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PaperclipPerfector  30d ago (text post)   29763 thread views

Culture War Roundup for the week of November 18, 2024

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Redacted - posted on December 2nd thread

I remember the Obama era narratives of the “Coalition of the Ascendent.” If demographics were truly destiny, Republicans wouldn’t touch the Presidency again. Obama’s “resounding” 2012 victory prompted the infamous Republican “Autopsy.”

This narrative ignores the numbers, though. 2012 wasn’t a triumph for Democrats, but a warning – while the Republican candidate had gained just under 1 million more votes than the 2008 Republican candidate, the Democrat had lost a little over 3.5 million voters. While Hillary Clinton eked out a plurality of the popular vote,* this trend continued in 2016: the Republican candidate gained about 2 million more votes than in 2012, while the Democratic candidate lost ~60k votes. A minor number, to be sure, but a trend nonetheless. 2012 wasn’t a victory lap, but instead a demonstration that the “Obama coalition” was a mirage, a flash in the pan – a demonstration that we all missed at the time.

As the 2024 election is mulled over by pundits to see what, exactly, went wrong, I wonder if we are missing similar “warning signs” in trends. The Bernie-Bro-turned-Trump-supporter pipeline a la Joe Rogan could be symptomatic of voters aligning more along an axis of “insiders vs. outsiders” instead of policy preferences, education, age, or race; while there are correlations with each of those things to an “insiders vs. outsiders” axis, none of them are definitive. Are we similarly looking at the 2024 election the wrong way, especially as we make judgment calls while several million votes have yet to be counted?

Some of the most prominent Republicans right now identified as Democrat-aligned during the Obama era (Trump, Vance, Elon, Tulsi; I’d throw RFK in there too but I’m not sure that he views himself as a Republican). Republicans are winning over tech bros and unions, and bleeding college-educated voters. There’s talk about this just being a Trump thing, it’ll go away. It was a big anti-incumbency year, worldwide. The elite will reclaim their rightful place as the only right, correct, egalitarian way forward. Etc.

*Talking heads bicker about how Trump “only” receiving a plurality of the popular vote decreases his significance, even while clinging to Clinton “winning” the popular vote in 2016 despite also receiving a plurality, and not a majority. The semantics are amusing from a culture war perspective – the war on language continues – but ultimately meaningless.

There's an image by https://x.com/patrickjfl that shows there's been a realignment between 1996 and 2024, but it has no dataset attached. To summarize (summarizing a tweet, lol), the parties have switched places: the GOP is now relatively more popular with the plebs, while the Dems have become the party of choice for the PMC.

There's another chart in comments by Kyle Saunders, with even less hard data on it, that shows that the cleavage line on the good old political compass has been rotating since 1960: it used to separate socialists from capitalists, but now it separates progressives from conservatives, with the GOP/Trump side becoming slightly more pro-redistribution that the Dems.

I think the real lesson from 2012 is that pundits are wont to proclaim realignments, because they desperately want to live in interesting and historic times. But seldom is it really so. The last realignment happened slowly over the course of several decades and is still ongoing.

Something approximating the left-right divide has now been with us for approaching a century, and it's not going away easily. This is something I think the reality of another term of Trump governance will expose. Left-disposed 'outsiders' are mostly not going to like what they get, which will probably consist of the usual Republican fare with the exception of tariffs, which will probably be as haphazard and anti-climatic as his first effort, and a higher degree of meaningless culture war bluster. Maybe he does meaningfully roll back support for Ukraine, but plenty of 'outsiders' are actually pretty pro-Ukraine, including the vast majority of former Bernie supporters.

I think the real lesson from 2012 is that pundits are wont to proclaim realignments, because they desperately want to live in interesting and historic times.

We've just seen, for only the second time, the re-election of an American President who lost an interim election. We're still seeing the echos of the fall of the Soviet Union (e.g. the Ukraine War). We recently got over a global pandemic causing worldwide oppression. We ARE living in interesting times.

We're going to have a divide, but subgroups have switched from one side to the other before (e.g. blacks in the 1960s) and they will again.

People have at least discussed this, although I don't know how much it's been internalized yet. Matt Yglesias had an article about the crank realignment, Hanania had an article about voters who see conspiracies everywhere, and Meskhout had this article.

In short, both sides have become dominated by delusional partisans screaming in echo chambers. The left have become experts in infiltrating institutions and corrupting them to woke ends, while the right have become eternal dissidents who are great at critiquing the left but terrible at actually building better replacement institutions. The left was a bit ahead of the right when it came to radicalizing, but it's also deradicalizing now in a way that will likely happen to the right in a few years. Around 2020 was "peak woke" after which things slowly calmed down. Now we're approaching the summit of "peak crank" on the right, which will also hopefully calm down.

All these articles about "cranks" to me are just wordgames. Radical/progressive/woke left believes in their own conspiracy theories, the main one is what I call as universal leftist conspiracy - courtesy of James Lindsay. It is really simple:

There are two groups of people: purple and beige. Purple people have access to some special attribute or property - let's call it purpleness. Purple people use this property to oppress beige group. Purpleness also helps purple group to create and reproduce system of purpleness, which reproduces oppression over to the next generation. Liberation from oppression and true equity will only happen if we dismantle the system of purpleness.

This is the most simple and primitive form of conspiracy theory which you can apply to mainstream ideas that for some reason are not considered as low status conspiracies. Some examples:

  • There are men and women. Men have access to male privilege which they use to oppress women. This system is called patriarchy and women will never be free unless we dismantle it.

  • There are heterosexual people and the rest such as queer people. The former group has ability to define what is normal, they have access to heteronormativity which they use to oppress nonheterosexual people. We will not have true liberation until we will not dismantle it.

  • There are white people and the rest, especially Black people. White people have access to whiteness to oppress other races. There can never be true equality until we will not dismantle white supremacy.

  • There are capitalists and workers. Capitalists have access to capital and they exclude workers from access to it, reproducing the system of capitalism. There can never be true equality unless oppressed workers have access to means of production which is the first step to dismantle capitalism.

These are all the simplest and crudest forms of conspiracy theory which if applied to anything else would be identified as some uncouth theory only stupid people believe in. Except these conspiracies are high status so they are fine to utter even in a good society. This universal conspiracy can also be applied to many other popular leftist systematic conspiracies, just define new groups and systems of oppression be it handicapped people or fat people or tans people or many more. This type of "analysis" is in my opinion absolute farce, people who believe in these things can identify racism and sexism everywhere - from knitting to hiking. Which is the point - once you are woke to this systemic conspiracy thinking, then you will see sexism, racism and white supremacy even if you see somebody throwing a bugger from his car as he waits on a red light.

A conspiracy theory typically involves some shadowy group doing something in a centrally planned way. Your bullet points are all just badly worded versions of perfectly reasonable observations about uncoordinated human behaviour.

A conspiracy theory such as flat earth or Qanon are in a completely different category.

What is the patriarchy or whiteness except the ultimate in shadowy central planning? With it white men crushed and destroyed the natural inclination of society to employ black women in every leadership role and it wasn't until about a decade ago that we finally realised that and ushered in the current age of milk and honey.

Uncoordinated behaviours wouldn't involve making up entire branches of science to trick people into thinking your ethnicity and sex is superior, and yet that is apparently one of two possible reasons white men do better than their counterparts on iq tests and tests of strength - either a shadowy cabal of evil white men engineered hyper specific tests that look like general knowledge testing or a strict measure of weight lifting while actually biasing these tests on behalf of other whites and guys, or every white just knows in their racist hearts how to pass an iq test the same way every man knows the secret sexist trick to win at arm wrestling.

The only reason q anon or flat earth is different is because it doesn't have the backing of the so called experts. But the experts have been peddling conspiracy theories for decades and the right have been pointing it out the entire time. Don't confuse holding institutional power for actual expertise. Progressives do not deserve endless charity and conservatives do not deserve endless scrutiny.

What is the patriarchy or whiteness except the ultimate in shadowy central planning?

Depends on how it's cashed out and elaborated on. I believe it to be patently obvious we live in a patriarchy that has been making slow-motion improvements, but that this fact is just a reflection on millions of people's net behaviours over time rather than something anyone has ever nefariously discussed in a group.

Yeah but when people are railing against the patriarchy they aren't taking issue with patrilineal descent, they do assume nefarious motives.

They rely on the same blurred understanding of intent and agency as the q anon types, in that the more thoughtful among them will, when you really get into it with them, call it a prospiracy in the ssc sense of an aligned group having the same motives and therefore moving towards the same goal without the need to coordinate, but then go to back to using language that implies deliberate action when speaking generally.

You present the 'prospiracy' as the machinations of society and I agree, but the crank sees it as the reason their life didn't live up to their expectations. In my experience that is a better delineation between the crank and the conspiracy theorist than the status of their conspiracies.

  • Innocent black men are routinely killed by corrupt police in large numbers, and the murders are covered up.

  • Donald Trump is a Russian Asset, controlled through Kompromat.

  • The Russians hacked the 2016 election

  • Brett Kavanaugh is a rapist, and the Republican machine helped him cover it up.

It seems to me that these four fit your definition of "conspiracy theory", do they not?

So the second one sounds like an example of a conspiracy theory – it's not just an exaggeration but implies a shadowy cabal who's really in control. Unless the speaker just means Trump is a 'Russian asset' in the minimal sense that his existence is of value to Russia (rather than in the spycraft sense).

The others seem a bit more like rash overclaims than complete fantasies to me though it really depends on how the speaker elaborates on what they mean when questioned. Russia did interfere with the 2016 election, for example, but it does not appear at all likely it made a significant difference to the outcome.

Unless the speaker just means Trump is a 'Russian asset' in the minimal sense that his existence is of value to Russia (rather than in the spycraft sense).

...What specific beliefs of the purported "Gribbles" are both widespread and remain preposterous when granted this level of charity? I do not think Flat Earth is a belief held by an appreciable percentage of Republican voters. Ditto for Qanon, which as a diffuse meme has the added benefit of being almost entirely undefinable. What specific Qanon claims are widespread among Republican voters, that we might compare to specific beliefs among Democratic voters?

The others seem a bit more like rash overclaims than complete fantasies to me though it really depends on how the speaker elaborates on what they mean when questioned.

This is a Russell Conjugation: I raise good points from a skeptical perspective, you rashly overclaim, he is a conspiracy crank.

Let's take something pretty spicy: One prominent point in the constellation of Qanon memes is that elites are abusing children and covering it up at scale. Or, alternatively, we could phrase it "Nancy Pelosi is raping and murdering children in a basement under Memories Pizza to harvest their adrenochrome". Now that more specific formulation I just made up; I have no idea if any specific person has ever used it in the wild, and my prior that it is true rounds to zero. But the former formulation is just straightforwardly true, as Diddy's prosecution is now demonstrating. It seems to me that the way you are using Qanon is meant to imply that the specific, explicitly ridiculous formulation is the central example of a Red Triber belief. It seems likely to me that to the extent that Qanon has ever been widespread, the most widespread versions of it have been the least specific and the most plausible, while the least widespread versions of it have been the most specific and least plausible. This should not be surprising, and is not unusually centered in Red Tribe even in the present.

Innocent black men are routinely killed by corrupt police in large numbers, and the murders are covered up.

With the inclusion of the word "routinely", this moves straightforwardly into the realm of conspiracy theory. Certainly there is at least one and perhaps as many as a dozen cases a year in a nation of ~350 million, but Blue Tribers routinely overestimate the number by two to four orders of magnitude, speaking as though this is how the vast majority of homicide against Black people is committed. It is not hard to find prominent Blues feeding the fantasy within the last few years. Nor is the conspiracy element extricable from the structure of this belief. The narrative is that cops routinely kill innocent black people and get away with it, despite obvious formal mechanisms to catch and punish such actions. Major changes in policy have been implemented nation-wide on the basis of this belief, both formal (body cams), semi-formal (the Defund the Police movement) and informal (biased rumor-mongering and disinformation, which remains endemic). The effects of this conspiracy theory have been devastating: nation-wide riots and a collapse in the effectiveness of policing, resulting in a serious violent crime wave and tens of thousands of additional deaths, most of them among Black people.

The Russians hacked the 2016 election

The central example of the claim I'm citing is that Russians hacked the voting machines and changed vote totals to ensure Trump would win. That is very clearly an example of a conspiracy theory. Then we have a motte and bailey where the motte is "Russia engaged in hacking relating the 2016 election" (true, and as you note irrelevent) > "Russia hacked the election, deciding the outcome" (not true and highly deceptive, but with a fig leaf of unfalsifiability) > "Russia hacked the voting machines and changed vote totals" (flatly false.)

Brett Kavanaugh is a rapist, and the Republican machine helped him cover it up.

Two of the three accusations against him were proven false and withdrawn. The third, original accusation was repeatedly proven false on specific questions of fact, only to be serially altered into unfalsifiability. The reality is that there is no credible evidence that Brett Kavanaugh is a rapist or an abuser of any kind, and there is no evidence that the Republicans ignored to secure his confirmation. The beliefs of a large portion of Blues shares no overlap with this reality. And again, conspiracy is implicit here; they're claiming that an obvious truth is being concealed by a definable hierarchy of people for nefarious ends.

Russians hacked the voting machines and changed vote totals to ensure Trump would win. That is very clearly an example of a conspiracy theory.

So here I for sure agree with you. Phrased like this, it's on a level with QAnon and flat earth.

The others not so much. That Kavanaugh for instance was a sexual abuser is nothing close to a conspiracy view, he was accused by a professor. This doesn't require any kind of nefarious shadowy cabal, it requires Democrats to be more disposed to 'believe women' and some motivated thinking, and the Republicans to see plausible doubt that he did anything at a party decades ago, certainly enough that they can give their ally the benefit of the doubt. There's no specific coordination, no outrageous nefariousness, just a he said/she said that's split along lines of self-interest.

Anyway, I agree that both sides use ambiguous and provocative claims, only for many to retreat to more reasonable specifics when under pressure. My only point is that such motte/bailey strategy should be separated from off-the-reservation beliefs that are different in kind because they include implausible specifics, usually to do with central coordination or schizo leanings that the believer is very special. That a pizza restaurant is a paedophile market. That a government higher up is speaking to you directly on the dark web. That the space landings were faked.

I maintain that's a useful distinction.

Innocent black men are routinely killed by corrupt police in large numbers,

Not a conspiracy theory, just a retarded belief.

and the murders are covered up.

Are there (a significant amount of relevant) people who believe this?

Brett Kavanaugh is a rapist, and the Republican machine helped him cover it up.

This also seems like a strained framing, a lot of blue tribers believe that Brett Kavanaugh is a rapist (unlikely but unknowable) and believe that Republicans don't care about it because they hate women/whatever (wrong, Republicans just don't believe he is a rapist).

2 and 3 are one point stretched into two. But it's true that Russiagate stuff is definitely conspiratorial thinking, but it's miles more believable than QAnon (so is the Stop the Steal stuff, for whatever that's worth).

Not a conspiracy theory, just a retarded belief.

But is the term "conspiracy theory" not already used in a pejorative sense, such that it can be defined as "retarded belief" in the minds of many? To put it in fewer words, these are one and the same, to some.

Maybe, but we're not many, we're few and (usually) subject ourselves to a higher standard. There is such a thing as conspiratorial thinking, which is distinct from just being stupid, and it could be that, as of right now, it's more prevalent on the right.

Now, I'm of the opinion that Richard Hanania and his consequences have been a disaster for the rat-adjacent discourse, but I wouldn't dismiss the idea out of hand.

I think the "peak woke" line is cope on the center left and right for different reasons. The center-left keep writing these articles as a smokescreen to let their radicals reload, and the people on the right are just deluding themselves that the extremists will give up and/or that the center-left will ever side with them.

Do you have any evidence that wokeness is still peaking, or has not yet peaked in the short to moderate term? I've gotten a lot of pushback from people on this site claiming how ridiculous it is to think wokeness has peaked... yet they kind of just handwave that as an assumption. By contrast, people like Noah have pretty good evidence in articles like this (non paywalled version available here)

I haven't seen any evidence that puberty blocker hormone prescriptions are down or anything of the sort.

Wokeness has lost a lot of battles, particularly in court recently, but that doesn't mean it stopped trying. Its just more land they still need to conquer.

I haven't seen any evidence that puberty blocker hormone prescriptions are down or anything of the sort.

Is there any data on this anywhere? The way you're wording this is a bit sus, making a claim without evidence, but implicitly demanding evidence of a specific kind for any rebuttal.

That is simply an example. But before I would consider wokeness to be in decline I'd like to see good hard data on real world results. Decline in trans prescriptions would be an interesting one; several prestigious colleges admitting 0-1 blacks in their freshman (or 1L law school) classes; several other tech companies following the Musk Model and firing 80% of the employees (the retained being overwhelmingly male and white+asian). Maybe you can think of some more, but those are ones off the top of the head.

Noah claims that progressives were in favor of immigration primarily, if not only, because Trump was against it, and that the right in general is against immigration on racial grounds. It's hard to take someone seriously after this kind of statement; The left has been very strongly in favor of immigration in general since the 90s, and this has been the case worldwide. The backlash to immigration has likewise happened worldwide, and for near-identical reasons: The number of immigrants were much higher than expected, the strain on the welfare systems, increased crime, etc.

Maybe it's because I'm in academia, but all the extremely woke people here haven't actually changed their opinion, and they haven't actually lost their positions, either. If I read the university newsletter, it's still full of "how to appreciate our diverse gender presentations" and very thin on hard science. If I walk around the campus, it's full of "critical orientation week" advertisements, which is exactly the kind of "critical" you'd expect. The university provides rooms for this week, which ostensibly is against the university, completely free of charge, of course. It's not even very long ago that the university kicked out a right-leaning moderate because "university is not political" and that the university should not "provide resources to political groups".

And this is the core problem imo: If there is a conflict and the right-leaning side is losing, the left will often successfully take away positions up to and including booting them out entirely. If the left loses, they just keep everything they try again after a while. Universities are still de-facto purging themselves of even moderately right-leaning people and promoting quite frankly completely insane people, so long as they are sufficiently far left. Unless we start kicking out far-left cranks the same way we do for the right, I don't see the general trajectory changing much. Sure this or that particular DEI statement gets discontinued, but the next thing is already being implemented.

The relevant line from Noah is here:

In the 2010s, immigration went from a technocratic consensus to a progressive cause célèbre. This happened for two reasons. The primary reason was that Donald Trump and his reactionary movement were against immigration, probably on racial grounds (though they never explicitly admit this). For many progressives, that made fighting for immigration a way of fighting against racism. A more minor reason was that many progressives either implicitly or explicitly bought into the idea that immigration would create a permanent Democratic majority.

This all seems broadly correct to me. The Gallup chart he posts indicates the left really did become much more pro-immigration during Trump's presidency, likely due to thermostatic equilibrium. They're WAY more pro-immigration than, for instance, the 90s as you say. And while not all people who oppose immigration (like me) oppose it on racial grounds, there are many (including on this very site!) who do.

While some schools may still be quite woke, the first derivative on DEI efforts overall is negative. The NYT published a very long hit piece on UMichigan's DEI efforts, for instance. There will still be some schools that are holdouts, but that's to be expected given academia is where wokeness was born and where its staunchest advocates came from.

I think of wokeness today like I think of evangelical Christians in the late '00s or early '10s. They still have some residual power, but they're losing on every front. Your perspective from academia is like someone from a megachurch telling me nothing has changed to evangelicals.

What will it take for you to acknowledge you are wrong about this? People just like you were saying that political correctness had peaked in the 90s, and that it was totally fine to stop noticing it (with the implicit threat that bad things would happen to you if you kept noticing anyway)

Can I quote stats on university hires? The percent of federal "science" grants going to DEI programs? The massive lawsuits against companies and agencies for having basic literacy standards? Is there anything I can say to get you to acknowledge that the giant elephant standing right in front of us isn't getting any smaller?

Can I quote stats on university hires? The percent of federal "science" grants going to DEI programs?

Ooo, please do. I'd be interested.

I don't think anyone's claiming that SJ is fully or even mostly gone. Certainly, I would tell anyone claiming this to extract head from own anus and take a look around. The claim @Ben___Garrison and @MadMonzer are making is that the six-metre two-tonne croc has lost a few centimetres and a few kilos, and (in BG's case) that the trend will continue. It's definitely still very big.

I would rather say that the croc is retreating back into its cage, which is only mildly reassuring because it has already escaped the cage twice in living memory.

Musk buying Twitter was a crippling blow to SJ, to be sure, but it's far from dead and it still holds the high ground of the academy. I'm not saying it definitely will make a comeback in the next few years - it's no longer got either stealth or an aura of inevitability, and that's a big deal - but it's premature to definitively say it's peaked; I'll believe it's decisively defeated when the SJ party here in Australia (the Greens) either falls below 10% of the vote or recants its hair-raising "let's ban politicians from taking anti-SJ positions" policy (relevant part's on page 5).

holds the high ground of the academy

The academy is the "high ground" in the sense that a defeated tribe can hide out in the mountains and wage guerilla war until a suitable opportunity arises (like Hilary wanting a way to attack Bernie from the left) - not in the sense that it is the key strategic terrain being fought over. That would be the government and corporate bureaucracies that actually implement cancellations.

A bunch of stupid nominally left-wing politics was defeated in the late 1970's, hid out in the academy for a decade, came out again as 1990's political correctness, lost again, hid out again, and came back as wokestupid in the 2010's. But wokestupid doesn't come out of academia - it comes out of tumblr - the changes from PC to wokestupid are very obviously driven by the need for social media virality. Academia was just a place where a parasite could be kept on life support until a new host turned up. If wokestupid is retreating into academia, it has been defeated (but not destroyed).

The academy is the "high ground" in the sense that a defeated tribe can hide out in the mountains and wage guerilla war until a suitable opportunity arises (like Hilary wanting a way to attack Bernie from the left) - not in the sense that it is the key strategic terrain being fought over.

No, it's the latter also. As @magic9mushroom points out, it can effectively gatekeep a large number of professions, and it can provide anointed Truth.

The academy is the "high ground" in the sense that a defeated tribe can hide out in the mountains and wage guerilla war until a suitable opportunity arises (like Hilary wanting a way to attack Bernie from the left) - not in the sense that it is the key strategic terrain being fought over. That would be the government and corporate bureaucracies that actually implement cancellations.

I think we're largely in agreement. I called it the high ground because it's relatively hard to conquer, because as the legible-qualification-providing institution it can fairly-effectively gatekeep a large number of professions with power (i.e. bureaucrats, middle managers, executives, lawyers, and less-directly schoolteachers), and because as the legible-fact-providing institution it's hard to stop listening to it without getting stuck in a whirlpool of insane delusion and losing effectiveness. It is, indeed, not the prize being fought over... but it's a mountain directly overlooking it. Cf. Moldbug: "Ideas check out of the university, but they hardly ever check in."

Musk buying Twitter was a crippling blow to SJ, to be sure, but it's far from dead and it still holds the high ground of the academy.

Wokey-wan Kenobi: It’s over, Elonakin, I have the high ground!

Elonakin Blueskywalker: You underestimate my power!

WK: Don’t try it!

All three of these articles about "cranks" on the right parse as: People who disagree with right-wingers think right-wingers are wrong. I am not a crank -- I'm right about everything!

I think this is an unfairly low effort dismissal. I don't like all the people above, but they are thoughtful and making more of an effort at fairness than you suggest. Read Ymeskhout's if you haven't and look at things like Trump's post about AI crowds that were included in it. I understand the traditional Motte argument that Trump lies like a used car salesman and Democrats lie like lawyers and there is certainly some truth to that. And I agree that at the moment Democrat lies are more dangerous precisely because they have a veneer of respectability and acceptability by institutions. However, I don't think that changes the fact that Republicans really have become the party of choice for conspiracy theorists that have very little grounding in reality. It is a very particular kind of mindset that is a not insignificant portion of the electorate and it has become increasingly partisan in recent years particularly since Trump and doubly so since COVID.

However, I don't think that changes the fact that Republicans really have become the party of choice for conspiracy theorists that have very little grounding in reality.

This seems like a strange comment in the wake of an election in which one of the most commonly talked about theories about why the Democrats lost as much as they did is that the electorate rejected their embrace of a massive conspiracy theory that has very little grounding reality, i.e. CRT, "wokeness," identity politics, social justice, etc. I think it's more accurate to say that Republicans have become the party of choice for low status conspiracy theorists that have very little grounding in reality.

Read Ymeskhout's if you haven't

He's my friend, I have a cameo in the article. His belief is that Republicans are going crazy, he respects my intelligence but thinks I have a reality distortion field that makes me irrational about Trump. Sure, he can think that -- and I think he's wrong! The theory is that we're wrong about everything, we're conspiracy theorists, we're cranks, we're crazy, we believe things without evidence, etc. etc. etc. Most of these guys don't actually know anything about the evidence: I sincerely doubt Hanania could give a steelman of RFK's position about vaccines, or Corona, or a steelman about anything, frankly. Yassine, at least, has been very patient in having these kinds of conversations, but I don't think he would really accept any of these arguments as legitimate: he isn't convinced, and he's not convinced anyone else should be convinced. So they're not just wrong arguments, they're crank arguments, conspiracy arguments, etc.

the fact that Republicans really have become the party of choice for conspiracy theorists that have very little grounding in reality

Democrats are the party of people who act as if there isn't a Replication Crisis. I see the worst nonsense taken credulously just because it was in a study somewhere. Corona came from wet markets? Puberty blockers are reversible? I can go on bluesky right now and find people arguing that Kamala won the election and has all the evidence and will coup Trump any day now. Please, please, I cannot stand to hear more about how I need to carefully consider the people who call me crazy because they didn't carefully consider me. The right does not have a monopoly on nonsense and that is so apparent that it's embarrassing to be told otherwise.

I think the left adopts this view because their self image is that of being the experts (by which they mean credentialed). The replication crisis strikes at the heart of this view. So they pretend it (and all of the other mistakes by the experts) don’t exist.

However, I don't think that changes the fact that Republicans really have become the party of choice for conspiracy theorists that have very little grounding in reality.

I just don't know man. What percent of people believe in Russiagate still?

Let's be honest. We're all cranks on some level. What percentage of people are religious? And for the atheist left, it's arguably worst. They seem to have replaced the religion sized hole in their hearts with a grab-bag of semi coherent belief systems.

What percentage of people believe in astrology? How many believe in bad luck?

I think what we're really noticing is that the left credentializes its cranks while the right does not. We have a (now resigned in disgrace) editor of Scientific American saying that the only reason male athletes beat female athletes is societal bias. The scientific establishment has been colonized by the left, who have used it to give a scientific sheen to many of their wacky, incorrect beliefs.

At one point, people who believed in antiseptic medicine were cranks. People who believed in plate tectonics were cranks.

But (going further back now) doctors of the church who calculated the age of the Earth using Biblical text were not cranks. They were credentialed experts.

I think what broke a lot of people (myself included) was the disastrous and anti-scientific response to Covid, which every step of the way was blessed by the so-called experts. It's not really about magical belief systems (which the Left has in plenty). It's about power.

I think what broke a lot of people (myself included) was the disastrous and anti-scientific response to Covid, which every step of the way was blessed by the so-called experts.

To add to this, if "conspiracy theory" was used in a neutral way instead of only being used against right-wing beliefs, then supporters of the mainstream response to COVID are conspiracy theorists. After all, they believe, without evidence, that masks stop covid, in the same way that a tinfoil hat might block mind control. They believe, without evidence, that imprisoning the entire population in their own homes, for just two weeks, with a "real" lockdown, will make covid go away. And they believe that governments that don't do this, such as Florida under DeSantis, are conspiring to commit mass murder while covering up the true number of deaths. Similarly, they treat all opposition to policies they support as motivated by criminal conspiracy (by some combination of Trumpists, Russians, the religious, or far-right) rather than by differing opinions or priorities.

While there are still serious concerns about how wishy-washy Trump is on Russia, that's a separate issue from "Russiagate" which was related to specific coordination possibly through blackmail. It might seem like any criticism of Trump's position on Russia is synonymous with "Russiagate", but when properly disambiguated I'd say not many Dems really believe in the crazier takes (e.g. Trump is a KGB plant).

I also think you're not really understanding what I (or the writers I linked) mean by "crank". A crank isn't just anyone who believes in stuff that isn't supported by science or evidence, it's specifically conspiratorial views like QAnon or "Bill Gates is microchipping us through vaccines" or "global elites want open borders to genocide white people". It's distrust of amorphous undefined "elites", who are perceived to have a secret evil agenda. Someone who believes in religion or astrology is wrong, obviously, but I wouldn't call them a crank.

Pretty much every crank view on the right has an equivalent on the left, just couched in academic language and with institutional support. There's plenty on the left that believe in a "Trans Genocide" or that Israel is committing genocide in Gaza, to state the obvious equivalents to white genocide conspiracy theories. And as for broader conspiratorial worldviews like QAnon, critical theory is just that: a conspiracy theory. Just one that's popular enough in academia that it dodges the definition.

Israel is committing genocide in Gaza

You cannot seriously say that this view is anything like QAnon or Pizzagate. As Ben Garrison was saying, “crank” doesn’t just mean someone that’s wrong.

Someone claiming Israel is committing genocide might be guilty of using an overly expansive definition of genocide for motivated reasons, but there’s nothing crazy about the claim, there’s nothing detached from reality.

The White Genocide conspiracy theory can also be steelmanned as people using an overly-expansive definition of genocide for motivated reasons, akin to the one originally proposed by Lemkin:

Generally speaking, genocide does not necessarily mean the immediate destruction of a nation, except when accomplished by mass killings of all members of a nation. It is intended rather to signify a coordinated plan of different actions aiming at the destruction of essential foundations of the life of national groups, with the aim of annihilating the groups themselves. The objectives of such a plan would be the disintegration of the political and social institutions, of culture, language, national feelings, religion, and the economic existence of national groups, and the destruction of the personal security, liberty, health, dignity, and even the lives of the individuals belonging to such groups.

And then the flaw of the steelman is that if we were to revert to Lemkin's original wording we'd have to reclassify a lot of stuff that isn't treated as genocide as such, and then would inevitably need a new word to replace genocide to describe the narrower meaning.

but when properly disambiguated I'd say not many Dems really believe in the crazier takes (e.g. Trump is a KGB plant).

It sure didn't seem that way back when it was discussed on the subreddit during Trump's first term. Maybe they honestly changed their mind, but it just feels like they got quiet after seeing they won't make a lot of hay with it.

I also think you're not really understanding what I (or the writers I linked) mean by "crank". A crank isn't just anyone who believes in stuff that isn't supported by science or evidence, it's specifically conspiratorial views like

"The police are hunting down innocent, unarmed, black men like they were animals"? "Patriarchy"? "Rape culture"? "Systemic racism"? Before you try to do a motte-and-bailey on these, bare in mind that there's no shortage of people actually believing the bailey.

Also how do true conspiracist beliefs enter into it? Were people who believed in Epstein's Pedo Island For The Elites back in, say 2018, cranks? Am I a crank if a believe in a conspiracy of Queer Theorist clinicians and academics to normalize and promote various forms of body modification? Am I a crank for believing children walk into gender clinics identifying as inanimate objects, and gender clinics are happily affirming them with little to no pushback? Am I a crank if I believe some global elites are coordinating to promote LGBT acceptance, including putting pressure on politicians through private channels, if the the pushback from the local culture turns out to be too high for them to take a stand publically?

If the term "crank" includes true beliefs I have to question it's usefulness. If it doesn't, how do you handle cases where the truth of a given belief is uncertain? Are people who thought it's plausible for Imane Khelif to be male cranks? What about people who think Epstein didn't kill himself?

How do your resolve these questions in a way that doesn't boil down to "people who disagree with me are cranks"?

How many headlines showed up, pointing to random studies, calling right wingers dumb or conspiracy-prone?

How many left figures show up now and imply that the left rejects grifters and grift in a way that the right does not? Perhaps this point is worth its own high-level post.

Maybe I get this impression just because I avoid leftist spaces like the plague, but it really does seem like the right is more inundated with obvious, low-quality grifters. I attribute this to the fact that Republicans have become more heavily dependent on the less educated, but also because a lack of established media orgs leads to grifters fulfilling the demand from an underserved market.

Maybe I get this impression just because I avoid leftist spaces like the plague, but it really does seem like the right is more inundated with obvious, low-quality grifters.

Since the left holds the high ground of academia, their grifters are defined as higher-quality. Ta-Nehisi Coates comes to mind. Nikole Hannah-Jones (1619 Project) also.

I think this probably comes back to one of the points Scott made in "Can Things be both Popular and Silenced?". If you're a woke person or a leftist and want to hear woke or left opinions, you have an entire media ecosystem made up of hundreds of thousands of extremely qualified writers, journalists, academics etc. If you have more unorthodox opinions, you are not nearly as well-served, and so the bar is lower for a writer or journalist trying to gain a foothold. A woke person trying to make a living as a blogger or journalist is going up against The New York Times; an anti-woke person trying to make a living is going up against a bunch of other small fries with Substack accounts.

I think this argument is applicable not just to honest people acting in good faith but also to "grifters", broadly defined. If you want to make a living by cynically parroting woke opinions or selling obvious woke-inflected bullshit you don't really believe in, the competition is so stiff that you have to be really good at it to do it at all, so it tends to be a long con (perhaps as much as ten years' training in academia before you set up shop as a "corporate diversity consultant" or whatever). Whereas for anti-woke grifters, the demand for comparable content is just as high but the competition isn't as stiff, so just about any idiot who can string a sentence together can start a podcast and be inundated with Patreon subscriptions within the year. Candace Jones can literally wake up one morning and announce "hi everybody, I'm black and I hate wokeness!" when she was a woke person quite literally the night before. That option is not open to Ibram X. Kendi - he must put in long hard hours in postgraduate degrees and speaking engagements before people are willing to throw money at him for doing nothing.

Are you talking about quantity or reach? Because the lowest quality grifter with the most reach in America is Ibrahim X. Kendi. Next you have the 1619 project, all BLM related orgs, etc. RW orgs with that much reach are people like Daily Wire and Vivek. You might not like their positions on everything, but those aren't grifters. One is a legitimate media business that has really innovated in the space, and the other is a serious politician and thinker, although odd.

It's a recent move, and the Left's grift is still there, however, they've started to tone things down in the advent of the ascending accelerationists. Granted, sites like Salon and NewRepublic seem to exist to prove the strawmen visions of the Democrats correct to a degree that feels deranged, even if one were to find the American Russophiles and Sinophiles unpalatable.

Yeah that will definitely have a selection effect, not just because you aren't seeing as many leftists, but also because people of all political persuasions generally hide their craziest beliefs unless they know they are in good company. So you hang out with rightists and they get comfortable with you and tell you their metaphors that they secretly believe, but are so rarely in a space that is comfortable for leftists that you don't hear their metaphors that they secretly believe.

I avoid leftist spaces like the plague, but it really does seem like the right is more inundated with obvious, low-quality grifters.

Probably true if we confine our examination to X.

But, literally, there are tens of thousands, probably hundreds of thousands, of people who are employed in DEI. They are being paid billions of dollars each year to grift in an official capacity. I think we should probably tackle the taxpayer-funded grifters before worrying about random Twitter bros.

I do agree that it's a great time to be a right-wing grifter, but only because it's a growth industry. The number of people making money off left-wing grifts still exceeeds the inverse by a factor of at least 10.

Ymeskhout called it a crazy conspiracy theory to think progressive prosecutors were using procedural manipulation to favor BLM rioters. It is absolutely a weaponised term.

As the 2024 election is mulled over by pundits to see what, exactly, went wrong, I wonder if we are missing similar “warning signs” in trends. The Bernie-Bro-turned-Trump-supporter pipeline a la Joe Rogan could be symptomatic of voters aligning more along an axis of “insiders vs. outsiders” instead of policy preferences, education, age, or race; while there are correlations with each of those things to an “insiders vs. outsiders” axis, none of them are definitive.

I'm on the record as saying that this has been coming for quite a while now. Google is broken and not finding my posts on the old subreddit, but I said this 10 months ago (https://www.themotte.org/post/842/culture-war-roundup-for-the-week/181915?context=8#context)

That said I think I go a bit further - I think Left/right as a meaningful political divide is going to either go away or simply transform into pro/anti regime/establishment, because neither of them can offer anything which actually helps people deal with the problems they're facing in their daily lives. Trump is just the early foreshadowing of that realignment.

because neither of them can offer anything which actually helps people deal with the problems they're facing in their daily lives

I think I agree with you, but I'd like to hear you elaborate: if we could snap our fingers and generate political capital for things that would help pepole deal with the problems they're facing in their daily lives, what would those things be?

The answer for me would be:

  1. Crime;
  2. Education;
  3. Immigration.

Most things that are expensive right now (and even pre-Covid) are not so because the are inherently so. Most cities and areas are not like SF/Silicon Valley. More are like Chicago and DC where a large part of the COL is caused by crime. Your groceries are more expensive because the store has 10% losses via theft and breakage, your commute is 100% longer because close to your work is a bunch of burned out homes from the 1940s occupied by squatters, your house itself is on more land that you need because property values need to be high to keep your kids safe, and because parks can't be kept safe.

Similarly education is expensive. We spend so much for so little, all you can possibly get is a good peer group by, again, paying for it with property values or tuition. And sometimes that doesn't even work (we are having trouble getting our son separated from a problem child despite all this). And that is just standard ed. Higher ed needs to be gutted. People are rightly feeling exploited. People dont understand the loans; or the degrees, and graduate feeling entitled to something they were sold but never actually deserved/earned. The people most affected want a handout, but that will only marginally help them and would make the problem worse. What we need is metaphorical arson.

And last is immigration. It causes problems with the first two, plus social cohesion. The cost of ESL in education and society is enormous. Immigrant populations routinely shelter criminals (very common crime being covered up is sexual exploitation of minors in my experience) and make policing generally more difficult by just committing so much low level crime it cant even be policed (think the 2001 New England Patriots defense, but as a whole community littering, setting garbage fires, having 100 free range cats, etc). There is then the signage, the court and other legal costs they add up.

For part 4) Id just end all transfer payments to people not injured on the job. Of course, that makes 1-3 (already impossible IMO) appear modest. The two biggest problems in the US are Medicaid and Welfare. Social Security and Medicare are a close 3/4. The only reason the feds should be cutting someone a check is if they got a limb blown off in Iraq or cut off while working in a factory. And ideally we restructure the factory portion of that so the factory is paying that shit.

That's a complicated question, and I don't think I can actually provide an answer for Americans because I am not one. I can tell you what those policies would look like for the country where I live (Australia), and those policies would probably look something like this.

  1. Cost of living adjustments - dramatic reductions in property values, dramatic reduction in immigration intake, increases in the amount of money provided to jobseekers/welfare recipients, muscular antitrust enforcement against major supermarkets engaging in price-fixing and collusion, nationalisation of toll roads run by overseas firms. I'd have to do some research and planning, but ideally I'd like to burst the real estate bubble while confining as much of the pain to the obscenely wealthy rather than the battlers who managed to get onto the property ladder despite the shithouse conditions.
  2. Actual taxation of the wealthy - creation of a petroleum resources rent tax, removal of all fossil fuel subsidies from major corporations, crackdown on tax avoidance by multinational firms and a full audit of everything PWC has ever done with public money. The entire fossil fuel sector in Australia contributes substantially less to national finances than payroll taxes on nurses and I think this is morally wrong (and not just inefficient). I'd also implement a progressive taxation system on income generated by real estate, with every property after the first getting taxed at increasingly ruinous levels.
  3. Muscular and substantial anti-corruption proceedings. Empower an actual body to go after incidents of government corruption and malfeasance, without being connected to the existing major parties and deeply compromised like the current NACC. There are a lot of scandals and naked corruption in Australian government and there's not going to be any trust in the government until that gets dealt with, and a lack of trust in government means there are a lot of good policies you just can't implement or pursue because the people don't trust government to do them fairly.

Re: 2, bear in mind that energy underlies everything we do and so energy costs propagate to everything in a way that others don’t. Ideally energy should be very cheap.

That's a very complicated question I've spent a lot of time posting about on here - but luckily, Australia is so comically corrupt that it is a lot simpler down under. Previous government leaders signed ruinously, comically bad deals that fucked over our national economy for personal profit. We're exporting natural gas during a domestic natural gas shortage, because corrupt deals were made that essentially result in us subsidising companies which extract fossil fuels then sell them to Japan at below cost so that Japanese middlemen can profit from the deal. Destroying all of that would actually lower domestic energy prices.

Fair

Ideally energy should be very cheap.

Good thing Australia has a bunch of uranium lying around!

Republicans are winning over tech bros and unions, and bleeding college-educated voters.

Unions sure, but I'd be surprised if Republicans were winning more tech workers than they did in 2012.

I'm sure there have been some converts, but I don't doubt that there have been enough progressive young tech workers joining the field to more than balance them.

Random theories about this election I’ve seen discussed so far:

We have left-wing musings that the failure to reach low-propensity voters comes from a “lack” of a left-wing media ecosystem, which makes me scratch my head somewhat, given the disproportionate skew of media to the left. There doesn’t appear to be any introspection or soul-searching here. The issue might not be a lack of left-wing media, but a lack of trust in that media; becoming more online creates a healthy level of skepticism about what we consume, especially as AI becomes more prevalent.

Some pundits are decrying the existence of right-wing echo chambers as corrupting our young men while fleeing to Bluesky and Threads so they don’t have to interact with conservatives. Bluesky “block lists” of conservative voices appeared almost overnight, to overcome the lack of algorithmic protections.

And, of course, everyone’s bringing up their favorite culture war issues as the “reason” why Trump won, but I don’t think it’s that simple. It’s not that factory workers in the rustbelt are transphobic, it’s that factory workers in the rustbelt are tired of someone’s pronouns being given more attention than their grocery bills. Abortion received a ton of support on referendums while their states still went to Trump; is it because we made having children a “women’s issue” instead of an economic one? Telling women they should lie to their husbands who they voted for isn’t a great way to win over men who already feel scorned by today’s society.

I also don’t understand how the party who claim to be championing women and minorities is also the party fighting so hard for mail-in ballots. Secret ballots are a feature of the system, not a bug. Filling out the ballot at your kitchen table makes it really hard to hide it from your husband, or your employer. The weird creepy ads about “people can look up your voting record and won’t date you if you don’t” also don’t help with this, especially when several of these ads didn’t clarify that while whether you voted is public, who you voted for is not. The social stigma of voting Trump is still high, as people get uninvited from Thanksgiving with their own families for leaning conservative.

In the meantime, my guilty pleasure is watching liberal election-denier conspiracy theories. arr “SomethingIsWrong2024” displays a shockingly bad grasp of data analysis, because “all my neighbors had Kamala signs!!” and the like. I feel like I’m in an alternate reality when I see things stated “Vance was a bad pick, no one was excited about him” because I remember the enthusiasm for having someone young and capable on the ticket. Maybe I’m just stuck in my own echo chamber, and don’t realize it; I should do my own introspection.

The weird creepy ads about “people can look up your voting record and won’t date you if you don’t” also don’t help with this, especially when several of these ads didn’t clarify that while whether you voted is public, who you voted for is not. The social stigma of voting Trump is still high, as people get uninvited from Thanksgiving with their own families for leaning conservative.

The Republicans were unfortunately no better on this front, though their social pressure went straight to registered Republican voters and so was less visible than the Democrats’ efforts. Here’s one of several texts I received in the days leading up to the election (emojis and text formatting are original):

🗳️Voting records are public—your friends, neighbors, and family will know if you stood with Trump when it mattered most. 🇺🇸🔥

Hi Lewis, this is [X] with the [state] GOP. Tomorrow is Election Day—your 𝐥𝐚𝐬𝐭 𝐜𝐡𝐚𝐧𝐜𝐞 to make a difference. Whether or not you vote is public, and your community will see if you stood with Trump or stayed home. Don’t let your country down when our 𝐟𝐮𝐭𝐮𝐫𝐞 𝐢𝐬 𝐨𝐧 𝐭𝐡𝐞 𝐥𝐢𝐧𝐞.

I received a few more that included variants on the same veiled threat. I wasn’t and still am not very happy with that approach, but I imagine it probably is effective, given that both sides were trying it.

We have left-wing musings that the failure to reach low-propensity voters comes from a “lack” of a left-wing media ecosystem, which makes me scratch my head somewhat, given the disproportionate skew of media to the left. There doesn’t appear to be any introspection or soul-searching here. The issue might not be a lack of left-wing media, but a lack of trust in that media; becoming more online creates a healthy level of skepticism about what we consume, especially as AI becomes more prevalent.

People who seriously identify as left-wing would often dispute this. Many on the left see the Democrats as a right-wing party, and the mainstream media as centrist, liberal, centre-right, or something else other than left. There is a sense among dedicated left-wing partisans that they are a tiny minority.

Like most of the narratives that people tell themselves about their own political tribes, this is probably false or at least illusionary, but the point is that when people complain about the absence of a left-wing media ecosystem, those probably are not people who regard most of the media as currently on the left.

People who seriously identify as left-wing would often dispute this. Many on the left see the Democrats as a right-wing party, and the mainstream media as centrist, liberal, centre-right, or something else other than left.

This is certainly true, but I think when Democrats are talking about this in the context of losing the election they literally believe that the Democrat-aligned media is lacking, not communist-aligned media. I see this all the time on Reddit.

I believe your average non-communist Democrat sees it this way. Republican-aligned media like Fox puts party support above all else. They put no value on truth, morality or fairness and just spew misinformation 24/7, anything to help Republicans. Meanwhile the NYT is primarily concerned with Truth, Justice and Objectivity. If this shakes out to favoring the Democrats that’s just because “reality has a liberal bias” and “it’s not politics just basic human decency”, the NYT only favors the Democrats by this convergence of their values but they would not lie, cheat or steal if it helped the Democrat cause. So the NYT doesn’t count as Democrat aligned in their mind

I’ve seen many Dems on reddit lamenting the whole “when they go low we go high” strategy and wishing they could fight dirty as they perceive Republicans are.

In general, both the Republicans and Democrats are centrist parties. And more ideologically-driven members of both parties are, IMO, correct when they say that "RINOs" or "neoliberals" are weaksauce versions of their ideologies.

Trump talks a big game about deportation and immigration, but will accomplish very little. No mass deportations will occur during a Trump presidency any more than under a Harris presidency. Trump also talks about repatriating trade, but will only implement tarriffs that will increase prices without increasing US manufacturing. Republicans also talk a lot about how great of a pro-life success Dobbs was, but as far as I can tell, handing control over abortion policy back to the states has resulted in a more pro-choice regulatory landscape than under the status quo. And there's a lot of discussion of "law and order," but the streets are unsafe even in red states, and forget about riding public transit.

Likewise, Democrats talked a big game about defunding the police, and while there were definitely areas where budgets were slashed, no actual "defunding" or "abolishing" took place. They've also talked about healthcare reform for a long time, but since 2010 have accomplished approximately nothing. Redistribution of wealth in any appreciable sense has never happened, and entitlements continue to be soaked up by boomers with fat wallets while the poor and disabled are still means-tested to the bone. Significant movement on workers' protections hasn't happened; instead delusional baristas are setting up labor unions, because when I think of exploitation of labor, I think of not putting up rainbow flags. And not, you know, what's going on in Amazon warehouses.

But while the serious economic and philosophical problems of the US continue to fester, we keep getting distracted by irrelevant culture war issues like weird sex and gender identity things and whether or not Trump is literally Hitler. It's good to know we're focusing on the important things!

DeBoer does this:

https://freddiedeboer.substack.com/p/clinton-and-obama-gave-us-trump

when the far-right party and the center-right party both move right, guess what direction the country goes in?

The Marxist left thinks of the left-right in economic terms and considers anyone not explicitly socialist/communist as being right wing, the reactionary right considers the divide mainly in cultural terms and thinks anyone not based is essentially left wing.

I was thinking of Robinson. I always remember an incident in his debate with Chris Rufo:

Robinson: But then I open the leading leftist magazine in the country, Jacobin, and I look at the headlines, and they are about things like the writers’ strike, or they’re about the fact that you can’t afford a one-bedroom apartment working full time.

Rufo: But would you say that Jacobin is representative of the—

Robinson: Of the left?

Rufo: Would you say Jacobin is the ideological force behind the largest movements of the left? I don’t think so.

Robinson: It’s the leading leftist magazine in the country. I think they’ve got a higher circulation than any other leftist publication.

Rufo: I don’t know about that.

This seems absurd, because it's obviously only possible to consider Jacobin "the leading leftist magazine in the country" if you have an extremely idiosyncratic definition of what counts as "leftist".

Whereas I'd say that most people would use the word 'left' to mean 'of America's two big political factions, the one that is further to the left'.

most people would use the word 'left' to mean 'of America's two big political factions, the one that is further to the left'.

I had a French friend who used words this way. He would use the terms 'far left' and 'far right' to refer to the most left party's beliefs and the most right party's beliefs. Obviously in France that gives you a bigger window.

I found the habit annoying because he always called me 'far right' and obviously that has a very negative implication in English, but he just meant 'UKIP supporter'. It's a nice, consistent system. Perhaps we should adopt it.

We have left-wing musings that the failure to reach low-propensity voters comes from a “lack” of a left-wing media ecosystem, which makes me scratch my head somewhat, given the disproportionate skew of media to the left. There doesn’t appear to be any introspection or soul-searching here. The issue might not be a lack of left-wing media, but a lack of trust in that media; becoming more online creates a healthy level of skepticism about what we consume, especially as AI becomes more prevalent.

Legacy media is left wing. New media isn't conventionally left or right, but the most popular versions tend to lean republican.

Now make no mistake, Rogan and Trump are allies of convenience. But they are allies nonetheless and arguing with him about dragons just makes democrats look shrill and out of touch(Rogan's audience, like most normies, answers esoteric paranoid schizophrenia with 'interesting, so, uh, did you see the game last night? How about that weather we're having, huh?).

Legacy media is left wing. New media isn't conventionally left or right, but the most popular versions tend to lean republican.

These are related. Just like how Fox News was the biggest cable news channel, despite being a drop in the bucket overall. They were the only people putting out a product lots of people wanted. In addition to that effect, the current crop of left wing views cannot sustain themselves in a questioning environment. Joe Rogan and the podcast sphere didn't start on the right, they slowly walked there because that is what happens outside of the left wing censorship regime.

New media isn't conventionally left or right, but the most popular versions tend to lean republican.

The more you tighten your grip, Tarkin, the more star systems will slip through your fingers

The total media dominance in print, tv and web news and the monoculture turned everyone even mildly dissenting to alternative pastures. And there was demand for right wing content and the market delivered.

New media isn't conventionally left or right, but the most popular versions tend to lean republican.

They do? Social media, except X, is all on the left too.

Certainly themotte didn't leave Reddit because Reddit was censoring Democrats.

I used imgur the other day (because someone couldn't see a catbox link), and it's literally worse than reddit. Then you go to funnyjunk or iFunny and it's all zoomer holocaust jokes. Same with the old forums, resetera vs rpgcodex(?) etc.

Social media is totally pillarized at this point, but it seems obvious to me that the leftist ones reach far more people. It's just that the leftist extremism has gone way too overboard to actually help the Democrats; they're trying to run a "we're normal, they're weird" campaign, but their entire youth wing is posting "glory to the martyrs for stomping magat colonizer babies to protect trans kids" memes.

Youtube comments sections have gotten signifigantly further right over the last 3 years. That's basically social media.

Youtube comments sections have gotten signifigantly further right over the last 3 years. That's basically social media.

You'd still get banned for saying "you cant be a woman and have a penis" so its still far left of the center.

Youtube and Facebook and to some extent Instagram are weird that way. Moderation is obviously slightly woke but the commenter base is definitively anti-woke. Places like Reddit, 4chan, X have a more typical convergence of leadership and userbase.

Reddit will ban you for such statements as well

The fact that the YouTube comments for Kirby's Air Ride: Item Bounce haven't been closed yet is proof that YouTube doesn't have complete control over ideology on their platform.

It’s interesting the Dems have been focusing on “we have to figure out a way to get our message out” and not on “maybe the problem is the message.”

The Democrat rank and file seem to have have largely convinced themselves that the Democratic party message is Just Being A Decent Human Being. It's hard to pivot from that to the message being a problem.

“SomethingIsWrong2024” displays a shockingly bad grasp of data analysis, because “all my neighbors had Kamala signs!!” and the like.

All my neighbors had Kamala signs. I mean, not all, but there were a lot of them. In my neighborhood of several hundred households, I counted exactly one Trump sign. My county went about 3:1 for Kamala, and since it includes Newark I would be very surprised if my particular neighborhood was worse than that (I don't know where to find precinct-level results, unfortunately). So there's likely lots of Trump supporters keeping a low profile.

I saw very few yard signs at all this cycle. I thought everyone simultaneously realized they were cringe.

One house on my street had a single sign that just said "Kamela". Every single one of the others had multiple signs, banners, and flags. One at the intersection had a big banner of trump snarling with some slogan about the face of stupidity, racism, and fascism. Most others also got updated What This House Believes signs with the new firmware.
They all popped up within a week of the Kamelanomicon being opened.

Suspect I'm on a list for not having one. With the neighborhood going 80D-15R it's pretty easy to spot the dissidents.

Wow, where do you even live? I live in Seattle, which is probably also 80D-15R and while there was a conspicuous lack of Trump signs (thanks Antifa!) there were not a lot of Harris signs either.

Putting up a Harris sign is a pretty cringe move in a place like Seattle, which is probably why so few people did it. Who puts up a sign to say "Yay Regime"?

My immediate neighborhood had very few signs, but there were absolutely places within a 15-20 minute drive where loads of houses had signs for one or the other. Roughly speaking, the places with quaint, walkable mini-downtown shopping area had mostly Harris signs, the people who seemed like they frequently used their pickup trucks to actually haul stuff had mostly Trump signs, and nice suburban houses with big lawns could go either way. (Location: Pennsylvania)

I don't know where to find precinct-level results

Link

Ah, thanks. My district actually IS worse than that, close to 4:1... but still, there's a lot less than 20% Trump support visible.

Here's a map of the Presidential vote swing from 2012 to 2024:

https://x.com/PatrickRuffini/status/1860310329248325759

It makes me wonder how much of Trump's appeal to midwestern industrial workers is dependent on trade rather than a broader, cultural working-class identity. I don't think farmers in Iowa swung massively toward him because they were mad their factories were being sent to China. Ditto with the Rio Grande Valley and Miami-Dade county.

I think the heavily hispanic areas swung towards Trump as a side effect of hispanics regarding themselves as having more in common with their white counterparts, leading them to vote with their coworkers and immediate bosses. This change has been more or less predictable for decades now even if most of the voices calling attention to it have done so prematurely.

I wish that infographic could include population change on the z-axis, in addition to the voting change.

I live in an extremely blue enclave of an extremely red region, and one thing I've seen is that all the aspiring PMCs move as close to the blue enclave as they can manage, or they flee to the DC/Baltimore/Philly/NYC megalopolis, never to be seen again.

NYT had a good article about political sorting:

https://www.nytimes.com/interactive/2024/10/30/upshot/voters-moving-polarization.html

all the aspiring PMCs move as close to the blue enclave as they can manage

This is as much about economic opportunity as it is about cultural sorting.

In our country, we have red counties and blue cities. So someone with the talent, interest, and capability to do the sorts of high-skill jobs you need to do to get ahead in this day and age often end up having to move to a blue enclave, whether they like it or not.

There are certainly some strivers who pursue trades, or other skilled professions with more geographical flexibility. But in general, the money follows population, and the population is clustered around blue areas.

The brain drain is real. But describing it in terms of a desire to become Democratic simply doesn’t explain the cause by itself. People are just trying to provide the best livelihood they can to themselves and their families, and to do that they have to follow the money = population = density = Democratic correlation.

More people are moving from blue areas to red ones than the opposite.

I would attribute that to the population getting older in general. City life, and its progressive paeans, are more attractive to the young who seek opportunity and change. They are willing to tolerate things like noisy neighbors and the homeless because they are willing to bear that burden, even if it annoys them privately. The old and those with families wish for the reverse and move away to where they can get away from that within their financial means.

It very well may be that the blues diminish because their societal bedrocks self-select and become redder in the bargain.

The population in New York (39) and California (37) is older than the population in Texas (median age 35). With a national median age of 38, New York is actually slightly older than the country as a whole.

However, Florida's is much higher, at about 43 (which makes sense, they are long known to be a haven for retirees!)

AFAIK median ages always include children. So any place that families go to will be much younger than a place with mostly singles, even if the singles themselves are younger.

It’s not just financial means. Nobody really wants to live in a downtown area of a city, because of homeless people, drugs, crime etc. unless you happen to be rich enough to afford one of the very expensive and exclusive areas of the city, you basically live with crime as an everyday reality of your life. Leaving the door of your car unlocked so thieves don’t smash it. Women carrying at least mace (because guns are illegal) and often being consigned to their homes after sunset. Using the buddy system or proactively telling people everything you’re doing so someone knows where to start looking if something happens. I can’t imagine any woman tolerating the idea of having a baby in the city if they have the means to flee somewhere safer.

I live in downtown Chicago and this does not reflect my experience. It's less that you need to be in an excessively exclusive area, just avoid the very bad areas. People actively want to live in several of the downtown clusters, especially in their youth. We'll probably move out to the burbs when we have out kid of school age for the better schools, not because we fear the area.

We'll probably move out to the burbs when we have out kid of school age for the better schools, not because we fear the area.

This is exactly the kind of problem Democrats need to solve if they want to win people back. People dont want long commutes and to move out for schools, but the reality is that if a default place requires very close oversight of a 2 year old, its not really fit for humans. If there is glass on the ground or shit, perhaps you have a dog and have had to pull them away in your neighborhood. Kids shouldnt be on leashes, they are humans that need to learn, but learning not to step in the dog shit is not so valuable a lesson for a 2 year old. Particularly when that dog shit is mixed with glass in a kids playground where, in more normal places, you can trust to just let said 2 year old march around while you enjoy a coffee.

Plus the playground bullies are out of control ATM in cities. Many biters. Cops will charge YOU if you discipline or physically separate a kid while defending your own. Particularly if the stack isn't in your favor.

And you know all this. You know "better schools" is a euphemism for better peer students and peer parents. No amount of Stuyvesant and Stevenson teachers would make Haitian kids learn. And I sure as heck know the Stevenson kids dont have any broken glass on their feeder campus.

I live in NYC, and I've never heard of anyone living like that. I've lived here for about 8 years, and I know of exactly 1 instance of somebody I personally know being affected by street crime, and that was just a phone snatching. Maybe some women carry pepper spray, but I've never noticed it. IMO, carrying pepper spray indicates that things are pretty safe because it's not very effective against much. I do know lots of people, men and women, young and old, who have no concerns at all about walking around alone late at night, even drunk. I've never heard of anybody telling people everything they're doing in case "something happens".

I'm not really sure if car break-ins are much of a problem honestly, mostly because very few people have them, and if they do, they mostly park them in expensive private parking garages. It does seem a little surprising I guess, but I would think I would have heard of it happening at least some if it was actually common.

It is fairly common for people who want to have kids to move out, but that's more because it's quite expensive to get a large enough space, not because of concerns about crime. There definitely are a lot of kids of all ages around, including in strollers and being walked around. Enough that it's reasonably common to be mildly annoyed by someone wheeling a baby stroller around in a place that seems kind of inappropriate, like inside a crowded store.

I live in NYC, and I've never heard of anyone living like that.

You're about 30 years too late for NYC. There still are cities like that, though.

Maybe! I've lived in or visited several big cities, and never seen or heard of things like that though. It seems more plausible to me that things might be more like what Maiq described in what I guess you could call "dead cities" - the medium-small cities that used to be thriving, but all of the industries that were there left for various reasons. Most of the decent people with good life potential also left due to the lack of good jobs long before things got bad. The resulting downward spiral leads to a pretty bad place.

But then, those places are not exactly havens of progressivism, and I don't think any blue-affiliated people are going to decide to move there, which was the point of this whole thread.

Detroit and Baltimore are typical examples. Both have areas where blue-affiliated people were moving (though to enclaves), though I don't know if they still do.

If you feel consigned to your home after sunset, you're more likely to need psychiatric medication than moving boxes. On average, people are moving to cities, and aren't afraid of the dark. I've never known a city dwelling woman to carry any means of protection. Fertility rates have remained about 10% lower in large metro areas than rural areas for over a decade. Not being able to imagine something 10% less frequent is caused by a broken imagination.

I've never known a city dwelling woman to carry any means of protection.

I know plenty, counting pepperspray. Are you not an American?

I've never known a city dwelling woman to carry any means of protection.

How many women have you known the contents of the purse of when they walk around at night?

Unfortunately old comment but over the years no woman has ever mentioned carrying protection. Hundreds if not thousands of women over decades in major American cities. I've dated a dozen or so. I don't recall the idea even being mentioned, though it probably has. I moved out of the US in 2019. Crime has an absurd socioeconomic divide. My crime bubble is probably 5% of the modal white American. I grew up in a small, isolated town of decent prosperity. I'm 40ish and have never been the victim of anything other than petty crime, and even that rare. Same with my friends in all places AFAIKT. Its one data point, but its an honest perspective. So rarely have I seen crime that it is not something I think about. I'm positive it exists and am happy to pay for competent policing everywhere. Criminal (In)Justice was a good read on the geography of crime. Without any forethought, I have live where crime isn't. And now I shall knock on wood.

“Downtown” / urban core parts of SF, NYC, Boston are some of the most expensive real estate in the US.

Manufacturing is a surprisingly large portion of the economy in rural areas. In dollar terms, manufacturing is a larger sector of Iowa's economy than agriculture.

Anne Selzer in shambles.

But yes, I think the party realignment is largely about cultural signalling. It's not like the average Iowan is going to have a coherent opinion on trade policy.

The average swing voter sees the election as a referendum on the direction the country, with Harris representing the status quo.

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.

While I don't disagree with the general comments on PMC status and the waste from overly restrictive supply of Dr.s. It's important to note that among some milieus PA/NP (even to some degree RN) are high status careers. Yes, they are largely working class jobs, but they are among the highest status working class jobs so you are getting many of the most competent folks in those milieus. Is it the same caliber as the marginally rejected medical student? probably not (our education system is pretty good at pulling out the occasional truly super bright folks that pop up and setting them on different paths).

It's a point of contention, but it is not at all established that care from NPs and, in particular, PAs is "vastly inferior" to care from Doctors for the situations they are typically used in. Studies on this matter are mixed (some have found PAs to provide equivalent or even in some cases better care, and, amusingly, generally much better documentation, while others have come to opposite conclusions on quality of care).

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.

This will lead to the same problem -- just in different terms.

The issue isn't the title -- it's the nature of the jobs. Bringing them all under the umbrella of "physician" just moves the status problem to intra-physician jockeying.

That’s fine. Let’s double the number of physicians and surgical specialties, leading hospitals, top medical schools will all still have their own prestige and standards. But there will be enough doctors for everyone.

Alot of the better students in my high school went to do nursing because it's easy money and has pathways to move up such as NP. Also anecdotally I've gotten good diagnosis and treatment from NP for stuff I couldn't figure out myself.

In fact doctors are the midwits saddling themselves with debt and a late start all in pursuit of prestige as seen by the PMC for a job that's not as lucrative as it looks.

We can't necessarily trust the BLS statistics to give us an accurate picture of wages in certain professions (notably waiting tables, bartending, some trades, and doctors).

While your average salaried internal medicine doc at the local hospital might only pull down 200k, that's barely scratching the surface of what a doctor can make.

Being a physician opens the pathway to starting your own practice, which can easily lead to a 7 figure annual income. Presumably, this does not get reported as wages to the BLS.

Yep.

There was a local eye doctor with big dreams when I first moved to this area 9 years back who now owns like 6 different offices in two different counties. Actually, I just checked, now its 7 in three counties. Could quite possibly be pulling in 8 digits annually.

Entrepreneurial spirit in the medical field can be rewarded heavily, and because it is gated so heavily, you generally have a built-in advantage for reaping those rewards if you have business savvy.

Of course, entrepreneurs from outside the medical field are absolutely SALIVATING to piece up the medical industry any way they can, and it all seems to trend towards consolidation, where big, established players will eventually come in to compete with you.

Most doctors I've known are happy enough to just build up a big book of patients then sell off their practice.

Being a physician opens the pathway to starting your own practice, which can easily lead to a 7 figure annual income.

Not anymore. Regulatory requirements have pretty much forced doctors into "health systems" where they may nominally have their own practice but they're basically employees.

It doesn't matter because unless they're so incompetent they actually kill people (and even then...) they have job security for life. In other jobs that have great job security like working for the federal government it's widely understood that this comes with a salary penalty. I don't care that doctors can't easily make millions, it's completely irrelevant, what they can do is make a 95th+ percentile income guaranteed for a 30-year career; no other profession in America has that.

No offense, but is this some sort of intra-elite career path feud? Like the management consultants who are mad that software engineers make too much money now?

(Yes, I'm aware that management consultants are striving fakers, and sofware engineers are the white collar equivalent of plumbers, but you know what I mean)

I'm a former management consultant and I'm not aware of anyone being mad about SWE salaries. The job paths are broadly comparable with broad salary scales, competition, risk, limited career length, compensation broadly tracking to productivity (usually more unequivocally so for SWEs), etc.

I feel like people complain about doctors roughly in the same way people complain about longshoremen or garbage men. A guild (or the literal mafia) capturing part of the economy, limiting access and extracting extreme rent, with doctors union arguably being even worse since they not only cost a lot of money but drain top talent from the more productive parts of economy (even within their own sector of the economy!).

I’m not sure that’s all bad. For the most part, medicine on a family practice level is pretty simple. It’s routine physicals, vaccinations, and common diseases about 80% of the time. The issue is less a NP or PA can’t handle that kind of workload than he or she is not handing off edge cases to doctors. If they were properly handling cases where patients had more complex symptoms or were complaining of serious pain with no known cause, there wouldn’t be much of an issue. Furthermore, wasting the talents of a full fledged doctor on walking into a room where a kid has a fever and runny nose and telling him he has the flu is a waste of the patient’s money and the doctor’s time. Doing routine vaccinations and physicals is likewise a waste of a doctor’s time and a patient’s money. And I don’t think at that point adding a bunch of doctors fixes the issue. You could do what happens in a dentist office in medical offices with no loss of care. The nurse does all the routine work and the doctors look over the data and only talk to the patients if there’s something more complicated than basic medical care needed.

Furthermore, wasting the talents of a full fledged doctor on walking into a room where a kid has a fever and runny nose and telling him he has the flu is a waste of the patient’s money and the doctor’s time.

Is it still a waste if the doctor is someone with a 120 IQ who would have got into medical school in the alternative system but ends up as a replacement-level software engineer in the US system as it is? The work of a GP in the British NHS, or in a well-run HMO where paid-for access to specialists is gatekept, does require more knowledge than an NP/PA, because you are gatekeeping access to specialists, so you need to know at least enough cardiology to know when to call the cardiologist etc. And the people doing that work don't seem to think it is meaningless - the complaints of British GPs are about pay and workload, not about the nature of the work. What it doesn't require is a gunner personality (except in so far as you need to deal with the rigours of residency) or a 130+ IQ.

FWIW, NP-equivalents in the UK are mostly people whose IQ is too high for nursing but were incorrectly sorted into it (I suspect, but don't know, that we make more errors of the "poor therefore stupid" type than the US does) and want a low-risk route to something better. My experience dealing with them (asthma care is handled by NP-equivalents, as is uncomplicated diabetes after initial diagnosis) is that they are as good as a GP within their scope of practice, as long as the understand the limits of said scope.

I’m not sure I’m following you here. I’m not talking about someone who doesn’t get into med school. I’m talking about a typical medical office visit in a family practice where the doctor doing much more than backstopping the NP or PA is in fact a waste of time simply because you don’t need 8 years of college and a couple years of residency to read blood pressure, heart rate, or oxygen levels. You don’t need that level of education for minor issues. I had a spider bite and needed to get an antibiotic for it. Nothing about that visit required a full fledged doctor to personally see me or prescribe antibiotics (other than liability issues and legal stuff) for a fairly minor complaint.

As such, I don’t see why it’s a problem that someone who didn’t go to medical school goes into software. It’s not going to make much of a difference in terms of the kind of care that I’m talking about. Probably 90% of medical care is pretty routine.

You don't train for routine issues, you train to know when an issue isn't a routine issue (and for how to deal with it).

If a patient comes in with abdominal pain, some times they need to fart and sometimes that person is going to die if they don't get transferred to a hospital immediately. You do the training so you don't get this decision making wrong, because society has decided it is unacceptable for us to get this wrong (which...fair).

Complicating this is the way that our regulatory and billing burden constantly pushes back against correct clinical practice, the science and practice are being always updated, and patients are grossly unreliable/muddy the waters.

Do keep in mind that a huge portion of clinical practice is not outpatient practice. What happens in a hospital is wildly different.

is that they are as good as a GP within their scope of practice, as long as the understand the limits of said scope.

Have you stayed abreast of the current furore? The two examples I gave of NP/AP failures were actually both from the UK.

Is it still a waste if the doctor is someone with a 120 IQ who would have got into medical school in the alternative system but ends up as a replacement-level software engineer in the US system as it is?

Sure, and this is the point. The 120 IQ person has too much dignity to accept the title of “nurse practitioner” or “physician assistant” , but let him call himself doctor and put him through some more training and he’ll do the same work for the same pay happily.

Maybe things are different in the UK but my experience, the preoccupation with "dignity" and titles over things like training, compensation, hours, etc... is generally a mark of lower intelligence.

The iq 130 nurse practioner who figured out that they could get 90% of the power, prestige and pay for 30% of the effort, vs the iq 105 doctor who's motivation to finish med-school was in part to shut up thier parents, teachers, classmates, et al.

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

To what exactly are you referring here? As another commenter has pointed out, there are no official gradations of "licensed lawyer": all people who obtain a lawyer license are officially lumped together in a single group, though they are required (1 2) under their ethics code to refrain from actually practicing outside their respective areas of competence. The same is true (§ II.2) of licensed engineers, and the National Society of Professional Engineers is explicitly opposed to divvying up engineer licenses as you suggest has already been done. And I don't think there's such a thing as a "licensed banker".

There are not official gradations of lawyers, but it's widely understood that there are (specialties aside) bad, okay, good and fantastic lawyers, and the public has a good idea where specific levels of quality are found. They know that is all you can get is a mall lawyer, your chances are much lower (for the same quality of case) than if you could hire a prestigious law firm. Doctors associations cling to the idea that (specialties aside) doctors are essentially fungible, and this is even more explicit in countries where a public system assigns doctors to the public. Of course, this is preposterous to the public, you don't have to be a doctor yourself to spot when one is particularly good or not. Anyone with a bit of life experience has seen lazy doctors, doctors who don't listen to them and give them an obviously bad diagnosis because of it, and on the other side doctors who spotted something from hard to read symptoms. My wife recently got assigned by our healthcare system to a shifty clinic in a bad neighborhood where the clinic also advertises "natural remedy treatments" alongside having actual licensed doctors, and to our system that's good enough: to them she needed to be assigned to a clinic, any clinic, they're all as good as one another, and if she wants to switch she gets shoved to the back of the line and likely will be without an assigned clinic for 5 years. And on the opposite side, an optometrist going above and beyond speculating about the reason for me having an uveitis led to me having an auto-immune disease diagnosed and my quality of life improved dramatically.

I don't understand your confusion. She says it right in the part you quoted. Instead of allowing physicians to have varying levels of competence to go with their shared license/title (like other professions do!), they overregulate quality by strangling supply of practitioners.

That there are no official gradations of "licensed lawyer" is her point. MDs don't need different licenses; just allow more variability among the licensed.

Thank you, yes, this is what I meant.

Licensing is one thing, but self-selection signaling is another.

If I graduate from the American Samoa school of Law (that's a Better Call Saul reference) I can handle wills and whatnot, but no real going business concern is going to hire me for complex corporate litigation. If I, this hypothetical business owner, enjoy spending my weekends enjoying recreational Columbia narcotics, I'm going to hire the lawyer who is ex-DA's office and knows all the judges, instead of the one man libertarian law firm who will passionately argue about decriminalizing all drugs.

Basically, we're talking about signaling-credentialism. If a Lawyer went to Yale Law and now works at Latham & Watkins, he or she is probably quite good. If a banker went to Harvard and is now at Goldman Sachs, likewise*. For doctors, we don't quite have the same gradations. If you're an attending in any major metro hospital, you're roughly interchangeable outside of specialties.

I think what OP is saying is he'd like to see more doctors, even those who are the equivalents of Saul Goodman - they can write a prescription for some antibiotics, but you're not going to them for your hip replacement. I could be wrong tho (not op)

  • They're good in the way that matters for these specific professions (law, banking) - they know the right people in the right places. Many of them are probably good at, you know, lawyerin' and finance and whatnot, but 80% of these jobs boil down to "yeah, I know that guy."

I would say right now that there is in fact broad variation in competence in the medical profession. You can see from the average medical licensing exam scores of different specialties that the best MDs tend to go into opthalmology, dermatology, and neurosurgery, whereas the worst ones go into family medicine and psychiatry.

About a year ago I had a rather severe case of mononucleosis, and was sick for about a month. I went to my primary care provider after having a 102F fever for about five days straight, but all the tests they ordered were negative, including the test for Epstein-Barr (though that particular test has like a 30% false negative rate), and they weren't able to give me a diagnosis. After the fever dragged on for ten days I went to the ER, where the resident suspected a cyst in my liver due to elevated enzymes and ordered a CT, along with a huge number of other tests. The next day I was seen by an infectious disease specialist, who suspected mono. Eventually a more accurate blood test confirmed the diagnosis. My health insurance covered everything, but in total my ER visit and 1 night stay in the hospital cost the insurance company about $18,000. There was no intervention except to rest, so I chose to go home. The fever went away like two days later.

Hilariously, my friend who's an anesthesiologist and medical school professor gave me the correct diagnosis before I went to the hospital. He advised me to go to the ER just to be safe but suspected mono, despite the initial negative test result. We've collaborated on research and I know him to be exceedingly competent, but this episode just reinforces in my mind that there are significant differences in the competence of physicians.

There definitely need to be more residency openings to keep up with demand, but part of that problem is that Americans are just so unhealthy compared to other developed countries. Japan has an older population, about 3/4 as many doctors per capita, yet they seem to be doing somewhat better.

but part of that problem is that Americans are just so unhealthy

Couldn't agree more. If you strip away chronic maladies that are directly due to poor lifestyle choices, you get rid of 50% of medical spend annually right there. If you then also exclude last two years of life care, you're at something like 90% of medical spend annually. And these two things interact. Getting old sucks, but it shouldn't be particularly painful or burdensome - but it is because people are getting obese first, then developing metabolic syndrome, and then getting old. Modern medicine and ethics keeps them alive, albeit with drastically reduced quality of life, pretty much up until the whole body just gives out.

Eventually, social security, medicare, and medicaid are going to run out of money. And, as this thread discusses, we're playing with the idea of a fundamental medical care shortage a la the NHS in Britain. If we don't grow our way out of this / come up with some seriously amazing medical technology innovations, I have two predictions:

  1. The cohabitation with an elderly parent will become ubiquitous in American society outside of the top 5%. For the top 5%, assisted living and retirement communities will become even more opulent and lavish then they are now. The wealthy elderly will become bizarrely hedonistic.

  2. There will be a large scale campaign for legalization of assisted suicide. It's already happening as a movement in the USA and they're already doing it in Canada.

I hate both of these things, personally. But I still believe they will happen. Getting wealthy in the next 50 years will be as simple as staying healthy, getting and staying married, staying employed (at pretty much any wage level that isn't working poverty), and caring about your children and family. Individualism will claim at least a third of society, perhaps more.

Yes there are general differences in competency and knowledge within the field, but this is mostly the system functioning as designed, if you go to the ED (which most doctors will recommend if their is any concern, because they don't want to get sued), and then the ED whose job it is to make sure you aren't dying will pan scan the hell out of you to make sure you aren't dying (because they don't want to get sued).

In another country they'd probably just send you home or admit you for observation and not do much.

Whether anyone in the ED actually suspected a less typical Mono presentation is very orthogonal to what they actually do.

In any case we already have a surplus of residency spots, posted about that elsewhere.

Lol I think about the same thing from time to time.

Back when I moved to a new area and had to face the terrifying fear of finding a new doctor, dentists, etc. all on my own, I spent a couple hours of research to find a doctor who accepted my insurance, was located conveniently close to my home, and seemed sufficiently competent from the dubiously reliable reviews and ratings systems there are for doctors (this shouldn't be difficult? There should be some easy way to ascertain if they've ever fucked over a patient or not?). The appointment had to be made a month or so out. I saw him a grand total of twice. Each time I waited about 20 minutes to be seen. I think I spent a total of 15 minutes in his presence. The first time he asked me all the standard health screening questions, including Tobacco use. I truthfully said that I'd had a cigar earlier that year, which he marked down on my sheet and noted "that might make it harder for you to get life insurance." Sent me to go get the standard battery of tests one gets as part of a general physical exam.

Second time, X months later I came back so he could review lab test results with me. All seemed good (BMI a little high but I COULD HAVE TOLD YOU THAT), and I requested politely that he make it clear that I am not a tobacco user, and he was good enough to remove that from the sheet. Hours of research and waiting to talk to the guy for <15 minutes and be told I'm in great health, if a little heavy.

Never went back. Felt like the time investment was simply not worth the so-called 'preventative' benefits. What was the point of him and me being in the same room other than allowing him to show face and justify however much he was billing to my insurance co.? Every single measurement he took could have been done by a nurse, any information he needed to diagnose could be provided without me having to make the appointment and such. I can give a blood sample, turn my head and cough, and get X-rays done somewhere else and send them to him for review without needing to coordinate our busy schedules to coincide.

That's how lab tests work! I go to a location that has plentiful availability, they do some tests and send the results to the Doc. Surely he could have looked them over and sent back some recommendations or concerns as needed. He can presumably do that from the comfort of his home, even!

If I feel something physically wrong with me and it doesn't go away, I go to urgent care and get attention on the spot. If I want to know about some given metric about my body I can usually purchase or borrow a tool that will give me acceptable measurements, then punch those into google (or, more recently, ChatGPT). As somebody with no chronic health issues I simply don't see the value-add of having a primary doctor that will just tell me things I already know, but with the authority of an M.D.

I donate blood every few months and they do a mini-physical that allows me to have a small insight into my health going back for years, so its not like I'm just sticking my head in the sand!

Now, OTOH I kind of love my Dermatologist. Visits last <30 minutes, about 10 of those she's physically present, and the entire time she's actually doing examination of the relevant organ. I pay in cash, I get another appointment 1 year out, and that's that. If something out of the ordinary is noticed, she can write the scrip and I can usually physically see the improvement the treatments bring.

I wonder how much of the prestige for doctors is still driven by all the Primetime shows that portray doctors as various types of savants or at least dedicated, hard workers who are subject to insane pressures and generally rise to the occasion. It probably makes the layperson think its GOOD that we limit who can be a doctor. "Doctors have to be like top 10% for intelligence and capable of working insane hours, that's not something just anybody can do!!"

Nevermind that the shortage of doctors is the reason they get insane hours and plenty of people in the top 10% for intelligence would avoid the field BECAUSE of that.

Why give blood every few months? Is that not excessive?

Far as I know it's just based on some eligibility criteria. Giving more often in theory means more blood available (for others) for emergencies. I like to think I'm banking some karma.

Donating blood also helps lower your microplastics levels (and donating plasma is even better!) https://pmc.ncbi.nlm.nih.gov/articles/PMC8994130/

Bloodletting was ahead of its time?

Yep, we discussed that a bit not long ago, so I can't say I'm donating entirely out of altruism.

I don't know if they filter out the microplastics from the blood somehow (probably not) or if they just get passed along to become the next guy's problem.

I think people receiving blood transfusions have bigger problems than microplastics, so I wouldn't worry too much about it.

Precisely. That's a tomorrow problem when you're in that state.

I assume they're talking about blood donation, not blood tests. When you go to donate, they test a drop for iron, and after your donation they test for a bunch of other stuff.

Somehow they don't even have to test the drop these days. They get the iron level some other way.

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).

My sister-in-law is a PA, and I'm friends with several others. I have no idea what you mean from the suggestion that PA's have lower status than any of these other people. Maybe because some people confuse them with medical assistants, but people who don't know the difference aren't among those whose opinions I care about. A lot of them end up being PAs not because they couldn't cut it as doctors, but because doctors themselves warned them against med school. The option is going to school for 4 years after college, spend another 4 years working ridiculous hours for poverty wages, and finally get to be a real doctor some time in your 30s. At this point you're in so much debt that the higher salary only allows for the kind of lifestyle a normal college grad would have, not that it matters anyway, because you're still spending all your time at work.

And who is exactly looking down on PAs anyway? I'm a lawyer. I don't know what you do exactly, except that it's in finance, but unless you're in senior management I'm going to go ahead and pull rank here. I don't sit in some sad fucking cubicle or worse, some trendy-looking open office. I have a private office—an actual private one, not one of those manager offices with the window or frosted glass door that's expected to be open unless you're on the phone or discussing something sensitive—that's almost large enough to include a sofa and has sports memorabilia and custom photo prints on the walls and a large picture window with a view of a forest. I have my own secretary, and an army of paralegals will stop what they're doing if they're needed. If I need something printed I call someone else and have them bring it to me. I get printouts of most things because my work space cannot be limited to two screens. I have a bookshelf full of binders I prepare for each case (I'd have someone do this for me, but I don't trust them to not fuck it up). I have people send emails on my behalf, and people stop by my office with stuff for me to sign. I don't do anything that could be conceivably described as "real work". 90% of my job is drafting informal memos that aren't assigned by a superior or even directed to anyone in particular but are simply placed in the file for my own edification and so there's a record of my thoughts in case another attorney needs to look at the case. Most of my actual time is spent looking through documents and pacing my office thinking about things so I can make a decision. The only supervision I deal with is case assignments and who is covering depositions and court appearances, if there's a scheduling issue there. I don't deal with project managers assigning me work and emailing me every five minutes.

Beyond work, I live in a 3-bedroom house in an upscale area that's filled with toys I use on the weekends pursuing expensive hobbies. So please tell me who exactly I'm supposed to be looking down on. A guy who runs a crane in a steel mill? A video editor? The owner of a dog grooming business? A low-level financial analyst for a large company? A schoolteacher? A mechanical engineer? An audiologist? A registered nurse? A college professor? An accountant who does asset valuations? The guy you call before you dig? A middle manager for the IRS? The guy who works for a large bank who's described his job to me several times and I still don't know what he does? These are all friends of mine, and I could go on, but this gives you an idea of what my social circle looks like. There are no doctors or lawyers I regularly see socially, though my cousin is a Worker's Compensation attorney. I don't know anyone, even among lawyers, who engages in the kind of ostentatious spending that's meant to signal status. I know people who are really into things like craft beer, but that doesn't correlate with income. I personally drink High Life and Coors Banquet as my regular quash. I don't think PAs are below me. And I'm not one of those unrealistic egalitarians who think that I'm everyone's equal; I wouldn't date a girl who worked at McDonalds (or, realistically, one who didn't have a professional job), but that's about as far as it goes for most people. I don't ask what people do for a living before I decide if I'm going to be friends with them.

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...

There are no gradations of lawyers in the US. Once you pass the bar you're allowed to handle anything any client is willing to give you. You might not exactly be qualified to do so, but all the ethical canons say about that is that you have to familiarize yourself with the relevant law. Medicine, by contrast, has actual board certified specialties that require specific training.

I get printouts of most things because my work space cannot be limited to two screens.

you can, and maybe should, purchase more than two large monitors

It would be easier and better for your psyche if, instead of getting upset at the idea of PAs having less status than doctors, you just dropped the stigma you currently associate with the working class.

The anonymity of the internet equalises the doctor, the cashier and the executive - online all their opinions are considered equally merited. And this has mostly wonderful effects imo, but one negative is that the wealthy express their opinions on working class jobs the way they think about them - calling them worthless jobs or saying the only people fit to push a broom or work at a supermarket are 70 iq or they're jobs for drug addicts - and they're right to an extent, they aren't as skilled as professional work, and don't require as much discipline or intelligence, and can indeed be performed by drug addicts (just like medicine and corpo blah blah blah).

But this has given the zeitgeist the impression that these jobs are worthless and as a result nobody wants to do them any more. They don't take pride in doing them and resent them. And so you get passive aggression at the deli and half missing fast food delivered cold, and people getting ticked off when their respectable friends are labelled working class. But there is plenty of pride in doing any job well and more importantly there is no shame in it. A janitor who takes pride in doing his job well is infinitely more respectable than a doctor who reads webmd at people in between smoke breaks.

Who cares if Rafa or I think your sister in law isn't in the same league as a doctor? You know her, is she the kind of person to fuck over someone's life through ignorance or is she going to do her best at all times? It's that spirit that is admirable, not her position in the pecking order.

You are in Pittsburgh, right?

It’s different in NYC in that my social circle is much more lawyer heavy. With that said, a lot of them don’t look down on other professions as much complain about the lawyer profession.

I mean we (being doctors) mostly hate NPs and PAs unless we are benefiting from them financially.

They have very limited training (in the case of NPs excruciatingly limited) and yet think they have the same level of knowledge and expertise.

All of us have lost patients are seen catastrophic avoidable outcomes.

And they can't be sued in the way we can.

I definitely agree that people don't, as a rule, look down on PAs/RNs/NPs. I seem to recall @2rafa lives in the UK, maybe this is a British thing? British people do have a reputation for being incredible snobs.

I don't sit in some sad fucking cubicle or worse, some trendy-looking open office. I have a private office—an actual private one, not one of those manager offices with the window or frosted glass door that's expected to be open unless you're on the phone or discussing something sensitive...

I am genuinely envious. Once upon a time such a thing was able to be found in the tech industry, but sadly those days are long gone. The only private office I'll ever have is when full time WFH.

Status is a thing outside of the UK, perhaps 2rafa was guilty of miswording it. Think about it like this, if you're introducing a potential spouse to your family, what would come off better? "He/She is a doctor" or "He/She is a nurse practitioner"? I don't think it's building consensus to state that everyone would agree on the first option.

I don't personally know anyone in the US who would care.

Right, and this is crucially true even if they do the same work for the same pay.

My only experience with a NP was getting misdiagnosed with asthma when I had whooping cough. The actual doctor (when I did see her) diagnosed me correctly in about a second. Prior to that I didn't really know what a nurse practitioner was.

I certainly agree that the doctors' cartel (the British Medical Association) are a gang of scoundrels though. The UK has a chronic shortage of doctors and a chronic oversupply of students who want to be, and are smart enough to be doctors. But the BMA artificially limits places at medical schools to keep their wages up, leaving the UK reliant on imported doctors who are objectively worse (with no disrespect to @selfmadehuman, I'm sure you're great).

The situation in the UK is as bad, indeed worse because of immigration as you say. The native (and 2nd/3rd generation immigrant) doctors who run the BMA and the colleges limit places because they know that almost all senior jobs in hospital trusts and places in elite surgical specialties will go to British-trained doctors because of networking and because they interview better than ESLs, and want to limit their number, forcing the NHS (as you say) to hire incompetents from abroad.

It’s got to the point where literally every elderly relative I have left can tell a horror story about their treatment at the hands of the NHS. I wouldn’t go to the NHS for a serious problem if you paid me.

For some things iirc you have no choice, even in London, because the private capacity just isn’t really there and they’ll just refer you back to the private ward of an NHS hospital.

And I don’t think ambulances will take you to a private hospital, though I might be wrong.

There is no such thing as a private emergency department / A&E in the UK, there are a couple of hospitals like the Princess Grace and St John and Liz that have urgent care (mostly only from 9am to 7pm and not usually on holidays) but it’s only for ‘non life threatening’ stuff and if you rock up and it’s bad they’ll immediately call an ambulance to take you to an NHS A&E.

That said if you need inpatient treatment you can get out on the private wing of an NHS hospital as soon as you’re out of intensive care (if necessary) which is much nicer.

Cool comment (seriously).

In your opinion what is the area of law that is at the optimization frontier for raw compensation and intellectual gratification? I have friends who do legal advisory work for the big banks, and they make crazy money, but they kind of hate everything. On the other hand, I know a guy from church who does small to medium local business law, fucking LOVES it, and makes more than enough money (though not Christmas-in-Aspen money). I have an older family friend who spent her whole career in family law and is now emotionally broken and sorta-kinda broke financially.

filled with toys I use on the weekends

Oh! Oh! What kind of toys?

Various marital aids, I presume.

US physicians (I will not call them doctors unless they are an MD, the word doctor comes form the latin docere, meaning to teach; unlike how the uncultured may think about it, true doctors are those with a Ph.D, not those with a BChir, there's a reason why in places like Germany these people are not allowed to call themselves "Doktor" but instead go by "Arzt") are so far up their own ass with how highly they value themselves that it boggles the mind.

I have met many many doctors and the vast majority of them are sub 98th percentile mediocrities pretending they are the intellectual equals of the 99.5th+ percentile thinkers. I've said before that the 95th percentile human being has a lot more in common intellectually with a 10th percentile human being than he does with a 99th percentile human being and something similar applies for the average doctor who isn't much better than a 95th percentile human but has the ego of a 99.9th percentile one (not saying there are no amazing doctors, I've met some of those too but they are the exception, not the average and they tend to be MDs).

I'd be very interested in comparing the average outcome of a NP with the latest AI models trained on giving medical diagnoses vs a lone doctor. My prior is that the NP+AI performs at least as well as a doctor in most non-surgical specialties. If so then the optimal thing for humanity is to cry havoc, give NP+AI combinations the same powers and responsibilities as "full" doctors and let slip the dogs of war on the protection racket US "doctors" are running. Of course this is a pipe dream (never mind the extreme litigiousness of the US meaning NP+AI malpractice insurance costs will be through the roof but that's a discussion for another day) but yeah, either we all grasp the nettle and do something like this or the economic rent seeking of the AMA will continue to extract blood from the rest of society.

I'd be very interested in comparing the average outcome of a NP with the latest AI models trained on giving medical diagnoses vs a lone doctor.

Not exactly that, but Zvi's recent post had this and this. Of course, I'd say that this is one of those areas where we probably care about some measure other than average, but it gets complicated.

I've said before that the 95th percentile human being has a lot more in common intellectually with a 10th percentile human being

Really? How many 10th percentile people do you meet?

The 10th percentile are the ones breaking into bald men's heads looking for gold or deflowering virgins to cure their AIDS. Or they star in the genre of youtube videos exposing how stupid and ignorant American university students are: https://youtube.com/watch?v=AkIUqH498PQ

The more cerebral of this cohort might subscribe to conspiracy theories about how the earth is flat, how everything is actually naval law and most countries are secretly enrolled as corporations in Delaware... They still cannot string a sentence together though, nor can they spell.

The 10th percentile are the ones breaking into bald men's heads looking for gold or deflowering virgins to cure their AIDS

I'd say those people are more like 2nd percentile. Either that or I have too high an opinion of the average human being (I find that hard to believe but am open to the possibility). I think 10th percentile is more like the people manning the tills at your supermarket rather than the dangerously stupid as in your comment. Would you not agree? If not then what percentile human being would you say is doing menial supermarket work?

If not then what percentile human being would you say is doing menial supermarket work?

Where I’m from, most supermarket workers are a mix of 1st generation immigrants, highschoolers, and university students. Is this not the case where you live?

Some 10%ers will be doing supermarket work of course, they might be perfectly fine, honest and upright people. Others will abuse welfare or spend their entire lives heading in and out of prison.

But on a global level, we see whole countries of the bottom 10% where nothing works: the bureaucracy is a complete shambles and infrastructure is a mess. The characteristic of the bottom 10% as a group is that they erode civilization, they're not merely pawns that do menial tasks.

Scott Alexander memorably pointed out that they do not have alphabetical organization in Haiti - this rather impedes efficient administration. They still have not managed to repair the National Palace where the President lives since the earthquake in 2010.

https://en.wikipedia.org/wiki/Haitian_crisis_(2018%E2%80%93present)

Or from another angle, someone actually wrote this as a story and published it. A real adult thought other people would like to read this. It's pretty bad: https://www.webnovel.com/book/30212039405390805/81118027365538549

I believe that the difference between me and von Neumann is less than the gap between me and this guy. Not in our work capacity but in our general faculties and comprehension.

My church is putting together a big fund for sending Haitian children to school and privately I thought, what's the point of educating Haitians?

Still not sure what to make of it.

Other than possible extreme edge cases in some distant regions literacy doesn’t seem to be an issue for any major human population, certainly not Bantus, and can benefit almost anyone. So I would say your church is - if the money is not taken via corruption and actually goes toward education - doing a good and valuable thing.

Well there's teaching basic literacy, and then there's sending to school for years and years. If those are the same thing I'm not convinced it's worthwhile.

I do not know what fractions of Haitians are educable, but I have worked professionally with educated Haitians who were able to perform the duties of a UMC professional job that normally requires a 120+ IQ. Of course Haiti, like most Caribbean countries, has a mixed-race elite and an almost-pure-black working class, and the people I worked with were from the Creole elite. So there is a separate question of what fraction of Haitians who are not already being privately educated are educable.

I have met intelligent and capable Haitians, they’re not hugely uncommon in Florida and there are a few in France too.

The tenth percentile of the general population is living off some combination of government aid and crime. They’re certainly not cashiers; even restricting to college students, the tenth percentile will not have the work ethic or the numeracy for this.

Yeah, people tend to flatter themselves that there is a huge gulf in abilities between their own tier and the tier immediately below them (but, strangely, never the tier immediately above them).

It's why so much internet energy is spent talking about "midwits".

A simpler and more accurate model : intelligence matters a lot at every level with no high or low cutoff.

(but, strangely, never the tier immediately above them)

I freely and openly admit that the people above me are much more exalted than I could ever hope to be. I recently interviewed a candidate at work who was applying for a quant job and he absolutely floored me with how intelligent he was, telling me things I hadn't realized about the mathematical question I ask people a few short tens of minutes after seeing the question for the first time. I came away from that interview thinking that I had just come into contact with someone blessed with true shape rotator greatness.

At least I am at the level where I could appreciate what I had just seen, unlike the average 95th percentile person who is so far removed from it that he wouldn't be able to tell the difference between me and this person had he been the one taking the interview instead.

What intellectual percentile would you rate yourself?

If I'm flattering myself probably 99.8, but in reality more like 99.5 or 99.4. (normalized to white western levels, compared to my own people I'm significantly higher).

One in 200 is probably how unique I think my intelligence really is. I'm quite conscientious and like learning about basically everything so I think I present as smarter than I really am because I can talk decently about a lot of things.

Back when I was a child I had delusions of being Great. Those were shattered very quickly when I began my maths degree at Oxbridge and got a chance to mingle with IMO hall of famers.

They were just at another level to me and despite initially foolishly thinking all I had to do was work harder and then I too could reach their level (note: I did not succeed, all that happened was I burnt out) eventually after getting smacked around enough by reality I learned to love my lot in life and go down a gear. I had a lot more fun too after I did this.

My dharma is not to achieve great things but at least I am at the point where I am capable of truly appreciating greatness when it is presented to me (unlike most humans) and I am thankful for that. It's much better to get into a state of resonance with the music of the universe ather than try and fight against it vainly. That way lies the path of Morgoth and we all know how that worked out...

I scored in the 99th percentile on verbal tests and somewhere around the 92-95th on spatial, so I’m not sure where that puts me overall, probably below you. Still, while I’ve met many much smarter people I find them generally easier to speak to and understand than people in the lower third of the population. Of course if the conversation turns to a niche special sub-field in theoretical physics or math or formal logic that I have never studied I’m not going to be able to follow, and my middling shape rotation ability means I’m not going to be able to hold my own with star traders at the poker table or when it comes to logic puzzles. But they don’t ever feel ‘foreign’ to me; I can understand the ideas even if I can’t derive them, if you want.

My dharma is not to achieve great things but at least I am at the point where I am capable of truly appreciating greatness when it is presented to me (unlike most humans) and I am thankful for that.

Well, you're doing better than Salieri, then.

Honestly I think Salieri gets unfairly maligned a lot. Modern scholarship (forget that movie, I'm talking academic scholarship) thinks there was no real beef between him and Mozart but the rumours, even during his life, led to him having a nervious breakdown and even now in the modern day the general public (to they extent they know of him) still boo him even though they wouldn't be able to distinguish a piece by Mozart vs one by him.

The dude tutored both Schubert and Beethoven, give him some respect!

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Fair enough.

For the record, I get midwit vibes from many doctors myself.

I think this is true for many professions with a deep moat around them, regardless of that is educational credentials or some level of career success. This doesn't have to be very highly compensated professions mind you.

In situations where you're "safe" once you're in many people check out mentally and this affects not only job performance.

Being a "midwit" is only partially an effect of intelligence but also of practiced intellectual rigour, often requiring a competitive environment, which typically means work. It's like if people who were professional athletes when they were young thought they're still competitive when they haven't really exercised in over a decade. Disconnect from competition and practice allows for personal preference rule uninhibited by reality.

Somewhat related but I've become convinced that the way the doctor profession works is a major drain on society.

A practicing doctor is a somewhat important profession that requires a reasonable amount of intelligence to do competently, but they also have horribly low productivity compared to many other highly paid professions, seeing as the doctor only ever helps as many people as they physically can see. Combine this with fantastically high base compensation and a borderline ironclad employment security until the grave and we have a societal problem where medicine effectively becomes a form of sinecure for the intelligent.

There are more productive professions within the realm of medicine like researchers and med-tech engineers (and there is some overlap with doctors here) but they generally aren't meaningfully better compensated than regular practicing doctors and often get paid less.

I'm not saying these people shouldn't be well compensated or that we shouldn't have doctors but the current incentives leads to a situation where a good portion of the most intelligent are drained away from the economy to do low productivity work at a very high cost.

This could all be solved with an increased amount of doctors. The intelligent and driven will go on to more productive work (whether in the realm of medicine or elsewhere) and society gets access to more doctors for a more reasonable cost (just how much lower depends on the country).

My friends and I were speculating the other day how this could be improved within the current constraints of our public health system, we landed on a mix of telehealth and licensed practitionners (could be NPs) who specialise in making observations (and auscultations, etc...) for doctors to extend the amount of ailments that can diagnosed by a remote doctor.

My work insurance has as one of its perks free access to a telehealth service and it's shocking how convenient it is compared to going through the public health pipeline, when it is able to help. I'm sure it's convenient to the doctors who work through that system too.

From an economic perspective, low doctor productivity is a huge issue. The Baumol effect means an ever growing amount of money needs to be devoted to medicine to make up for the shortfall. It really doesn't have to be like this, but nobody in the field wants to disrupt the gravy train, and/or regulations make it too difficult to change anyways.

I feel like a lot of what doctors do could be done algorithmically by chatbots. From what I've seen, most doctors just respond to simple cues as to what the problem is. Testing could be done at outpatient facilities, then the meatspace doctors would only need to come in as a last resort.

Chatbots are interesting and have a lot of potential, but their dynamics can become a bit complex once you get into multi-chat conversations.

I know one person who’s deployed one as a full-fledged product. It solves a relatively simple problem and even then, babysitting it is giving him grey hairs.

My alternate formulation would be that while a surgeon might be a man (or woman) of import, a doctor is almost certainly trash.

There's also the pressure to publish and research while also being a doctor that downgrades the focus the profession has on actual patient care.

My friends jumping through the residency hoops rn are kind of frustrated about it; they have to explain their "side hustle" almost instead of being able to say "I just want to be a doctor" to get "good" residency spots.

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.

This seems like a problem that fixes itself: while not perfectly, status does eventually follow money. As it does, these jobs should start to get filled with more competent people.

I'd be more worried for countries with socialized medicine, particularly those that don't have that high median income: there's only so many immigrant doctors to prop up your system.

And a cynic might suggest that this is why the parasite class is so gung ho about socialized medicine.

I'm going to push back on the assumption that nurse practitioners, or even registered nurses, tend provide worse care than doctors for most patients. I want something more than an impression of anecdotes--preferably actual studies--because in my circle complaining about getting misdiagnosed made by doctors is a well-honed pastime.

I dig your take that those born to the PMC class who strive for Doctor status don't downgrade to nursing. In my experience, nursing Bachelors programs are still very competitive, and there are plenty of children of PMC that go into it (heck, I know a few). These are young women (for the most part) who like to work with people, who like clearly meaningful work, who are not put off by the prospect of hard work, and who by-and-large aren't strivers.

Nursing Bachelors programs also draw plenty of (mostly) women from the working class--because it's clearly meaningful and hard work that's well-renumerated--and only the smartest and most conscientious tend to make it into--and then through--the competitive Bachelors.

It therefore seems to me that there is a positive selection for a combination of conscientiousness, intelligence, and willingness to work hard. So without looking more into the data on the subject, I predict that a study comparing rates of misdiagnosis would be similar for Nurse Practitioners and Doctors, and probably not much worse for Registered Nurses.

Especially if the study counts the final diagnosis of the system rather than the initial diagnosis: a good Registered Nurse can look at a first-time patient, say "I think it's anxiety, but since I am not certain, so please wait while I consult with the Doctor on staff", and that may be the right call when the Doctor then identifies it as a blood clot. A good diagnosis by Registered Nurse should be "I know it's this" or "I need to send it up the chain of specialization".

(My thanks to @ToaKraka for posting earlier the info on what various nursing type professions require.)

preferably actual studies

This is an area of ongoing research, for a long time there was a bunch of non-inferiority type studies published by the nursing lobby which were apples to oranges comparison. Ex: NPs with simple cases and MDs with hard cases had similar outcomes.

Now that the NPs have made such a mess of things you have more research such as this: https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs#:~:text=The%20study%20found%20the%20physician,complexity%20of%20the%20patient's%20condition.

It's important to keep in mind that NPs get effectively no training. Even if you think medicine is grossly simple (which....sigh), you should have some training.

I think people really struggle to understand how big the gap is no matter how often it's pointed out. You wouldn't trust Juan the day laborer working construction with designing a skyscraper, but that's a reasonably apt comparison in training differences and amounts.

NPs don't save the healthcare economy because while they do get paid less they do more unnecessary testing, it's just a wealth transfer from MDs to hospitals. They also stress the system more with unnecessary consults and admissions which only makes the doctor shortage issues worse.

Thanks for sharing the study, it is really very good! Reading it was a Sunday well-spent.

The conclusions that the authors reach have a lot of nuance, and help explain both why so many people have negative impressions of NPs while others have positive impressions: the variability of the productivity[1] within each profession dwarfs the difference between the average NP and the average doctor.

The other useful estimate from the study: randomly pick an NP and a Doctor working for VA emergency department; 6 out of 10 times, the Doctor is more productive, 4 out of 10 times, the NP is.

I understand that VA hospitals have trouble attracting talented doctors, though I assume that they have similar problems attracting talent in other professions, NPs in particular.

If I were in charge of VA, I would make a rule that any doctor who got their license in any OECD country can work unsupervised (provisional on training on HIPPA or whatever other US-specific medical laws). Then get a whole bunch of H1 Visas for any doctor who wants to come work for VA for five years.

[1] "productivity" was operationalized as the total cost of care (negatively coded), including the cost for any avoidable hospitalization due to screwing up, which makes sense in the VA emergency department.

If I were in charge of VA, I would make a rule that any doctor who got their license in any OECD country can work unsupervised (provisional on training on HIPPA or whatever other US-specific medical laws). Then get a whole bunch of H1 Visas for any doctor who wants to come work for VA for five years.

What do you gain from this? If the goal to decrease healthcare costs this doesn't do much. If it's to solve the shortage it also doesn't help that much.

I would love to know why you don't think it wouldn't help with the shortage. I figure that, having a shortage of doctors willing to work in VA, combined with doctors from other countries who are willing to work at VA because it will gain them the higher US pay + a path to US citizenship, would indeed alleviate shortage of doctors at VA. However, I am not a medical doctor, so what am I missing?

However, I am not a medical doctor, so what am I missing?

Coming in way too hot.

The VA has had hiring freezes for the last two years, to my understanding. So no traditional shortage there.

Hiring extra VA physicians does nothing for the general problems we have in any case (which isn't a traditional shortage).

VA had a hiring spree last year, in large part because of the expanding benefits from the PACT Act.

Your impression of a hiring freeze remains partly correct, because VA has budget shortfalls and plans to lay off staff:

More recently, though, the VA told Congress it now expects to have about 5,000 more employees in VHA next year compared to this year. That's created a new problem, as the VA is warning it is facing a multibillion-dollar budget shortfall.

I suspect that VA tends to paint a bleak picture to Congress as a standard operating procedure, in hopes of getting more funding. Though my nephew assures me from his VA experience that more funding would not go amiss.

So back to my off-the-cuff idea of importing doctors: my point is that any VA hospital that finds it challenging to attract a decent US doctor ought to be able to do what the private sector does. Right now, the VA follows AMA's standards, which require any non-US-trained doctor to do 3+ years of residency (plus other things) before they can practice medicine in US. Residency slots are, apparently, the bottleneck for US doctor supply in the first place.

My question is: just how crucial is it for someone already practicing as a doctor in a French or German hospital to do 3+ years of residency in US?

My question is: just how crucial is it for someone already practicing as a doctor in a French or German hospital to do 3+ years of residency in US?

I've never met a foreign trained doctor who came to the U.S. with Medical School and Residency training in Western Europe. We might actually have reciprocity agreements for those countries, I don't know, I've never encountered one. Scott did his Medical School in Ireland IIRC, which is note quite the same. The vast majority of foreign doctors I've met are from Asia (mostly India) and do absolutely need retraining and will generally admit as such, however frustrating it is.

Every time this comes up I have to drag out a few facts.

-There is actually a surplus of residency spots. Yes you heard me.

-We do have something of a shortage of some specialties, but this can't adequately be solved by increasing spots without decreasing training quality.

-Nobody wants to go into primary care because it pays significantly less, is one of the harder jobs, and has been made less attractive by regulatory burden and other factors.

-Most jobs are in primary care anyway, aka most doctors work in primary care.

-Even within primary care we have more of an allocation problem than a shortage. Doctors train very hard and start their adult life late. They want to be in desirable locations so Iowa has a shortage but NYC does not.

-NPs and PAs were meant to fix this but make it worse - they still want to go into specialties (and can since they have no specialty training, they can just do what they want) and they still hang around the same urban areas.

-You could hypothetically fix this by importing a ton of foreign doctors but you'd have to enslave them and force them to work in the undesirable locations long term or they would just leave immediately when given the option.

-You can fix this using the resources we have by raising salaries to what incentivizes the behavior you want. Nobody wants to do this, they just want to continue giving doctors the pay cuts they've been getting for the last 20-30 years, even though doctors are not a high percentage of healthcare costs.

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That AMA link gives such a laughably biased summary of the actual study, though. The paper itself suggests a far more nuanced picture than your metaphor about Juan the day laborer-- and that's a study led by an MD who presumably has his own professional axe to grind. (I'd be much more interested in seeing some adversarial MD-DNP research collaborations in this area.)

Notably,

  • The study focused almost entirely on costs in an ED setting; on a skim, I can't find that it examined detailed health outcomes at all beyond 30-day mortality and "preventable hospitalization," the latter of which seems difficult to define in terms of patient welfare. They say NPs and MDs had no significant differences in 30-day patient mortality.
  • The study did find that treatment by NPs cost the system more than treatment by MDs, owing to NPs calling for longer hospital stays and more tests. But the difference in costs diminished with more experienced NPs.
  • The cost difference also diminished to a relatively trivial level for less complex cases, and the authors themselves suggest that this means NPs could be valuable substitutes for physicians in primary care.
  • They found almost as much variability in productivity from clinician to clinician *within* professions as there was *across* professions. Money sentence from the abstract: "Importantly, even larger productivity variation exists within each profession, leading to substantial overlap between the productivity distributions of the two professions; NPs perform better than physicians in 38 percent of random pairs."
I agree with you that NPs receive a disturbingly small amount of training before they're turned loose on patients. But I think the question we should be asking is what it suggests about doctors' care if MDs still realize such minor gains over DNPs.

I mean you are always going to run into study design limitations. In this case most of the money in medicine wants NPs to look good so there isn't good funding for this. The VA (generally) has pretty much the worst healthcare in the country and the quality of care in the ED is also pretty much the worst in the hospital (because of how it gets misused). This is likely to flatten the curve a little bit - good doctors almost never work at the VA.

Psychiatry is a better example - psychiatric interviews and pharmacology are the most complicated in medicine. Mental health care NPs are terrible at both of these things, give people unnecessary medications and incorrect diagnoses and are legible experienced as lower quality by patients and staff with some regularity. In general hospital medicine nurses line up each other and that includes NPs but in most mental health care settings nurses will say they think the NPs are shit.

However the bad outcomes are mostly increased lifetime mortality and risk of side effects 20 years down the line when the patient is seeing someone else. This becomes effectively impossible to study so we don't.

Now you could argue that you don't really care about those problems and if its not obvious their is a skill difference in outcomes lets save money, who cares if people have the wrong medication or diagnosis. But that goes back to the ED stuff - you have a difference in mortality and morbidity, it may be small but most Americans value "the best possible" not "good enough."

Also, since this is why people normally bring it up - if you magically paid all doctors NPs salaries and didn't really change anything else......healthcare costs wouldn't go down at all in any substantive way.

However the bad outcomes are mostly increased lifetime mortality and risk of side effects 20 years down the line when the patient is seeing someone else. This becomes effectively impossible to study so we don't... Psychiatry is a better example - psychiatric interviews and pharmacology are the most complicated in medicine. Mental health care NPs are terrible at both of these things, give people unnecessary medications and incorrect diagnoses and are legible experienced as lower quality by patients and staff with some regularity.

I should emphasize that I have a lot of respect for psychiatrists, who seem to hurl themselves into the breach of various social ills in a way I certainly wouldn't want to do. But if we're searching for a test field where rigorous evidence makes it very legible which are the "necessary medications" and "correct diagnoses," so that MDs' highly effective healing practice contrasts clearly with NPs' useless flailing, then I'm not sure psychiatry is the obvious pick. We're talking about the same psychiatry that regularly diagnoses from subjective surveys and patient self-reports, correct? Where almost none of the biological mechanisms are thoroughly understood, either for the ailments being treated or the medications that treat them? Where exercise, healthy diet and getting plenty of sun/fresh air seem to work as well as the best drugs a lot of the time? Where official medical conditions pop in and out of the DSM with every passing political wind?

Would you say that psychiatry does a good job of monitoring its physicians' contribution to patients' lifetime mortality and/or risk of third-order side effects 20 years out, either across different levels of physician talent/conscientiousness, or versus not receiving psychiatric care at all?

Also, since this is why people normally bring it up - if you magically paid all doctors NPs salaries and didn't really change anything else......healthcare costs wouldn't go down at all in any substantive way.

I don't quite get the reasoning here. Is the idea that receiving NP salaries would cause physicians to practice as badly as you believe NPs practice, because all the competent MDs would decamp for higher-paid professions (notwithstanding the additional benefits of prestige, flexibility, autonomy and meaning in medicine)? Doctors in Canada, the UK and Germany earn about 1/3 to 1/2 what they earn in the US; is the contention that they must practice incompetently and waste a ton of money doing so?

It's called the art and science of medicine for a reason, in psych it can be pretty evident to the lay man, in other specialties it's less but still present. This means experience, heuristics, gestalts, they lead doctors astray yes, but for a lot of things we don't have good guidelines or understanding.

Importantly, doctors can be sued - this causes all kinds of problems but it does serve as a feedback mechanism that assess for problems and gives patients recourse.

Let me give a specific example of how this happens, sticking with psych because it's more interesting than me mumbling about open vs lap vs conservative appendix management.

Most people are aware of Bipolar disorder, at least superficially. Lots of people say "I have mood swings" and tell that to healthcare workers with less training, these people dutifully write down Bipolar in the chart. Or they say "you ever like have mood swings and be unable to sleep?" Gets the diagnosis. Someone who actually has Bipolar 1 with a manic episode barely sleeps for a week of more, does illegal things, or spends ALL of their money in the bank account and all kinds of other stuff. The diagnosis is serious and life limiting without treatment. The medications are also serious - most patients get antipsychotics these days which increase all cause mortality. They are worth it if you actually have the disease. Put undertrained staff give the dx to people who don't have it and then suddenly...

NPs also do things like mix benzos and stimulants, put people with depression or anxiety on antipsychotics which will result in an early death....just all kinds of ridiculous stuff.

The skill ceiling in psych (and medicine) is very high, but if you don't work in healthcare you'll (hopefully) never see it come into play. Most medical work isn't your quick annual physical with your doctor but for many patients (especially young ones) that's all you see.

As for the second point, no the issue is that physician salaries are less than 10 percent of healthcare spending, and it's been decreasing every year. Cutting doctor salaries does not solve the problem and introduces all kinds of new problems.

Likewise NPs don't save money because they do more unnecessary testing and over consult, which drains the specialists and slows down care.

Most people are aware of Bipolar disorder, at least superficially. Lots of people say "I have mood swings" and tell that to healthcare workers with less training, these people dutifully write down Bipolar in the chart. Or they say "you ever like have mood swings and be unable to sleep?" Gets the diagnosis. Someone who actually has Bipolar 1 with a manic episode barely sleeps for a week of more, does illegal things, or spends ALL of their money in the bank account and all kinds of other stuff. The diagnosis is serious and life limiting without treatment. The medications are also serious - most patients get antipsychotics these days which increase all cause mortality. They are worth it if you actually have the disease. Put undertrained staff give the dx to people who don't have it and then suddenly...

OK, this is a good example for illustrating the difficulty I'm having with the binary MD-competent/ NP-incompetent model. So here we have a fairly clear, potentially dangerous error in practice. Insofar as it is fairly clear, you were able to explain it to me in a paragraph or so: now I, a random Mottizen, understand that it's bad to diagnose and medicate bipolar just on the basis of "mood swings" or "poor sleep," and that patients should instead be experiencing very florid manic episodes with clear life consequences. That's facile, but for someone going on to psych practice, I'd imagine a few additional hours of video case studies would eliminate the lowest-hanging 80-90% of obvious mistakes of the form "don't diagnose bipolar in this clearly not-bipolar patient, dummy." So presumably that same advice and video training could be administered to a DNP before they begin psych practice, problem solved.

Fine, says the MD, but what about the top-10% "art of medicine" situations where the line is far more nuanced? There aren't empirical tests to verify a diagnosis; what if the situation sounds right on the border? The precise mechanisms of bipolar are poorly understood; what if there are a lot of other things going on and it's not clear how they interact? Or it's not clear how medication will impact any particular patient, so what if the risk-benefit math around prescription is very challenging?

I can easily see how what you call the "skill ceiling" could come into play there, leading an NP to get those questions wrong. What I don't see is the training value-add that makes you confident a random board-certified psychiatrist would clear the skill ceiling and get them right. There's not good basic science around these issues, so the organic chemistry and anatomy from med school certainly won't help. Residency? Presumably this means that the MD encountered some difficult cases under supervision and was admonished to approach each case the way their attending would do it. However, (a) that could have been an indefinite amount of time ago, and there's nothing beyond some trivial online quizzes to ensure the MD has kept up with new data since their training; and (b) even back in training, nobody was checking to make sure the supervisor was themselves particularly judging the situation "correctly". Indeed, how could anyone even define "correctly," if the case was by definition so difficult and subtle, the kind of situation where the wrong call would just make a patient sadder and less functional 20 years hence, not cause them to keel over and die on the spot? Doubtless the attending felt confident that their approach was making a real difference; but we all know the various cognitive biases that would lead doctors to overestimate the correctness of their judgment and the effectiveness of their treatment under those circumstances.

I guess it boils down to the broader question "when psychiatry works clearly, it should work for DNPs too; but when it doesn't work clearly, how can you be sure it works at all?" One established answer is to turn to empirical investigation to discipline our judgment; but as you point out, psychiatry isn't a field with a lot of options for carefully blinded RCTs and massive long-term studies.

I think people in other fields fail to understand how egregiously poor a lot of NPs are. Most settings they are still supervised or deliberately have low complexity cases sent their way or have some other aspect of the environment that protects them (for instance inpatient NPs just consult specialists for everything and those specialists manage the patient even though the NP is on charge on paper).

Surely they must have some training, and they can't be that bad, right? Like who would let them practice if they are that bad?

They are that bad.

It's been hard to extract the data about this because of financial interests in NPs, and the general difficulty of doing medical research.

So much of medicine is opaque to those outside the field and even inside of it (I know nurses who have been working for 40 years and go "huh" when you tell them the resident has been working 24 hours in a row).

Fundamentally I see midlevels every week who make decisions that would make me go "holy shit you are the worst doctor in your specialty I've ever met," it's near constant.

It sounds histrionic and unbelievable but that's how so much nonsense in healthcare is.

Amazon, google, apple, tons of finances firms have all come into medicine and gone "damn that shit is run so poorly surely we can do better" and then run away screaming.

I'm going to push back on the assumption that nurse practitioners, or even registered nurses, tend provide worse care than doctors for most patients. I want something more than an impression of anecdotes--preferably actual studies--because in my circle complaining about getting misdiagnosed made by doctors is a well-honed pastime.

I haven't been able to find it again, but I remember reading a story somewhere (possibly by Dave Barry, but I could be wrong) that went something along the lines of:

My tongue was swollen, and I went to my doctor. He did an examination, then diagnosed me with two Latin words, that when I looked them up later, turned out to mean 'swollen tongue', and told me to come back if it hadn't gone away in two weeks. I then asked a nurse, who told me to gargle with salt water; I did and the swelling was gone quickly. I'm hoping my dog's tongue becomes swollen; if the vet tells him to gargle with salt water, I'm taking all my medical problems to him.

(If anyone knows the source of this, please let us know.)

I had severe and persistent shoulder pain a few years back, it would radiate down my arm to the point it it became actually debilitating. Went to urgent care, they did X-rays, a doc came in and felt around, asked me some questions, and looked at the X-ray results.

Said I likely had bursitis and gave me a scrip for muscle relaxers and painkillers, that BARELY got me through the next couple weeks until the pain went away.

Last year, the pain came back. This time I spoke to one of my Physical Therapist friends who I KNEW saw tons of patients a year. She agreed to do an exam for cash, then give me her thoughts and possible options.

Took her about 10-15 minutes of prodding around to diagnose elevated first rib and a muscle imbalance causing possible shoulder impingement.

She gave me some stretches to ease the discomfort, then some exercises to remedy the imbalance once the pain subsided. Took <1 week for the pain to alleviate, and after easing into the exercises everything started working even better than before. No drugs needed.

Sort of broke my last remaining faith in Doctors as the gatekeepers of health.

I know this is an immensely frustrating experience as a patient but it is important to understand that this is not what urgent care is for.

If you saw a physiatrist (which is the specialty that handles this kind of problem) and they get it wrong....that person's license should maybe go away. A good PCP should get this right but these days we don't do nearly as much MSK work and hospital demands mean we aren't as good at this kind of thing as we used to, you may have PT be the replacement for managing it since it isn't really a medication issue.

But it's effectively out of scope of practice for Urgent Care and ED.

Patients go to UC and ED because it's more convenient than getting a PCP, but ED physicians don't handle these kinds of issues, their job is to triage and manage emergencies, which would likely involving turfing this back to a PCP or PM&R doctor for outpatient management.

There's all kinds of reasons why patients use UC and I get it, but ultimately it results in a lot of disastifiaction because it's generally not the right doctor for the problem.

The fact that I was able to get an issue solved by a Physical Therapist with an investment of about $50 and 30 minutes of time seems to suggest that the medical industry is overcharging for certain services.

Not sure what you'd suggest I do when I'm experiencing ongoing immense pain but no immediate danger and it'd take weeks or possibly more to get in with a specialist.

If the urgent care folks had said "oh, we aren't really geared for this, go see a physiatrist" then I'd give them credit.

That ain't what happened.

I mean a physical therapist is the appropriate medical professional for the issue you had. You went to the "am I dying" doctor and they said "shit I don't know, you aren't dying," if you were dying they would be able to help you. They have limited training in diagnosing MSK issues because that's not what they are for.

Routine issues and urgent care level emergencies are supposed to be managed through your primary care doctor who would say "this seems like an MSK problem, here's as prescription to go see a PT for that, as they are the experts in this area and can spend an hour with you twice a week and I can't do that without it being cost prohibitive."

We see this all the time, people go to the ED for non-emergent issues and get frustrated when they get what seems like poor quality care and it takes forever.

Furthermore patients don't like hearing this so you get some half-assed attempts at managing these issues in those settings instead of the correct response which is "no go see your PCP."

Ultimately if you say, go to your lawyer and ask for accounting help, they may charge you for it and try and help but they aren't an accountant.

Well conveniently I explained what happened with my primary care physician elsewhere in this thread.

i.e., he's been 99% useless to me compared to the time and money cost, so urgent care is simply the better option.

Ultimately if you say, go to your lawyer and ask for accounting help, they may charge you for it and try and help but they aren't an accountant.

Ackshully, as a practicing lawyer, I can say that that may very well be malpractice, and its for this exact reason I keep a number of trusted accountant and financial advisors in my rolodex to send clients to rather than even risk that issue.

PCPs have sick visits, you establish with a PCP and they'll schedule you urgently if something needs to be managed urgently, if you have an established relationship with a PCP they'll know how reliably you are and will do somethings over the phone. This is how it is supposed to work, Urgent Cares exist because people these days refuse to use the system how its designed (and it's because of incentives, I get it and have committed this crime also) but they aren't really designed for the care people ask of them.

Additionally, physician pay has decreased year after year for longer than the majority of the people in this forum have been alive. This has a number of important effects one of which is: most of the shit that annoys you most about doctors is not their fault, they are required to do it because they aren't in charge anymore (most people in most specialties are employed now and not in independent private practice).

-Can't do something simple over the phone has to be an appointment? It's because that doctor's employer requires it so they can bill.

-Appointment short and unrewarding? It's because that is how the employer wants appointments scheduled.

-Doctor pays mostly attention to the computer? It's because there is no admin time and if he wants to go home before 8pm he's gotta start charting in the room.

-Doctor asks you annoying repetitive questions? Someone has mandated they ask them in order to bill or satisfy regulatory requirements or some other annoying thing. Or some incompetent front desk staff person said you were a smoker or a drinker or are missing your appendix and it requires forms in triplicate to remove from your chart.

Doctors no longer work for themselves and are now required by law and by their employer to do things that annoy the hell out of patients and we hate it but its not our fault please dont blame us thank you.

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It seems to me as someone who only uses the healthcare system but has friends who went into medicine that there is a huge fraction of medicine, mostly in general practice where we already have a shortage of doctors, that consist of handling the same dozen ailments over and over again. How much time do pediatricians spend diagnosing ear infections in kids and writing notes to send them back to school and prescriptions for amoxicillin? Or GPs asking the same lifestyle questions and giving the same advice ("quit smoking, lose weight, get more exercise"). The AMA cartel would have you believe that it takes years and years of specialization to handle this, but it seems that most of the front end stuff really can be handled by someone like an NP who knows those dozen ailments well, and most importantly when to ask for a more expert opinion.

Clarification of all these healthcare professions from the Bureau of Labor Statistics:

Occupation Entry-level education Median pay (k$/a)
Nursing assistants and orderlies High-school diploma 38
Registered nurses Bachelor's degree 86
Nurse anesthetists, midwives, and practitioners Master's degree 129*
Physician assistants Master's degree 130
Physicians and surgeons Doctoral degree **

*Median pay specifically for nurse practitioners is 126 k$/a.

**Median pay is off the chart, in excess of 239 k$/a. Mean pay ranges from 206 k$/a for general pediatricians to 449 k$/a for pediatric surgeons.

Nursing assistants provide basic care and help patients with activities of daily living. Orderlies transport patients and clean treatment areas.

Registered nurses provide and coordinate patient care and educate patients and the public about various health conditions.

Nurse anesthetists, midwives, and practitioners coordinate patient care and may provide primary and specialty healthcare.

Physician assistants examine, diagnose, and treat patients under the supervision of a physician.

Physicians and surgeons diagnose and treat injuries or illnesses and address health maintenance.

Thank you that was interesting. Quick question on NPs, I thought they typically made pretty good money (google claims around 120k a year in Las Vegas). This is pretty reasonable compensation and is similar to what you can earn as an early career software person.

Sure, they’re well-paid but they’re still a working class profession. It’s like how plumbers often make more than junior state department officials and NYT journalists, but the latter are clearly higher status professions.

What's the long term upside of being a PA/NP? Are their managerial and executive equivalent roles for PAs/NPs? Beacuse while making $130k is great out of school and pretty good for a full career (inflation adjusted, of course) ... junior state department officials can build careers that end in Congress, advising /consulting F500 corporations, or just good old fashioned Sinecures at Think Tanks that can push them past $500k / yr. Sure, definitely not all of them will get there, but there's at least the possibility and the pre-established career path.

I'd argue that this is one of the defining features of the PMC approved career paths - that they all have the possibility of creating eye-watering levels of income (bonus points, however, if they have some way for you to pretend you're doing it out of genuine passion and not just for the money. This is why politics is so PMC attractive).

What's the long term upside of being a PA/NP? Are their managerial and executive equivalent roles for PAs/NPs?

I think that as with both nurses and doctors, the smartest and most ambitious can rise into hospital management.

Which raises the question- I see a lot of recruitment and advertising around me to become electricians, underwater welders, pilots, etc. I see some recruitment to become an RN or EMT but functionally none to become a PA or an NP.

Now it's possible that I just miss it, because it's aimed with surgical precision at eg medics leaving the army, currently employed lower healthcare professionals, etc, but I think it much more likely that these fields are just doing a bad job of recruiting the best and brightest out of strata that see $130k/yr as a salary that makes lack of social respect with a masters degree worthwhile.

I can't drive down twenty miles of highway without seeing a nurses wanted sign, usually with a prominent signing bonus advertised as well. Maybe it's a regional thing?

Is that a function of education time/costs? Employers are willing to take on apprentice welders and electricians, but the educational hurdle for an NP is several years of training before someone becomes employable. Pilots need (preferably paid) hours to hit minimums for airline work. Nobody seems to be willing to hire to train engineers or lawyers either because those are harder to learn (earn licenses) while working at more entry levels.

Pilot training is so expensive that it probably evens out here(planes, man).

In the book Where's my Flying Car?! The author does a great breakdown of how, because of over-regulation, general aviation died by the 1960s. If it hadn't, he lays out a good case that a pilot's license would be roughly equivalent of (good) driver's education for the same cost, and hundreds of thousands more people would probably fly. It would reshape highway systems and transportation in general.

Regulation doesn't just slow existing business / industry, it aborts new ones from forming and developing before they ever have a chance (emotive metaphor definitely used on purpose)

The non-flying car in its current form only exists thanks to a collective irrationality about safety - people (both individually behind the wheel and collectively as voters) treat life as being an order of magnitude cheaper on the roads than it is in other contexts. There is no comparably dangerous activity except driving where it is socially acceptable to do it in a public place with only $50,000 of liability insurance. If someone proposed cars, driven by ordinary citizens, as a new transportation technology then we would ban it - and by the criteria we normally use to judge dangerous technology we would be right to do so. Car crashes are the largest cause of premature death in most rich countries.

Even with the current regulatory environment, general aviation is about 10x more dangerous than driving. (We tolerate this because private flying is seen as an expensive extreme hobby in the tradition of yachting or snowboarding. Also because the regulatory environment makes it very hard for a pilot to injure other people through ordinary non-culpable stupidity. And even so a pilot with less than a million dollars of liability insurance is going to get the stinkeye from airport and hangar operators.) Another way of putting it is that the mean time between fatal crashes (slightly over 100,000 hours) is only slightly longer than a career (80,000 hours). If a job was as dangerous as an average licensed pilot flying a plane maintained properly by average licensed mechanics, then most people doing that job would not survive to retirement. A plane flown by someone with the skill level of the average driver and maintained by the average motor mechanic would be dramatically more dangerous.

The sequel to Where's my Flying Car should be called The Texas Planesaw Massacre.

Even with the current regulatory environment...

I am arguing in the exact opposite direction. I would write that sentence as "Because of the current regulatory environment..."

We over-regulated general aviation and so froze it in time. If we had more people flying more planes more often, GA safety would progress faster. This is exactly what happened with cars - seatbelts, cruple zones, airbags etc.

I definitely agree that if cars were to be magically re-introduced today, we would preemptively ban them. And this is safteyism run amok and horrible for human growth and development. It is sad that people die in car crashes, I wish that wouldn't happen. I am extremely grateful for automotive transport, commerce, and sport - it helps the species generate more wealth, interact more broadly, and deliver more individual freedom.

Imagine the kind of wealth, interaction, and individual freedom one could get in an affordable and easy to fly aircraft.

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and hundreds of thousands more people would probably fly

But the FAA wouldn't know how to handle that. So they made it impossible.


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