ebrso
1mo ago
In my experience (both second-hand and personal), getting pushed-out of a job you don't like is often a very positive thing - essentially a "blessing in disguise."
ebrso
2mo ago
One idea I've seen is having a multiplicity of status hierarchies . . . In practice, we could have that now, but we don't.
My instinct is that we absolutely have a multiplicity of status hierarchies operating today in a largely independent fashion. For example, there are plenty of American sub-groups in which status and money don't seem closely aligned. If you're a full professor of history at a large state university, then your status among colleagues will derive primarily from your research output and its reception. If you're a Hasidic Jew in Brooklyn, then your status in the synagogue will derive from your knowledge of Torah. If you're a Texas adolescent boy, then your status at school will derive from how many touchdowns you throw. These qualities are not closely related to earnings (if they're even related at all).
ebrso
3mo ago
ebrso
3mo ago
I lost my beloved younger brother a few years ago to drug addiction. He was 35. He struggled for years (and I mean really struggled) to stop using heroin, with some periods of success. When he was using drugs, he would lie and steal. But even during those times, he was always a very generous person when he could be. He was very sensitive (in some ways, I think this was actually a burden for him), and he made friends easily. He was funny and smart (which was perhaps another burden). He had very serious depression and anxiety his entire life. I'm sure my parents will never recover from the loss.
My point here is that many of the drug addicts you despise are actually struggling desperately. Most have had difficult lives. Some have loved ones that care deeply about them and want to see them get healthy. Others don't have anyone in the world who cares about them, either because they never had a family, or because their families died, or because they alienated them through their behaviors.
There are important conversations to be had about whether drug addiction is more of a choice or more of a disease. And there are conversations to be had about the balance between community interests and the interests of those with substance abuse disorders, and how community burdens should be fairly distributed. And there are conversations about which policies or actions actually help individuals with substance abuse disorders, versus which policies are counter-productive because they just enable or encourage these disorders.
But calling someone "dysfunctional scum" or "druggie" or "biowaste" isn't the way to start these conversations. That's the kind of language people use to dehumanize others. I think you should be ashamed of yourself.
ebrso
4mo ago
Kamala is not going to win. She's going to say things like "space is neat" and "who doesn't love a big yellow schoolbus" on the debate stage.
These pithy, assured pronouncements are tedious and call to mind the expression often wrong, but never in doubt. The betting market consensus now is that Harris has a nearly 40% chance of winning in November; it's moronic to declare that "Kamala is not going to win."
ebrso
4mo ago
but not really—the robots won’t play trivia and if they do, the questions will be a lot harder
Two robots can play chess with each other right now, but humans still do it because it's fun and challenging for us. I walk in the park even though jets can outpace me.
I think the implication - possibly tongue-in-cheek - was that robots will replace humans within 200 years.
Sure, I don't doubt that many of the people you think about in consulting / finance / tech at even 2nd-rate places like Accenture / Deloitte / Oracle will make six figures as starting salaries.
Still, statistics show that the average American working in the consulting, finance, or tech industries will never make six figures - even if we restrict attention to the college educated. I think you're just really out-of-touch to not recognize that. This is wrong. Maybe I'm the one who's out of touch. The median American salaries in tech and finance are both around $100k, suggesting that most people will attain them at some point. The median consulting salary is still lower than $100k.
ebrso
5mo ago
Re-reading what you wrote, I agree - I quoted your remark about humility in an abbreviated form that misrepresented the point you were making. I apologize for that. It genuinely wasn't intentional.
ebrso
5mo ago
Yes undergraduate it's fundamentally more or less the same classes, with the caveat that you have to get pretty much only get As (average GPA is somewhere in the 3.7 to 3.8 range)
The average GPA at a school like Brown is about 3.8. This is hardly exclusive tier. It reminds me of Mr. Evil (one milllllion dollars).
you have a ton of demands on your time outside of class work (shadowing, volunteering, MCAT prep).
Many students have, like, actual jobs outside of classes. And grad schools have grad school admissions test (LSAT, GRE, MBA, etc.) - test prep is hardly unique to medicine.
You know any other jobs where you'll be sewing up a corpse on hour 36 of being at work and awake while your attending shouts at you "hurry up you useless fuckhead he's dead already anyway, we've got to move on" until you finish?
Bullies exist in all professions. If someone said that to me in a professional environment, I'd look him in the eye and calmly explain why it was inappropriate, and why he couldn't treat me that way going forward. And then he wouldn't treat me that way going forward.
ebrso
5mo ago
Every physician I know who doesn't have a financial stake in midlevels (and isn't in admin) tells their friends and family to only see doctors whenever possible. That's for a reason.
Every acupuncturist I know tells me to see an acupuncturist. It's funny how that works.
Physicians spend years being abused and called idiots in order to develop caution, intellectual humility.
I don't consider American doctors as a model for intellectual humility. Do you?
ebrso
5mo ago
Do the math. When do similar high education fields start cracking a million? I'm not talking about a partner at McKinsey or a top level google engineer. I'm talking an average person in consulting, finance, or tech making low six figures.
It's interesting you ask this. Of course, the average person working in consulting, finance, or tech will never make six figures.
4.5% is a lot of money in real dollar terms but it is a drop in the bucket in terms of percentage and you know it.
There are more than 22 drops in a normal bucket (100%/4.5%). I agree that 4.5% isn't a silver bullet for solving American health care costs, but it's a start, and American physicians would still make twice as much as their European counterparts under this new regime.
If you halved salaries then a lot of specialties would die on the spot. Nobody is going to procedural work or surgeries of any kind in the U.S. under that model.
I think this is simply detached from reality. The average American orthopedic surgeon makes $573k / year per here. Are you really suggesting that nobody would do it for just $286k / year? I assume people would still be falling over each other to compete for the spots.
And we don't need to theorize what would happen if you just increased the supply. We already did that with mid levels. They made the problem worse.
You seem to be suggesting that the law of supply and demand doesn't apply to health care, i.e., that there's some bank shot argument whereby we should expect increasing the number of doctors to increase the costs of the services they provide. Can you make this case more explicitly?
ebrso
5mo ago
If you sacrificed your college experience and didn't have any fun of any kind in your 20s and took on a half a million dollars in debt in order to become a surgeon then yes, obviously.
I guess I just don't understand this mentality. I don't see why you can't have fun in your 20s and also become a doctor. You seem to maintain that American medical training is uniquely hard and awful, and I'm just not convinced. I appreciate that many pre-meds think their training is hard, but I took orgo and biochem in college, and I can tell you, it wasn't any harder than the classes for my math major.
I also think there's some distortion in the choice of comparison group. If anything, it sounds like a lot more fun to spend your 20s in medical school and residency than to spend this period in a cubical farm. Sure, it's probably more fun to spend your 20s relaxing on a beach somewhere in Mexico than either of these options, but this plan faces its own challenges.
Separately, this $500k debt figure seems like misdirection. It seems manageable for a normal doctor. More manageable, certainly, than a $100k debt figure for an MFA.
Many medical trainees will refuse to practice in that environment and will drop out or just choose to make less money practicing in a bigger city with a worse patient population or job.
I'm extremely skeptical that medical trainees leave the profession at rates higher than any other profession. And this complaint that doctors are forced to make financial tradeoffs in choosing where to practice seems bizarrely out-of-touch to me - who among us doesn't face financial considerations in choosing where to live?
ebrso
5mo ago
Great outcomes are gone yes, as are the good and okay.
Just to be clear, is your position that a life making $200k/year practicing internal medicine in a small town 50 miles outside Philadelphia is not an okay outcome? Why not?
ebrso
5mo ago
I think if you'd framed it in these terms originally, then I wouldn't have objected.
I agree. Failing your medical licensing exam (as 2% of test takers do) limits your ability to earn $1M/year as an LA plastic surgeon.
ebrso
5mo ago
you have yet to acknowledge that American doctors don't make what you think they do. The average American doctor probably has a lower net worth than the average Australian doctor . . . Doctors have relatively low net worths into their 50s, here's a citation. https://www.bfadvisors.com/net-worth-by-age-for-doctors/
This is grossly misleading. The first line of the article is literally, "When it comes to wealth-generating occupations, physicians usually make the top of the list." The graph shows that 50% of doctors ages 45-49 have a net worth of at least $1M, and that average physician comp is $350k/year. I appreciate that American doctors choose partners at Goldman Sachs as their peer cohort for compensation comparisons, but this is not based in reality.
Decreasing doctor salaries also does nothing substantial to decrease U.S. health care costs.
Physician compensation is roughly 9% of U.S. health care costs per here. If you slashed physician comp 50% (so that physicians were "only" averaging $175K/year), U.S health care costs would be reduced by 4.5%, or about $250B across the U.S. per year (4.5% of $5T total annual health care spend). A few $250B here, a few $250B there . . . pretty soon we're talking about real money.
And your solution [of importing physicians from other countries in order to drive down physician costs] seems to me to be wildly immoral and you make no effort to defend it.
Again, Is that your true rejection? If so, would you be satisfied with importing international physicians if those physicians pledged to remit some of their American comp to their countries of origin? Because I'm sure they'd be happy to do so.
ebrso
5mo ago
I mean what I say quite literally, you can be a top of your class science student at a reasonably good institution, study for two years specifically for the test (including a multi-month "dedicated" period where your only job is to study for this test), spend thousands of dollars on incredibly well designed test prep material and that still might not be enough.
That might qualifier is doing an awful lot of work here. The same student might also get crushed by a falling piano on the way to the test center. The point of statistics is to evaluate likelihoods, not possibilities.
and while the [USMLE Step 1] fail rate is low, failing it fucks you over incredibly
This seems hysterical (marked by hysteria). The same data set showed that re-takers had an almost 70% chance of passing. Substantially anyone who manages to drag himself across the finish line will be able to make $200k/year as a GP in a high status profession (more if they're willing to live outside a major city, where the money will go further). I don't know in what universe this qualifies as being fucked over incredibly. Even the small minority of medical students who can't gain licensure to practice will still have fine life outcomes, by and large.
ebrso
5mo ago
NPs have 500 hours of training and doctors have 10k-20k. That gap is enormous and even if each hour of training is mostly worthless....it's a lot.
This seems to refer to clinical hours. Per wikipedia: During their studies, nurse practitioners are required to receive a minimum of 500 hours of clinical training in addition to the clinical hours required to obtain their RN. Let's leave aside the RN component. If clinical hours are the focus, then a typical NP who's been practicing professionally for 10 years has more than a physician who's been practicing professionally for 5 years.
This conversation brings to mind Yud's Is That Your True Rejection. Doctors are better than NPs, they have more clinical experience. No? Well then doctors are better, they have better outcomes. No? Well then doctors are better, they cost the system less money. No? Well then, doctors are better, their training is more rigorous. No? Well then, doctors must be better for some other reason.
ebrso
5mo ago
Figuring out the cause of dropping out is hard because people lie for ego defense reasons which complicates matters, I do know people who have claimed some other kind of hardship but it was academics.
I mean, sure, if someone leaves an academic program, then on some level it's related to academics. But even in cases where someone's involuntarily separated from their program due to bad grades, those bad grades don't necessarily indicate a failure of earlier-stage preparation or a deficit of natural ability. Often, bad grades are downstream from emotional problems, or from a general ambivalence about the training. I speak from some personal experience here, albeit outside of medicine (I don't think this is simply "ego defense").
I don't want to get too distracted from my main point, which is that, based on data and personal observation, I'm skeptical that American physician training requires as much intellectual horse power (or even hard work) as American physicians maintain it does. I do think it requires a high level of conscientiousness, which is surely related, but also different.
ebrso
5mo ago
Medical exams are hard (and not like most exams you see), someone who was in the top 5% of their class at a respectable undergrad institution can spend two years studying for Step 1 and still barely pass it.
In 2021, before USMLE Step 1 moved to pass-fail, 98% of 1st-time takers from MD programs passed per here. By comparison, the first-time pass rate for the California bar exam (to practice law in the state) is roughly 45% per here.
ebrso
5mo ago
The problem is about to get much worse [due to preferential treatment of URMs].
Separately, I'm concerned about the effectiveness of medical (and pre-medical) training performed remotely during the pandemic. I also think the integrity of admissions / promotion standards are potentially compromised by pandemic-era shifts, particularly rampant cheating and grade inflation.
ebrso
5mo ago
When I think about "bad" doctors the ones I run into are generally lazy/burnt out types, or outright malicious/unethical types. Traditional incompetence is rare,
This is my impression as well, although I attribute it to gatekeeping effects (entry into American medical schools is traditionally so hard as to exclude truly incompetent candidates, and entry to practice in America from foreign training has similar gatekeeping).
By the way, I've always found it interesting that Scott, who seems like a brilliant and caring, almost ideal physician, attended medical school in Ireland - was that personal preference, or could he not get admitted in the U.S.? I remember him mentioning that he had a very difficult time achieving placement into a U.S. residency afterwards.
Traditional incompetence [among American physicians] is rare, because those people get kicked out of medical school or residency
I thought the stats showed that the overwhelming majority of individuals entering American medical schools are promoted to full privileges? Like, well over 95%. And presumably, a non-trivial part of those who don't get promoted aren't "kicked out" of medical school / residency for lack of competence, but rather leave due to other factors (medical problems, voluntary career change, etc.).
I'm sympathetic to the arguments that American medical school screening processes (appropriately) exclude candidates that lack the skills necessary to be successful as physicians. But alarm bells start ringing in my mind when I hear one set of people saying "admissions standards aren't necessary in the current system because we have such exacting training standards," while the other set of people is saying, "serious training standards aren't necessary in the current system, because we have such exacting admissions standards."
ebrso
5mo ago
More research has shown pretty wide outcome disparity and things like a dramatic increase in costs from the NPs (due to unneeded referrals and excess testing, the later of which is often a direct harm to the patient).
Here's an example link: https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs?utm_campaign=Advocacy
It's worth noticing that this source is from the AMA, which is an American physicians' group that lobbies to protect American physicians' class interests, including preventing mid-level health care professionals (NPs, PAs, etc.) from encroaching on practice areas seen as reserved for physicans. The url itself identifies this article as part of an advocacy campaign. The article highlights:
The AMA is advocating for you [American physicians] The AMA has achieved recent wins in 5 critical areas for physicians.
That doesn't necessarily make anything it says wrong, of course. But I'd expect the article published by the corresponding NPs' association to emphasize different observations and to reach different conclusions.
ebrso
5mo ago
From the article
One professor said that a student in the operating room could not identify a major artery when asked, then berated the professor for putting her on the spot.
She knows literally less than a decent butcher.
The qualifier major is carrying a lot of weight here. There are thousands of named arteries in the human body, ranging from the aorta (which every medical student in clinical rotations really should be able to recognize, at least when it's exposed to plain view) to tiny branches that exhibit tremendous variation across individuals, and which even the absolute best students (and expert physicians) won't be able to reliably identify in cadaveric dissection (never mind in the operating theater). Viewing angle, anatomical posture, and similar (physical) factors can also make it much easier or harder to identify individual vessels.
So, even if we take this anonymous source's claim at face value (i.e., we assume that some incident occurred in which a medical trainee failed to identify a "major" artery on request, and then reacted badly), how should we understand the term "major," and why do we assume that there was a clear presentation? (And of course, one case, however egregious, doesn't establish a trend.)
Anyone have tips for combatting the green-eyed monster? I often find myself begrudging others’ successes and good fortune. My resentment applies to friends [1], but also extends to people whom I barely know in passing (or even public figures).
[1] Although am I really their friend if I react this way?
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