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OliveTapenade
just now
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
9m 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
12m 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
13m 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
22m 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
23m 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
28m 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
28m 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
34m 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
37m 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
1hr 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
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, 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
1hr 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.
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.
orthoxerox
If you can read this, you're using a custom theme
2hr ago
Xiaomi something something, 6 liters, mechanical controls (Alec Watson convinced me I didn't need a fancier one).
hooser
2hr ago
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.
FormerPothead
2hr ago
I just blew through 1,000 page Exodus by Peter F Hamilton. I’m pretty mixed on PFH. I loved Commonweath but I’ve tried and fail to get into his others. I’m taking a stab at Nights Dawn but that’s besides the point
I thought Exodus was great. His best work in quite some time. The universe, pacing, major plot lines - all great. Good characters. The dude is really really imaginative.
The book is actually contract work where it’s and in-universe tie in novel with a new sci fi RPG that’s in development but some legit ex-BioWare guys. I’m very skeptical that the game won’t be woke slop since it’s being published by WOTC.
All this is to say that I hope more people read this book and it has some success. PFH is legit and doesn’t seem to have gone performatively woke even if he has been bullied into no longer including sex scenes in his stories.
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.
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