site banner
PaperclipPerfector  5mo ago (text post)   30413 thread views

Culture War Roundup for the week of November 18, 2024

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.

5
Top Bottom Old Controversial Comments
Jump in the discussion.

No email address required.

You Did It To Yourself

Again, the endless seething by doctors over their ongoing replacement by “physician associates/assistants” (PAs) and “nurse practitioners” (NPs) rears its head. The many concerns that physicians have about NP/PAs are, of course, entirely valid: they’re often stupid, low-IQ incompetents who have completed the intellectual equivalent of an associates degree and who are now trusted with the lives of people who think they’re being cared for by actual doctors.

Story after story describes the genuinely sad and infuriating consequences of hiring PAs, from grandparents robbed of their final years with their families to actual young people losing 50+ QALYs because some imbecile play-acting at medicine misdiagnoses a blood clot as “anxiety”. Online, doctors rightfully despair about what NPs are doing to patient care and to their own ability to do their jobs.

But there’s a grand irony to the nurse practitioner crisis, which is that it is entirely the making of doctors themselves. If doctors had not established a regulatory cartel governing their own profession, the demand that created the nurse practitioner would not exist. The market provides, and the market demanded healthcare workers who did the job of doctors in numbers greater than doctors themselves were willing to train, educate and (to a significant extent) tolerate due to wage pressure. It is a well-known joke in medical circles that doctors often have a poor knowledge of economics and make poor investment decisions. This is one of them; the market invented the nurse practitioner because it had to. Now all of us face the consequences.

I had multiple friends who attempted to get into medical school. Some succeeded, some failed. All who tried were objectively intelligent (you don’t need to be 130+ IQ to be a doctor, sorry) and hard working. The reason those who failed did so was because they lacked obsessive overachiever extracurriculars, or were outcompeted by those who were unnecessarily smarter than themselves (there is also AA, especially in the US, but that’s a discussion we have often here and I would rather this not get sidetracked).

The problem goes something like this: smart and capable people who just missed out on being doctors (say the 80th to 90th percentile of decent medical school candidates, if the 90th to the 100th percentile are those who are actually admitted) don’t become NPs/PAs. This is because being an NP/PA is considered a low-status job in PMC circles; not merely lower status than being a doctor, but lower status than being an engineer, a lawyer, a banker, a consultant, an accountant, a mid-level federal government employee, a hospital administrator, a B2B tech salesman etc, even if the pay is often similar. To become a PA as a native born member of the middle / upper middle class is to broadcast to the world, to every single person you meet, that you couldn’t become a doctor (this isn’t necessarily true, of course). This means that NPs and PAs aren’t merely doctor-standard people with less training, they’re from a much lower stratum of society, intellectually deficient and completely unsuited to being substitute doctors (the work of whom, again, doesn’t require any kind of exceptional intelligence, but it does require a little). Almost nobody from a good PMC background who fails to get into medical school or, subsequently, residency is going to become a PA/NP for these reasons of social humiliation, even if the pay is good.

Nobody who moves in the kind of circles where they have friends who are real doctors, in other words, wants to introduce themselves as a nurse practitioner or physician associate. A similar situation has happened in nursing more generally. Seventy years ago, smart women from good backgrounds became nurses. Today some of those women become doctors, but most go into the other PMC professions. Nursing became a working class job, and standards slipped. Still, nursing is still often less risky (although there are plenty of deaths caused by nurse mistakes) than the work undertaken by NPs and APs. Nursing became if not low status then mid status, and is now on the level of being a plumber or something - well remunerated, but working class.

The result is a crisis of doctors’ own making. Instead of allowing (as engineers, bankers and lawyers do) a big gradation of physicians, all of whom can call themselves the prestige title doctor but who vary widely in terms of competence, pay and reputation in the profession, doctors have focused on limiting entry, reserving their title for themselves and therefore turning away many decent candidates. (Of course there is a status difference between a rural family doctor and a leading NYC neurosurgeon, but the difference between highs and lows is different to the way it would be if medical school and residency places were doubled overnight.) The karmic consequence of this action is that they are now being replaced by vastly inferior NP/APs who deliver worse care, are worse coworkers and who will ultimately worsen the reputation of the broader medical profession.

What will it take to convince the medical profession, particularly in the US, to fully embrace catering to market demand by working to deliver the number of doctors the market requires, rather than protecting their own pay and prestige from competition in a way that leads to ever more NP/APs and ever worse patient outcomes? The US needs more doctors, especially in disciplines like anaesthesiology, dermatology and so on paid $200k a year (which, much as it might make some surgeons wince, is in fact a very respectable and comfortable income in much of the country). Deliver them, and the NP/AP problem will fade away as quickly as it began.

I have many friends in medicine with whom I talk about these issues fairly often. My understanding based on these conversations is that you can't just go out and increase residency positions because the whole point of residency is to get sufficient exposure to cases. A surgical resident needs to do X gallbladder surgeries, Y appendix surgeries, etc. to reach competence and be able to perform independently. There are only so many patients who actually need those surgeries per year. Also, there are only so many teaching surgeons willing to supervise residents (teaching is almost universally a pay cut in medicine). Freeing the cap on residencies would mean a lot of doctors-in-training who waste time sitting on their hands and come out underprepared.

Ugh I bring this up every time and it gets ignored every time by people with axes to grind.

To further explain - common surgeries still happen (duh) but you have things like:

-Needing to experience complications, which happen less because we are better at stuff now.

-Stuff that used to be always or often a surgery being managed more conservatively leading to less cases.

-Changes to how surgeries work to be less invasive but more complicated to learn. Might take 100 open cases to be proficient and a 1000 robot cases or whatever.

-Duty hour restrictions. We used to work 100% of the fucking time. Now we get to sleep, but that means stuff happens without us.

This is pretty surgery specific but a number of other types of specialities have similar issues where you can't maintain training quality with increased residents.

If this was truly the issue you think it is, a reasonable solution would be to have some of residency take place abroad in poorer countries where there is a need for healthcare; the local would likely appreciate it and residents would get more exposure to surgery.

In order to learn the U.S. standard of care you must learn with a U.S. level of resources and training. Much of Europe can meet that standard but the third world cannot. This is magnified by the fact that the U.S. population is more challenging due to obesity and other factors.

Putting aside that general point, with surgery in specific we are talking about modern surgical modalities - I don't know how many da Vinci's are in the entire continent on Africa but I doubt it's more than a handful.

For anyone wondering.

A Da Vinci is a robotic surgical setup meant to be less invasive. I had thought they were relatively new but that Wiki link says they were introduced in 2000.

For anyone wondering

Laparoscopic surgery is the other main issue on this front, but you'll have more of that available in Africa.

But who would pay for necessary infrastructure and surgical supplies. Where are the patients going to get the MRI and CT scans necessary for pre-operative planning? The places that already have resources for those things have their own surgeons to train.

This can’t be right. The number of doctors needed for any given discipline X should scale linearly with the number of cases in discipline X. If there are not enough cases to train doctors, then there is no doctor shortage.

Suppose surgery X is only needed by P patients per year per hospital, but surgical residents on average need to do at least C cases under supervision to reach competency. If residency is Y years long and you have R residency spots per hospital, then R is limited to C > Y P R.

It depends whether you're modelling the increased demand for doctors as coming from pure population growth, in which case the point by @Quantumfreakonomics stands, or having greater demand for doctoring from the same total population in area, in which case your point stands and there's a natural cap

you can't just go out and increase residency positions

This is the problem, but not for the reason you suggest, at least in the US. The issue is funding - training residents costs hospitals money, which is covered by CMS. Technically, I guess hospitals could fund residencies above and beyond their CMS allocations, but then they are spending money to train a future doctor that may or may not work for them. The financial incentives aren't there for hospitals to fund residencies themselves, so we end up with the number of residencies CMS is willing to fund. That number was mostly static for over 20 years, until Covid made stark how lacking in medical personnel the US is. So they've slowly been increasing the allocations over the last few years, but of course, at a much lower rate than general population growth.

Quick Google search suggests that there's something like half a million gallbladder removals per year in the USA. I'll leave it as a simple exercise for the reader to estimate how many residents per year could be trained to do gallbladder surgeries at such a rare.

You'd have to do this exercise for every type of surgery that a competent surgeon should know. Gallbladder is one of the most common (hence, one of the first to come off the top of my head), but you still need your local surgeon to be able to do the less known things as well. If I'm betting my life on a baseball player hitting a home run off a knuckleball pitcher, I want him to have at least gone up against a lot of knuckleballs in his life instead of a guy who's mostly only hit against fastball and curveballs and is going to be out there winging it for the first time.

Isn't that what specialists are for, though? If you need a guy who knows what to do with a knuckleball, you go to that guy, who specialized in it. But if you're dealing with fastballs and curveballs, then your local guy is good enough.

There's a death of generalists in medicine underlying a lot of this, in part because everyone wants the guy who's good with knuckleballs. But not everyone is going to face a knuckleball, and you don't need to go to the specialist otherwise.

I think the problem here is that you often don't know what you're dealing with until you're already knee deep.

If we're keeping with the baseball analogy, the specialist is the guy you call when you already know you're up against the absolute best knuckleballers. The generalists are still out there dealing with most pitchers, who aren't the best at it but do mix in knuckleballs among fasts and curves. I guess the analogy I should have used is:

"If I'm betting my life on a baseball team, I want most of their batters to have at least gone up against a lot of knuckleballs in their life instead of a bunch of guys who've mostly only hit against fasts/curves and are going to be out there winging it for the first time if it turns out the opponent team has many solid knuckleball pitchers." (Sorry if this is bad baseball, I don't actually follow baseball)

This would be a problem if every hospital was already a teaching hospital, but that is not the case.

If what you are saying was truly the real problem then the easy solution would be to allow foreign doctors trained in European countries/Australia/NZ etc. to come and work in the US without needing to redo their residency. Medical standards in these countries are no lower than the US in aggregate and may well be higher. Sure you can ask for equivalency exams (like how the UK does for foreign doctors) but there's no valid argument that the 90th percentile British doctor is worse than the 10th percentile American doctor, so why block the former from working in the US?

That we don't see this is Bayesian evidence that this is not the true objection for why the US medical cartel wants so few licenced doctors.

Yes, this is another major thing and one we’ve discussed before.

If that were true it would be self-fixing. You'd have the number of surgical residents that are needed to do surgeries going forward. Or at least, current demand. But instead all these positions are basically people working more hours than is healthy a day, making a paltry salary, and then once freed from the artificially contained program immediately making 4-10x they were.

Suppose surgery X is only needed by P patients per year per hospital, but surgical residents require C cases to reach competency. If residency is Y years long and you have R residency spots per hospital, then R is limited to C > Y P R.

This is plausible. But the real world data is that P is very high compared to R. So Rs are being subsidized with not-Rs in the post-R environment. All indicia point to X>C

This may be true for some very common surgeries, but you still need the surgeons on staff to be trained in less common situations/surgeries as well. Otherwise, you have scenarios where you need a surgery but turns out the surgeon on shift has done that particular surgery once in his life and has to wing it.

If something is happening at your hospital like once a year, that seems inevitable.

Even for something that happens every week at an average hospital, if you go from 10 residents to 40 you're going from residents who have trained on it 25 times to residents who may have only done it 6 times.

I think this happens anyway. If you need a complex surgery in New Mexico, they will send you to Phoenix or Texas, even if it’s fairly urgent.

What is this place?

This website is a place for people who want to move past shady thinking and test their ideas in a court of people who don't all share the same biases. Our goal is to optimize for light, not heat; this is a group effort, and all commentators are asked to do their part.

The weekly Culture War threads host the most controversial topics and are the most visible aspect of The Motte. However, many other topics are appropriate here. We encourage people to post anything related to science, politics, or philosophy; if in doubt, post!

Check out The Vault for an archive of old quality posts. You are encouraged to crosspost these elsewhere.


Why are you called The Motte?

A motte is a stone keep on a raised earthwork common in early medieval fortifications. More pertinently, it's an element in a rhetorical move called a "Motte-and-Bailey", originally identified by philosopher Nicholas Shackel. It describes the tendency in discourse for people to move from a controversial but high value claim to a defensible but less exciting one upon any resistance to the former. He likens this to the medieval fortification, where a desirable land (the bailey) is abandoned when in danger for the more easily defended motte. In Shackel's words, "The Motte represents the defensible but undesired propositions to which one retreats when hard pressed."

On The Motte, always attempt to remain inside your defensible territory, even if you are not being pressed.


New post guidelines

If you're posting something that isn't related to the culture war, we encourage you to post a thread for it. A submission statement is highly appreciated, but isn't necessary for text posts or links to largely-text posts such as blogs or news articles; if we're unsure of the value of your post, we might remove it until you add a submission statement. A submission statement is required for non-text sources (videos, podcasts, images).

Culture war posts go in the culture war thread; all links must either include a submission statement or significant commentary. Bare links without those will be removed.

If in doubt, please post it!


Rules


Recommended Posts And Communities

Recommended Realtime Chats