Throwaway05
1mo ago
Scott promotes CBT-i apps as a good way of doing CBT-i. One for the medico-commies - the best CBT-i apps (apart from ludicrously expensive prescription-only ones) were developed by the VA, and are free to users as a result.
Endorse this!
The biggest problem with CBT-I is that it can be hard to find someone who does it and even harder to find someone in your price range. An app will never be as good, but access is access and free is free.
Throwaway05
1mo ago
The U.S. medical education consists of 4 years of undergrad (which is a mash of yes you absolutely need to take this in advance (basic sciences), eh it is going to be hard without it (learning biochem for the first time in med school is gonna suck) to totally pointless (yes working in a soup kitchen twice a week for three years is totally helping me be a better doctor. Then you do medical school which is four years*. Then you do residency which is ~3-7 years, and sometimes fellowship which is 0-X years.
Finally you are an independent practicing physician.
Here's the thing. The process is confusing. An intern outranks a med student. A fourth year medical student and a first year resident are super different - one is in school, one is an employee....but depending on the program and student they can be doing the exact same thing and have similar knowledge levels.
Coverage in the U.S. of medical scandals almost always mixes up multiple parts of this and misses things like - a first and second year medical student is mostly in lecture and a third and fourth year student is mostly in the hospital seeing and to some extent treating patients. Sure looks like a full on doctor to most patients!
It seems pretty likely that various interests in this story are intentionally or unintentionally mixing some of this up.
*Some path exist for changing these time lines but they are rare.
Throwaway05
1mo ago
Saying most effective in medicine is probably overstating my case, although if asked to justify that I could easily point to adherence issues being the primary point of failure for CBT-I and say something like "if only the patients actually followed the treatment it would work!" which is absolutely true but is a bit dickish.
If you look at your link in the key points section it says things like "CBT-I across several delivery modes improves global and sleep outcomes compared with passive control in the general adult population (moderate strength evidence). Evidence was insufficient to assess adverse effects of CBT-I."
Keep in mind that that the quotes you pulled out are looking at individual sleep metrics as opposed to global sleep outcomes. It is not unreasonable for a treatment method to have more impact on say sleep onset than sleep maintenance.
The AAFP guidelines note:
"Psychological interventions included stimulus control, sleep restriction, relaxation techniques, sleep hygiene education, and CBT for insomnia. CBT for insomnia is a combination of cognitive therapy, behavioral interventions (i.e., sleep restriction and stimulus control), and education (i.e., sleep hygiene). There were insufficient data to draw conclusions on the effectiveness of specific interventions alone (e.g., stimulus control, sleep restriction, relaxation techniques), but based on a meta-analysis of 20 trials, CBT for insomnia improved global and sleep outcomes in the general adult population."
Which is fair and measured.
That said if you change my quoted statement to "CBT-I is the most effective treatment modality for sleep" it becomes significantly more relevant and strictly speaking more accurate. All of the guidelines recommend CBT-I over medication in most circumstances because of severe safety/benefit issues with medication management.
Throwaway05
1mo ago
Looking at our mundane problems and existential threats (ex: climate change) the biggest problem is people not thinking long term.
Inheritance helps force people to think longer term than their own lives.
That has value!
Throwaway05
1mo ago
Agree with this.
I know some people who point to the OJ chase or trial as one of their first concrete memories.
Nothing since comes anywhere close, not even any of the BLM adjacent trials.
Throwaway05
1mo ago
Rather, the league and the Browns and Watson came to an agreement to let Watson fake an injury, collect his checks, and the Browns are able to recoup some cap room through an insurance policy.
I feel like this requires a level of planning and intellect which is essentially never observed in the league.
Throwaway05
1mo ago
With the exception of Scrubs it's probably the best medical TV show period (in terms of vibe capturing and medical accuracy).
And yes it captures the reality. So much fighting about if kidney labs are racist.
Throwaway05
1mo ago
Absolutely true to life though! Some mostly not burnt out and energetic trainee yelling at a more junior trainee who is just trying to not die and then herself getting yelled at by a much more burnt out supervisor. This is life!
The resolution of the arc you are thinking about is done very well, don't worry.
And yes practical experience of medicine can be very black pilling - homeless, drug users, illegal immigrants...but then also fat people, people who refuse to take their meds or listen to other advice...it gets murky very quickly.
Throwaway05
1mo ago
Arcane is very clearly about class struggle and has a lot of woke casting and other type things, but it is also simply good, and is able to do the class struggle through enough of a historical lens that it doesn't run into modern woke issues.
The Pitt recently finished its first season and is an excellent medical drama. Some of the doctors get mega preachy and at times their is some serious "very special episode" energy but it's overall very good and anyone who has worked in those settings know that's how a lot of people talk.
Throwaway05
1mo ago
Here you sometimes hear of people suddenly committing murder---but in a bizarre way, like randomly stabbing a girl, or randomly stabbing a woman, or a bunch of people, or doing the truck ramming thing then leaping out of said murder truck and, again, stabbing. The stabbing isn't that surprising (as a technique I mean) since knives, unlike guns, are readily available. What's surprising is the sudden randomness.
You'd be surprised how common this is in the U.S. actually.
Background: I spent some time working clinically in corrections.
A number of things need to go wrong for someone to engage in egregiously violent behavior (this is most studied when it comes to serial killers but applies all the way down). Society is filled with people who have things like intellectual reserve, good impulse control, social resources, appropriate time preference, and so on but have the underlying psychiatric and psychological temperament to do really bad shit. These people usaully end up run of the mill shitty people or things like your classic corporate raider sociopath.
In the U.S. (and many other countries with a significant amount of the criminal element) you see people who are missing one or more of the protective factors sliding into the criminal class, getting into trouble early, and so on. This knocks off a lot of people who would be doing what you describe and puts them in another bucket early.
The number of people who have had thoughts about killing others for little reason is shocking, but most are somewhat repressed by social pressure, fear of consequence, and adequate impulse control... but they still have those thoughts. Again the U.S. has mechanisms like the criminal underclass which lets people with interest get it out and get in trouble etc, but fundamentally a lot of people are walking around with "what if I stabbed people" and absent opportunity to misbehave they don't unless something else goes wrong.
In the U.S. usually this is things like said criminal stuff, substance problems, medical/psychiatric issues or sufficient life stressors. I imagine Japan is similar.
Salarymen wonders his whole life what killing people would be like, but likes the "deal" society gives him enough to maintain his other psychological needs so he doesn't do it. Then he gets fired....and well why not?
Now Japanese police have their issues so it is certainly possible that is what is going on here, but my suspicion is that modern Japanese society keeps these people buttoned up more adequately than the U.S. and sometimes you run into the rare thing that causes them to snap and check out what they've always thought about.
About 3% of the male population has antisocial personality disorder (ASPD). Most of these people would kill if the right situation came up, but it doesn't...most of the time.
Plenty of people don't really care about others adequately. Some of this is clearly pathology (think stereotype of a gangbanger - that's gotta be ASPD). Some of it is in-group outgroup bias type stuff. Some of it is things like woke advocates whose virtual signaling overtakes actual virtue. This is a spectrum that applies to a lotttttt of people in some way or another. Get far enough down the spectrum and have anything that makes you ask certain questions, and you have random killer in the making waiting for the "right" change in their life or stressor.
Throwaway05
2mo ago
In other countries prison is bad because the guards are bad and don't care about the prisoners.
In the U.S. the prisons are bad because they are filled with American prisoners. Somehow this is often worse. Additionally in the U.S. guards are frequently prevented from "managing" the prison which can cause unnecessary problems.
Throwaway05
2mo ago
Despite online feminist complaints the biggest users of "females" to describe women (well outside of scientific literature anyway) is the American Black community.
Keep this in mind when people complain about use of "female" and accuse nerdy white males of doing it.
Throwaway05
2mo ago
Sometimes I look at this stuff and wonder if this what it was like to be pro Civil-Rights back in the day. Just watching all of these pillars of society being told "don't be racist" and hearing "no" in response while much of the influential nod their heads along like it's a good thing.
It is a chilling feeling.
Throwaway05
2mo ago
Parts of the show are intentionally cringe, as they are satirizing corporate America's choices, abuses, and aesthetic.
Part of the show is enjoying the severed characters rolling with corporate bullshit because they don't know any better and then later going...wait...this is so stupid.
Throwaway05
2mo ago
calibrated do this a lot in general and VERY STRONGLY not his particular topic.
calibrated do this a lot in general and VERY STRONGLY not (on t)his particular topic.
aka covid broke people's brains + me making typos
Throwaway05
2mo ago
Probably stems from purchasing like baked goods?
Throwaway05
2mo ago
I mean I'm sure not everyone did this but my cohort of family and professional contacts which is typically smart, educated, but not particularly politically informed or calibrated do this a lot in general and VERY STRONGLY not his particular topic.
Throwaway05
2mo ago
I very much do not believe it's a left or right thing. Some people blow with the wind.
Oh yeah for sure, not saying one side has a monopoly on this. The leftist-doublethink seems to magnify though. "No not literally defund the police" "wait yes literally" "no that's ridiculous."
Throwaway05
2mo ago
Your story about "Daily Kos grandmas" who literally don't remember what they used to believe in is of course nonsense (just like all those Never Trumpers who are now MAGAs do, in fact, remember what they used to believe in). People remember, they just rationalize it or else they develop coping mechanisms for the cognitive dissonance.
I'm not sure this is the case. The one that sticks out to me the most is the initial response to COVID. So many people don't remember the early days where believing in COVID was racist and bad. They just swapped back and if you try and remind them now you'll get a lot of "holy shit I forgot about that" or "no way!!!!!!"
Throwaway05
2mo ago
The Great Books program is specifically supposed to be a replacement for a traditional college curriculum in which you learn things from primary sources in and see Western Civilization being shown off.
Much of what you ask for is contra to the mission - if you made the changes you are suggesting it would be something else.
It's like getting annoyed at Western Canon lists for not having Eastern material.
Throwaway05
2mo ago
Rideshare apps completely slaughtered traditional cabs and cabbies, especially the racket of medallions. Sucks to be some poor cabbie who saved up for years to get his own medallion only to have his entire investment torpedoed.
It's worth noting that one of the main reasons for this transition is the sheer depth of poor quality service and outright fraud associated with the old yellow cab model. It truly was unbelievably brazen and hard to convey if you didn't live through it.
Now back to my regularly scheduled defense of doctorhood.
- We don't have a MD stranglehold in the US anymore.
There's a range, everything from pretty much parity (MD, DO, MBBS) to obviously inferior but often not in a way that patients notice (NP, PA, Psychology Prescribing), to actually quite dangerous (Chiropractors, Naturopaths, Alternative Medicine providers - some of these have full or mostly full rights in some settings/states).
You see all kinds of tensions associated with these options and I know plenty of doctors who have lost out on jobs to one of the others, but in terms of improving care well... we have evidence it makes it worse, and we have evidence that it saves no money or even costs money (example: unnecessary testing).
Many of physician job responsibilities extend outside of direct clinical work and you can't replace them adequately with the others (they make better administrators, managers, and executives). Others also can't fulfill the educator roles or research roles.
Most doctors do some form of teaching and research and essentially all of them have done both at some points in their career.
That kinda stuff doesn't track well on research into these matters but is important. Likewise physicians pick up the slack in the way the the others (especially nurses) do not.
We've been running a natural experiment for awhile now and having growing evidence of that gap.
- Again, physicians do more than you think. Carpal tunnel doctor actually needs to be able to know the physiology medications, and so on. Emergency overnight staff like a surgeon or surgical resident need to be able to cover part of the work of others otherwise you'll need full time overnight staff that you might not otherwise....a million things like this means the training is relevant and necessary.
You also have to consider that if you box someone into say total knees from the beginning then they have to do that 100% of the time they can't switch to another specialty to avoid burnout or other things like that. It's very common for surgeons to switch around and extend the longevity of their careers by doing that sort of stuff.
Throwaway05
2mo ago
I think this is easy to say in principle but if you look at how successful identity politics were at taking over such a large part of the public discourse and intellectual framework...well we don't need to speculate what happens in practice, which is that some people figure it out (cough cough looks around) but most don't and it isn't enough.
Moral panics and crowd hysteria and Hersey have always been part of human culture. Expecting that to not be the case is foolhardy, even if we can feel comfortable tossing out labels about lack of ethics or whatever.
Throwaway05
2mo ago
I think the flip side of this is important to hold onto when it comes to why so many people hate medicine.
For most people, the most important things that happen in their lives (aka life and death and the prevention of the latter) involve interaction with medicine.
When it goes poorly, that sticks and it hurts. If your mother passed away as a complication from a clot treatment (assuming ischemic stroke) you'd hate that intervention, and maybe even your doctor and healthcare. Maybe you have the wherewithal to know that's an emotional response - but it would still hurt and feel that way.
One invalidating interaction, one missed diagnosis or bad outcome...and suddenly the emotional connection to the idea that the system is useless and needs to be burned down is established. It's really hard to avoid and generates a lot of the ill feeling.
The opposite happens too! But you only have to get it wrong once and that's not avoidable.
Throwaway05
2mo ago
EDIT: It's true that Trump also genuinely has a habit of saying stuff he doesn't mean seriously, like locking up Hillary Clinton.
I suspect you was serious about that but that he actually listened when people tossed out the arguments against it (like "we dont do that so they don't do it to you").
Now it seems like they defected anyway... but I do believe in his original intent on that one.
Later you can make builds that rely less on this, but I found it helpful to know that one of the main developers is a Sekiro speed runner - the game is 100% designed around the realtime inputs. Once you give up and embrace that (and get gud) it becomes more enjoyable.
At least, that's the process I went through.
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