This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.
Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.
We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:
-
Shaming.
-
Attempting to 'build consensus' or enforce ideological conformity.
-
Making sweeping generalizations to vilify a group you dislike.
-
Recruiting for a cause.
-
Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.
In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:
-
Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.
-
Be as precise and charitable as you can. Don't paraphrase unflatteringly.
-
Don't imply that someone said something they did not say, even if you think it follows from what they said.
-
Write like everyone is reading and you want them to be included in the discussion.
On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.
Jump in the discussion.
No email address required.
Notes -
We should probably figure out how to hyper-specialize people by the age of five
It’s known that to be the best chess player or instrumentalist you need to start at a young age, with ~5 being a common age to start for the best in the world. If you’re a chess prodigy or world class cellist, you hyperfocus on these skills throughout your childhood, and it’s accepted that you sacrifice normal schooling and extra-curriculars to pursue your skill. But why do we only allow this for the most worthless skills? There’s nothing unique about chess or cello — to be the best at any skill you need to start at around five. The Olympian Yuto Horigome started skateboarding before he could walk; Mark Zuckerberg started making apps before he was a teenager; Noam Chomsky joined political discussions as a child when accompanying his father to the newspaper stand; Linda Ronstadt learned all the genres of music she would later perform before 10; Von Neumann and Mozart had legendary childhood specializations.
But every skill is like this. If we want the best therapists, they need to be practicing conversation and understanding people by five, hours every day. If we want the best philosophers or practical thinkers, they need to be arguing and testing themselves by five, hours every day. Similar for movie directors, novelists, designers. This even applies to skills that are essential but not economical, like being a good mother, or being a good friend. And to skills that are essential for implementing political change, like writers and representatives and propagandists and moralists. Imagine if your teacher in school were a master at motivating, disciplining, and explaining, and had training in these skills like Mozart with music? Imagine if everyone’s gym teacher or exercise trainer had training to be like Jocko Willick and Tony Robbins? How much more accurate would your doctor’s diagnosis be if he had trained in medicine since five, instead of 21? (By five, a child can learn 5 different languages without accent. By 13, Magnus Carlsen’s skill equaled that of a 40yo Garry Kasparov). We all enjoy Scott’s writings — now imagine a version of Scott that is a better writer, specialized in writing, who outputs even more?
I think we are wasting enormous potential for social improvement by corralling every child into the same mandatory (and inefficient) skill-training, instead of specializing them at an early age. Would Mozart be more valuable for knowing biology? What if Caravaggio knew calculus? What if Einstein took a Spanish class for 2000 precious childhood hours? What if George Washington knew what an atom was? We would have just made them worse, and the world worse by consequence. We are raising up a generation of woefully mid professionals — a whole society of sub-perfect workers across every industry. Everyone a jack of trades, master of none.
And this is more serious than just “they aren’t as good”. It’s also that they can’t perform as many work iterations in a day, their working years are shorter, and they are more stressed (which has multigenerational effects). That little kid you see at the Chinese restaurant ringing up the order for his parents hasn’t just learned to perform that specific skill well, he is also able to perform it for more hours in the day, he can start at a younger age, and he incurs less of a stress cost. That means he is happier, which means you get happier, and it also means his stress is reduced, which means his kid is healthier, and so the cycle goes on. There’s no reason why this shouldn’t apply to a number of industries.
Lastly, I wonder if the “wasteful hobby specialization” among Western youth isn’t due to our denial of their specialization instinct. Boys love becoming experts at something, and today they become experts at video games, or their hair, or some entertainment product, or memes. We have excluded them from any useful specialization, and so they specialize in uselessness, forming a perverse “pair-bond” with a hobby instead of a career. This is a grave evil. How many Asmongolds have we brought into the world, experts at a fantasy world because they have been denied real life’s RPG? This element can’t be ignored. A world where everyone you meet is as passionate in their work as a WoW player would be close to perfection.
It would seem there are some things that benefit from a focus on hyperspecialization at an early age, and some things that don't.
Chess and gymnastics? Absolutely. Medicine or personal training? Not so much.
Totally agree. The practice of Medicine just isn't that deep. It's some pattern recognition (sick / not sick), extracting the right features from the patient (patient says "man my chest feels weird" and figuring out if they mean chest pain, shortness of breath, etc.), heuristics (this cluster of signs and symptoms matches this), and then a short decision tree (D-dimer --> CTA).
It turns out that at the end of that relatively shallow decision tree, if you can't figure it out, 99% of the time it's not because there's a Dr. House moment waiting on the other side, it's because nobody knows. Sometimes that's -- well we've discovered that you have stage IV pancreatic cancer. Here's a clinical trial but otherwise that's the end of human knowledge. Sometimes it's "well, I don't know why your chest feels weird, but we've ruled out the bad stuff so let us know if it gets worse!".
And obviously there's bad doctors who can't go through that without fucking something up along the way. Maybe there's even a lot of them? But outside of a small handful of surgical subspecialties (like you do open heart surgery on babies), I would guess that there's not much difference between an 90th percentile doctor and a 99th percentile doctor -- and almost certainly not between 99th percentile and 99.9th percentile.
As is usual when this kinda thing comes up, time for me to jump in and defend the field.
Doing medicine isn't what people expect.
For most specialties the hard part isn't knowing what to do for any specific patient (outside of fields with technical skills like surgery, or fuzzier guidelines with broader knowledge bases like Psychiatry), it's balancing all of the tensions of medicine. Some things are complicated. Radiology needs to know everyone else's shit. Neurology involves tough, at times technically challenging physical exams that are actually meaningful for diagnosis.
However most patients really only interact with primary care or basic bitch outpatient medicine, and then they go "I can toss this shit into google and get myself the diagnosis and the management." Yeah you can, we get paid for knowing the situations where the first hit on google is wrong, but that doesn't seem to excite people so let's talk about the other shit.
The hard parts of medicine include the long training period, brutal hours even as an attending physician, working nights, weekends, holidays, and 24+ hours in a row. Managing multiple types of intensely dysfunctional bureaucracy (the government, insurance, the hospital system, medical records), dealing with constant death and bad outcomes, writing notes that need to be clear for whoever is coming on to replace you and will protect you from getting sued if you fuck up, or if you don't, and doing all of this an environment where people are screaming, constantly trying to get your attention, and with a chair and keyboard that a homeless shelter would reject for being too gross.
It's the summation of requirements, including empathy and related fatigue and burnout, and also the necessary customer service/patient interaction skills, and the need to be doing stuff other than your work constantly like basic research and the need to continue to study continuously every year for the rest of your career...
Most doctors are teachers, researchers, and all kinds of other shit in addition to the doctor.
Balancing all this stuff without becoming an alcoholic or killing is absolutely a challenge and well, we see high rates of both of those things in the MD population.
I can't really think of many jobs that combine reasonably high intelligence, massively high work ethic, significant administrative burden, massive hours, catastrophically poor resources and equally disruptive customer service needs.
Takes a lot to balance.
To put some context in, most jobs involve things like lunch breaks and misc. downtime during the day where you can shoot the shit, unwind, and refocus. It's extremely common for a physician to work 16+ hours with barely enough downtime to piss and shove a flaccid banana down your throat like a two dollar hooker.
That's absolutely foreign to most sectors of the economy (including nursing).
I'll note once again that the way to fix "My job is hard mostly because there are so few of us that we have to work long shifts with many patients and it is exhausting" is to lower standards and introduce more workers into the job, making it easier and reducing the standard of quality needed to perform the job, which would allow those lower standard workers to perform at the necessary level.
What you're describing is the inefficiency of a medieval guild system engaging in rent seeking.
No no, it's not simple like that. For one, patient handoffs are so dangerous that one of the reasons we work stupidly long shifts is because someone so sleep deprived they are drunk is safer than having someone else come in for a complicated patient.
For another, we've been part of a multi-decade long project to remove the "guild" and reduce training requirements to bring in replacements. When I first started complaining about this the jury was still out, it's back - and it doesn't work. NPs and PAs have much less exhaustive training requirements and have been in place and growing for years. They suck. They don't save any money because increased testing costs money (it's just a transfer from the doctor to the hospital) and the increased testing and consults create burdens any everyone else. NPs and PAs just consult everything, overloading the sub-specialists even more. Radiology is near breaking from unnecessary testing.
Train more doctors you say. Sure, fine. Except that that takes a long time, requires professors and other resources (we don't have enough cadavers for anatomy lab already) and things like surgery specialties don't have enough procedures to adequately train in a timely fashion. You need to see a variety of cases and patients and advancements in medical care have made this harder (which is mostly good but not for this specific issue).
Import foreign doctors you say. Okay better. Yes most foreign doctors are very much not as good. They are also mostly good enough, especially after retraining. But then you are stealing doctors from other countries, which you know, need them. You are also stealing jobs and wealth from Americans, which is sometimes justified but most of the people making this complaint don't like it when it happens to them or people they like.
In the longer term you'd kill Americans going into medicine, and Americans going into medicine and our absurd wealth is responsible for a huge amount of medical advancement.
Even if you fix the hours worked issue (which for most specialties is a problem during training more than anything), you won't remove the other major causes of burnout which include administrative burden, malpractice, American patients, fucking dealing with dying people, and so on.
How do you handle this when you do eventually have to switch off? I'm imaging trying to hand off a tricky piece of software to a new team every 24 hours - I guess a short interview plus some notes? How complicated is a complicated patient?
As is usual for us there's a whole bunch of different ways this happens. I'm going to simplify some of this for ease of reading.
Surgical rounding team (ex: post-op patients). A team of 4 residents manages 80 post-op patients they know nothing about. Some of them are very complicated, but they are complicated in a relatively small number of ways that can be picked up and put down as needed. Someone prints out a hand out from the computer that tells the residents everything they should need to know, which is generated automatically. Some particularly weird situations get handed off verbally. Nobody remembers what was said. Every X amount of hours the team changes over or new people come on and off. Shift times are generally vague, they exist on paper but emergencies are constantly happening and surgeries run long. One intern (first year resident) who doesn't really know anything about anything is hypothetically in charge of making sure floor patients don't die, while everyone else hides in the OR as much as possible. Handoff risk: low-to medium.
Radiology. You finish your worklist and everything is done. No handover. Ish. Handoff risk: low.
Medical floors. During the day 12 residents manage 120 patients. 2 them stay overnight or two fresh people going on to work 16 hour nights for a week straight. If something happens overnight you hope it's someone you know, otherwise you look at the chart, the notes are good because it's medicine, ideally if something complicated is expected to happen the day team told you about it. Sometimes they don't or it's a new problem. Fuck. Also the nurse will call you at 10pm asking for an update on the discharge plan because the family asked. You don't know because you've never met this patient before and never will. Handoff risk: normally low-to medium, but sometimes high.
Surgery. You don't hand off, you can't. Handoff risk: incredibly high, but because the docs stay until they are done, low. If the surgery has NPs/PAs involved (most typically Anesthesia). Can be hugely problematic since they don't have responsibility and try to stick with shift times.
Surgical/Medical ICU. Patients have failures of multiple organ systems. Documentation is good and on paper tells you what is up. In real life you lose track of how often fluid or blood products went in. Complicated stuff happens constantly. You takeover a patient and have to tell their kids and their mom is going to die. You've never meet the mom. Actually that was the other patient. This person is a dad and is fine. Fuck. Okay now someone else is dying. How many units did the first person get again? You've worked 90 hours a week for the last two weeks. Handoff risk: fuck my life.
Obviously I'm making this sound more ridiculous than it is for the most part, but in real life we do endeavor to write good documentation that supposedly allows an oncoming doctor to pick up the patient, we have handoff reports with automatically summarized information, and a verbal signout (or written via computer for like a weekend daytime doc on a psych unit) happens. But the reality and complexity of the situation often gets in the way.
Lots of research has been done to get this as safe as possible, and it works to some extent, but you can't substitute for actually knowing the patient and being the one who did the surgery or admitted them last week.
Thank you very much for the explanation.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link