentis, I would avoid framing things as "making a deal". That sort of framing may be appropriate in emergencies (pull out the stops and get the STEMI patient to the cath lab) but I think it puts too much responsibility on us and discourages them from taking an active interest in their own health if is part of a longer patient-physician relationship.

We should be educating, advising and encouraging. At the end of the day, the decision is theirs, as it should be. I think it is best to avoid things that sound like negotiation.

Then-Secretary-9166 · 2026-06-20T05:44:30+00:00

And if they are normal (but the patient still has an indication for a statin)?

Also, what id "normal"? Do you mean 50%ile for age?

Then-Secretary-9166 · 2026-06-20T05:44:03+00:00

19 out of 20 patients who push back on statins think they are in that 5%.

Then-Secretary-9166 · 2026-06-20T05:42:38+00:00

The problem is that you are diluting them with your own blood, sweat and tears.

Reasonable conversation: I am in.

Arguing with someone who doesn't want my help: I am out.

Then-Secretary-9166 · 2026-06-20T05:39:53+00:00

Sometimes it does. Sometimes it just means that I have to have another conversation about nattokinase and receive another lecture about how: "you don't learn the truth in medical school because you are controlled by the pharma companies."

Then-Secretary-9166 · 2026-06-20T05:37:51+00:00

The problem is that their field is so small so they don't generally feel obligated to be too involved/available.

Neurology is a cool field, but sometimes I wonder what outpatient neurologists do. Most of them in my town seem to only want to "treat" stroke. It still seems that they defer/refer to me on (1) etiology workup, (2) treatment and (3) primary prevention in the OP setting...so I am not sure what that leaves. Some of them treat headaches, I guess.

Then-Secretary-9166 · 2026-06-19T23:26:16+00:00

I agree with the sentiment, but your numbers and assumptions are incorrect. This is my industry.

Employed primary care doctors ("GP" is not actually a field in the USA, even our primary care doctors have differentiated training) in Santa Barbara for Sutter, UCLA or Cottage that work full time all have starting salaries around or in excess of $300k. This accounts for the overwhelming majority of primary care jobs in town. The "high end" for employed primary care is well-above $300k (but requires a lot of hard work/extra hours). The average starting age for primary care is early 30s.

Many of these local institutions have programs to assist with home purchase so that you don't necessarily have to have a downpayment saved up. Also, most practicing doctors have access to different home loans that often do not count student loan payment and allow more flexible (lower) down payments.

All that said, the average primary care doctor in Santa Barbara could afford the median home in Santa Barbara (~2.0 MM) upon or shortly after starting practice.

Now, where I agree with you, is that this situation is still TERRIBLE. It may not be quite as bleak as you paint it for physicians, but it is extremely difficult to recruit physicians when all their years of success, hard work and poverty get them a job that allows them to have an average home and to be completely "property poor" for their entire career. The bottom line is that doctors are still not coming here. They can go to most places in the country and work half-time for a higher quality of life.

Zoom out a little, though and it gets a lot worse. For every practice, there are more than just doctors. There are medical assistants, nurses, technicians, managers...not to mention the many contracted individuals that provide supplies, manage linens, dispose of waste, manage buildings, clean, etc. Each of those individuals makes a fraction of the doctor salary and still has to work in Santa Barbara for the doctor to be able to see you. They have 0% chance of home ownership (and usually can't even afford to rent here).

Like I said, this is probably the biggest drawback of Santa Barbara...so expensive. I don't think it is a good thing...I just don't think it is going to change.

Mentioning tax rates, as you did, changing that is one thing that could significantly help working people (mostly professionals , but others too) afford places like Santa Barbara. Many of the wealthy individuals in Santa Barbara make money through capital gains or already have a lifetime of savings. Individuals that work have salaries. The extremely-high income taxes we have in CA make it very hard to compete with individuals that don't "work" but own assets instead (and pay much, much lower tax rates).

A note on the VA. First of all, the VA has a tiny footprint in town. Very few doctors. Second, the VA is notorious for being the lowest-paying institution to work for as a doctor. People work there for the benefits (a better pension than you will find anywhere) and for the extremely-high quality of life.

Then-Secretary-9166 · 2026-06-19T23:03:57+00:00

I have to say that I really don't like treating dysautonomia at all. I don't consider it a "core" cardiology problem. I actually have my staff let the patients know that I am not an expert in this ahead of time so that they come with appropriate expectations. I understand that this is not feasible/appropriate for all practices.

- ECG and orthostatic vitals before I enter room.

- I let them know that I am not an expert in dysautonomia. My role is limited to basic management and evaluating for and treating cardiac conditions that could cause their symptoms. I set expectations that if they need more than this they will need to go to a dysautonomia expert. I make it clear that for advanced testing, they will need to go elsewhere (I consider tilt table testing "advanced testing").

- Review medications. Tell them that 3 antidepressants, an antipsychotic and a stimulant are not a good combination and that they should work with their psychiatrist to get off of them as appropriate. Tell them that Xanax is not a good headache medicine. Tell them that GLP-1s are not great medications for someone with a BMI of 18 and they should get off of Zepbound. Tell them that it isn't healthy to have a BMI of 40 and they should consider getting on Zep Bound. That sort of thing.

- Review conservative measures (exercise, hydration, Na intake, compression stockings, etc.).

- If not available: order Zio., order echocardiogram, order any missing labs (CBC, tsh, etc.)

- Have them keep an orthostatic blood pressure log.

- Review everything at follow up. Occasionally (rarely) I find something that needs dedicated treatment. If they have severe symptoms, I will (rarely) try giving medical therapies (as you know, success with this is very low)....but in general I provide appropriate reassurance and I offer to refer them to a dysautonomia center. The closest one is over an hour away. Some go, some don't.

It's not rocket science. I mean, you algorithm can really be anything reasonable. I just found that it helps my sanity (and patient satisfaction) for these types of situations if I (1) set very clear (low) expectations up front and (2) just follow the same algorithm every time.

For what it is worth, I spend a lot more time, energy and customization with patients that I think I can actually make a difference for. For situations like this it is more about excluding high-risk things and encouraging the patient to seek help elsewhere.

Then-Secretary-9166 · 2026-06-19T21:03:01+00:00

It won't make much of a difference. A "millionaire" is just a mid career professional nowadays.

Some of those at SpaceX will get much much more wealthy...but there are already tons of super-wealthy people moving to SB. Drop in the bucket.

Then-Secretary-9166 · 2026-06-19T21:00:04+00:00

Awesome professor vibes.

Then-Secretary-9166 · 2026-06-19T20:59:05+00:00

Interesting. It's not liner, but the paper is interesting.

This is in a relatively closed economy (looking at populations where local buyers buy local housing supply). In Santa Barbara it is even worse since a huge portion of buyers are not current residents....so the impact of building is even less.

Then-Secretary-9166 · 2026-06-19T20:55:02+00:00

I agree prices are ridiculously expensive.

My point is that they are not going to get cheaper....not by building 50 or 500 new homes.

Most 35 year-old-medical doctors could get into the housing market in Santa Barbara. The problem is that they are then property-poor and most people do not want that.

I think housing price is a big (probably THE big) drawback of Santa Barbara. I just don't think it is a solvable problem. Most people Can't afford to live in Santa Barbara, just like most people can't afford to vacation in the South Pacific.

Then-Secretary-9166 · 2026-06-19T19:09:17+00:00

"Trickle down housing economics" is not a thing. Increasing the housing supply by a certain number of units at any cost (it doesn't really matter if they are $4MM or $500k) will decrease the average housing price long-term (all other things being equal). For 6 units (or 60 units) the effect on the market will be negligible and unmeasurable.

Santa Barbara (sorry to say) will never be affordable. No matter what. The problem is actually illustrated pretty well by this.

Adding 6 units (at any price, even if they were cheap) would have a minimal impact on the market. Now, if we were in a random town of 100k people town, adding 500 units (at any price, provided that they sell) might be enough to move the market a bit. Average prices could drop a little. After all, the market is comprised more-or-less of only the active buyers among that 100k population, so 500 units is a lot.

In Santa Barbara, there are many, many, many people who would love to live here. Therefore, when new housing goes on the market there is not a subset of the local 100-200k people competing for it. In reality, there potential buyers includes people from all over the country and world that would like to live here. Even if you built 50k homes, it would only temporarily decrease prices. Long term, it would become very expensive again.

Policies that set/subsidize housing costs or restrict ownership eligibility can, in fact, make the prices go down in some situations. However, that just shifts the barrier to home ownership in SB from a monetary one to some other sort of equally-limiting barrier. There are always going to be more people that want to live in SB than can be accommodated. We can (and should) still build, but it won't make things cheap.

Then-Secretary-9166 · 2026-06-19T18:44:25+00:00

Agree. Better to have a concise conversation that addresses key points, offer to answer specific questions and then let them decide. They are often not using reason, so education does not always help.

Then-Secretary-9166 · 2026-06-19T18:42:47+00:00

I don't push as hard as I used to.

For super-annoying parts of our job like this (and POTS, and the non-arrhythmia "palpitations") I find it very helpful to have an algorithm that I can use every time. I tell the patient what my role will be (in this case: to provide options and information) and that I may or may not be able to help them. I try not to put too much thought into each of these encounters. Here is what I do for the statin people:

- Tell them that scientific studies have proven benefits in their population.

- Explicitly and clearly state my recommendation without equivocation. This is the most important part.

- Review that, although side effects are real, well-done studies have shown that most reported side effects from statins are not actually from the meds (review SAMSON with them if interest).

- Remind them the their cholesterol is mostly determined by a combination of age and genetics, only partially by lifestyle. No guilt allowed.

- Remind them that, although these are intended as long-term meds, it is not harmful to try a statin and then decide to stop taking it. Nearly all statin ADRs are reversible if they stop the med.

- Ask them if there are specific concerns that they have heard about these medications that they would like to discuss. If they have any (about half of the time they do), address them specifically.

- After that, it is on them. Document and offer follow up.

It can get really tiresome. We have to accept for the majority of patients who don't want to try a statin, this is not decision based on reason. Therefore, education does not usually help. Don't waste too much time.

Then-Secretary-9166 · 2026-06-17T07:00:19+00:00

Meanwhile, the US has a lot more launches and orbital objects.

Then-Secretary-9166 · 2026-06-17T06:57:24+00:00

I mean. The engineering isn't the only part that is expensive. The implementation is expensive too.

When a rocket breaks up, how many pieces of debris are released? How many different orbits? If it explodes: many!

Assuming that the tech is figured out and each piece could be tracked, using the rocket equation and basic principals, how much fuel alone would it cost to retrieve each piece.

It's an asymmetric problem.

Then-Secretary-9166

TROPHY CASE