domain:alexepstein.substack.com?page=6?page=3?page=0?page=0
Absox
3m ago
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.
jeroboam
3m ago
What's the best body temperature?
Bryan Johnson, anti-aging zealot, recently raised eyebrows on X when he claimed to have a body temperature of just 93.4 °F (34.1 °C). He claimed that this was evidence of superior health. To me, his claim seems immediately suspicious and more likely to be a faulty measurement. Others pointed out that it would be very difficult for his body to fight infection at such low temperatures.
Nevertheless, body temperatures do vary between people and, interesting, over time.
We all "know" that the normal temperature is 98.6° F (37 °C). As it turns out, this was true once, but no longer. Body temperatures have been consistently falling. Today, the average temperature is closer to 97.9. My temperature is typically around 97.
Why is this happening? No one knows. Of course, many people blame measurement error. Other theories are that 1) people today have lower infection load 2) people today have lower metabolisms.
And there does seem to be some indication that lower temperatures correlate with longer life spans (in mice, of course). This is likely to be similar to caloric restriction where it might help humans, but nearly as much as mice.
But what if I don't want to live forever, I just want to be hot? It turns out that there are people who take the opposite approach as Bryan Johnson and say that we need to increase our body temperature. For one, it will help prevent illness. But it will also increase one's metabolism and allow him to eat like a hummingbird while looking lean and ripped. Here's a guy who invented a diet where you can eat unlimited sugar before 3pm. There was another guy on Twitter who posted about his sugar maxxing diet and bragged about his body temp of 99.5. He looked pretty ripped. (Curse you, Twitter search).
These high-temperature guys all seem to follow an obscure Oregon dietician named Ray Peat who doesn't have a Wikipedia article, and is indeed only mentioned in Wikipedia on the article for Bronze Age Pervert.
So, what's your body temp? What should it be?
SlowBoy
6m ago
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!
SlowBoy
10m ago
These same Republicans voted for Merrick Garland, who proceeded to try to throw Trump in jail. They have completely different standards from what constitutes "unfit" from the mainstream Republican voter. It's a two-party system, you vote for your guy and against the other. Talking about vetting candidates for being "fundamentally unfit" is missing the point: that's why Republicans continue to lose! Trump wins specifically because he's not the party of Murkowski, McConnell, Collins, et al. Republicans would have lost without Trump, and instead of going along with what Trump wants to do, they sabotage his cabinet. That's "defecting".
Literally any combination of picks could be rationalised in this way.
Describing cabinet appointments as managing factions is basically a truism. Calling cabinet appointments fundamentally random, as OP did, is an anti-explanation.
Her only political experience is as a backbencher and later twitter poster
Tulsi served in Hawaii and was the heir to a minor Hawaiian political throne. She served in the military and was at one point No. 2 at the DNC. She's not some grizzled veteran, but come on: She has more experience in politics than Obama or Trump did when they assumed office.
MaiqTheTrue
Renrijra Krin
23m ago
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.
OliveTapenade
23m ago
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.
Throwaway05
32m ago
I would hesitate to use a study from that far back because the American health landscape is so different now (in terms of population health, costs, and availability of interventions). Diabetes alone could fuck up the results (and almost certainly does).
I mean what you are asking for is available. Catastrophic plans are available on the marketplace and plenty of family practice doctors offer a practice sort of what you are suggesting. It is expensive but that's primarily because this model is a thing of independent practice which is dying outside of high tax brackets. Doctors aren't in charge when they are employed so they have to do what the employer says. Although my PCP is boring and they can do that (minus cash pay).
Ultimately nearly everything most people hate about healthcare is stuff that doctors don't have any control over and also hate, but we get blamed and people want to make our lives more miserable. It is very frustrating.
jeroboam
35m ago
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"?
TitaniumButterfly
36m ago
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.
Throwaway05
44m ago
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.
Throwaway05
46m ago
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.
JulianRota
51m ago
Reading JD Vance's Hillbilly Elegy. It's a much shorter book, I'm halfway through already.
I'm not sure if there was much in the way of ghostwriting or assistance on this, but if it's not much, then it's remarkably good writing for a sitting politician.
It reminds me a little of Sowell's Black Rednecks, White Liberals, which put forth the idea that quite a few of the dysfunctions affecting black culture were actually copied from the white hillbilly culture.
faceh
51m ago
Look, all I want is to be able to buy health insurance that covers only catastrophic injuries and the attendant recovery. I want to be able to pay my doctor in cash for any other services, and be able to have medical care for any minor but debilitating injuries readily available on demand. Why is that practically impossible under the current system?
As it stands, with health insurance tied to employment, I can lose access to a doctor if I switch jobs or the my employer switches insurance plans, and I can't actually be sure how much anything costs because there's no price transparency.
So I'm 'forced' into getting health insurance that covers every little thing, which most studies show doesn't actually improve outcomes for people.
Ben___Garrison
Voltaire's Viceroy
57m ago
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.
Throwaway05
1hr ago
If you want us to redesign the system you need to sacrifice something else, most likely increased paternalism - is that what you want?
There are no penalties for misusing the system now, inducing penalties for bad behavior is the primary way we correct things and make systems function.
Or do you want Urgent Care to be staffed by ED and FM? That would certainly address the issue but would dramatically increase expense.
It's designed well, people just refuse to use it correctly and we can't force them.
"People refuse to use it correctly" sure looks like bad design from the outside.
Ever heard of "Desire paths?". You can have a beautifully engineered and designed walkway, and people will still walk through the dirt if that makes more sense to them.
Similarly, you can try to get people to use their PCP as the doorway... but if that's too complex or annoying of a process they'll skip that and use urgent care.
Maybe just maybe there's a way that accommodates people's preferences.
Terracotta
1hr ago
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.
SteveKirk
1hr ago
I saw the imgur front page 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 while their entire youth wing is posting "glory to the martyrs for stomping magat colonizer babies to protect trans kids" memes.
anti_dan
1hr ago
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.
FirmWeird
Randomly Generated Reddit Username
2hr ago
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.
SteveKirk
2hr ago
I saw the imgur front page 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, and their entire youth wing is posting "glory to the martyrs for stomping magat colonizer babies to protect trans kids" memes.
I'm honestly surprised he's still around considering everything, still more that he's getting that kind of work. Read the first two nights dawn books in elementary school, and the Commonwealth trilogy when it first came out.
Probably should get around to rereading and finishing the former, but it's harder to justify burning through a pile of doorstops in a weekend the way you could as a kid.
Quantumfreakonomics
2hr ago
After the assasination of Franz Ferdinand, but before the outbreak of war, the Russian ambassador to Serbia, Nicholas Hartwig, died suddenly while visiting the Austro-Hungarian embassy in Belgrade. The official explaination was that he died of a heart attack.
Interesting, thanks! By the way, if you want a modern take on possession, read "Impro: Improvisation and the Theatre". It has a section on masks and letting yourself getting possessed by characters. Psychologically, they probably have a lot in common. There's also some research on how virtual avatars and characters, and even ones social rules, affect ones identity and behaviour. As for the ceremony, is the bell and incense used? For that would affect the senses. The whole divinity/godly aspects are almost required in order for one to take something seriously. Things have the weight we give them, so we use rituals in order to legitimize them. Praying, for instance, is likely a form of visualization, but we envoke the idea of god because we cannot believe in our own power. Tarot cards and Rorschach tests help you read yourself without filter, but in order to believe in the power of their subconsciousness, people need to believe that a diety is present (The oracle). People can barely meet a wise character in a dream without thinking that some external being helped them. It seems like we need to believe in something higher than ourselves, or even in something higher within ourselves (being made in the image of god, the transcendental function, being connected to a higher power, etc). Not that we should take all the credit for ourselves, making ourselves out to be gods (at least not the ego or the self we identify with). Nietzsche kind of tried with the ubermensch thing, he regards the human body as divine because all of this is hidden within it.
Anyway, that was a bit of a tangent. I will try various breathing techniques, but only when I feel certain that I won't be giving myself brain-damage (I'm a bit high in neuroticism).
We experience life through ourselves, so truths about ourselves are truths about the world as we experience it, or truths about our relation to the world (not the agent nor the environment, but the agent-environment interaction). But the truth simply is, right? Figuring our a profound truth feels good, and results in viewing the world differently, but it doesn't change anything. By the way, I do believe that these ancient sages did figure out important things. The hermetic principles and modern physics have a lot in common. Can you understand the world just by thinking? Probably to an extent, Einstein seemed to manage this, and Tesla also ran physics experiments in his working memory (which was huge, likely due to anesthesia with his visual field or spatial intuition).
This is a huge factor in what's called enlightenment. But isn't this just a function of the ego? It thinks it can control reality by rejecting parts of it. It even thinks that having negative thoughts against something helps protect against it or weaken it. That worrying about a family member helps in keeping them safe. But you can "let go" of all of this tension and just let things happen, and everything will continue as it did before, because you never controlled anything. The river flows all the same, and all your resistance amounted to was exhausting yourself. The truth is always bearable for you're already enduring it. What's false can ever harm you, as it cannot exist. It's realizations like this which helps people relax and approach the mindset of a sage. The brain wants to be correct, and to have what it already believes confirmed. It's like your memories and beliefs themselves are afraid of death, or like the brain sees the loss of a belief as the loss of a part of yourself, and reacts as if somebody tried to cut off your hand when somebody attacks a belief or a value you have.
And to generalize these contradictions: All splitting, multiple personality disorders, internal conflicts, etc. are caused by internal contradictions. Nietzsche wrote a lot about this, especially about how willpower affects our ability to control these fragments rather than getting swept away from them. But he also spoke of the positives of contradictions: "Because we forget that valuation is always from a perspective, a single individual contains within him a vast confusion of contradictory valuations and consequently of contradictory drives. This is the expression of the diseased condition in man, in contrast to the animals in which all existing instincts answer to quite definite tasks. This contradictory creature has in his nature, however, a great method of acquiring knowledge: he feels many pros and cons, he raises himself to justice-to comprehension beyond esteeming things good and evil. The wisest man would be the one richest in contradictions, who has, as it were, antennae for all types of men - as well as his great moments of grand harmony - a rare accident even in us!" By the way, if you try to solve all contradictions by taking the intersection of all beliefs and knowledge, you will likely end up with the empty set. Like I said in another comment, there's no one true worldview, you simply need to choose one.
I also want to point out that contrast between two things are required in order to feel much of anything. To feel your strength at the gym, you need to lift a weight which makes you use this power. To feel heroic, you need to feel like you're facing a great difficulty. Even the flow state requires a task with sufficient stimulation and resistance. Some people feel a lot of hate, but they don't want to point it at other people, so they ultimately point it at themselves. If they could just point this at a safe target, like "Poverty", then they could allow themselves to feel this emotion and even use it towards a constructive goal. In other words, be careful of removing any Yins as the Yangs will disappear as well. As I got less lonely, I found myself caring about other people less. As I got more confident, I started valuing compliments less. My Youtube feed is recommending a video called "How to never feel shy again", but it's considered bad to be "shameless" for a reason. Shyness is cute, I don't want to destroy it. I agree with everything you wrote here, though!
Haha, I might try this!
Looked him up now. His "insanity", so to speak, of letting go of memories is actually just letting go of the map and living in the territory, no? To live in pure experience, rather than living in cognitive models of the world. I found a quote saying "To live in the eternal present there must be death to the past, to memory. In this death there is timeless renewal". Earlier I wrote that the ego just wants its memories validated, and like you said, for its models to be correct, and to feel bad when there's a conflict between reality and ones model of it (the experience of cognitive dissonance). I too wish to experience life like I experienced as a child, and if possible, experience things as if experiencing them for the first time - but this means to erase ones memory, at least in a sense. I don't think this is "insanity". Do you know how some people lose faith in love because they deconstruct it to being mere chemicals? That is to overwrite life and experience by creating lifeless mental models and making them out to be actual reality. What sages tells us to do is merely the opposite of that. To deem reality and experience as real, and mental models as false, rather than doing the opposite and becoming excessively objective and robotic.
Interesting idea. I don't think it's false, but we have two models of thinking, system 1 and 2, in other words, conscious and unconscious processing. Ever felt down and then suddenly felt better with no explanation? I think that's what happens when subconscious processing resolves a conflict. So "thinking" is still taking place doing this, unless even the subconsciousness is calmed.
I found a book on libgen called "Mahamudra and Related Instructions: Core Teachings of the Kagyu Schools". Page 31 starts out by mentioning impermanence, but we already know that "Change is the only constant" and why getting stuck in the past is not a good idea. The book recomments letting go of this life (as it's not permanent anyway). By the way, this is probably for the same reason that one can't think clearly on topics that they're biased about. In order to see things as they are, you must not have beliefs about how they ought to be (resulting in that cognitive dissonance) so it makes sense that understanding these teachings is helped by being alright with any conclusion and implication, even when they suggest something that most people feel threatened by. Then it mentions the "ultimate bodhicitta" which is basically just letting your mind do its thing, letting things be like they are, and accepting what comes, as it's all there is. In the words of Werner Erhard: "Take what you get, for its all you get".
What's new to me is how Buddhism practices good and morality, rather than just complete indifference. This seems a little inconsistent of them, but I suppose they just assume that morality and altruism the true default which is corrupted by the ego and the brains self-survival medhanisms. There's 780 more pages than this, but I believe that I already got the general point of Buddhism, and I've come to like Samsara, and since I've learned to enjoy life despite my suffering, escaping Samsara would be a loss for me. If you can modify your perception as much as the Buddhists recommend, then you can certainly learn how to enjoy imperfection, in which case there's no need to escape anything. This worldview would probably offend a lot of gurus though.. If they're still capable of being offended, I'm not sure. And there may be more interesting ideas covering psychology that I don't yet know, I'm just very unconscientious/lazy. And sorry about my arrogance, I hope the information makes up for it.
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