domain:alexepstein.substack.com?page=6?page=2
bonsaii
6hr ago
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.
SubstantialFrivolity
I'm not even supposed to be here today
6hr ago
As is so often the case, it comes down to the outgroup/fargroup distinction. For leftist in America, Muslims (even the ones in the country) are the fargroup. They just don't care about them that much. But Christians (especially the conservative, fundamentalist strain of Christian) are the outgroup. They hate those people, and so they target all their ire at them.
WhateverHappenedToNorman
6hr ago
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.
hooser
6hr ago
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.)
No_one
6hr ago
Gleba got us (me & cjet) pretty stumped. And yeah, we imported everything to start, power generation, tesla turrets etc.
I deleted everything I built on Gleba that researched the basic tree Ag-tech using stuff, and built a better base that's almost hands off. Took a good look at what I was doing, scaled it up, plugged every inserter into a combinator so resetting the filters on inserters is more convenient.
One mistake I made was running nutrients around the base. That's dumb - you run bioflux around and generate nutrients in each module. I feel ideally it should all be run around the base on a loop, I think I'll try that next time I'm rebuilding it.
Apart from that, one needs a really robust spoilage removal system. My second build usually gets clogged on spoilage removal. The nice thing is all the junk or unspent jelly or mash produces enough energy that my nuclear reactor is mostly just backup. The Heating tower has something like 400% efficiency for some bizarre reason. vastly better than boilers.
The one unsolved issue is how to avoid wastage and export only the choicest unspoiled flux. I'm thinking maybe running bioflux in a loop is the way to go so no more than needed gets generated.
As to defenses, we are at evolution 1.0 and spamming 4 rocket 16 normal turret firing positions, spaced 2 pylons apart works fine and stops every attack but gets half-stomped. If you add in a tesla turret that prevents the stomping altogether,just damages it. It's key to not taking losses without having vastly more rocket turrets. Don't think mines do anything to the stompers. Didn't try flamer turrets.
We never had really serious issues with the Gleba wildlife bc of early pruning and artillery.
but I think I'm going to play around with delivering ammo by drone to gun pods and see if that can keep up with threats
They really could've made Gleba way messier by increasing the gravity. I'm even harvesting the fruits with drone, still no issues with power.
hydroacetylene
7hr ago
It's possible this is a regional thing. But my experience with hunting camp is that wives and daughters might be hanging around, and might be claiming to be shooting, but they're really just there to get their husband or father a bigger bag limit- and will happily take credit for shooting something to outsiders, even trusted ones, for that purpose.
IGI-111
God was a dream of good government.
7hr ago
I seem to remember testimony from 14 year olds (at the time). The evidence is evidence in general in this case isn't particularly forthcoming, for obvious reasons.
2rafa
7hr ago
I ask because a lot of recent anti-tech action
I read that some of this started under Trump.
hydroacetylene
7hr ago
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.
IGI-111
God was a dream of good government.
7hr ago
I like my political operators to understand basic operational security because I want them to succeed in enacting the goals of my coalition.
That the enemy uses diverse tactics that make this only relevant sometimes doesn't invalidate that preference.
2rafa
7hr ago
All the famous Epstein victims were 16/17. There was some dark hinting about younger ones but the evidence is extremely thin on the ground.
2rafa
7hr ago
Nah it’s cringe to hire 17 year old prostitutes as a 40 year old man, people are entirely within their rights to consider that sleazy behavior.
SlowBoy
7hr ago
Who cares? This is up there with stealing a balloon on free balloon day. Sloppy? It doesn't matter how careful you are, they will make scandals up. See Kavanaugh
AlexanderTurok
7hr ago
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.
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.
SubstantialFrivolity
I'm not even supposed to be here today
7hr ago
Not everyone uses rustfmt, and it's configurable anyway. So I wouldn't say that everyone uses the same style.
2rafa
8hr ago
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.
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.
stuckinbathroom
8hr ago
None of them have been dishonorably discharged for their shenanigans.
Though if you look under the dog masks, there’s a good chance you’ll find some dishonorable discharge
sarker
It isn't happening, and if it is, it's a bad thing
8hr ago
,>Because there's usually a rule about maximum line length, in order to keep lines fitting inside the screen or window.
There's really no need for this anymore, it would be trivial to have the editor wrap the line in a nice way (go has no line length limits in the official style guide).
Not to mention that sometimes we use tabs to deliberately format things into columns, not just indent code. Variable-length tabs throw that off.
That's just an abuse of notation. Spaces are for alignment.
IGI-111
God was a dream of good government.
9hr ago
I'm still amazed that someone would be not only so stupid as to not use cash for an illegal transaction, but would actively document it using transparent innuendo.
If anything, being this sloppy should be disqualifying. If you can't even get consorting with whores right as a politician, how are you going to do anything more sophisticated with the whole bureaucracy against you?
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.
That's not really comparable. 17 is well past the sexual majority in most countries. The Epstein scheme recruited girls as young as 11.
Not to mention there's a world of difference between paying for sex and setting up an underage brothel.
There is a difference in both nature and degree between these moral transgressions.
Ironically, my only major complaint about this mouse is that it’s too light for my tastes. Next time I have shoe goo or something like it in the house, I’m going to crack mine open and see if it’s got anywhere good to put some heavy iron nuts in.
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