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Solidarity

[Epistemic status: I am not British, it’s been years since I’ve been in the HSE, and the HSE is not the NHS. All of this may be misunderstood or outdated.]

I don’t usually blog on labor disputes here, but I want to talk about one on which I have a tiny bit of inside knowledge.

Last month junior doctors in Britain went on strike for two days, protesting imposition of a new contract. There’s a lot of anger about this, and admittedly when you’re being rushed by ambulance into the emergency department for sudden onset chest pain, “doctors are on strike today” is not something you want to hear. My normal instincts would be to question whether this is really necessary. My experience tells me it is.

“Oh, you’re a junior doctor. Of course you would support a doctor’s strike.” Okay, but I’m not a British junior doctor. I work in America, where I would describe conditions as “tough, but fair”. Sure, Dr. Cox yells at you a lot, but only because he secretly thinks you’re one of the best doctors ever to pass through the doors of this hospital. My own specialty of psychiatry is a lot better than most and overall I have little to complain about in my own life.

But that’s not to say that I don’t have any special knowledge here. I went to medical school in Ireland, where I worked alongside junior doctors in a system very much based off of the British one. And it was pretty shocking.

Technically European law caps junior doctor work weeks at 48 hours a week. Then again, technically American law caps junior doctor work weeks at 80 hours a week. My first week on a non-psychiatry service as an American junior doctor, I worked a bit over 100 hours – and so did everybody else I encountered. When I asked about the law, everyone just gave me that “oh you sweet summer child” look.

Such caps seem to be honored more in the breach than in the observance, and this is the British custom too. Physicians Weekly describes it as “the 48 hour trainee work week sham”, and the Telegraph and The Daily Mail both seem to agree that many British doctors are working 100 hour shifts. They seem to circumvent the law either by giving them a few weeks off afterwards and saying it “averages” to 48 hours/week, or else by doing what my hospital did – carefully schedule a 48 hour shift in big bold letters, assign 100 hours worth of work, and then get angry if anyone goes home before their work is done.

Many of the junior doctors I worked with in Ireland were working a hundred hours a week. It’s hard to describe what working 100 hours a week is like. Saying “it means you work from 7 AM to 9 PM every day including weekends” doesn’t really cut it. Imagine the hobbies you enjoy and the people you love. Now imagine you can’t spend time on any of them, because you are being yelled at as people die all around you for fourteen hours a day, and when you get home you have just enough time to eat dinner, brush your teeth, possibly pay a bill or two, and curl up in a ball before you have to go do it all again, and your next day off is in two weeks.

And this is the best case scenario, where everything is spaced out nice and even. The junior doctors I knew frequently worked thirty-six hour shifts at a time (the European Court of Human Rights has since declined to fine Ireland for this illegal practice). Dr. Brid McGrath (my lab partner in medical school) has been collecting some stories for the Irish media:

My stories are like my colleagues’ stories: working through illness, personal turmoil, and deprivation of sleep, food and toilet breaks. The worst stint was working 73 hours within an 82 hour period. I have been bullied, and to my shame, bullied others. I realised I was falling into the trap of treating others the way I had been treated. My self esteem faltered and I began to believe I truly was a nasty person. I had the insight to get help, but not everyone is so lucky.

I came to talk to you about the imminent arrival of your very premature baby, at just 24 weeks. I held your hand and passed you tissues as we talked about his name, how tiny he was, how hard his life could be, but how we would try to give him the best possible chance… and how we might also have to accept the reality that he might not make it. That same day, I’d worked a 28-hour shift while I was 24 weeks pregnant myself. I fought back tears before I saw you. I worried about how I would cope with your pain and distress, barely able to think about the baby growing inside me. I had dinner a 1am, and worked on. An incredible nurse sat me down for a glass of water. She had to force me to. I was so busy.

The other night, after a particularly busy 16-hour shift in the Emergency Department and Theatre, I went up to the wards to take blood samples for a patient. I’d had no dinner. A patient in the same room was handing around coconut buns, and gave me one. I inhaled it, it smelt so good. She then pushed the box into my hands and said “You look like you need them more than me!”

Imagine having to decide between going to the bathroom or getting a bag of crackers from the vending machine because you don’t have enough time between cases to do both. Imagine having to remember the difference between nephritic syndrome and nephrotic syndrome (two totally different things) after ten hours of work, after getting three hours of sleep the night before. Imagine that you’ve just admitted a neurotic old woman to the hospital and you know in your heart that you should take her hand and explain to her in a soothing voice that everything is going to be okay, except that you already feel like every nerve of yours is beaten raw and you have three patients left to go before you can so much as sit down for a few minutes. Imagine your attending yelling at you because you got something wrong and saying you need to spend more time studying, and you trying to keep your mouth shut instead of telling him that you literally have only a half-hour in the day that could be considered free time by even the broadest stretch of the imagination and you are damned if you are going to spend that studying endocrinology.

The psychological consequences are predictable: after one year, 55% of junior doctors describe themselves as burned out, 30% meet criteria for moderate depression, and 12% report considering suicide.

A lot of American junior doctors are able to bear this by reminding themselves that it’s only temporary. The worst part, internship, is only one year; junior doctorness as a whole only lasts three or four. After that you become a full doctor and a free agent – probably still pretty stressed, but at least making a lot of money and enjoying a modicum of control over your life.

In Britain, this consolation is denied most junior doctors. Everyone works for the government, and the government has a strict hierarchy of ranks, only the top of which – “consultant” – has anything like the freedom and salary that most American doctors enjoy. It can take ten to twenty years for junior doctors in Britain to become consultants, and some never do. In Ireland (I don’t know about the UK) there was a very scary distinction between “training” and “service” positions, the former of which were always in short supply. Imagine that you’re a freshman in college, and your university announces that due to budget cutbacks there are only about half as many sophomore positions available this year, so the top fifty percent of freshmen can go on to become sophomores, and the rest will have to stay freshmen until more money comes in. Also, there are no other colleges in the entire country so you have no choice but to follow along and hope for the best. This is what being a junior doctor is like.

Faced with all this, many doctors in Britain and Ireland have made the very reasonable decision to get the heck out of Britain and Ireland. The modal career plan among members of my medical school class was to graduate, work the one year in Irish hospitals necessary to get a certain certification that Australian hospitals demanded, then move to Australia. In Ireland, 47.5% of Irish doctors had moved to some other country. The situation in Britain is not quite so bad but rapidly approaching this point. Something like a third of British emergency room doctors have left the country in the past five years, mostly to Australia, citing “toxic environment” and “being asked to endure high stress levels without a break”. Every year, about 2% of British doctors apply for the “certificates of good standing” that allow them to work in a foreign medical system, with junior doctors the most likely to leave. Doctors report back that Australia offers “more cash, fewer hours, and less pressure”. I enjoy a pretty constant stream of Facebook photos of kangaroos and the Sydney Opera House from medical school buddies who are now in Australia and trying to convince their colleagues to follow in their footsteps.

Upon realizing their doctors are moving abroad, British and Irish health systems have leapt into action by…ignoring all systemic problems and importing foreigners from poorer countries who are used to inhumane work environments. I worked in some rural Irish towns where 99% of the population was white yet 80% of the doctors weren’t; if you have a heart attack in Ireland and can’t remember what their local version of 911 is, your best bet is to run into the nearest mosque, where you’ll find all the town’s off-duty medical personnel conveniently gathered together. This seems to be true of Britain as well, with the stats showing that almost 40% of British doctors trained in a foreign country (about half again as high as the US numbers, even though the US is accused of “stealing the world’s doctors” – my subjective impression is that foreign doctors try to come to the US despite barriers because they’re attracted to the prospect of a better life here, but that they are actively recruited to Britain out of desperation). Many of the doctors who did train in Britain are new immigrants who moved to Britain for medical school – for example, the Express finds that only 37% of British doctors are white British (the corresponding number for America is something like 50-65%, even though America is more diverse than Britain). While many new immigrants are great doctors, the overall situation is unfortunate since a lot of them end up underemployed compared to their qualifications in their home country, or trapped in the lower portions of the medical hierarchy by a combination of racism, language difficulties, and just the fact that everyone is trapped in the lower portions of the medical hierarchy these days.

If Britain continues along its current course, they’ll probably be able to find more desperate people willing to staff its medical services after even more homegrown doctors move somewhere else (70% say they’re considering it, although we are warned not to take that claim at face value). I work with several British and Irish doctors in my hospital here in the US Midwest, they’re very talented people, and we could always use more of them. But this still seems like just a crappy way to run a medical system.

I don’t know anything about the latest dispute that has led to this particular strike in Britain. Both sides’ positions sound reasonable when I read about them in the papers. I would be tempted to just split the difference, if not for the fact several years of medical work in the British Isles have taught me that everything that a government health system says is vile horrible lies, and everybody with a title sounding like “Minister of Health” or “Health Secretary” is an Icke-style lizard person whose terminal value is causing as many humans to die of disease as possible. I can’t overstate the importance of this. You read the press releases and they sound sort of reasonable, and then you talk to the doctors involved and they tell you all of the reasons why these policies have destroyed the medical system and these people are ruining their lives and the lives of their patients and how they once shook the Health Secretary’s hand and it was ice-cold and covered in scales. I don’t know how much of this is true. I just think of it as something in the background when the health service comes up to doctors and says “Hey, we have this great new deal we want to offer you!”

(I remember reporting into the hospital one day and seeing almost a carnival atmosphere, and one surgeon who had never been known to do anything but yell at his subordinates gave me a friendly nod and smile as he passed me in the corridor, and I started to worry I had walked into some Stepford Wives bizarro-world. Finally I learned that, the evening before, the Irish health minister had resigned in disgrace. This is the only time anyone ever saw that surgeon happy.)

[EDIT: a strong argument that the junior doctors have the right of it and the NHS’ position is based on a misunderstanding of patient care statistics here]

Whatever caused this latest dispute is probably relevant mostly as a straw that breaks the camel’s back. If British junior doctors today are anything like the Irish junior doctors of a few years ago, all of their complaints are legitimate and they’re also hiding several dozen other legitimate complaints you have yet to hear about. I sort of sympathize with the government’s complaints that they don’t have enough money to make a system where doctors don’t have to work a bunch of 36 hour shifts, but I feel like if you don’t have enough money to run a health system that treats its employees like human beings, maybe you shouldn’t be running your country’s health system.

Labor disputes suck, and I have no good theory of them. Part of me is outraged at people being mistreated, and another part of me worries about a world where anybody who can convince the media that they’re being oppressed can force other people into paying them whatever amount of money they think they deserve. I long for some kind of principled system that will solve these problems more elegantly than letting everybody shout their grievances at each other and seeing which ones stick. I long for something that will take care of the deeper problems underlying unfair labor practices like dualization of entire industries. This is why I find libertarian ideas like letting competition among firms determine people’s pay and conditions so attractive.

But these may or may not work, insofar as they do work they only work in certain situations, and insofar as they do work under certain situations a 100% socialized industry run as a government monopoly probably isn’t one of them. So we’ve got to do the thing where people get mistreated and have to cry out for redress of their grievances. And my experience tells me the grievances of British junior doctors are copious, horrifying, and entirely valid.

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928 Responses to Solidarity

  1. Mets says:

    Importing foreign workers sounds like a fairly good temporary solution. In Estonia, Finnish language courses in university are always full of medical students. However, Britain is also an option, since (judging from this blog post) the conditions are about the same, but the pay is much better, and everyone understands English pretty well anyhow. I guess other Eastern European countries could be similar.

  2. Deiseach says:

    From the Letters page in the latest issue of “Private Eye”:

    Sir,

    I am prompted to contact you to express my sincere thanks to Mr Jeremy Hunt, Secretary of State for Health. I understand that his current contact details may soon be redundant and wonder if you can pass this on to him.

    I am a Consultant Orthopaedic Surgeon working entirely within the National Health Service and have been very concerned about the gradual deterioration in morale within the older echelons of hospital medical staff. I have often tried to contrive a mechanism that could reintroduce the professionalism that once made us proud and the camaraderie that made it a joy to work, but sadly lacked the required imagination.

    For the last two days I have worked with senior colleagues covering the wards. This has had an extraordinary effect and I struggle to remember a time when consultants worked together in such a happy and cohesive manner.

    Mr Hunt has been an inspiration and his foresight is to be congratulated.

    FERGAL MONSELL,
    Redland, Bristol

    When even the consultants are taking the piss out of you, your tenure as Health Secretary is looking short! 🙂

  3. Boba says:

    cool Article
    I already have Burn Out from tooo much work in hospital with bad conditions and payment

  4. My wife suggests a Kipling story, “The Tender Achilles,” that gives an older picture of the pressures doctors (in this case in wartime) worked under.

  5. Laura K Morris says:

    When I was training in the US in the 1970’s we had to work more than 100 hours per week, often with no time for food, much less sleep. I vowed that the system should be changed, and I think that in the US, conditions are quite a bit more humane. I strongly oppose the inhumane treatment of Ireland’s junior doctors.

  6. Albatross says:

    I read recently that one group wants to correct the CDC and make medical errors the 3rd leading cause of death in the US right after cancer and heart disease. I worked some 16 hour shifts as a coffee shop manager and even in that super easy job errors increase exponentially after 12 hours. At 36 hours I suspect the people dying around you would die less often with a fresh doctor and past 70 hours in a single shift you killed some of them with terrible decisions. Lawyers work 100 hours a week, but they get to count meals with clients and reading on the toilet as “work.”

    At Sears, f-ing SEARS, I watched a company training video that said to reach peak performance a manager works 30 hours a week. If you are young or in particularly good shape you can be at peak for 50 hours a week for four months a year max. After that and I guarantee a person working less than you makes better decisions and does better work. It doesn’t matter if you are pouring coffee or analyzing financials or doctoring. At 13 hours you suck compared to you at 8 hours.

    I hear medical workers say “but its different.” Bullshit. You just think its different because sleep deprivation has impaired your judgement.

  7. Ed says:

    Such caps seem to be honored more in the breach than in the observance, and this is the British custom too.

    The phrase “honored more in the breach than in the observance” refers to a bad rule that ought to be broken, not (as here) to any rule that is frequently broken. It originates in Hamlet, Act I, scene 4.

  8. Steve in Mo says:

    The American system is based on the doctors having malpractice insurance so they are responsible if anything goes wrong so they are liable to be sued.
    The lawyers then can pursue the malpractice case on contingency and probably obtain about 50% of a settlement.
    The amount may vary but I think 50% on contingency is about the rate.
    The British Barrister system has a different situation, in that contingency is against the law, or at least I think that is the British system with reference to lawyers and a contingency was be seen as unethical if not actually unlawful.
    The lawyers are the primary lawmakers or the most common profession in the American congress, both in the states and in the Federal government.
    In the British parliament, it appears members of parliament or MP’s probably have more representative professions than the American congress, since there are a number of other professions besides barristers such as doctors, dentists, teachers, farmers and some laborers. There were more miners at one time but now considerably fewer, but surveys have indicated there is a desire on the part of the UK public to have a number of professions or occupations besides lawyers or Barristers.
    Why am I going on about lawyers and barristers and comparing the American and UK systems.
    The American system is deeply interrelated to the legal profession and the ways the American system enables lawyers to obtain contingency fees for legal services. Suing for malpractice is a big legal business in the US and has become commonplace, so that doctors are not infrequently sued, especially in some of the high risk categories such as OB, Neurosurgery and orthopedics, but no specialty is immune.
    The only reason the American system changed was that a hospital lost a malpractice case since the doctors were overworked by long hours and fatigued. This resulted in a transformation of the American system.
    It’s not likely the UK system will change since the lever of malpractice is apparently much less frequent in the UK, and is not as financially lucrative.
    Probably change will only occur though public outcry, or if doctors simply give up and the system collapses.
    Czech doctors had gone on strike in the nineties for greater pay, and were joined by nurses and laboratory workers.
    The Czech system underwent change, going from a centralized monopolistic system under the former communist government to a more capitalist, competitive market after the “Velvet revolution” with fee for service care funded by mandatory, employment related insurance plans since 1992.
    The National Health System is apparently a socialized medicine program based on a centralized, monopolistic system, and such as system may, like the old communist system of Eastern Europe and Russia, eventually unstable and impossible to maintain in a modern democratic state which gives people individual rights and freedom.

  9. alaska3636 says:

    I would like to take a moment to appreciate the comments from Jill. Her big-government, leftism is really framing how much closer to libertarianism the “center-left” voices on this board really are.

    🙂

    Also, 1,000,000 points to Jill for sincerely using Diversity as an unambiguous, net-positive.

    • Jill says:

      Thanks, Alaska.

      Diversity really is amazing. Many different points of view put together can help us all to see different parts of the picture we’re looking at, and the interrelationships within the picture, and the whole picture– all much more clearly.

      • Jill says:

        Many Libertarians are not so far away from “big government Leftism” either– although I do not identify myself in that way at all. Some of you folks are one pre-existing medical condition of yourself or a family member away, from falling down on your knees and thanking Obama for Obamacare. And you are one serious illness of yourself or a family member away, from begging to have something even more like “socialized medicine” than Obamacare is.

        As some have noted here, although one technically has a “choice” about whether to seek treatment for a serious/expensive illness, in the U.S., once you decide to do so, you have pretty much consented to be kidnapped and held ransom by the medical system. Because no one can or will tell you how much a procedure will cost you, or if it will bankrupt you, until it’s already been done. Your out of pocket expense may be very high, even if you do have insurance. And/or your insurance may decide not to cover some very expensive procedures or items.

        And the other side of your technical “choice” may consist of unnecessary suffering and premature death.

        And in some other areas too, Big Corporate Libertarians are only a few neighborhood earthquakes away, or just a bit of drinking water pollution away, from losing sympathy with the most powerful Libertarians– the Kochs– when you decide you just don’t want to have flames coming out of your water tap.

        Being a Big corporate Libertarian, seems to me to be dependent on getting more out of corporate rule of people, than out of government intervention in corporate rule. The government is a small time power. It’s the multi-national corporations that have the lion’s share of the power to limit human freedom and well being. The biggest danger of government, for most citizens, is that it so often ends up being bought and paid for, to be the servant of ruthless mega-corporations.

        If Big Money can be gotten out of politics, that danger might disappear.

        But if you are an heir to a corporation, or an heir to a large fortune that you don’t want to pay taxes on, then your self interest is definitely served by Libertarianism, even if you or a family member becomes seriously ill, or if flames come out of the water tap on one of your family’s numerous large and expensive properties.

        I can see why the Kochs and a few other people are Big Corporate Libertarians. I just can’t see why members of the 99.99% are Big Corporate Libertarians– other than persuasion by the propaganda that paints mega-corporations as wonderfully benign entities and government as always the problem, never the solution.

        But as the vox.com article about the American Enterprise Institute political scientist Norm Ornstein points out, we’ve been immersed in such anti-government propaganda at least since Newt Gingrich in the 1990’s. And close to 900 million dollars is being spent this year alone by the Koch brothers and their associated group of donors, to disseminate propaganda– this for the purpose of electing the politicians who have been purchased by that group to carry out a pro-mega-corporation anti-government agenda, once in office.

        So, realistically, it’s only to be expected that many people will believe it. That amount of money can buy a lot of persuasion.

        I really like the kind of free market capitalism, where the government keeps the whole thing from imploding, the way does when oligopolies or monopolies rule every aspect of everyone’s life, and pollute the air, drinking water, earth, food, etc. at will, with no laws to prevent that. So you don’t end up with a situation like that animated movie WALL-E.

        So I do not consider myself a Big Government liberal at all. I have the highest respect for those corporations that act as good citizens and honorable members of their communities. People like Martin Shkreli, I could do without. And yet I am aware that he is only a small fish, and that the big fish doing the same thing are getting away scot free right now.

        As Lord Acton said “Power tends to corrupt, and absolute power corrupts absolutely.” And what keeps me from being a Big Corporate Libertarian and siding with the Kochs, is the fact that mega-corporations are a lot closer to having absolute power over people than government is, at this point in history.

        • ” The government is a small time power. It’s the multi-national corporations that have the lion’s share of the power to limit human freedom and well being.”

          That’s wildly wrong. Governments, in my lifetime, have killed–literally killed–millions of people. They have held prisoner–prevented from leaving, or even moving freely within their own country–hundreds of millions of people.

          The complaint about corporations mostly comes down to “they haven’t done good things for people that they could have done.” Occasionally it rises to the level of “they have done things that make lots of people somewhat worse off and result in some excess mortality” (air pollution, say). All things that have also been done by governments–compare pollution in the Soviet Union to pollution in the U.S.

          Almost all of the interaction you have with corporations is voluntary–to deny that, people have to expand “involuntary” to include “your other alternatives are worse,” in which case “involuntary transaction” becomes equivalent to “transaction that benefits you.”

          Most of the interactions you have with governments are involuntary. It’s a lot harder to hurt you if one requires your consent to do so.

          • Jill says:

            I am not a Big Government fan at all. I only wanting government programs to take care of problems when private industry has effed up big time. E.g. the medical insurance industry, when the leading cause of bankruptcy is medical bills.

            I know that the person has a technical “choice” to suffer and die quickly vs. to get incredibly expensive medical treatment for a serious illness. But that stretches the definition of choice. And a system like we had before Obamacare where a pre-existing condition could keep you from getting medical insurance, and so you would have to pay the exorbitant rates that people without insurance pay.

            You do have a point that the most extreme governments in history have been awful, even more awful than private industry so far in history, on the average. But that certainly doesn’t make the case that Big Corporate Control Libertarianism is always the answer to every problem and that government programs are the worst way to handle every problem, no matter how badly private industry has screwed things up in a society.

            Comparing someone like me who wants private industry to take care of almost everything in society until and unless they eff up this badly– to compare someone like me to the imaginary person who supposedly wants the U.S. to turn into a system like the former Soviet Union–this makes no sense.

            In our current world in the U.S., mega-corporations are a lot closer to having the amount of control over our lives that the former Soviet Union had over people’s lives, than government is.

            Perhaps if people imagine me as a “Big Government Leftie” to the extent that they imagine I would love to live in the former Soviet Union, perhaps that false idea of me, makes your own position seem less extreme, by comparison?

            A lot of folks here seem to want government to stay out of everything, no matter how badly private industry screws up air, water, food, access to medical care etc. Even if private industry made those things far far worse than they were in the former Soviet Union, would some of you here still be in favor of Big Corporate Control Libertarianism? Or are you less extreme than that?

            Does your view depend at all on the situation? Or only on ideology? Do you think people should have some recourse to defend themselves against huge powerful corrupt entities that are raining down destruction upon their lives? Or do you only think so if the entity is a government, rather than a mega-corporation? Is there no crime by a mega-corporation so severe that you aren’t willing to allow them to get away with it? Slave labor? Anything?

          • HeelBearCub says:

            @David Friedman:
            When “business” obtains the power to do the bad things you ascribe to government, wouldn’t we then just call it government?

            This seems like one of those cases where you are just defining away the isusue. What would you say about Fordlândia? Were the impositions on Freedom “government” or “business”?

          • Jill says:

            HeelBearCub, I don’t understand your question to David.
            >When “business” obtains the power to do the bad >things you ascribe to >government, wouldn’t >we then just call it government?

            It seems that no matter what businesses do, or how much power they have, Big Corporate Control Libertarians call them “businesses”– and see them as the Supreme Good.

            There can indeed be some confusion here, since the currently small time power of government in the U.S. is indeed a bought and paid for servant of mega-corporations. it is simply an extension of the power of mega-corporations. But that could change, if we got campaign finance reform.

          • Cerebral Paul Z. says:

            Big Corporate Control Libertarians do not call businesses the supreme good– we call raising colored babies in cages for food the supreme good. Business is only a means to that end.

          • HeelBearCub says:

            @Jill:
            I’m fairly, even very, progressive/liberal. I believe in a social welfare state. But your statements are too broad.

            There are big differences between your average “chamber of commerce” style business oriented conservative and various different shades of libertarians. For instance, for most libertarians who care about the economic application of their philosophy, regulatory capture and corporate subsidy are things to be fought against. When you swipe with broad brush of “bought and paid for by mega-corporations”, you are conflating very different approaches that both exist inside the current Republican coalition.

            David Friedman is about as dyed in the wool an economic libertarian as there is. I disagree with him on many, many things. But he isn’t a corporatist.

            Heck, I’m not even sure if he thinks corporations should be allowed to exist.

          • HeelBearCub says:

            @Cerebral Paul Z:
            You think that is funny. You are trying to be snarky. I don’t think snark really works in this context.

          • Eggoeggo says:

            Whether or not the person the snark is directed at understands it doesn’t affect the value of the snark.
            Personally I find Paul’s insinuation that we might stoop to eating unbaptised and even non-white infants quite droll. Everyone in the know is aware we drew the line at Irish babies.

          • ” But that certainly doesn’t make the case that Big Corporate Control Libertarianism is always the answer to every problem and that government programs are the worst way to handle every problem, no matter how badly private industry has screwed things up in a society.”

            I wasn’t claiming to. I was only pointing out that what you had written was wildly false, not making any claim about what the right answer to the private/public issue was.

            Your statement, to which I was responding, was:

            ” The government is a small time power. It’s the multi-national corporations that have the lion’s share of the power to limit human freedom and well being.”

            Do you now agree that that claim was not true, that governments have much more power to limit human freedom and well being than corporations do?

            Your newer claim:

            “mega-corporations are a lot closer to having the amount of control over our lives that the former Soviet Union had over people’s lives, than government is. ”

            That simply isn’t true. The government can order me to serve on a jury and fine or jail me if I refuse. A corporation can get me to work for it only with my consent. The government can produce goods and services and charge me for them via taxation without my consent, a corporation can only sell me things I choose to buy. The government can forbid me from making a mutually agreeable exchange with another private party–agreeing to work for less than the minimum wage, buying marijuana. A corporation cannot.

            Almost everything a corporation can do consists of offering transactions that I can accept or reject. Governments, even the relatively mild government I live under, do not operate under that limitation.

          • “When “business” obtains the power to do the bad things you ascribe to government, wouldn’t we then just call it government?”

            Not necessarily. Criminals have the power to do some of those things. Slaveowners did. Neither is usually called a government.

            The closest I can come to defining a government is to observe that, in any society, there are things people believe that other people don’t have a right to do to them and will resist, not without limit but well beyond the amount actually at stake. A government is an organization that can do such things and not provoke corresponding resistance. My old short hand for that was “an agency of legitimized coercion,” where “legitimized” isn’t a statement about the moral status of government action but about how people respond to it.

            If sufficiently curious I can point you at a chapter of a book of mine that goes into that approach in more detail.

          • “It seems that no matter what businesses do, or how much power they have, Big Corporate Control Libertarians call them “businesses”– and see them as the Supreme Good. ”

            You are attacking a philosophy of your own invention. Libertarians don’t see businesses as the supreme good. They see certain forms of interaction as voluntary and so not rights violations, other forms of interaction as involuntary and rights violations.

            The fact that a person or firm doesn’t violate rights does not make it the Supreme Good, or a good at all. But it means that it isn’t bad in a particular way, that one isn’t entitled to use force to prevent what it is doing.

            Consider a publisher that publishes books arguing for left wing ideas. A libertarian is unlikely to see it as the Supreme Good, or as a good at all. But it isn’t violating his rights, so has a right to do what it is doing.

        • Glen Raphael says:

          @Jill:

          Big Corporate Libertarians are only a few neighborhood earthquakes away, or just a bit of drinking water pollution away, from losing sympathy with the most powerful Libertarians– the Kochs– when you decide you just don’t want to have flames coming out of your water tap.

          If you think flammable tapwater is caused by fracking, you’ve been snookered. Flammable tapwater is indeed a natural phenomenon in a few parts of the country but has been so for about as far back as there’s been indoor plumbing. One popular example of “flammable water” among fracking activists was of that nature – a case where (according to testing done by the State of Colorado) the local groundwater passed through coal seams producing methane that was unrelated to any gas development projects. Another such example (featured in a documentary called “Gasland”) involved outright hoax – the filmmaker attached a gas line to a hose to achieve the desired effect.

          Here is a collection of newspaper clippings going back to the 1950s reporting (natural, pre-fracking) cases of flammable tap water.

      • Brian Donohue says:

        I’m all for many different points of view, but my impression is that when people use the word ‘diversity’ nowadays, it suggests something closer to the opposite of this.

        • It’s worse than that. At least in the academic world, “diversity” is used to mean affirmative action, mostly by institutions that are opposed to intellectual diversity. But it’s used because the word suggests intellectual diversity, which would be valuable to those institutions–a rhetorical bait and switch.

      • “Diversity really is amazing.”

        Yes. Are you aware of the degree to which elite American higher education is an ideological monoculture, and if so does it bother you? That would seem to be one of the parts of the system were intellectual diversity was most important.

        • Jill says:

          Yes, I am very concerned about the bias in higher education.

          Brooklyn College Defends Academic Freedom by Saying No to Koch Millions for Its Business School

          http://www.alternet.org/education/brooklyn-college-defends-academic-freedom-saying-no-koch-millions-its-business-school

          Koch Foundation Funding to Universities (2005-2014): $109,778,257

          http://polluterwatch.org/charles-koch-university-funding-database

          • John Schilling says:

            People not named Koch funding to colleges and universities (2015): $40,300,000,000

            https://philanthropy.com/article/US-Colleges-Raise-40/235059/

            For your 2005-2014 period, the total is $303,850,000,000, give or take a few hundred million. The Koch brothers and their foundation are literally a rounding error on this one.

            We all understand that in your usual circles, “Koch” is basically a call to suspend debate and rally against the imminent threat of Pure Evil. For most of us, it’s cause for eye-rolling. The Kochs donate 0.036% of the private money the American higher education system receives. Since this sort of thing is apparently important to you, go find numbers on how much of the remaining 99.964% comes from sources of various political alignments.

          • Jill says:

            Very few, if any, of the other people who donate to colleges and universities attach big strings to their donations e.g. that only Right Wing Libertarian style economics be taught in economics or business departments. Many donations to colleges are from alumni, who are simply proud of their alma mater, without any strings whatsoever attached.

          • Cerebral Paul Z. says:

            The Kochtopus is requiring that only Right Wing Libertarian style economics be taught at MIT? Jonathan Gruber’s going to be some kinda surprised!

          • John Schilling says:

            @Jill: Very few…, Many…

            Numbers, please. If 99% of all private donations to colleges and universities are entirely apolitical, which I do not for one minute believe, the Kochs are still less than 4% of the politically-aligned higher education funding.

            So, the actual numbers. Start googling, or ask your professor if he’ll support you in an independent research project in a critically neglected area of social science.

          • Wrong Species says:

            But when universities discriminate against conservatives that’s not a problem right? Who cares about conservative diversity?

          • Jill says:

            Wrong Species, specifically what are you referring to when you say “when universities discriminate against conservatives”? If you mean that they refuse to teach Creationism, no, that’s not a problem. If you mean that they refuse to teach Adam Smith’s economic theory because it’s too conservative for them, which has probably never happened, yes that would be a problem.

          • Jill says:

            John Schilling, this is an interesting board. A number of people have been demanding– not even requesting, just demanding–that, in order to support my arguments, I dig up all kinds of specific data and numbers that THEY are interested in, not me. Because only these specific numbers would they accept as proof of my points.

            Feel free to demand away. But don’t hold your breath waiting for me to meet your demands. I don’t spend months doing research on matters that don’t interest me, and that I do not see as pertinent to the points I am making.

            This seems to be a custom in some faction of people within Right Wing culture, to do this. I am learning a lot about that on the Internet. It’s a dominance/submission paradigm. The Right Winger just assumes they are the boss of anyone they happen to converse with, and have the right to demand all kinds of things. Good luck with that, LOL.

            In that particular segment of Right Wing culture, people do not converse to understand others, or to be understood themselves, but to win– or to convince themselves and/or the other that they have won. So they demand ridiculous amounts of specific data and research that is actually not terribly relevant to the subject of the conversation. Then they find that the other person does not deliver on those demands. This convinces the Right Winger that they have “won.”

          • Jill, one of the features of this interesting board is that we’re in nigh-unanimous agreement that Specific Numbers Matter.

            This isn’t a dominance/submission thing, excepting the degree to which we should submit to the truth when it’s staring us in the face.

            I mean, you can make factual claims and then neglect to back them up in any meaningful way, because backing up your statements doesn’t interest you, but I don’t think that this plan will do great things for your general credibility here.

          • Quite a while ago, a very respectable university pushed out two economists, both of whom later got Nobel prizes for the work they had been doing. We know it was deliberate because the dean responsible carelessly left paperwork that a different dean found. There is good reason to think that part of the reason he did it was that the economists in question (Coase and Buchanan) were seen as conservative, and having them made it harder to get foundation funding.

            If you think donations to universities are more likely to support right wing views than left wing views, you are living in a fantasy.

          • ” A number of people have been demanding– not even requesting, just demanding–that, in order to support my arguments, I dig up all kinds of specific data and numbers that THEY are interested in”

            I can’t speak for anyone else. What I suggested was that, when the source you yourself had linked to strikingly contradicted the claim you made, you ought to either admit you were in error or find some support for that claim. What you did in that case was simply to ignore the contradiction. The obvious implication was that you either didn’t read responses or don’t care whether what you say is true.

            The real world matters. Labeling requests to look at it as a dominance/submission game doesn’t change that.

          • John Schilling says:

            @Jill, this is indeed an interesting board, and as others have pointed out, one of the things that makes it interesting is that everyone here understands that numbers matter.

            But I will add to that, a single big number generally does not matter. If you come here to tell us that the Koch brothers have donated One Hundred Million Dollars to the cause of Evil Conservative Education, pretty much everyone here is going to ask “One hundred million out of how many?”

            Seriously, just about anyone of any political persuasion for whom that isn’t the obvious next question, will probably long since have left for someplace more aligned to their tastes. If you understand why that is the obvious next question, and learn to ask it yourself, you may find yourself understanding far more about the world. In particular, about how and why it is that people don’t all leap to action when you point out the bit about the Kochs and their hundred million dollars.

            Which isn’t to say that you need to have a spreadsheet of statistics to persuade people here. But if you’re going to bring numbers, and you did, you have to do it right.

          • Jill says:

            John Schilling, you said yourself
            “So, the actual numbers. Start googling, or ask your professor if he’ll support you in an independent research project in a critically neglected area of social science.”

            So you knew that you, thinking you are the king of the world or something, were demanding that I do some big long research project, just because you had decided that this was the kind of evidence you wanted me to supply, to support my point, in the way you thought I should.

            No, I won’t.

          • houseboatonstyx says:

            @ Jill,
            Are you famliar with CS Lewis’s books such as Miracles or The Problem of Pain — and Studies in Words? There he talks briefly about language issues which were explored in more detail in General Semantics and other systems.

            I’m rusty on the terms, but here’s an example of ‘dictionary meaning’ vs ‘referential meaning’.

            Alice: ‘Hey, that monkey is stealing your lunch!`

            Bob: ‘Impossible. Monkeys are blah genus blah blah species and not allowed in this zoo. Please go away and read up on the subject.’

            Alice is using the word ‘monkey’ in a referential sense; as a term for the animal she’s pointing at, ie referring to. The referent doesn’t have to be close enough to point to: you can also make useful generalities using referents.

            I think this may be part of what’s happening with your conversations with DF/JS et al. I think you (Alice) are referring to the corporations that here and now have a lot of direct power over us (like, all the things we can’t do or buy because the stores’ insurance won’t allow it), as well as indirect power over us by their donations’ influence on our politicians.

            People who talk like them, seem to be using ‘dictionary meaning’ to override the referential, here and now meaning that you seem to be using.

            It seems you have a good instinct for not letting them draw you into the weeds. If you look up terms for these differences in usage, I’d be very interested to see what the current terms are.

        • Jill says:

          David Friedman, I don’t know which conversation between us you are referring to there. I did lose track of some conversations on the first blog I commented on, as it was so long, and at first I didn’t know how to locate my previous comments.

          On this issue, where you said

          “Quite a while ago, a very respectable university pushed out two economists, both of whom later got Nobel prizes for the work they had been doing. ”

          That was wrong, of course. I am not doctrinaire about Right vs. Left as you seem to imagine.

          I wonder do you think it is right for the Kochs to bribe university business departments to teach only Right Wing economics and not other economic theories? Or is that excusable in your mind, for some reason?

          • HeelBearCub says:

            @Jill:
            Can you actually point to some evidence that the Koch brothers are trying to prevent specific other theories from being taught? I think you will only be able to find evidence that they are requiring their funds to be used for specific purposes. That’s fairly standard for lots of funding, not just the Koch’s. But it’s very different to ask that Mises be taught and preventing Keynes from being taught. I doubt the latter is happening.

            Although, I wonder how the conservatives here would feel about George Soros funding a Keynes only research building.

            This is the kind of statement that is getting you wrapped around the axle, so to speak.

          • Glen Raphael says:

            @Jill wrote:

            David Friedman, I don’t know which conversation between us you are referring to there. I did lose track of some conversations on the first blog I commented on, as it was so long, and at first I didn’t know how to locate my previous comments.

            One relevant conversations was the one in which you claimed (as evidence that “we are immersed in Right Wing propaganda”) that the Koch Brothers alone were going to spend 889 million dollars in a single year to elect the candidates they want. I pointed out that you had misread your own source and that source was outdated and mistaken on a few points, making that number a vast overestimate.

            I was curious what you thought about this. If it turns out the amount the Kochs are spending on electioneering this year is only in the tens of millions rather than many hundreds of millions, does that change your opinion about anything?

          • @Jill:

            I don’t think the Kochs are bribing departments to teach only right wing economics–that is a better description of the situation with the University of Virginia that I described. They are bribing universities to teach right wing economics in addition to whatever else they are doing. At least, I don’t know of any case of the Kochs saying “we won’t donate unless you fire left wing professor X” or the equivalent–perhaps you can point at one.

            That said, I don’t think it is wrong for the Kochs to contribute money to a university earmarked to hiring a professor who agrees with them, any more than it would be wrong for Soros to contribute money earmarked to hiring a professor who agrees with him. The university, in each case, might want to turn down the offer, but I see nothing wrong with making it.

            My university hosts the Northern California Innocence Project, which tries to identify people who have been convicted of crimes they did not commit and get them released. Do you see anything wrong with someone making a contribution to that project? He is doing it because he approves of the particular activity being done.

            Donors routinely endow chairs, sometimes intended for a particular faculty member, sometimes earmarked for a particular sort of work. Sometimes they endow centers for doing some particular kind of academic work. Is that wrong?

          • @ Glen:

            I was referring to the same case you just described, where Jill made a claim about the Koch expenditures and someone pointed out that it was false, based on what she herself had linked to. I don’t think she ever either conceded that she was wrong or offered evidence that she was not.

            The detailed errors (from memory):

            1. It wasn’t the Kochs’ money. It was money spent by a group of people which included the Kochs.

            2. Only about a third of it was spent on politics.

            3. It was two years’ expenditure, not one.

            The second and third points mean that Jill was overstating by at least a factor of six.

          • Cerebral Paul Z. says:

            All the shouting over the Kochs’ political expenditures makes people forget how much Plain Old Philanthropy they do. The dinosaurs in the David H. Koch Wing at the American Museum of Natural History didn’t look any more libertarian to me than any other dinosaurs.

          • Glen Raphael says:

            @David:

            Jill made a claim about the Koch expenditures and someone pointed out that it was false[…]
            The second and third points mean that Jill was overstating by at least a factor of six.

            That someone was me. One other point I brought up – we’ll call it #4 – was that Jill’s “889 million” was an early goal as to how much might get raised by this network during this election cycle but according to that Politifact check the actual number raised by the network was coming in at less than the goal. From the article:

            In an October radio interview with American Public Media’s “Marketplace,” Charles Koch dialed back the spending projection, saying he expected his political network to spend $750 million, with about $250 million of it dedicated to campaigns.

            So 889 was about a 20% overestimate to begin with.

            Jill might have gotten her misconceptions here by listening to Bernie Sanders – he made similarly erroneous claims on the campaign trail.

  10. Pseudonymus aeruginosa says:

    Hi, UK Junior Doctor here. De-lurking with a monster-sized comment (in the spirit of SSC) to try to add some clarity.

    There were plans to move to a new contract for all junior doctors working in the UK a few years ago and negotiations between our union the British Medical Association and the department of health were reasonably productive. However when the Conservatives won the last election, this idea of a “7-day NHS” started being thrown about. The NHS already provides elective care (outpatient appointments, routine investigations, elective operations) 5 days a week, and emergency care 24 hours a day, 7 days a week. This emergency care is largely provided by junior doctors.

    BMA Negotiations Timeline

    They have never explained what a “7-day NHS” would look like, and have been forced to admit they haven’t tried to find out how much more money or additional staff this would require. The government have used this as an excuse to add in some fairly objectionable clauses into the contract. To justify this the Health Secretary has essentially misrepresented data on weekend mortality to make it appear that there are large numbers of people dying as a result of inferior care at weekends. There isn’t really any evidence to support this. A recent study in the Lancet showed no relation between staffing levels and mortality at weekends. The best theory so far is that it appears to be the effect of people that are solely acutely unwell being admitted at the weekend i.e. absolute mortality not increased, but proportionally appearing increased compared to weekdays.

    Relevant papers
    A cross-sectional study

    Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission

    Possibly one of the most controversial issues is a change to how we are paid. At present we earn a basic salary and are paid supplements to that for the number of “unsocial” hours we work, ie nights and weekends. That can make up a fairly significant chunk of our paycheque. The government constantly misrepresent this in the press as being lucrative “overtime” payments, however we have no choice over the hours we work. These supplements are being done away with in exchange for an increase to basic pay. Many of us have calculated that this will still result in a hefty take-home pay cut. And this isn’t simply about our pay despite the government portraying it as such. The hardest hit specialties will be those that work the most out of hours work in acute specialties. We already struggle to recruit and retain doctors in Emergency Medicine, Psychiatry and Acute Medicine. This will only worsen the already existing crisis that is leading to hospitals closing their emergency departments.

    There’s more. Safeguards to ensure limits to working hours are enforced are being de-fanged, pay protection for those doing research or doing less than full time work are being cut. I have heard from people looking at how to implement the new contract-compliant rotas that they simply do not have enough doctors to fill the shifts. I know several people leaving medicine or moving abroad as a result of this contract imposition.

    The whole thing is a mess, either through incompetence or malice. I have really tried to be charitable to the government’s position, but the impression I get is that they don’t actually understand what they are doing, and are trying to look strong and not admit they have screwed up. Scott implied this was a fight between “the NHS” and doctors, and many of you have placed “socialised” medicine as being at fault here. Many of us see this as part of a larger, deliberate attack on our system of “socialised” medicine that we do not want to see go. There seems to be a huge tribal gulf between people in the US and UK about the relative virtues of state-provided, free-at-the-point-of access care, and I don’t think I will convince anyone on the other side of the abyss, but you should bear in mind that basically nobody working in healthcare over here wants any further encroachment of the private sector into the NHS and the services it provides.

    As an example: Transfer of services from NHS to private provider was “unmitigated disaster,” report says and a consultant’s personal commentary

    I should also clarify that during the all out strikes mentioned full emergency cover was provided by consultants, at the expense of elective care. Concerns over the new contract have been as much related to patient safety concern as they have been a reaction to our own conditions.

    Thankfully there are ongoing talks at the moment that will hopefully deal with this mess. Imposition has been “paused” and I hope something productive will come out of it.

    • alaska3636 says:

      Voluminous, but informative – thank you.

      “They have never explained what a “7-day NHS” would look like, and have been forced to admit they haven’t tried to find out how much more money or additional staff this would require.”
      Government-run anything runs into the problem of pricing scarce goods.

      “The whole thing is a mess, either through incompetence or malice.”
      Nobody knows how many medical services people require or at what price they should be supplied at until people make the decision to purchase medical services. Of course, nobody knows how to price and allocate anything. All decisions are based on estimates of free-market prices or arbitrary guesses.

      The USSR didn’t fail for lack of effort.

    • Jill says:

      Super! I love this when people are discussing something, and then someone shows up and says “I have firsthand experience with exactly what you folks are discussing here.”

      Thanks a mil, Pseudonymus, for contributing what you see going on, and what you are experiencing.

    • onyomi says:

      I find the Canadian and British national pride about nationalized health care, to the point where people say things like “private healthcare is un-Canadian” kind of creepy. I guess one could argue it’s a fair thing to be proud of if you believe in it. Still find it kind of creepy.

      • Anonymous says:

        Can you expand on that? Why do you find it creepy?

        • Why would you celebrate banning the private sector from a sizable portion of your economy? The profit motive and price mechanism is ethically sound and responsible for a large portion of our well-being.
          Holding hands and dancing around in a circle, singing “Kumbaya, we banished our capitalist overlords” seems….uhhhh…weird.
          “You shouldn’t make profit on people’s health” strikes me as both uninformed and unethical.

          That’s creepy.
          But whatever. Different strokes for different folks and all that. There’s no point imposing your system on someone else’s.

          My major concern, sitting on the other side of the pond, is more about Americans thinking we can eliminate scarcity. We just need to queue “Elective” care. That’s no big deal, right?
          See the Aussie above mentioning “Elective” care includes ACL surgeries. My brother has had 3 ACL ligaments. My grandmother needs her knee surgery because she can barely walk up stairs. These aren’t “elective” to me. I’m not interested in arguing: I elected a Senator and a Congressman to do that for me.
          Another thought: People suggesting we can just import other nation’s healthcare system irritate me. These are path-dependent systems that developed over generations.

          • Ninmesara says:

            My (uninformed, probably wrong) intuition is that when you have state-managed public sector, banning the private sector from health care feels good because the only way to earn a profit in health care is by cherry picking the easiest patients and procedures and leave the rest to state-managed health care (which can not refuse patients) or to have ceilings in how much money you’re going to spend on each patient. These are attitudes people don’t like. There is no magic that turns the “bloated & inefficient” public sector into the lean & efficient private sector people admire, it’s patient selection all the way down.
            Of course, caring for the easy patients in the private sector will be much cheapeer.

            [end of uninformed intuition]

            In any case, a state-managed system can be more aggressive when negotiating prices with the pharmaceutical industry than can individual insurance companies, which usually leads to cheaper care.

            Because insurance companies often have limits on how much they spend per patient, if there is no public sector to pick up the slack, patients who go over the limit are simply left out. Modern medicine is good at healing people, but unfortunately even better at burning money. Medical research usually exacerbates this problem, as more people who would be just left to die on cheaper supportive treatments are treated with the more expensive newest treatments.

            We’re way past the point in which the productive activity done by an individual in the extra years of life bought by newer treatments compensate for the price of the treatments. Also, many treatments are done to preserve not years of life, but quality of life. In your grandmother’s case (assuming she will get a prosthetic device), even if she is not in retirement, it is likely she won’t be able to earn enough money in the rest of her working life to pay for the surgery and prosthetic material (which is crazy expensive). These economic considerations mean health care now tends to grow inexorably as a percentage of GDP, and short of aggressively rationing care, there seems to be little we can do about it.

            There was a golden era somewhere in the 20th century (I can’t be precise with the dates) in which more medical care saved money from the state, but this is unlikely to repeat itself, short of revolutionary discoveries like vaccines or antibiotics (which were nothing short of miracles). With clean water and sanitation, even improvements in infrastructure probably won’t produce the same kinds of benefits in the short term.

          • sweeneyrod says:

            Private healthcare is hasn’t been banned in the UK, and from wikipedia 75% of Canadians have private health insurance, so it clearly exists there in some form.

          • houseboatonstyx says:

            @ Ninmesara

            Here’s a more encouraging point. Not perhaps as low-hanging as vaccines and antibiotics, but high-tech diagnostic imaging and such are getting cheaper, fast.

          • John Schilling says:

            …the only way to earn a profit in health care is by cherry picking the easiest patients and procedures

            In the United States, cosmetic surgery, laser eye surgery, and to a large extent dentistry are practiced quite profitably in the free market. Do you think your description applies to those? Because focusing a laser powerful enough to vaporize flesh onto someone’s eye,s such that they wind up seeing better, is not what I would call “easy”.

            And as Mark Atwood noted, the US health care industry provides surgically-implanted artificial joints where the Canadian health service provides wheelchairs. Which of these is easier?

            People who have lots of money, are generally willing to pay lots of money, their own if necessary, to ensure or insure that their bodies remain healthy and functional. The American people have, collectively, about thirteen trillion dollars of money. If you can’t figure out how to make a profit selling high-quality medical care, leave it to those who can. But do please trust that they can.

            But if all you’re looking for is a wheelchair and a pair of BCGs, the market will make a (smaller) profit selling you just those.

          • HeelBearCub says:

            @John Schilling:
            I think that is just cherry-picking of a different kind. The question is how one provides care across an entire society and whether this can be done in a market without some sort of society level government intervention. You can find individual people or procedures or conditions, but what about healthcare for everyone, over their entire life?

            The solely market based approach has to say “not everyone gets healthcare.”

          • John Schilling says:

            but what about healthcare for everyone, over their entire life?

            What about food for everyone, over their entire life? That’s vastly more important, but nobody suggests we need a National Food Service or a single-payer food system or whatnot. Even the British don’t do that.

            One-size-fits-all, fits most people very poorly. If are people you think are ill-served under a particular system, propose something to help those people. The more other people you try to encompass, the worse you’ll make it for everyone. And then the farmers will go on strike…

          • Joe W. says:

            @HeelBearCub

            That’s true of all approaches, as there is not an infinite amount of healthcare.

            Nor, unlike what people sometimes imply, is there a fixed amount of it, with the only question being how to allocate it to whoever needs it most.

          • Ninmesara says:

            @John Schilling

            There is a huge gulf between what you consider easy and what I consider easy. This is probably a problem of not agreeing on definitions, and if this is the case, I’m sorry for not having defined the word correctly. I define easy as something which is predictable from the point of view of the doctor, can be treated quickly and with a low risk of complications. It doesn’t really matter if you use expensive state of the art technology, because if the result is predictable, you can just factor the price of technology in the cost of the procedure.

            Yes, I consider the procedures you list as very easy indeed. Cosmetic surgery, dentistry and laser eye surgery are some of the easiest procedures I can think of, and good examples of “cherry picking” among the general population.

            cosmetic surgery

            Requires technical skills and dexterity, but the surgery itself is often skin deep, has a low rate of life threatening complications, and is usually done on healthy young people. Patient is out of the hospital very soon after surgery. If surgery requires a general anesthesia, the risk of a life threatening complication is higher; If it doesn’t it is quite low. Even if you can’t guarantee perfect aesthetical results, the procedure is quite predictable and “easy” according to my definition. I’m obviously not referring to young children with serious malformations, which might be associated with severe organic disease.

            to a large extent dentistry

            Not very invasive surgery, relatively low rate of complications, and if complications appear (such as serious infections), the dentist (if not a medical doctor) can always pass the responsibility to a doctor, who gets the complex cases.

            focusing a laser powerful enough to vaporize flesh onto someone’s eye,s such that they wind up seeing better, is not what I would call “easy”.

            I call it easy. Short procedure, extremely low rate of complications, patient out of the hospital the same day. A single surgeon can perform tens of procedures a day. They are standardized, and often almost automatic and controlled by computer. Despite being high tech, from the point of view of the doctor and the clinic it is very, very easy.

            A hard case is a smoke with COPD, two previous strokes, with heart failure from a myocardial infarction treated with a stent 2 months ago, who must be kept on blood thinners (technically antiplatelet drugs) for 1 years with a recently diagnosed sigmoid tumor. You have to balance the need for surgery to remove the tumor (which shouldn’t be done with the patient on antiplatelet agents) with the need to keep a functioning stent (which depends on continued use of antiplatelet agents). You’re then playing a dangerous game of increasing myocardial infarction risk in order to attempt to cure a tumor. Would you risk surgery? Will he have another stroke during surgery? Would you require a bed in an Intensive Care Unit in order to operate? Absent such bed, would you postpone the surgery?

            Another example is an old diabetic patient with dementia, slowly going blind from the diabetes, still capable of walking on its own (and thus able to hurt himself accidentally or getting lost), but mostly incapable of self care, and with a nasogastric tube for feeding, since he is now unable to reliably swallow on his own.

            People who have lots of money, are generally willing to pay lots of money, their own if necessary, to ensure or insure that their bodies remain healthy and functional.

            Unfortunately, due to the high costs of many medical treatments, very few people have enough money to pay for these treatments without some kind of insurance. Maybe with more competition between healthcare providers and industry companies prices could be brought down, but currently you need to be very wealthy indeed to be able to pay with your own money.

          • Ninmesara says:

            @John Schilling

            Please read this comment from some months ago, as it probably answers your questions: link.

            Also, most developed countries prevent their poorest citizens from starving with food stamps or charity kitchens. If only you could keep everyone healthy for the price of three meals per day…

          • HeelBearCub says:

            @John Schilling:
            The difference between food and medical care is, very obviously, that the distribution of need for food in a populace is incredibly consistent. The need for healthcare is almost as far away in consistency from food as you can get. This is why health care is an insurance market and food isn’t.

            It likely still would be in a completely libertarian society, although an unregulated insurance market would make insurance look far less attractive. Pyramid schemes would be rampant, and of course the pre-existing condition issue likely means that you are never quite sure you will be covered in the event of an illness.

            In any case, we don’t as a society, generally think that even the most destitute person should be allowed to starve to death, and we act in such a manner. It’s much easier (and cheaper) to design and implement a food safety net, though.

          • It’s much easier (and cheaper) to design and implement a food safety net, though.

            Relevant:
            https://artir.wordpress.com/2016/05/11/the-soviet-union-food/
            The Soviets certainly could provide some things in abundance, but couldn’t keep the stores stocked with fresh fruits.
            I would grant that food markets are generally simpler than healthcare markets, but through most of human history, food insecurity was a real threat. Healthcare markets are behind the curve only because it took so long to figure out how to produce enough food.
            So, yes, perhaps demand for food is consistent, but that doesn’t mean people haven’t tried (and failed) to introduce wide government control to make things better, including the US.

            That the health care and health insurance markets are different than food markets suggests the need for different government regulation, not necessarily the wholesale nationalization BY government. There’s always perverse incentives in any system, but there’s still regulatory and design mechanisms in place to address many of the problems already suggested.
            Obama-care already implements some reforms like medical cost ratios and lifetime cap modfications. So it’s not as if we cannot regulate the private sector to accomplish certain goals we have.

            So when people proudly point to socialized medical systems, I feel like I’m talking to a vestigial meme that has not been sufficiently supplanated by successful regulated private sector examples. No one says “Yay socialized automakers” because of the plethora of successful private sector makers (who are regulated and required to implement certain safety measures). But medicine, as a field, is not subject to the same review.

            Overall, that’s not my issue. The various socialized systems work for their nations and deliver cost-efficient results. Whatever skins the cat. The US system is far more expensive and it’s not obvious the extra dollars deliver results. Far be it from me for me to lecture foreigners on their healthcare.

            My first issue is the heuristic “everyone should get the healthcare they need,” which my economic thinking cannot process. The variables aren’t defined and the goal values aren’t defined.
            My second issue is the seeming idea that we can eliminate scarcity through effective rationing of “elective” care. See wheelchair example. Again, I do not want to argue this, you are trying to take my money, so you can argue with my Congressman or Senator. The Illinois Senators are Mark Kirk and Dick Durbin. You can argue with them that grandma’s wheelchair is “elective” care.
            My third issue is the idea that profit in healthcare is immoral and wasteful, which is really something that should’ve been dismissed well before I was born in the 1980s.

            It’s impossible to have any useful conversations about healthcare (on this side of the pond) with those issues in place.

          • HeelBearCub says:

            @Beta Guy:
            I believe you are arguing against a strawman. At least you are not arguing against my position, although you are quoting me.

            I’m not arguing against a market system in healthcare. I’m arguing against a market system without effective, universal insurance. Yes, effective, universal insurance changes the incentives of the market. Everything has trade-offs.

            You are correct to point out that ending starvation requires, in essence, a post scarcity food market. To some extent, this is trivially true, although experiences in parts of the world where starvation still does occur show that civil order is also necessary.

            None of this addresses the issue I mentioned above, which is that the need for healthcare is so unevenly distributed. Now you seem to be taking exception with the word “need”, presumably because if someone cannot afford it, then they must not need it. All healthcare consumption is just revealed preference until government distorts the market?

            Presumably if I am a ditch digger, and I have not saved enough to cover the cost of my compound fracture treatment including the long physical therapy, not to mention covering expenses during the period of unemployment that follows, then I have revealed that I preferred this outcome, my amputation and subsequent life of begging. I had better uses for the money before than saving it. Yes, this is an easy and simplistic example.

            I think this ignores, among other things, that I may have been injured before I had earned enough money to cover this one event in my whole lifetime, even before any expenses.

            That essential problem is why healthcare has to be an insurance market. And once you admit that, many of the problems and distortions come in to play.

          • As a general point, governments have been bad at supplying food, and at least somewhat capable of supplying medical care. There are enough examples that there should be a theory for why it works out that way, but I don’t have a theory. Thoughts?

          • HeelBearCub says:

            @Nancy:
            I think I would reject the premise.

            If you look over the history of humankind, we’ve been pretty awful at providing healthcare at all until the last 100 years or less.

            Things have to be insanely bad for people to die of starvation. People die of treatable medical conditions all the time, even in the modern world.

          • Matt C says:

            Nancy, off the top of my head, the governments that try to provide medical care are ones that are doing it as layer on top of an mostly market based society, and the governments that try to provide food are totalitarian governments that are trying to centrally plan everything.

            I have heard people rhapsodize about medical care in Cuba, but my guess is it was not actually very good.

          • I am objecting to the notion that because health care resembles an insurance market, it must be government controlled, for certain definitions of government controlled (Medicare on one end, full nationalization of all providers on the other).

            I’m not sure if that is your stance, so my apologies if it is not.

            More broadly, that’s not my issue with health-care debates. My issue is with the scarcity issue. You cannot avoid scarcity. This means all health-care debates are ultimately about appropriating my health-care dollars from care from my family’s “elective” procedures to other people’s “needs.”
            Again, I don’t argue that. That’s a political threat to my well-being. You can argue with Mark Kirk. He’s here:
            http://www.kirk.senate.gov/

            To your point:
            There are plenty of insurance markets that have the potential for market failures, but are still dominated by private market actors regulated by various government agencies.

            But that’s besides the point. Food markets are easier than health insurance markets, but food markets still sucked through much of human history. And plenty of people thought the answer was government regulation, ranging from price controls in Quebec to collective farms in the Soviet Union.

            I’m not a libertarian, so I support at least some government regulation. In both health insurance and food markets. I reject out-of-hand the notion that any industry needs to be solely government managed and provided besides inter-state warfare and suppression of internal rebellion.

          • HeelBearCub says:

            @Beta Guy:
            That link to Mark Kirk’s isn’t helpful as it’s to the top level. I don’t know what your point is.

            This means all health-care debates are ultimately about appropriating my health-care dollars from care from my family’s “elective” procedures to other people’s “needs.”

            No. That’s why I keep making the point about insurance. This is like saying that life-insurance is about taking away your dollars for dead people’s families needs.

            Most people don’t die young. Some do and the pooled money of everyone supports the beneficiaries left behind.

            Most people don’t have major auto accidents. Auto insurance uses the pooled money to take care of the damage in those rare instances.

            Medical insurance works much the same way, with the added kicker that proper healthcare provides pooled benefits of many kinds (vaccines, for instance, which spend partly on herd immunity). And the further added kicker that the young are healthier than those who are older, but everyone who is young will eventually grow older. It is a much more complicated problem space, but similar in nature.

            You assume that your health expenses somehow will never be higher than you can afford to pay. On average this might be true. But over the population space, it’s not true.

            Edit:
            And yes, health care scarcity is an issue that has to be dealt with until some time in the future where all health care is cheap and ubiquitous. I don’t deny that.

            But unless you are comfortable with very high incidence of preventable death due lack of access to healthcare, some sort of insurance system is necessary. And once you have insurance, universal is all but mandated unless you want what we had before, which is the pre-existing condition problem.

          • I don’t understand your point about insurance. That’s a payment mechanism. Healthcare is still a rivaled good/service bundle. If you get a surgery, you are taking up doctor hours that I cannot use, in the exact same way that if you eat an apple, I cannot eat the same apple.

            This is exactly my problem: trying to hide the obvious scarcity inherent in any redistribution system. Yes, it’s an insurance mechanism, and I do expect there is a chance that I will have healthcare payments higher than my ability to pay, which is why I have health insurance. However, when everyone has government-mandated health insurance, it crowds out my access to health care.
            And, of course, I am paying for the privilege of having other people wait in line, because many people cannot afford the premiums without subsidies.

            I don’t necessarily mind this, but don’t pull a Bernie Sanders and say’s costless to me, or improving my access to healthcare. It’s a redistribution entitlement heavily obfusucated through accounting tricks.

          • HeelBearCub says:

            @Beta Guy:
            If I am in surgery for something non-elective, the odds that I am taking the surgeon away from any given individual are very close to zero, as most people aren’t in surgery today.

            You aren’t wrestling at all with the fact that most people pay way more for their insurance (of every kind) than they ever get out of it. That’s how insurance works. Most people don’t have events that require the benefit of insurance.

            The scarcity exists regardless of whether the system is redistributive. The scarcity is determined by the pool of premiums paid. Public or private, an insurance system is an inherently scarce system.

            Now, given that you admit to the need for health insurance, do you want insurance companies to have the right to a) prevent you from purchasing insurance if you are already sick, b) fail to renew your coverage if you get sick, and c) remove your current coverage if they can find any evidence that you were “sick” when you purchased coverage? Because that is how private insurance in a non-universal, unregulated system works.

          • “Now, given that you admit to the need for health insurance, do you want insurance companies to have the right to a) prevent you from purchasing insurance if you are already sick”

            Do you mean “charge you a price for insurance that reflects the increased chance of your collecting, given that you are already sick?” Is your assumption that insurance companies have a moral obligation to sell insurance below cost to people for whom cost is high?

          • HeelBearCub says:

            @David Friedman:
            That is, as I believe you know, the free-rider problem. I don’t think people should be able to go without coverage and then simply pay for insurance when they get sick. I don’t think you should be able to buy home insurance as your house is burning either.

            Given that need for healthcare is very lumpy, and said lumpiness extends over a whole life, a decent healthcare insurance policy really needs to cover your whole life. If I am your consultant in a completely private market, I would advise you to get health insurance when you are born and keep it until you die, provided said coverage is actually available and reputable. That is the kind of policy you need to have.

            So, any rational system of healthcare insurance needs to make lifelong coverage work, while avoiding the free rider problem.

          • John Schilling says:

            @HeelBearCub: The difference between food and medical care is, very obviously, that the distribution of need for food in a populace is incredibly consistent.

            That argument would be a lot more convincing if we weren’t being told how vital it is that the ACA ensure that e.g. every woman gets free birth control pills.

            And for that matter, it is now taken for granted that catastrophic health care expenses should covered by insurance of some sort, which means however unpredictable they are in the end, the user price should be a priori as predictable as that for food or birth control.

            Finding edge cases where health care costs can’t be insured, predicted, or afforded and developing solutions for those cases, is a Good Thing. Using these edge cases as excuses for a one-size-fits-all universal national health care program, is a Very Bad Thing.

          • “So, any rational system of healthcare insurance needs to make lifelong coverage work, while avoiding the free rider problem.”

            Medical risks increase considerably with age. If people buy lifetime insurance at twenty, that covers the overwhelming majority of the problem. Earlier than that they can have insurance bought by their parents.

            At present, it probably doesn’t pay to buy insurance at twenty because, as I understand the situation under Obamacare, young people are being overcharged to subsidize the insurance of older people. But in a free market there’s no obvious reason why people couldn’t contract at twenty for insurance at a price schedule that matched, year by year, expected cost. As long as they didn’t get sick, they could at any point switch to another provider on similar terms. If they did get sick, they would be covered.

            I see a lot of talk about insurance companies dumping people who got sick, but that would be a violation of their contractual obligation and I have no idea whether it was really common or not. The cases might be ones where someone got sick, bought insurance while claiming not to be sick, and then complained when the insurance company discovered what had happened and refused to pay.

          • ” banning the private sector from health care feels good because the only way to earn a profit in health care is by cherry picking the easiest patients and procedures and leave the rest to state-managed health care ”

            The public sector is still getting a free ride in that case, since even the easiest patients cost something to treat and it’s being paid for by someone else. The customers paying for the private health care are still being taxed to pay for the public.

            So I don’t follow the argument.

        • onyomi says:

          I think what clinched it in my mind as creepy was the inclusion of a dance number about the NHS in the Olympic ceremonies. As if socialized medicine were an important part of British culture, like, I dunno, drinking tea or Cricket or something.

          What caused me to think of this was the poster’s use of phrases like “attack on our system” which he doesn’t expect others, on the other side of a “tribal gulf” to understand. Like, “you would understand, if you were British, how belief in socialized medicine is an important part of British cultural identity.” The idea that belief in a particular government program would be part of a cultural identity strikes me as weird and fascistic.

          • Anonymous says:

            Hah, I agree (as an American) that the NHS segment in the Olympic opening ceremony was weird.

            The idea that belief in a particular government program would be part of a cultural identity strikes me as weird and fascistic.

            I think blue-ish people might feel the same way about the stereotypically-red pride in the military.

          • onyomi says:

            “stereotypically-red pride in the military.”

            That can be creepy too.

          • houseboatonstyx says:

            @ Blue Anonymous
            >>The idea that belief in a particular government program would be part of a cultural identity strikes me as weird and fascistic.

            I don’t see why it necessarily should. If the German telephone system at one time used a pure Middle C as its dial tone, for the convenience of musicians … and the French government funded the Academy that tries to keep the language pure … I would find both of those government expenditures charmingly indicative of their respective national characters.

            >I think blue-ish people might feel the same way about the stereotypically-red pride in the military.

            It makes sense for some USians to be proud of having the biggest and best military. What’s said above sounds like the Brits are proud of having any national health service at all — which also makes sense, as having one at all for all this time is rather an accomplishment.

          • keranih says:

            I too found the NHS in the olympic ceremonies deeply confusing and creepy. You guys are celebrating having sick people?

            Being red tribe, I am less put off by military appreciation, but I have spoken with multiple service members who – while appreciating the swing in public perception from the 1970’s-1980’s – refer to “military groupies” and wish they could travel on assignment in civilian clothes.

      • sweeneyrod says:

        I can see why you would find people referring to private healthcare as un-Canadian to be creepy, but I’ve never heard anyone in the UK disparaging private healthcare. I think it’s easy to see why people would be proud of a system that provides free healthcare to everyone (regardless of what disadvantages you might think it has). I probably have a very different opinion on the 2nd amendment to American gun fans, but I don’t think being proud of easy access to guns is creepy.

      • John Schilling says:

        I find the Canadian and British national pride about nationalized health care, to the point where people say things like “private healthcare is un-Canadian” kind of creepy.

        British people don’t say that, of course, and it’s not clear that they say private health care is un-British, either. I’ve heard a lot more praise or defense of the NHS out of the UK, than I have attacks on (British) private health care.

        We’ve got plenty of people in the United States who are proud of NASA, Apollo, and so forth, in spite of SpaceX and Blue Origin existing. Is that creepy? Build a great institution that does neat and/or useful stuff, and people are going to be proud of it. It is I think worth distinguishing between that, and the weaker tendency to attack the competition.

      • Garrett says:

        I moved from Canada to the US for several reasons, including this. It bothered me that any time I wanted to discuss Canadian healthcare policy I was shut down with “what do you want – a system like they have in the ‘States?” That does not lead to productive conversation.

  11. Ruprect says:

    Problem is this:
    Everyone discounts their future pain because they don’t think there is any way to stop it. I’m 30 (ish). Who knows, if everyone believed there was some way to prevent cancerous death age death, maybe it would happen in my lifetime.
    Maybe not.
    What do we have to lose? The Superbowl?

    And, yes – that is the real question with respect to sickness/healthcare – can we solve this problem?

    • Jill says:

      And then there are the sub-questions within that one. If we can’t solve it completely, can we solve some parts of it? Can we do a better job on solving the problem than we are doing now? And beginning questions: Can we understand exactly what is happening and specifically where the problem lies? Exactly what is the malfunctioning part. or malfunctioning relationship/system? Or where is the individual incentive to do things that will mess up the system? Can we be as observant as Sherlock Holmes about it?

  12. TD says:

    Related: how much of NHS spending goes towards A&E and how much goes towards less serious matters? I was wondering because of the amount of free prescriptions I’ve got for relatively minor ailments over the years (I. Am. Part. Of. The. Problem.). This is all linked with other government benefits like income support, which is also rising.

    The NHS is frequently treat as all one thing in the media, as if the entire thing is vital to the survival of every poor person in the country. If I was to create an NHS from scratch, I would want to focus on covering people’s costs for stuff that would kill them or cripple them if they didn’t get treatment. I honestly don’t know how much of the NHS right now is PEOPLE WILL DIE IF YOU DON’T stuff, and PEOPLE WILL HAVE TO PAY FOR SOME RASH CREAM stuff.

    If PEOPLE WILL DIE IF YOU DON’T stuff (A&E, but I assume cancer screenings could come under that category) comprises only 10% of the NHS budget, then you could cut from the NHS the 90% that comprises other stuff, and then, let’s say, triple the funding for those A&E/Other/High stress health jobs, and now you can raise their salaries, or even make things more efficient so they don’t have to work so many hours, while making an overall 70% cut in this big blocky thing we call the NHS. I call this sneaky trick budgetary reapportioning. This example is obviously extreme, but it all depends on just how much money the NHS needs to sew people’s legs back on and remove fence posts from their faces, and how much money it spends on everything else.

    • There’s a big intermediate range of treating chronic conditions which have a big effect on quality of life but aren’t immediately deadly. Joint replacement is one example. Care for type 2 diabetes is in a slightly different category– not doing it doesn’t have a huge short run effect so far as I know, but does have a large long run effect.

      • TD says:

        I don’t mind people paying small amounts for that stuff. They could pay the NHS rather than letting it be purely private and have to pay at market prices.

    • Scott Alexander says:

      I kind of feel the opposite. The stuff that’s about heroic efforts to save the lives of an 81 year old so they can die at 82 are the source of a lot of waste. The person whose lupus is just bad enough that they’re in constant pain and can’t walk or work, but not bad enough that they’ll die immediately if it’s not treated, and who can’t afford to get it looked at themselves, are the sort of people who I think are the strongest argument for government-subsidized health care.

      • TD says:

        Perhaps it’s better to distinguish further between egregious conditions and more personally manageable ones. So we can amend PEOPLE WILL DIE IF YOU DON’T to PEOPLE WILL DIE IF YOU DON’T OR SUFFER IMMENSELY FOR AN INDEFINITE PERIOD OF TIME. Then you’ve got everything else remaining that it should be acceptable to exempt from being “free at the point of use”.

        • John Schilling says:

          Get rid of the PEOPLE WILL DIE IF YOU DON’T part. Seriously. Because, yes, but PEOPLE WILL DIE EVEN IF YOU DO, every last of them. Rephrase the formula in terms of what you are actually trying to do, see if it is realistic, and maybe you can do some good.

          • TD says:

            I feel like the context is clear. We’re not trying to stop aging with the NHS. People are dying before they are expected to due to serious injury/illness.

            Honestly, if “immortality” becomes possible and people start being able to live indefinitely, then they should pay an exponentially increasing fee for fixes after they pass a certain age, perhaps 100.

          • John Schilling says:

            People are dying before they are expected to due to serious injury/illness.

            When are people “expected” to die, exactly? Scott’s example was an 81-year-old who might, with herculean effort make it to 82.

            Does it make a difference if it is a 41-year-old who might make 42 but won’t see 43, and if so why?

            Does it matter that the cause of death is listed as “old age/natural causes”, and if so why?

          • TD says:

            Of course, it’s totally subjective, but it matters socially. An 18 year old girl who dies in a car accident is considered a tragedy, whereas an 80 year old who dies from their heart giving out is considered a shame, but perfectly normal.

            “When are people “expected” to die, exactly?”

            Overall life expectancy for the UK is listed at 81 according to wiki. Obviously, an unhealthy person will die sooner than that, but the average isn’t extremely warped here by outliers.

      • Anonymous says:

        It’s remarkable how generous welfare can be when you limit it to a few favored classes of people.

        • Hlynkacg says:

          And which classes would those be?

        • Jill says:

          Health insurance companies and other crony capitalist welfare queen corporations feeding at the public trough?

        • Anonymous says:

          Old people get all the best welfare programs in the US. Well, aside from farmers but there aren’t that many of them in the grand scheme of things.

      • BBA says:

        You say they were both 67. Was the American on Medicare or private insurance?

        • houseboatonstyx says:

          @ Mark Atwood
          Private insurance

          So shouldn’t the cost of the American woman’s premiums be counted into the situation? And iirc, the Canadian system also allows private insurance for those who want to pay such premiums.

        • Anon says:

          @houseboatonstyx the Canadian system already has healthcare premiums, they’re just called “higher taxes” so you don’t think critically about them.

        • HeelBearCub says:

          The American was on Medicare PLUS private insurance. Medicare is mandatory past 65, IIRC.

        • Anonymous says:

          Maybe Mark Atwood’s relative is an hero just like him and rejected Medicare despite the penalties for doing so.

  13. sconzey says:

    Scott, you exhibit an almost astonishing ability to switch off your enviable stats and rationalism skills when it comes to something something in-group. Your entire argument consists of ‘junior doctors work in terrible conditions and this new contract won’t fix it because evil people’

    Please, actually read the details. There’s a handy summary on the UK government website. The main point of interest to you is that it puts a hard limit of 72 hours per week that a jdoc can work. Although it reduces the number of hours which are considered ‘unsociable’ it increases the pay for them.

    The other aspect to this dispute is that unlike the US, the State carries the majority of the cost of sending a student to medical school. There’s a small copayment from the student, but it’s no more than you’d pay for a history degree, and can be covered by our generous (and state-guaranteed) student loans program. The jdoc tendency to migrate to the antipodes and default on their student loan loses them a lot of public goodwill.

    I struggle to see how this is anything other than a good-faith effort by the government to fix some of the more glaring problems with the NHS.

    • JDG1980 says:

      The main point of interest to you is that it puts a hard limit of 72 hours per week that a jdoc can work. Although it reduces the number of hours which are considered ‘unsociable’ it increases the pay for them.

      As Scott pointed out in his original post, restrictions on how many hours hospitals can force a doctor to work have never been enforced (at least in the Anglosphere). Why should we believe that this promise will be any different?

      • sconzey says:

        There are a number of differences between this and the EWTD, but they are besides the point: An unenforced limit of 72 hours a week is – in the worst case – no worse than an unenforced limit of 91 hours a week.

        And for this, doctors are striking and accusations of non-humanity are being bandied about.

    • Murphy says:

      Oh you precious, trusting, little darling.

      “There will be a new absolute limit of 72 hours in any week, lower than the 91 hours that the current arrangements allow. Alongside this, we are removing the financial incentives in the current contract that encourage doctors to work unsafe hours.”

      Translation: ” removing the financial incentives ” means that they’ll just not pay you for extra hours.

      You’ll still of course be given 91 hours worth of work to do but won’t be paid for it if you take more than 72 hours to do that work and will of course be personally reprimanded for breaching those hours limits. (Of course any failure to either complete 91 hours worth of work in 72 hours or failure to keep your hours within “safe” levels will be considered entirely the fault of the individual worker)

      “The jdoc tendency to migrate to the antipodes and default on their student loan loses them a lot of public goodwill.”

      “Them”? So the people striking, who happen to be the people who are still in the UK lose your good will because entirely different people have made the rational choice to move elsewhere?

      You don’t seem to be thinking this through. Even a little. Do you by chance read the daily mail regularly? (Or worse,the telegraph, the daily mail for people who think they’re better than daily mail readers but want to hold all the same poorly informed positions.)

      • sweeneyrod says:

        Behold, a reader of the Grauniad! (Unjustified snark about choices of newspaper does not make your position seem stronger, from any perspective).

        • Murphy says:

          if someone parrots the kind of tripe that constantly gets shouted by one newspaper then you can make some decent guesses.

          If they were posting about the threat of giant mutant french rats invading the UK you could make a decent guess that they read either the Sun, the Star or the Daily mail, if they believe the Tories are all a bunch of really solid chaps who would never do anything negative are only trying to do what’s best for everyone and that what the poor really need is a darned good thrashing then the telegraph. If they’re more concerned about some random troll misgendering a celebrity on twitter than any notable issue then the Grauniad.

          The newspapers in the UK are disturbingly well controlled by the various parties and a hell of a lot of people get all their opinions directly from one of them without any kind of filter in between.

          It was a weird minor culture shock to realize that there were no major papers without close ties to a party.

          I could have been more kind but when someone blindly parrots the standard party line you can either nod sagely and pretend they’re offering wise advice or call them out on it.

          sconzey’s post might as well have been copy-pasted out of the telegraph. It’s 100% exactly down the party line with zero critical thought applied.

        • hlynkacg says:

          @sweeneyrod
          I agree, but…

          any failure to either complete 91 hours worth of work in 72 hours or failure to keep your hours within “safe” levels will be considered entirely the fault of the individual worker

          …is pretty strong all on it’s own.

      • Anonymous says:

        It seems like if they have the solidarity necessary to go on full strike a work rule strike, including leaving after the scheduled work period is over, would be both easier to accomplish and to defend.

        • Murphy says:

          Work to rule? why would they need work to rule? If the official policy is that they are not working more than 72 hours (unless of course the individual doctor is breaking safety policy by officially logging working more than 72 hours and thus should be brought up for fitness to practice over their safety violations or breaking safety policy by failing to do all the tasks required of them to care for their patients) then there’s no problem with them only working 72 hours.

          Of course if patients get neglected (tasks not all being done)then of course the individual doctors will need to be brought up for fitness to practice.

          Strikes are legally protected, implementing your suggestion would be stupid because the individuals would have no protection.

          • Anonymous says:

            Whether or not a work-rule strike is legally protected is rather irrelevant. They can’t fire all the junior doctors for leaving after 72 hours any more than they can fire them for not showing up for two days of work. There have been cases where such bluffs have been called but I don’t think they could pull that off in this case.

            All that said, while I’m not familiar with all the ins-and-outs of the rules and regulations, I’d be very surprised if there were written rules (safety policies or otherwise) that required all tasks to be completed regardless of the time needed or that someone could formally be brought up on charges for failing to complete all tasks if he simply ran out of time. Informal pressure and blackballing seems far more likely.

      • Eggoeggo says:

        “Do you by chance read the daily mail regularly? (Or worse,the telegraph, the daily mail for people who think they’re better than daily mail readers but want to hold all the same poorly informed positions.)”

        I do love when “you don’t seem to be thinking this through” is used to mean “you don’t seem to have reached the conclusion my favourite newspaper told me was right”.

        • Murphy says:

          No, in this case it’s “I can see you’ve apparently (surely only by chance) settled on precisely the conclusion that the paper that parrots the party line did”.

          Pointing out that someone might as well have copy pasted from one of the newspapers does not imply that I think one of the other papers got things right.

          It’s about as telling as someone’s views perfectly mirroring those of the chinese People’s Daily while arguing that obviously the party is just doing what’s best for everyone.

      • sconzey says:

        I admire your cynicism, but I wish you’d apply it more evenly. You’ll go through life constantly surprised and disappointed if you assume everyone who disagrees with you is either evil or an imbecile.

        I’d ask you what you’d expect the contractual changes to look like if this were a good-faith effort on the part of the government?

        • Murphy says:

          When the party making the change is the one trying to hamstring things always be a little more suspicious.

          If a hard-core left wing pacifist like Corbyn who’s made it clear their goals include dismantling chunks of the military proposed a “good-faith” change to the contracts of the employees of the MOD that involved paying them less take-home pay and those same employees claimed that it was a horrible contract that was going to cause a lot of them to quit… then I’d be far more inclined to believe them than if the same change was being made by a war hawk who spent most of their time trying to expand the MoD.

          For another parallel: If a pro-abortion group tries to bring in extra rules to prevent people from being pressured into abortion then they’re probably acting in good faith. If a party who’s stated position is staunchly pro-life tries to bring in the same measures then you know damned well it’s an attempt to kill it with a death by a thousand cuts because they’re not going to be acting in good faith.

          The Tories don’t get the assumption of good faith when it comes to the NHS because they don’t generally act in good faith when it comes to the NHS, as such they have to work for it.

          how might the contract have to look? It probably wouldn’t involve trying to get 7 days worth of work out of people for the same 5 days worth of money.

          • sconzey says:

            You’re making a false equivalency– unlike the other groups you cite, the Conservative party in both public statements and policy documents are very much in favour of the NHS, pretty much as it presently exists. You may well disagree with their policies, but surely you will concede that correct policy is not so obvious that different means are evidence of different ends.

            Your entire argument seems to be: the filthy Tories are known evildoers, so there must be some catch in the policy proposals, and if we’ve not found one yet that is only further evidence of the depth of their perfidy, hiding it so well. We know they’re evil of course, because otherwise why would they put some catch in the policy proposals to destroy the NHS?

  14. John says:

    It sounds like conditions are pretty terrible for those doctors. It’d be great if something could be done about it. But the “lizard people” are fighting a phenomenon — health care cost inflation — that is eating the first world from the inside out. It’s a big problem, and the groups that represent doctors in various countries are not exactly voluminous in proposing solutions.

    AFAIK every first world country is facing this, some started from far worse bases, and in some the rate is worse than others, but none have managed to go the last couple of decades without cost growth above the rate of general inflation even after adjusting for changing demographics.

    I know the libertarians will say we need to free market harder and there’s be no problems. Maybe they are right, I’d be very interested to see an experiment — not in my country mind you, but in Singapore or something. Until and unless someone comes up with a workable solution though the politicians and administrators are in a very tough spot.

    • Eggoeggo says:

      The politicians and administrators seem to be in the best spot. I mean, they’re not working 100 hour weeks, and they all have access to private medical care.

    • Scott Alexander says:

      I think you make a good point.

      But I don’t know what to say about health care inflation. By its very nature there will always be more of it. You can get doctors to work 100 hours, then 110 hours, then 120 hours, kick patients out of hospital in 3 days, then 2 days, then 1 day…and all you’ll have done is buy yourself a couple of years before you have to make the system even worse.

      (also, it doesn’t seem to me that trying to get “a seven day NHS” is an example of health care inflation, unless it’s a cover for something else they need to do for other reasons)

      • John Schilling says:

        all you’ll have done is buy yourself a couple of years before you have to make the system even worse

        No, a couple of years before your successor has to make the system even worse. Particularly if you can spin your temporary fix as a wonderfully clever solution and get a promotion out of it.

  15. “If there are salaried positions where the employers are scrupulous about keeping the hours down, I’m not sure why they do where others don’t.”

    Because their employees value the leisure at more than the value to the employers of the extra labor.

    Suppose a worker who works seventy hours instead of forty produces an extra thirty thousand dollars a year net revenue for his employer. If employees are indifferent between forty hours with wages of 70,000 and seventy hours with wages of 110,000, the employer is better off offering them the former deal.

  16. Jill says:

    I prefer to see creation more than destruction, although both are necessary, of course. When problems arise with what the government is doing, one can create alternate government programs, or else private programs, or else combo private/government programs, and see if the new thing does better,. Or if there is good reason to believe the new plan will do better, once enacted.

    If private industry is screwing up, as with the 2008 financial crisis, then maybe you see if some form of government regulation might keep that from happening again, or at least make it less likely. (BTW, I am aware of the Right Wing tale that 2008 happened because of too much government regulation, so you there’s no need to inform me of that one.)

    There is actually some good discussion up above on the causes and possible cures for Britain’s junior doctors, so that is encouraging.

    There’s no need to spend a lot of time bashing government, or bashing private industry– although if someone has done something illegal, they should be prosecuted. Other than that, if it isn’t working, then just figure out how to fix it.

    We seem to have a trend in our country of spending a lot more time bashing, than we do creating solutions to problems.

    Health care is one of these problems. Obama did the best he knew how. If someone knows a better way to fix it, why don’t they propose it? The GOP kept trying to overturn or de-fund Obamacare. But they didn’t come up with an alternate plan, except suffer and die and go bankrupt. And you can hardly say there wasn’t a problem in health care before Obamacare, when medical expenses were the leading cause of bankruptcy in the U.S.

    • keranih says:

      (BTW, I am aware of the Right Wing tale that 2008 happened because of too much government regulation, so you there’s no need to inform me of that one.)

      Evidently there is need to inform you of the non-partisan facts that multiple, bi-partisan administrations strong-armed lending companies in accepting increasing numbers (and percentages) of risky, unwise loan applications, on the grounds that too many of rejected applicants were minority/poor borrowers.

      This was a significant factor – but not the only one – in the eventual and inevitable collapse in the financial market. Yes, financial institutions over-borrowed and had very poor accounting to track their risk. Yes, quasi-private risk assessment firms were at best incompetent and more likely committing fraud.

      But the bottom line was that people were borrowing money they couldn’t pay back – and the federal government was threatening legal action against banks who did not loan money to people who could not pay back the loans. This drove everything else.

      You can call it a Fable if you like. But you would be incorrect. Again.

      If someone knows a better way to fix it, why don’t they propose it? The GOP kept trying to overturn or de-fund Obamacare. But they didn’t come up with an alternate plan, except suffer and die and go bankrupt.

      Eighty percent plus of the American population was very happy with their healthcare and their healthcare insurance. Most of the population who were not covered prior to Obamacare still are not covered. Healthcare for those who are covered is, on average, more expensive, more restictive in providers, and in most measurements worse than previously.

      And you can hardly say there wasn’t a problem in health care before Obamacare, when medical expenses were the leading cause of bankruptcy in the U.S.

      Again, that study (medical bankruptcy) does not mean what you think it means. Quit using it until you start using their definition for “medical bankruptcy” in your day to day life.

      But most importantly, you commit, again, the error of assuming that because there is a problem and this is something which can influence the problem that this something will fix the problem. The null hypothesis always is that there is no difference between using the something and not using it – and if you are not including the possibility that the something will actually make things worse, you shouldn’t be allowed within a hundred miles of policy.

      Shorter version, true in life and in medical specialties: Often the best course is to not do something, but to just stand there.

      • Teal says:

        I’d be interested in seeing a citation on the 80% were happy. I’ve worked for a small business since well before the ACA rules come into force. Every single year, both before and after, my health insurance premiums increased significantly and my coverage got worse. Out of network coverage or seeing a specialist without first seeing my primary (and paying a co-pay for the privilege) was already a distant dream in 2013.

        The people that were very happy with their healthcare and didn’t see what the issue was were hypocrit old people and government employees that got, and get, fantastic highly subsidized government health care. Also, employees of very large firms that didn’t make the connection between their “cheap” and comprehensive health coverage and anemic wage increases.

        On housing, you are in the right ballpark, but the focus on the fair housing act enforcement is too narrow. All levels of government — local, state, and federal — massively distort the housing market to further their constituents insane obsession with owning land. The 30 year fixed mortgage with no prepayment penalty, which only exists because of government intervention, is far bigger cause than a little fiddling on the edges regarding minority borrowers.

  17. BBA says:

    This seems like a fine time to remind everyone that there hasn’t been a truly free market in medicine since before there was modern medicine. The first law requiring physicians and surgeons to be licensed was passed in 1511, early in the reign of Henry VIII. Authority to issue medical licenses was given to the bishops of the still-Catholic Church of England, to give you a sense of how long ago this was.

    • JDG1980 says:

      This is probably true in the UK, but I had the impression that in 19th-century America, there were essentially no medical regulations and anyone who wanted to could hang out a shingle and claim to be a doctor.

      • BBA says:

        De facto, probably. De jure at least the eastern states had some form of medical regulation.

    • Urstoff says:

      how much did medicine actually matter to health outcomes before the 20th century?

      • I was told, by an academic who had studied the question, that the medicine available to the British elite improved health outcomes pretty early, I think at least back to the 18th century. That’s my memory of a conversation from fifteen or twenty years ago, however.

        Her research was in part made possible by the fact that we have good data for the English elite–who was born when, died when, etc.

  18. ad says:

    If you proposed scrapping the NHS, how many British doctors would agree?

    • sweeneyrod says:

      I expect very few (although it would depend to a large degree on the proposed alternative).

      • ad says:

        I daresay you are right. It seems I am being asked to believe two things simultaneously:

        “Doctors are striking because they are so badly treated by the NHS”

        and

        “Doctors support the NHS”.

        Either I’m being misinformed, or striking doctors are idiots.

        • Loquat says:

          (c) You’re misinterpreting the statement “Doctors support the NHS”.

          You can support the existence and overall mission of an institution and still think it has problems that need fixing.

        • TheAncientGeek says:

          Almost everybody supports the NHS, because the perceived alternative is something like the US system, which is regarded with widespread horror. There is a polarisation problem … it is very dificult to communicate any kind of third way without people seeing it a trojan horse for Americanisation.

  19. c0rw1n says:

    Here in Belgium most everything is reimbursed quasi entirely.

    Doctor visit? Blood test? ~40€, refunded.
    Cancer treatment? Cost 250€ all told.
    Tooth extraction, cavity, cleaning? Fully reimbursed.

    Our systems of reimbursement are called mutualities, they’re sort-of competing semi-public things aligned with political identities for some historical reason.

    They cost -outside of our ridiculous tax levels- at most a few hundred € a year, with various discounts for unemployed, old, children, etc.

    (I don’t know much detail of how it works, and every time I went to look at how anything works in Belgium all I got was how incredibly obfuscated it all is.)

    Don’t get me too wrong, it’s notoriously inefficient. But at least nobody gets condemned to poverty just for being sick (of pretty much anything even remotely frequent) or refused treatment.

    • keranih says:

      But at least nobody gets condemned to poverty just for being sick (of pretty much anything even remotely frequent) or refused treatment.

      Where are people condemned to poverty for just being sick? At all or routinely?

      And if I understand this correctly, all treatments of any kind are available? To everyone?

      • Jill says:

        Where? Before Obamacare, in the U.S.

        Medical Bills Are the Biggest Cause of US Bankruptcies: Study
        http://www.cnbc.com/id/100840148

        • keranih says:

          That is not what that study says. Dig into it and find their definition of “medical bankruptcy.” That study has been debunked repeatedly, and should not be circulated as evidence that people in the USA were beggared by medical bills.

          The major cause of bankruptcy in the USA is “lack of work.” Which can be related to illness, and often is, but is not related to medical bills.

          • Murphy says:

            It would have been far easier if you’d just quoted it rather than making people chase it down.

            Bankruptcy: We relied on a widely cited Harvard study published in 2009. NerdWallet Health chose to include only bankruptcy explicitly tied to medical bills, excluding indirect reasons like lost work opportunities. Thus we conservatively estimated medical bankruptcy rates to be 57.1% (versus the authors’ 62.1%) of US bankruptcies.

            aaand the harvard study definition

            For all other analyses (ie, those not reporting time trends)
            we adopted a definition of medical bankruptcy that utilizes
            the more detailed 2007 data. We altered the 2001 criteria to
            include debtors who had been forced to quit work due to
            illness or injury. We also reconsidered the question of how
            large out-of-pocket medical expenses should be before
            those debts should be considered contributors to the fa-
            mily’s bankruptcy. Although we needed to use the threshold
            of $1000 in out-of-pocket medical bills for consistency in
            the time trend analyses, we adopted a more conservative
            threshold—$5000 or 10% of household income—for all
            other analyses. Adopting these more conservative criteria
            reduced the estimate of the proportion of bankruptcies due
            to illness or medical bills by 7 percentage points.

            Unless you really want to believe these definitions seem pretty reasonable. People who declared bankruptcy with a big chunk of money going to out-of-pocket medical bills and excluding lost work possibilities.

            As far as I can find it’s only been “debunked” in the sense that someone shouted insults about it then the people who really wanted it to not be true declared it “debunked”

            https://slatestarcodex.com/2014/12/13/debunked-and-well-refuted/

          • Cerebral Paul Z. says:

            Medical bills could be a factor in 100% of all bankruptcies, and it still would not establish that they’re the biggest cause. If I were as quick as Murphy to impute disreputable motives, I might think the phrase “medical bankruptcy” was engineered for the specific purpose of leading people to that unwarranted assumption.

          • keranih says:

            Murphy –

            I wasn’t the one trying to use that as support for my stance without reading it and thinking about the implications of what the study was trying to prove.

            Think this through, and consider substituting any other expense for “medical bill”. Now the bankruptcy under consideration is exactly the same – except that instead of a $1500 medical bill, it’s a $1500 auto collision bill. Or a home repair bill. Or anything else.

            These people are going into bankruptcy. All allowable bills are added to the heap (student loans are not, for instance.) They are declaring bankruptcy because of bills in excess of $45K to $450K. For any level of discharable debt the bankruptcy was determined to be “caused by medical bills” if as little as $1k of that debt was medical bills. ANY OF IT.

            Some of these people were going into receivership because of medical bills – but very few. Instead, overwhelmingly, they were struggling with significant amounts of other debts, *and* were out of work, with some medical debt.

            Loosing everything because you were ill and out of work is bad. I wouldn’t wish it on anyone. But the key problem there is not going to be fixed by someone else paying for medical care, and pretending that it will be is crap and dishonest politicking.

          • Cerebral Paul Z. says:

            Well, they did raise the threshold to $5000 (or 10% of income) in medical bills in the 2009 study, but I doubt that makes much of a difference. The average “medical bankruptcy” involved nearly $45,000 in negative net worth.

          • CatCube says:

            @ Cerebral Paul Z

            Is that “average [of nearly] $45,000” a mean or median? Because if it’s the former, it’s going to be very sensitive to outliers.

  20. Rick Hull says:

    Half the fun of this post is reading between the lines.

    Does anyone else remember Dr. Paul’s (Ron or Rand, or both?) point that when you grant a right to healthcare, you make slaves out of the healthcare providers?

  21. Jill says:

    There are a few other aspects of this issue that I’m thinking of now.

    –That all the people that survive in medicine, and certain other professions fields probably have superhuman energy and superhuman stress tolerance. There may be other people who only have normal human energy and normal human stress tolerance, who would have a lot to contribute to the field in question. But they can’t make it through so they are not allowed to contribute.

    — Even the people who do survive it may have a lot of problems due to exhaustion and burnout, and this hampers the progress of the field too. When people are super stressed, then they are less creative, less attentive to their job and to what’s going on around them, and they see fewer options for solving problems.

    –I imagine that for a certain percentage of the people in these fields, once they do get through the period of super long hours of work, they may feel justified in coasting along– or they may be so burnt out that they are only capable of coasting along by that point. So that later coasting period may be the reason why medical errors are now the 3rd leading cause of death in the U.S.

    So there is a lot that is given up by a field and by the society that should benefit from the field, by working people almost to death.

    • keranih says:

      I imagine that for a certain percentage of the people in these fields, once they do get through the period of super long hours of work, they may feel justified in coasting along– or they may be so burnt out that they are only capable of coasting along by that point.

      You might want to consider doing some observation/investigation into this – esp as many people on SSC are in a medical field – rather than imagining.

      So that later coasting period may be the reason why medical errors are now the 3rd leading cause of death in the U.S.

      Possible. Far more likely is a combination of a) the huge amount of complex medical care provided in the USA and b) that people have stopped dying of other things first.

  22. sweeneyrod says:

    Although the linked article states that 37% of UK doctors are white British, further examination reveals that a further 37% are British of another kind (from experience, I think mostly South and East Asian).

  23. Vox Imperatoris says:

    So are the “lizard people” truly being so unreasonable here?

    I mean, I think Britain would be better-served by a free-market, laissez-faire system of healthcare.

    But if they’re not going to do that, what exactly is the problem with paying doctors very little and working them long hours, and mainly relying upon importing foreign doctors from abroad whose prospects are even worse? Is it causing health outcomes to go down? That doesn’t seem to be the case.

    So it’s a win for the British taxpayer, and a win for the foreign doctors. The only people it’s bad for are the native British employed as junior doctors. But…is the purpose of the British government to serve the special interest of British doctors? Or is it to serve the interest of British citizens as a whole?

    Basically, I’m not exactly seeing—from the perspective of the British taxpayer—why the NHS should offer junior doctors better pay and working conditions. There doesn’t seem to be any shortage of people willing to do the job.

    • sweeneyrod says:

      The junior doctors are arguing that their conditions impair their capacity to treat patients (although they may be wrong).

      Another group could lose out are foreign citizens who are losing their doctors.

      • Joe W. says:

        Alright, as long as you’re not also agreeing with Scott’s (implied?) claims that British doctors moving to Australia also counts as a loss. I would say that’s cheating.

        • sweeneyrod says:

          I don’t really see why you would view that as a loss (other than for the doctors), if the quality of care isn’t suffering.

    • Scott Alexander says:

      Shouldn’t this imply that the British should do the same with every public job – importing foreign police, teachers, firefighters, etc? And probably private job, importing foreign fast food workers, managers, assembly line workers, etc? Why should any industry have super-subsistence wages or humane conditions at all?

      This isn’t meant to be snarky, by the way. I think it’s an important question. It’s just misleading to make it about doctors.

      • Vox Imperatoris says:

        Well, I think every job should be exposed to foreign competition and that we should import foreign fast-food workers, managers, assembly-line workers, etc.

        That doesn’t mean wages / working conditions drop to subsistence. It means they drop to the level of full employment, which is the point at which the wages equal the productivity of labor. And I think the average productivity of labor is very far above the point of minimum subsistence.

        If people are paid higher than their economic productivity, then competition among employers will drive the wage down. If they’re paid lower, then competition will drive the wage up. For instance, in WWII, when the US government enacted wage freezes (essentially maximum-wage laws), employers collaborated with employees to give them fake managerial positions in order to be able to increase salaries. And famously started giving them employer-provided health insurance, which led to the mess we have today.

        ***

        In the British healthcare system, you have factors going both ways with regard to doctors’ salaries. Some of them, such as the licensing and whatever bureaucratic hoops you have to jump through to offer private care, act to raise the salaries of doctors above the market level. Others, like the fact that a government-run monopoly controls most of the healthcare system and has legitimate monopsony power, act to lower the salaries and/or working conditions of doctors.

        The question is, are the salaries and working conditions higher or lower than they would be under free competition? Well:

        1. If doctors’ salaries were below the market level, then there should be a shortage of doctors. People aren’t forced to become doctors, and those who have the capacity to become doctors have the capacity to perform many other jobs, as well.
        2. There is (apparently) not a shortage of doctors. In fact, there seems to be such an excess of doctors that there is stiff competition for positions.
        3. So it seems like doctors’ salaries are not below (what would be) the market level.

        The argument could be, of course, that they’re driving out / discouraging from entering in the first place the high-quality doctors. This is not too implausible, but from what you say the quality seems not to differ that much.

        In other words, the very fact that people are still competing to become doctors under the current regime seems to show that salaries / conditions are not too low—and that if competition were really opened up, they might be lower still.

        • Scott Alexander says:

          I’m confused. There will always be Ethiopians willing to work for pennies (assuming no minimum wage). Unless you have imported all the Ethiopians already, why would wages ever rise above what the poorest Ethiopian (with the relevant skills) is willing to work for?

          • Jiro says:

            Because most people outside the LW-sphere don’t favor open borders, and not enough Ethopians would be permitted to enter the country to have a significant effect.

            (Unless the government is incompetent or is beholden to special interests who want to import them.)

          • keranih says:

            Leaving aside how we don’t have to get to the last of the poor-but-competent immigrants in order for shrinking supply to start having an effect on wages, and how population inertia is going to keep some imbalance in the supply/demand set points across a broad enough region…

            They won’t. People of equal competence willing to take lower wages will (over the long run) be hired, and those who demand higher wages will not. This is why people hate competition from immigrants, negroes, non-profits, scabs, unlicensed tradesmen, and anyone else who does not have as high of a cost as they do to provide the same labor, and will (usually effectively) lobby their government to restrict the access of the lower-cost group to the job pool. And why people intent on maximizing the use of their wealth will hire scabs, illegals, ect if possible.

            Where it gets sticky is when group substitute is not quite as good as group better, but group substitute’s demanded wages are even lower, so that even if you have to redo, say, 10% of the work due to group substitute being shoddier workmen, you’re still paying only 80% of what group better would have charged, and you still come out with more work done for the same amount of money.

            An additional fuzziness is in consumer preference – if the average customer has a strong preference (say, 20%) to be operated on by a non-Ethiopian (even if equally competent) then if one paid equal wages for Ethiopian labor vs native domestic MDs, one would be losing money. But if the Ethiopian worked for 75% of the native domestic wage, then you could still hire Ethiopians and make money.

            (Which means that there are times when being a racist ass is the only apparent way to stay in business and feed your kids. People are hard.)

          • Vox Imperatoris says:

            @ Scott Alexander:

            The point is that the Ethiopians can be much more productive in a capital-intensive country with greater economic freedom. One major way they can be more productive is that they’re physically present to perform services for the richer American population that won’t be performed if they have to be done at wages Americans are willing to accept. Such as becoming maids, nannies, and chauffeurs.

            So when you bring in Ethiopians, you’re not splitting the same amount of wealth among more people. You’re increasing the amount of wealth.

            The nominal wages of (some) Americans may go down, but their real wages also go up insofar as everything they buy becomes cheaper. The nominal wage loss is one-time per-immigrant, but the real wage gain is compounded every year as the immigrants continue producing year after year.

            As more and more workers leave Ethiopia (or wherever) to come to the United States, workers there become more scarce, causing wages to rise. Until eventually the point is reached where the wage gain from going to America isn’t worth the trouble of leaving.

            You do have arbitrage in the price of labor, with the end result that there is, more or less, a single world price of labor (relative to skill). But you’re acting like that merely means that the price will move down in developed countries until it hits Ethiopian levels. No, at the same time, in less developed countries it moves up. And since the effect of this is to more efficiently allocate labor and thereby increase production, the result is not that American and Ethiopian incomes are averaged out at some medium level, but rather that real income goes up—and continues to go up.

            As George Reisman writes:

            It is also claimed that a larger population must reduce the productivity of labor because it means a higher ratio of labor to capital goods, or, what is the same thing, less capital goods per worker. Those who advance this argument believe that population growth and increases in the supply of capital goods are independent processes. Capital accumulation, they believe, is determined simply by saving, which allegedly has no connection with the growth of population.

            The fact is that a larger number of people working and producing is itself the cause of a larger supply of capital goods. A larger number of people working and producing in conjunction even with an unchanged supply of capital goods results in an increase in total production. This no one can deny. It is only necessary to realize that what is produced in an economy is not only consumers’ goods, but also capital goods. Labor and existing capital goods are used to produce both consumers’ goods and capital goods, and, as we shall see in later chapters, they do so in accordance with the relative demands for the two types of goods.116

            The implication of this is that if there is any single, one-time increase in the number of people working and producing, it automatically tends to be followed by a growth in the supply of capital goods per worker and thus in output per worker at least back to their original levels. This is because the larger number of workers produces more capital goods with which that same larger number of workers then works in the next period, and with the aid of which it enjoys a higher productivity. The further effect is another increase in production in the following period—both of consumers’ goods and of capital goods, until the original levels of capital goods per worker and the productivity of labor are equalled and, indeed, surpassed.

            Now, if all the additional immigrants as a result of a policy of free immigration came in one single year, there would indeed probably be a significant short-term drop in American wages until it was counterbalanced by the greater production. But if, as is more likely, they come over time, then as each new wave is coming to lower the nominal wages, the ones who have already come are already acting to push up the real wages.

            ***

            Also, I should note that your opinion here is very much at odds with the opinions you’ve expressed before that a) the level of wealth, and therefore of growth, in an economy doesn’t matter because people spend the excess merely on “signalling games”, and b) wealth doesn’t make people happy, anyway.

            Of course I disagree with these bizarre opinions, but if they were true, then it wouldn’t matter if immigration brought us all down to Ethiopian standards of living. Which, I stress, I don’t think it will.

            @ Jiro:

            (Unless the government is incompetent or is beholden to special interests who want to import them.)

            Ah yes, open borders is a Koch-brothers idea…

            Thank you, Bernie.

          • onyomi says:

            Oh George Reisman, no one crushes an economic fallacy like you.

          • Jiro says:

            So when you bring in Ethiopians, you’re not splitting the same amount of wealth among more people. You’re increasing the amount of wealth.

            Why would I want to increase the amount of total wealth at the cost of decreasing it for citizens?

            I’m sure that if I gave away my computer to some third worlders, I would increase the total amount of wealth.

          • Vox Imperatoris says:

            @ Jiro:

            Why would I want to increase the amount of total wealth at the cost of decreasing it for citizens?

            I’m sure that if I gave away my computer to some third worlders, I would increase the total amount of wealth.

            Why should the poor not vote to confiscate the wealth of the rich, hang them from lampposts, and transfer that wealth to themselves? Why should white people not vote to reinstate slavery and round up black people to work for them? Why should anyone oppose the granting of special privileges of any kind?

            Because whatever they might gain in the short term, they lose in the long term as a result of decreased economic growth.

            As I said in my post, the hit people take to their incomes as a result of immigration is one-time. But the gain people receive compounds as the immigrants continue producing more than they would have otherwise.

            Von Mises on the issue of privileges:

            The unpopularity of economics is the result of its analysis of the effects of privileges. It is impossible to invalidate the economists’ demonstration that all privileges hurt the interests of the rest of the nation or at least of a great part of it, that those victimized will tolerate the existence of such privileges only if privileges are granted to them too, and that then, when everybody is privileged, nobody wins but everybody loses on account of the resulting general drop in the productivity of labor. However, the warnings of the economists are disregarded by the covetousness of people who are fully aware of their inability to succeed in a competitive market without the aid of special privileges. They are confident that they will get more valuable privileges than other groups or that they will be in a position to prevent, at least for some time, any granting of compensatory privileges to other groups. In their eyes the economist is simply a mischief-maker who wants to upset their plans.

          • Jiro says:

            Why wouldn’t the “one time” loss also compound? If someone loses a lot of money, he doesn’t suddenly stop suffering merely because he stops losing more money; the loss of money manifests as debts, a permanent decrease in his savings, permanently having less infrastructure than he would have if he hadn’t lost money, etc.

            Also, by your own reasoning, wouldn’t adding immigrant doctors cause the market to adjust by having the number of native doctors go down over the long run in the same way that the salary goes up?

          • Jaskologist says:

            I’m not convinced this loss is one-time. If my salary/hourly rate goes down, that’s a recurring hit. Maybe it’s balanced out by increased productivity, but that’s not a sure thing, especially on the individual level.

          • Vox Imperatoris says:

            @ Jiro:

            Why wouldn’t the “one time” loss also compound? If someone loses a lot of money, he doesn’t suddenly stop suffering merely because he stops losing more money; the loss of money manifests as debts, a permanent decrease in his savings, permanently having less infrastructure than he would have if he hadn’t lost money, etc.

            All the things you point out are one-time losses…

            For instance, if I cut off your finger, that’s a one-time loss. Of course you continue not having the finger; that’s the result of its being a loss and not a loss combined with an immediate compensating gain. But it’s not the same as if I cut off a new finger every year.

            @ Jaskologist:

            I’m not convinced this loss is one-time. If my salary/hourly rate goes down, that’s a recurring hit.

            Let me rephrase things. There is a downward force on income, the result of increased competition.

            There is also an upward force on income, the result of lower prices.

            The downward force is, true, not applied one time and then instantaneously countered. That would mean it has no effect whatsoever, which is not what I’m saying. The downward force is applied one time and the effect remains constant, without increasing in magnitude.

            The upward force is applied immediately begins to raise real wages insofar as the immigrants lower the price of consumption goods. If the economy were constant and did not grow, then this upward force would also be constant and would not increase in magnitude.

            But insofar as immigrants contribute to the production of capital goods and to economic growth, their labor continues to lower prices and raise real wages. And therefore the upward force they have on wages grows larger over time.

          • Jiro says:

            The same applies to cutting off a finger. It may be true that you don’t keep losing fingers, but your past loss of a finger compounds; you will continue to have effects forever from the loss of that finger. And compounding was your whole point.

    • Spaghetti Lee says:

      The British taxpayer is also the British worker, and as Scott points out, follow this logic far enough and eventually everyone’s job is on the chopping block. What’s the point of cheap imported labor if the people it’s being imported for can’t afford to buy its products?

      From my perspective, this is what slogans like ‘An injury to one is an injury to all’ cut to. I’m concerned about the working conditions in jobs I don’t have because it’s quite possible what happens to them will happen to me. Groups like doctors make an easy target because they’re assumed to be rich and privileged, so any discontent on their part must be groundless complaining.

      • Joe W. says:

        What’s the point of cheap imported labor if the people it’s being imported for can’t afford to buy its products?

        The imported labor buys the products.

        • Hlynkacg says:

          The government has seen fit to dissolve the people and elect another. 😛

        • John Schilling says:

          Wouldn’t it be easier to move the existing British government (including NHS management) to e.g. Pakistan, than to move the entire population of Pakistan to the UK to take over all the British producer/consumer roles?

          This might have the advantage of improving health care, quality of living, and standard of governance in both countries.

          • JBeshir says:

            Britain has tried policies a little like this in the past and they didn’t turn out to be very popular.

          • John Schilling says:

            More or less popular than keeping the government and NHS management at home in Britain?

          • Randy M says:

            The reverse are tending likewise to be unpopular, but fortunately new strides are being made in hate speech policing.

          • Vox Imperatoris says:

            Founder Effects.

            I would very much be in favor of re-colonizing Pakistan and imposing liberal capitalism if I thought it would work. But unfortunately, it’s quite difficult to systematically change an already-existing polity. And that’s even when the people performing the change have good intentions, which colonizers historically didn’t.

            So, as a second-best option, I support allowing all Pakistanis who desire to, to immigrate to places where the institutions of liberal capitalism already exist in more or less imperfect form. Institutions which the Pakistanis are unlikely to destroy for the same reason that Americans didn’t find it so easy to establish liberal capitalism in Iraq and Afghanistan.

            Unfortunately, it seems that many people subscribe to the theory upon which it is impossible for Westerners to change the institutions of non-Westerners, but perilously easy for non-Westerners to do the reverse.

            This is beside the point that the more obvious fallacy you and hlynkacg are committing here is characterizing the situation as the Pakistani population “replacing” the English population, as opposed to adding to it.

          • Randy M says:

            Question to Vox: Do you think British culture of 2016 is more or less accommodating to foreign views and requests than Iraqi, Afghani, or Pakistani culture?
            Follow up question: Which culture do you think has more need of change?

          • hlynkacg says:

            @Vox

            You’re ignoring the fact that Westerners can’t change the institutions of non-Westerners without being condemned as horrifically racist and literally worse than Hitler.

            Face it, you can have tolerance and multi-culturalism, and you can have liberal immigration policies, but you can’t have both.

          • Jaskologist says:

            @Vox

            Unfortunately, it seems that many people subscribe to the theory upon which it is impossible for Westerners to change the institutions of non-Westerners, but perilously easy for non-Westerners to do the reverse.

            Depends on why you think it is hard for us to change their institutions, doesn’t it? If it’s simply that institutions in general are deeply rooted, then yes, the difficulty should run both ways.

            But what if our best institutions rely on getting into a Cooperate-Cooperate equilibrium? Then these would in fact be very hard to export, but pretty easy to break.

          • Vox Imperatoris says:

            @ Randy M:

            Question to Vox: Do you think British culture of 2016 is more or less accommodating to foreign views and requests than Iraqi, Afghani, or Pakistani culture?
            Follow up question: Which culture do you think has more need of change?

            Of course I say that it is British culture that is less in need of change and Iraqi, Afghani, and Pakistani culture that is more in need of change.

            Now, “accommodating to foreign views and requests” is a nebulous concept—but in fact Middle Eastern cultures are gradually becoming more Westernized, to a far greater extent than Western cultures are becoming Islamicized. The strength of the reactionary elements like ISIS comes precisely in reaction to the fact that they can see their people are being influenced to a greater and greater extent by Western ideas.

            I think this process—especially within Western countries—is retarded by multiculuralists who insist that any one culture is just as good as another. But it still happens. And the worst of the effect is to slow down the adoption of Western norms among the immigrants. The immigrants aren’t making the broader culture more Islamic.

            @ hlynkacg:

            You’re ignoring the fact that Westerners can’t change the institutions of non-Westerners without being condemned as horrifically racist and literally worse than Hitler.

            Face it, you can have tolerance and multi-culturalism, and you can have liberal immigration policies, but you can’t have both.

            Tolerance and multiculturalism are not the same thing. Tolerance means refraining from violence and hatred directed toward people of a certain culture. It doesn’t mean that you think it’s just as good as your own.

            The problem with the anti-immigrant right who claim to be the defenders of Western culture is that, well, they don’t seem to really like any of the distinctive features of it:

            4) Tribalism is not ‘pro-Western.’
            The big fig leaf of the alt-right is that they want to protect Western Civilization—by throwing out its distinctive ideas and achievements.

            The central theme of the Western intellectual tradition is about rising above tribalism to arrive at universal values. That’s a common theme that connects both secular and Christian traditions in the West. It was the whole distinctive idea behind the Ancient Greek revolution in thought. Philosophers like Socrates launched the Western tradition by asking probing questions that were meant to sort out which ideas and practices are based merely on historical accident and social convention, versus those that are based on universal laws of human nature.

            Tribalism, by contrast, is the default state of every culture and can be found among every people in every corner of the world. There is nothing distinctively Western about it, and it runs against the whole grain of the Western intellectual tradition.

            So by reverting to tribalism, the alt-right is saying that they had to destroy Western Civilization in order to save it.

            They’ve simply adopted the left’s caricature of the right:

            5) The alt-right are dancing to the left’s tune.
            The alt-right originated by looking at the left’s caricature of the right as racists and pro-white tribalists and saying, in effect: sure, we’ll be that.

            For example, a recent apologia for the alt-right makes a big deal of quoting liberal social psychologist Jonathan Haidt’s condescending description of Republican voters as authoritarians motivated by “in-group loyalty,” who are therefore suspicious of the people in other groups. This is an old smear. Democrats desperately need Republicans to be small-minded racists, because that’s how the party of slavery and segregation has managed to slough off its own disreputable history and push the stigma of it onto their political opponents.

            The alt-right is enabling this fraud. They accept the left’s intellectual framework and eagerly take on the role of the villain that the left assigned to us. Then they have the effrontery to present themselves as big rebels against the left. What a joke.

            You could argue that the alt-right is a consequence of the left’s abuse of the stigma against racism. By reflexively denouncing as a racist everyone who disagrees with them about economics, and by making every detail of ordinary life into a minefield of hidden racial transgressions, they have burned up their own credibility. In the process, they have weakened the culture’s immune system against racism and made it possible for a young cohort of racists to repackage their odious creed as resistance to political correctness.

            As tempting as it is to point this out, we still have to take responsibility for dealing with the problem. If the left has destroyed the credibility of its own resistance to racism, then it is up to us to take up the slack and do the job right. It’s up to the right to take the lead in fighting the ancient scourge of tribal hatred and to diligently purge these new racists who are trying to attach themselves to our movement.

            The alt-right isn’t part of the intellectual traditions of the American right, nor is it an alternative to anything. It’s just the same old white-sheet set, repackaged with red “Make America Great Again” golf caps. They’re serving as ignorant tools of the left, and they should be exposed as such.

          • Randy M says:

            The strength of the reactionary elements like ISIS comes precisely in reaction to the fact that they can see their people are being influenced to a greater and greater extent by Western ideas.

            This is wrong. Strength doesn’t come from lessening of influence. Maybe you mean desperation or appeal?
            Your broader point might make sense only if you define the time frame carefully and include basically any change as being westernized. Iran, Afghanistan, Turkey, Lebanon, compared to early last century or so are more heavily Islamic, are they not?

            The immigrants aren’t making the broader culture more Islamic.

            I think this is false on several levels.
            British converts to Islam, for one.
            Protesting against freedom of speech, anti-blasphemy, etc. of ways other religions aren’t. (These aren’t simply demands to be able to police their own, but rather others.)
            Simply ceding territory culturally. Not an example, perhaps, of British culture affected by Islamic, but simply withdrawing and being replaced by it is little improvement.

            Also, going back to your earlier point,

            Institutions which the Pakistanis are unlikely to destroy for the same reason that Americans didn’t find it so easy to establish liberal capitalism in Iraq and Afghanistan.

            -Institutions are easier to destroy than create.

            -The methods are entirely different. Colonists moving in permanently, demanding accommodations of an overly hospitable host culture will accomplish different results than occupying a large hostile territory with a comparatively small army and hoping they secretly wanted to be like us all along.

          • Brian Donohue says:

            @Vox,

            very good comment.

          • Vox Imperatoris says:

            @ Randy M:

            This is wrong. Strength doesn’t come from lessening of influence. Maybe you mean desperation or appeal?
            Your broader point might make sense only if you define the time frame carefully and include basically any change as being westernized. Iran, Afghanistan, Turkey, Lebanon, compared to early last century or so are more heavily Islamic, are they not?

            My point is that the strength of those radical groups grows in proportion as people feel threatened. For instance, in the American South, you saw the slaveholding “firebreathers” grow more radical as they perceived the growth and expansion of slavery to be threatened. If the future of slavery had been totally secure, there would have been no need to speak loudly in favor of it or to fight for it.

            In the examples you give, I would say that the elites are (in some cases) more Islamist, but the people are significantly less. In a way, of course, it’s been the influence of Western democratic ideology that’s resulted in the elites more resembling the people. In this case, a negative aspect of Westernization…

            That’s beside the fact that the upsurge in Islamist reaction has been due in large part to the failure of Western-influenced socialism and nationalism. I think the socialists and nationalists certainly bear great blame for exporting that to them in the first place.

            The message that ought to be exported is consistent support of liberal capitalism—which is exactly the opposite message that the reactionary right is exporting. Those supporting tribalism at home have no moral high ground over people supporting tribalism abroad.

            I think this is false on several levels.
            British converts to Islam, for one.
            Protesting against freedom of speech, anti-blasphemy, etc. of ways other religions aren’t. (These aren’t simply demands to be able to police their own, but rather others.)
            Simply ceding territory culturally. Not an example, perhaps, of British culture affected by Islamic, but simply withdrawing and being replaced by it is little improvement.

            I think these are negative things, but the problem is that the anti-immigrant right blows them completely out of proportion and, on that basis, advocates measures that would be justified on their hysterical view of the facts but which are not justified on the basis of the facts in reality.

            British converts to Islam: not only are the numbers completely insignificant; not only are they converting to a very moderate and Westernized version of Islam that’s not any worse than Christianity; but conversions to Islam are greatly outnumbered by conversion from Islam to secular ideas.

            Protests against freedom of speech: yes, I agree that these are very bad. But the question was whether they are converting the broader culture to Islamist ideas. They are not. The left sympathizes (to the extent that they do inappropriately) with such protests not on the basis of agreeing with Islam but on the basis of relativism. There’s also the simple fact that a lot of the criticism of Islam really is motivated by racism and xenophobia; Muslims are not idiots and they can see this; and even the moderate ones resent being singled out and demonized.

            The anti-immigrant right impedes the ability to criticize Islam from a non-racist basis because they show up and confirm every stereotype the left says about opposition to Islam just being a convenient excuse to kick brown people out of your country. The left doesn’t agree with Islam, but they don’t like to denounce it too much because they see opposition to it mainly as a pretext for xenophobia. Just as they don’t approve of rape but see fear-mongering about blacks hiding in alleys waiting to snatch white women as a pretext for racism. And every alt-righter they see confirms to them that their suspicions were right all along. (Same dynamic when they see “libertarians” waving Confederate flags, by the way.)

            No-go zones: have you ever heard of “Chinatown” or “Little Italy”? Again, I’m not saying that these are good, but immigrants tend to segregate into communities—that tend to be poor and crime-ridden—reflecting the culture they came from. I think the crime could be addressed better. I think more could be done to encourage assimilation. But “Europe for the Europeans” and “identitarianism” is the exact opposite of encouraging assimilation.

            ***

            Overall, the thing I especially dislike is how weak the anti-immigrant right considers Western culture. This is perhaps connected to the fact that they don’t like it very much, considering how much time they spend complaining of its “degeneracy”

            They think it has basically negligible ability to persuade anyone else to adopt it, that the only people who would ever like it are those born into it.

            They’ve basically adopted relativism for themselves: Western culture isn’t the best because of any feature it has; it’s the best because it’s mine. Well, that’s the same logic any Islamist can use.

          • Randy M says:

            measures that would be justified on their hysterical view of the facts but which are not justified on the basis of the facts in reality.

            Can you tell me the facts at which these measures (immigration restriction, I assume?) would first become justified in your view?

            but conversions to Islam are greatly outnumbered by conversion from Islam to secular ideas.

            Numbers are meaningful, especially numbers demonstrating trends. Assertions less so.

            But the question was whether they are converting the broader culture to Islamist ideas. They are not.

            No, the question is whether they are converting the broader culture, period. A culture where multi-cultural concern for Muslim sensitivity is enforced but some love of truth and freedom simmers below the enforcement of radicals and officials is better than one converting on mass, but both are worse than what we had.

            The anti-immigrant right impedes the ability to criticize Islam from a non-racist basis because they show up

            Someone needs to.

            No-go zones: have you ever heard of “Chinatown” or “Little Italy”?

            I’ll take the Mafia over Rotherham.

            I think the crime could be addressed better. I think more could be done to encourage assimilation.

            Name three things you think are likely to both work and be enacted. Please factor in the accusations of racism you are likely to receive to suggesting change is needed.

            Overall, the thing I especially dislike is how weak the anti-immigrant right considers Western culture.

            Shrug. I dislike how weak it has become. Western culture today sees its history as shameful, its value as at most equal to any other, its people as interchangeable, its values negotiable, its borders a hindrance, its land for sale, its weapons regrettable, and its children a burden. It is unique in this unilateral cultural disarmament. I do not see us as being unable to promote our culture, I see our cultural leadership as being too ashamed of it to do so.

            They’ve basically adopted relativism for themselves: Western culture isn’t the best because of any feature it has; it’s the best because it’s mine.

            Eh, I disagree with that characterization, although perhaps the alt-right is more willing than other conservatives to say other nations are welcomed to their own culture.

          • Salem says:

            Hmmm. Let’s use the example of Iraq (that’s where my family is from) but it’s a similar narrative across the Arab world.

            There is no question that between 1914 and 1958 Iraq became much more Westernized. People consciously aped Western modes of speech and dress, Western schools and universities were set up to teach students, in English, about Western subjects, the best and brightest were sent to the West to learn, and then come back and reshape the country, the political and legal institutions of the country were reshaped to be more Western, and so on. It was the time of high modernism, and Western = modern = progress, and so on. My dad caught the tail end of that era, and by all accounts it was a great time to be alive.

            But that era ended. And it ended, in large part, because the West lost faith in itself with the crisis of modernism, and that (plus Western support of Israel) undermined the legitimacy of those governments and that way of being. So instead of a pro-Western outlook, you get Arab Nationalism, and following a distinct, non-Western trend. This moved Iraq further away from both traditionalism and the West.

            ISIS, and Islamic fundamentalism in the Arab world more generally, is a reaction to the failure of that trend. They are not like embattled fire-eaters worried that slavery will be abolished, and they are not particularly concerned about their societies becoming Westernised. If anything, their societies have become markedly less Westernised, both because of Arab nationalism, and the so-called ‘Bedouin-ification’ of Arab cities since the 1970s, a process which has been strongest in Iraq. What they are trying to do is find common ground and a narrative of resistance, in societies where the ruling regime’s legitimacy has failed, but they nevertheless cling to power.

            The most Western, and Westernizing, country in the Arab world is the UAE, and yet that’s the one where Islamic fundamentalism is weakest. The direct opposite of your thesis. It’s not because there are no devout Muslims there – it’s because the government has legitimacy. Islamic fundamentalism in the Arab world arises in failed states, where people are stuck in defect-defect, and Islam is the one thing that can help people to a co-operative equilibrium.

            In the Western world though, Vox is right. Islamic fundamentalism here is absolutely a reaction to waning cultural power and sense of loss.

          • Randy M says:

            Thanks for the perspective. I don’t quite understand the last paragraph, though:

            In the Western world though, Vox is right. Islamic fundamentalism here is absolutely a reaction to waning cultural power and sense of loss.

            You mean Islamic immigrants in the Western World have radicalized because of a sense that the islamic culture back home is less powerful than their new country? Or that attacks from Islamic countries against the west by, say, Al Queda, are due to a feeling of loss of power?

          • Salem says:

            I also worry when Vox says that the “distinctive feature” of Western culture is… non-tribalism. It’s weak tea, because it’s defining Western culture purely in negative terms. Islam, too, is non-tribal, you know. It makes it sound like the alt-rightists are right, that you really don’t see any positive features of the culture. You shouldn’t surrender so easily.

            What really is special, and worth defending, about our culture?

            1. Rule of law (see e.g. Dicey).
            2. Secure property rights (see e.g. Hayek).
            3. Bourgeois norms (see e.g. McCloskey).
            4. Nuclear families (much more specific than a vague “non-tribalism”).
            etc.

            But then you have to concede:
            1. These notions aren’t generically “Western,” they’re all English, and are much less entrenched in the West outside the Anglosphere.
            2. Even there, these concepts are under sustained attack from within.

            And this is why it’s so hard to assert any positive identity, because a good half of the West rejects their own inheritance.

          • Salem says:

            You mean Islamic immigrants in the Western World have radicalized because of a sense that the islamic culture back home is less powerful than their new country? Or that attacks from Islamic countries against the west by, say, Al Queda, are due to a feeling of loss of power?

            I mean that Muslim immigrants into the West become deeply and continually Westernised, and they often experience this as a sense of loss. They struggle to transmit their culture to the next generation, and they experience alienation both from the host culture, and from the culture in their original country (which has of course changed since they, or their family, left).

            Many react to this by seeking to rediscover “authenticity.” For example, every Muslim girl I knew went through a phase of wearing a headscarf as a teenager, many fighting against strong parental disapproval to do so. Islamic fundamentalism is a more extreme place on the spectrum, and then at the very far edge you have people going off to join ISIS.

          • Hlynkacg says:

            I had a longer post that seems to have been eaten by the auto-mod, and I don’t have time to type it all out again but here’s the general gist…

            @Salem
            Thank you for the substantive replies. *doffs hat*

            @Vox
            It should come as no surprise that I disagree on multiple fronts

            I disagree with the assertion that Wahhabism is a reaction to growing western influence. If anything the opposite seems to be true. The fundamentalists are expanding to fill the power vacuum left by western culture’s retreat. See Salem’s comments above.

            Likewise, having a “better” culture doesn’t do any one any good if you aren’t willing to promote or defend it.

            You say that the Alt-Right doesn’t seem like any of the distinctive features of western culture. My first impulse is to ask; do you? does any one on the left? I agree with Salem, your “defense” sounds a lot like surrender. What you call “tolerance” has metastasized into the “unilateral cultural disarmament” Randy described above.

            The mainstream right has been arguing that things like political correctness, social justice, and anti-nationalism erode social cohesion and exacerbate rather than discourage racism/intolerance for years.

            The alt-right, with their “dank memes”, is what happens when those arguments are dismissed out of hand and white kids realize that they can play the identity politics game too.

          • “I disagree with the assertion that Wahhabism is a reaction to growing western influence.”

            At a slight tangent … . Islamic history shows multiple cases of fundamentalist revivals, successful for at least a few generations. The Almoravids and the Almohads would be examples from long before western influence was an issue.

          • NN says:

            At a slight tangent … . Islamic history shows multiple cases of fundamentalist revivals, successful for at least a few generations. The Almoravids and the Almohads would be examples from long before western influence was an issue.

            Also the Wahhabis themselves. I’m fairly certain that the level of Western influence in Ottoman Arabia during the 18th century was minimal to non-existent.

            “but conversions to Islam are greatly outnumbered by conversion from Islam to secular ideas.”

            Numbers are meaningful, especially numbers demonstrating trends. Assertions less so.

            I don’t know about Britain (though I do know that only about 2-3% of British Muslims are converts), but in France a full 20% of people with a Muslim background now identify as having no religion, whereas only about 1-2% of French Muslims are converts. The only Western country that I know of with a significant number of converts to Islam is the United States, and even there they are only just numerous enough to cancel out the number of American apostates from Islam (23% of American Muslims are converts and 23% of Americans with a Muslim background are no longer Muslim).

          • NN says:

            On the subject of Muslims in the West and Fundamentalism, I recently came across this table from a study on the origins of foreign ISIS fighters. The higher rates of joining ISIS among Western Muslims than in many majority Muslim countries can be at least partially explained by Western Muslims being more likely to have the resources to travel to Syria, but what really strikes me is how much lower the US’s rate is compared to pretty much every other Western country. I had heard that the US was doing better than Europe at integrating Muslim immigrants, but I had no idea that the difference was this stark.

            In particular, compare the US to Australia. Both countries are on the other side of the world from Syria and separated from the Middle East by vast oceans. The Muslim populations of both countries seem to be composed of a very similar mix of immigrants apart from the US’s large number of (majority black) converts. Neither country has a history of colonizing Muslim nations. Anti-Muslim sentiment appears to be significantly more prevalent in America than in Australia, as far as I can tell. Yet Australian Muslims are 4.5 times as likely to join ISIS as American Muslims are.

            Seriously, what is America doing right that every other Western country is apparently doing wrong?

          • sweeneyrod says:

            @NN

            Part of it may be that the US has proportionally fewer Muslims (~1%, vs ~2% in Australia and ~5% in the UK).

          • NN says:

            @sweeneyrod:

            Canada’s population is ~3% Muslim, and its rate of ISIS fighters per 100,000 Muslims is in between Australia and the US. Denmark has proportionally fewer Muslims than the UK (3.7% compared to ~5%), yet its rate is more than twice as high.

          • sweeneyrod says:

            @NN

            Interesting. I have some ideas, but I’m going to avoid speculating further based on that table because I think there is something wrong with it. It seems unlikely that bringing a Muslim from Pakistan to Finland makes them 4000 times more likely to join ISIS (or that Finnish Muslims have 4000x greater capacity to join ISIS).

          • With the thoughts you'd be thinkin says:

            NN, the differences in muslim intergration etc. is most likely due to selection the barriers of entry to US is greater than the barriers to enter Europe from MENA and US is english so the US attracts more ambitious and educated muslims. Australia’s muslim who have joined ISIS are most likely descended from Lebanese refugees, they have significant issues like commiting higher rates of crimes.

            Vox, immigration policy in many countries is not based on skills or personality but based on family reunification. Pakistanis in many UK cities, paticularly in the north were imported from particularly rural and tribal areas in the Punjab, the mills shut down so most live on welfare. Now unlike Sikhs and Hindus from similar areas the Pakistani Muslims have continued cousin marriage to a greater extent, so they import kin they are related to from the Punjab marry, with effects to be seen in terms of disproportinate medical issues based on inbreeding.

            http://www.tino.us/2010/12/the-amazing-truth-about-pisa-scores-usa-beats-western-europe-ties-with-asia/

            http://lorenzo-thinkingoutaloud.blogspot.com/2010/06/integrating-islam.html

          • John Schilling says:

            It seems unlikely that bringing a Muslim from Pakistan to Finland makes them 4000 times more likely to join ISIS (or that Finnish Muslims have 4000x greater capacity to join ISIS).

            It seems quite plausible that Finnish Muslims have 4000x less capacity to join the Taliban. A wannabe Islamic militant in Pakistan joining ISIS, would be roughly equivalent to a wannabe soldier in the United States joining the French Foreign Legion.

            Count total militants per Muslim. And count only military-age male Muslims, which are I suspect overrepresented everywhere the Muslim population is a creation of post-2011 or even post-2001 immigration.

    • Wrong Species says:

      As far as I can tell, the main argument isn’t that doctors should have better living conditions so they can be better doctors. The argument is that these living conditions are appalling and they don’t deserve it. So yes, it’s a selfish demand but I wouldn’t say an unreasonable one. They aren’t appealing to the voter’s self interest, they’re appealing to their humanity.

  24. Decius says:

    Would it help if the people responsible for enforcing the hours limit were in an adversarial relationship with the doctors? I’ve seen cases where competing interests cause the parties to catch each other breaking the rules, resulting in better enforcement.

  25. Anonymous for good reason says:

    Having worked 80 hours in 5 days (I never did much weekend work) for weeks at a time i know how bad it is (upon today any including thoughts about suicide).

    Ultimately however neither doctors nor investment bankers nor consultants (the three occupations bitching the most about their hours) are slaves. They are free today walk out. With all the consequences that entails but free they are. That’s not totally say they can’t try fighting it but they are at least complicit in their own exploitation…

    • Jill says:

      There are certain choices that are like being between a rock and a hard place. So the “choice” is not very much of one. Yes, you may be free to abandon your chosen career that you worked your butt off for, for years. To abandon all hope of ever paying back your student loans. One usually has very little power as an individual– and more power as a group on strike.

      • Cfor good reason says:

        Student loans are much less of a topic in Europe than in the US (not altogether sure for the uk but definitely not on the continent)

  26. Spaghetti Lee says:

    The problem with ‘If you don’t like negative feature x, don’t take job y’ as an argument against worker-friendly labor law happens when you start applying it to everything. If you don’t like backbreaking hard labor, then get a degree so you don’t have to be a fieldworker or a longshoreman. If you don’t like 100-hour weeks and mountains of responsibility, you should have thought of that before you became a doctor. And if you don’t like financial insecurity and irregular paychecks, you should have known that before you went into freelancing. Etc. etc.

    • Wrong Species says:

      It’s unreasonable to ask an IQ 80 person to go be a programmer. The doctor has a wider variety of choices.

      • Feeble says:

        Surely you’re overestimating the prerequisite intelligence for being a programmer, and underestimating the intellectual capabilities of people in the 80 IQ range.

        Having a large number of choices available at the onset of one’s career does not, I think, strip one of the ability to voice complaints about your work conditions.

  27. Nacht says:

    Interesting to a complete non-medical person only versed in global manufacturing. How much of the hazing and autocracy (UK), Meritocracy with extreme waste (USA), complex efficiency (Germany), bizarre bureaucracy (France), or poor state-run but good for an extra fee (China) is attributed to culture?

  28. eqdw says:

    This is really interesting, and something I have never considered before. In all the US talk about health care policy and health care politics, now that I think about it, we never, ever, ever hear the opinions of the people who work within this system.

    Which is doubly odd in my case, b/c I am Canadian and my dad is a doctor there.

    Thanks for opening up this dimension of this discussion, Scott. I’ve a lot to ponder and read up on now

  29. Tom Hoffman says:

    I am confused by the lack of distinction between the devolved systems in England, Scotland, Wales, etc. My understanding is that Scotland’s NHS is better funded, but England’s has really been cut to the bone. Are the differences only slight?

  30. onyomi says:

    Reminds me of this, and, weirdly enough, the “regulating Uber is just one more way to prevent anybody easily getting a job without a lot of red tape” issue. Nowadays it’s actually become a kind of meme or joke, I’ve noticed, to make fun of how older people say things like “don’t have a job? Why don’t you just ask a friend if they’re hiring?” We really need to find a way to undo this.

    Obviously being a doctor requires a lot more training than being an Uber driver, yet obviously, also, there is a serious shortfall in doctor supply in the system you describe and, to a lesser extent, in the US as well. The “freshman class is told the size of the sophomore class can only be half as big” scenario is perfect, since that’s exactly what it is.

    But I think it points to a bigger systemic problem: every time you regulate and control supposedly in the interest of patient protection, etc. you put one more bottleneck on actually being able to break into that industry, which results in skyrocketing prices, miserable professionals, long wait times, etc.

    Seemingly no barrier is too high for a job like doctor where peoples’ lives are in your hands, but that’s really no more true than it being a good idea to mandate all cars be equipped with massive armor plating to reduce the risk of auto fatality.

    • Psmith says:

      Nowadays it’s actually become a kind of meme or joke, I’ve noticed, to make fun of how older people say things like “don’t have a job? Why don’t you just ask a friend if they’re hiring?”We really need to find a way to undo this.

      t e c h n o l o g i c a l u n e m p l o y m e n t

      (Maybe.).

      • onyomi says:

        I really don’t think that’s the issue. It’s not technology replacing doctors that makes the “doctor finds friend doctor job” story a joke. Part of it, of course, is the idea that one could become a doctor with so little training. That is exaggeration for humorous effect. But part of the joke is that this happens much less often even in much lower-skill professions. You can’t just jump right in and learn on the job and that’s not because of robots. It’s because of labor regulations, reporting requirements, etc.

        I recall a 24-hour convenience store/grocery in town which got in trouble for hiring illegal immigrants, paying below minimum wage, not providing state-mandated benefits, etc. Interviewed about how they felt about the cruelly unfair labor practices of their exploiters, a worker said, “well, they didn’t pay well, but they always had work. You could always make a buck there.” Of course we had to put a stop to that for the greater good and all that, you know.

  31. Glen @ APL says:

    Regardless of what you think of the intention of the strikes, it has to be said that the government have played their hand incredibly poorly.

  32. Swami says:

    The system is screwed up from the foundation up in both countries (US and UK) — though each is screwed up in its own unique way.

    From what you describe, in the UK there is a government enforced monopoly on health care. Citizens are required to use the monopoly service, or at least pay for it. Doctors are required to work for the monopoly service at terms set by bureaucrats. In addition the terms differ between senior and junior members, where the senior members have more privilege than the juniors in terms of working conditions and hours. Finally, there is a union monopoly representing all members, but rather than fighting for the elimination of the privilege of seniority, they are fighting for higher wages.

    Thus, in the UK’s situation, wages and working conditions, prices, benefits, privileges,, product features and so on are set not by constructive competition and voluntary choice but by power struggles.

    I have no opinion on taking sides other than to suggest the system is FUBAR. That is a shame. And again, it is FUBAR, but differently so in the US.

    Perhaps if we step back we can learn something here?

  33. keranih says:

    There’s a lot of anger about this, and admittedly when you’re being rushed by ambulance into the emergency department for sudden onset chest pain, “doctors are on strike today” is not something you want to hear.

    When you have a six and a ten year old and a presentation to the head of the board at 10 am, “teachers are on strike” isn’t something you want to hear, either.

    When you have orders stacking up like crazy for a new product, Christmas is five weeks away, and your warehouse is empty, “longshoremen are on strike” isn’t something you want to hear.

    When you live 45 minutes from work by train, “municipal train drivers on strike” isn’t something you want to hear.

    There is *never* a time when “garbagemen on strike” is a fun and happy experience.

    Strikes are a form of non-violent force against the population in order to get concessions for the strikers. I am not a fan.

    • Shieldfoss says:

      Far superior to the alternatives though

      EDIT – Also not against “the population,” against their employers. This might or might not be the population but its not the same.

      • keranih says:

        Also not against “the population,” against their employers.

        I disagree – in each of those, the pressure is being placed on the population, in the hopes that the population will blame the employers and not the striking employees.

        As to the alternatives…well, unions in the USA have a long rep for violence and property destruction. Is it preferable for the unions to only threaten violence, rather than use it? Or could we have an alternative where economic strikes are possible (ie, deprive the business of income by withholding labor) but social pressure ones are not (BART/garbageman strikes)

        • Shieldfoss says:

          That’s pressure on the employer.

          I, as a member of the public, do not have any right to your service as a sanitation worker. I have made no such agreement with you, I have made no such request of you and you have made no such promise to me.

          I may have the right to having my garbage trucked away. This is an agreement between me and the garbage company (or between my municipal bureaucracy and the garbage company.)

          The fact that a group of sanitation workers have all collectively decided to stay home from work does not impinge on me at all, because I expect nothing from any sanitation workers.

          The fact that the garbage company has decided to pull negotiations out for so long that they now have no way to fulfill their contractual obligations to me, that impinges on me, because I have an expectation that they will fulfill their contract.

          You appear to be doing Schödingers Ethics, where interaction with the problem causes associative guilt. Let me assure you: The last time your local garbage company couldn’t haul your garbage, I was as guilty as the sanitation workers, because I, too, did not help haul garbage. You were as guilty as the sanitation workers, because you, too, did not help haul garbage.

        • Randy M says:

          Strikes are one thing, but strikes with picket lines that customers are expected not to cross when stores stay open by using temp replacements are clearly intended to inconvenience customers as a tactic to put pressure on the owners, as in the grocery store clerk strike around here some years back.

          • Shieldfoss says:

            Oh absolutely, picket lines are pretty terrible.

          • Randy M says:

            I don’t want to imply there was actual violence or anything, but employees were there in person encouraging you to support them and go elsewhere.

          • One possible solution to the strike problem would be to make “no strike” employment contracts enforceable–impose significant penalties on employees who agree to such a contract and then violate it. Employers in vulnerable industries should be willing to pay extra for such contracts.

          • Shieldfoss says:

            One possible solution to the strike problem would be to make “no strike” employment contracts enforceable

            If a number of employees cannot collectively stay home, they can instead collectively resign. If you refuse them the right to collectively resign, they can each of them individually resign simultaneously. All the methods I can think of that prevents this are gross violations of free speech and freedom of association.

          • keranih says:

            I don’t think anyone who has posted here on this (Correct me if I’m wrong) wants people chained into contracts that they were forced into at gun point, nor would have anyone quitting a job that they didn’t feel like working at any more. I’ve specifically said otherwise.

            Declining to work for an offered wage and conditions is how the bargaining is supposed to go.

            Striking violates this principle because it is refusing to work but still demanding to be employed.

          • Salem says:

            If I resign without serving my notice, the company can sue me for breach of contract. If I go around to a bunch of my co-workers (or suppliers, etc) and encourage them all to breach their contracts, the company can sue me for inducement to breach of contract. So it’s very hard for me, or anyone else, to hijack a company’s operations – any effect will have to wait for the notice periods in our contract, the break periods in suppliers’ contracts, etc, which will give the company plenty of time to find replacements. Which, of course, is exactly why those clauses are in there. Note too that if the company really can’t find alternative workers, they will have to bow to our demands

            Union legislation (at least in the UK) hijacks all that. If (and only if) you are a trade union, none of that applies. The ordinary workings of tort law were set aside for them, so a company can’t sue a trade union for inducement to breach of contract, can’t sue the workers for going on strike, and is extremely restricted in its ability to hire replacement workers. It’s literal privilege – a private law – for the trade unions.

            I am surprised that David Friedman, in particular, doesn’t just argue for making unions subject to tort law in the ordinary way. That might even please some of the left, because it would mean that laws about the closed shop (what I believe Americans call Right to Work laws) could then be abolished too.

          • baconbacon says:

            @ Shieldfoss-

            Lots of these contracts contain language about seniority and pension contributions based on service time. Collectively resignation and then rehiring could be priced in through these mechanisms. The point is not to prevent any strikes every, the point is to stop them from being asymmetrical in their pain bringing.

          • vV_Vv says:

            @David Friedman

            Employers in vulnerable industries should be willing to pay extra for such contracts.

            What would stop all employers to require all labor to be on no-strike contracts without paying any extra?

            The purpose of strikes and any form of organized workers action against employers is to balance the bargaining power between employers and workers, which is usually very lopsided in favor of the employer in one-to-one negotiations. If employers were allowed to individually negotiate with prospective employees to have the employees forfeit their rights to organized actions against employers, then employers would recover all the bargaining power that strike and trade unions were supposed to take away from them. It would completely defeat the purpose of having them in the first place.

          • Vorkon says:

            This is pretty much my position on the matter, too.

            Overall, I think Keranih’s original point goes too far: I’m no big fan of unions and strikes as they currently exist, but mostly just because the balance of power has shifted too far in their favor, and they very often represent the same sort of unhealthy monopoly they were intended to be a check against. But at their core, they are a good thing, and provide a valuable service to society.

            But picket lines? Picket lines can fuck right off.

            In the case of the garbage collector strike, for example, nobody is trying to stop me from just driving my own damn trash down to the dump, if I so choose.

          • “What would stop all employers to require all labor to be on no-strike contracts without paying any extra?”

            The same thing that stops all employers at present from paying the minimum wage to all employees.

            There’s a labor market out there, with prices determined, as on other markets, by supply and demand. If you offer less, whether in money or labor conditions, than other employers you don’t get employees.

            You seem to be imagining a hiring cartel of all employers agreeing on the terms you describe. What keeps such a cartel from driving all wages down to the minimum wage at present? Cartels work very poorly unless they either involve a very small number of actors or have government enforcement.

          • Joe W. says:

            @David Friedman

            I think the claim being made is that the question of who captures the surplus in a transaction is determined by the relative size of each party. In a market where each buyer buys from many sellers, the buyer gets most of the surplus. Similarly, in a market where each seller sells to many buyers, the surplus goes to the seller.

            The implication is that this doesn’t require a monopoly or cartel or anything similar. If there are 1000 buyers and 1000000 sellers, with each seller selling to only one buyer but each buyer buying from 1000 sellers, the claim is that the buyers get to set the price and thereby capture almost all of the surplus, due to each buyer being 1000 times as large a player as each seller.

            What exactly is the mistake (if any) in that argument?

          • John Schilling says:

            What exactly is the mistake (if any) in that argument?

            The part where the 1E3 buyers/ 1E6 sellers market implicitly breaks up into a thousand mini-markets where the thousand sellers have to buy from the one buyer.

            If there are at least a thousand buyers, there are at least a thousand options for each seller. If there are at least a thousand sellers, there are at least a thousand options for each buyer. That’s the part that matters for making it a competitive market. An imbalance may drive down the market-clearing price for one side or the other, but it doesn’t stop them from seeking that price across the whole of the market.

          • Joe W. says:

            @John Schilling

            An imbalance may drive down the market-clearing price for one side or the other, but it doesn’t stop them from seeking that price across the whole of the market.

            What do you mean by an imbalance? Okay, let’s assume that each buyer in our scenario is actually a group 1000 buyers who have formed a firm together. Further assume that doing so does nothing to increase or decrease their efficiency – so no economies of scale, no internal monitoring problems.

            Can we expect the price each firm pays in this market to be less than 1000x the price each buyer would have paid had they not formed firms but acted independently instead? Or, in other words, is ‘bargaining power’, as determined by the relative size of the buyers and sellers, actually a relevant concept in a competitive market?

          • vV_Vv says:

            @David Friedman

            In some labor markets workers have enough power to negotiate benefits (but they would still have to renounce some of their wage to get a right to strike if it wasn’t protected by the law). But in labor markets that are already at the minimum wage this doesn’t happen.

            And in fact unionization is stronger in labor markets where most workers are paid at or near the minimum wage.

            According to this site, the minimum hourly wage in the UK for somebody over 25 is £7.20.
            According to this site: a second year junior doctor makes £28,357 per year, which is £5.45 per hour assuming 100 hours per week (I don’t know if this is before or after taxes).
            So a junior doctor in the UK actually makes less than the minimum wage.

          • Joe W. says:

            @vV_Vv

            (but they would still have to renounce some of their wage to get a right to strike if it wasn’t protected by the law)

            Sure, but their wages would be higher to compensate, so they would be renouncing them back down to their current level.

          • “If there are 1000 buyers and 1000000 sellers, with each seller selling to only one buyer but each buyer buying from 1000 sellers, the claim is that the buyers get to set the price and thereby capture almost all of the surplus, due to each buyer being 1000 times as large a player as each seller.

            What exactly is the mistake (if any) in that argument?”

            That each seller has a thousand possible customers, so there is no practical way for them to coordinate to force down the price. Once you have large numbers on both sides, their relative size doesn’t matter.

            You seem to be assuming a thousand separate markets, each with one buyer and a thousand sellers. But that doesn’t correspond to the real world situation.

    • Swami says:

      Keranih,

      A voluntary strike among non monopoly (competitive industries) workers where employers have the freedom to replace workers and consumers have the freedom to substitute providers is not a form of force or coercion. The issue isn’t striking, which at its root is collective cooperative actions between employees, it is the forceable creation of the underlying monopolies (monopoly providers, monopoly unions, etc) in the first place.

      • Edward Scizorhands says:

        This. I tend to be against labor positions, but for some reason, perhaps Scott’s description of his own side, I am totally agreeing with the doctors’ side here. Possibly because they aren’t using threat of force and slashed tires to keep others from filling in for the work.

      • keranih says:

        it is the forceable creation of the underlying monopolies (monopoly providers, monopoly unions, etc) in the first place.

        I see this. Thanks for articulating it.

        @ Edward –

        The docs don’t have to resort to force, the government has already done it (ie, imprisonment for practicing medicine without a license) for them.

    • Spaghetti Lee says:

      If that’s their strategy, maybe they ought to reconsider it, because I’m hard-pressed to recall a strike where the public was on the side of the workers. The tenor of the coverage is always ‘get back to work, you bums’. The reason workers still engage in them is because they’re sometimes the only weapon available. No one in any union I’ve ever known would want to go on strike for shits and giggles, or over comparatively minor disagreements with their employer.

      • TheAncientGeek says:

        But the actually do have a lot of sympathy. Don’t genealse from US attitudes

      • vV_Vv says:

        Whether they sympathize with the workers or not, the public want to get things done.

        If the bus drivers are on strike, you may curse them and use my car or walk for that day, but you will not buy a bus ticket just to support the company.

        Strikes are not pleas for sympathy, they are shows of power.

        • TD says:

          Usually times of big public strikes are followed by a collapse of left wing support and an increase in support for the right. People support the workers when they think about poverty or not having enough money and so on, because they can relate to it, but when the services they need or enjoy start being interrupted, they might feel differently.

          In the UK, union actions in the late 70s and their fall out with Labour over pay, led to big strikes ending in the Winter of Discontent, which surely helped Thatcher gain power.

    • TheAncientGeek says:

      What’s the alternative for unhappy workers? Leave for a possibly noexisent alternative job? Why is “if you don’t like your employer, leave” so much more acceptable than “if you don’t like your country, you can always leave” ?

      • Joe W. says:

        What’s the alternative for unhappy workers? Leave for a possibly noexisent alternative job?

        Yes. Note though that the worker’s ability to do this is determined largely by how flexible the labor market is.

        Why is “if you don’t like your employer, leave” so much more acceptable than “if you don’t like your country, you can always leave” ?

        One, because there are a great many more employers than there are countries. Two, because changing employer requires far fewer other changes to your life than changing country.

        A world in which changing countries was as easy as changing employers currently is would be a libertarian’s dream – and in such a world, I predict they absolutely would say, “If you don’t like your country, then move to a different country”.

        • Can confirm. I’m a libertarian/an-cap/an-mutualist and would gladly get on board with the like it or leave it train if there were as many countries as employers, and switching was as easy as hopping companies.

          That’s the main difference for me at least, can’t speak to if other anarchists/libertarians would or wouldn’t, but ideology isn’t the motivating factor but the realistic factors. Likewise if someone is made to have as difficult a time changing jobs as the average person has changing countries, I am totally on board with calling that involuntary work that they should not feel morally compelled to cooperate with. Don’t get me started on some of the poor business practices in my city that I think are much closer to that line than I’d like.

        • Cerebral Paul Z. says:

          I’d add to this that the government’s claim to be legitimate owner of an entire country is a lot more ambitious than an employer’s claim to be legitimate owner of the cash it pays it’s workers.

        • TheAncientGeek says:

          But bear in mind that if you think it is smeones job to provide you wit suitable countries to go to, or unclaimed land to start your own, you are demanng a positive right.

          • I would carry the point a step further. If you believe it is someone’s job to make sure nobody kills you or robs you, you are claiming a positive right.

            Having a right not to be murdered means that if someone murders you he is acting wrongly, and you or others are entitled to use force to stop him from doing so. It doesn’t imply that others have an enforceable obligation to protect you.

          • Eggoeggo says:

            Does it imply a positive right that creates an obligation for someone to find and punish the guy who murdered you?
            Or does it just mean that your friends and family have the right to do that on your behalf, which they may alienate to a police and judicial system?

          • The latter.

            But it also implies that the person who murdered me acted wrongly.

            That’s taking rights as a moral category.

          • vV_Vv says:

            Isn’t this like saying that the bear that mauled you or the tree that fell over your head acted wrongly?

            What’s the point of discussing rights if they are unenforceable?

          • TheAncientGeek says:

            @David

            Then you are back on the other horn of the dilemma. The right to exit is a negative right, meaning only that no one should impede you. Which means at you can’t complain about being told to leave the US I you don’t like it…that is asmuch of a right as you can demand .

          • “Isn’t this like saying that the bear that mauled you or the tree that fell over your head acted wrongly?”

            No. Neither of those is a person.

            What do you think a moral system is, other than a set of rules about what actions by persons are wrongful, admirable, … ?

          • “The right to exit is a negative right, meaning only that no one should impede you.”

            Correct. Nobody else is obliged to provide me transport.

            “Which means at you can’t complain about being told to leave the US I you don’t like it…that is asmuch of a right as you can demand .”

            I can’t complain about being told to, but I can complain about being compelled to, or about being compelled to do other things, such as pay taxes or get drafted, if I don’t leave. Those things violate my negative rights.

    • Eggoeggo says:

      At least the gravediggers don’t go on strike in the UK any more. That got really bad. And the striking doctors aren’t actually forming picket lines to stop patients getting treatment these days, either.

  34. Jill says:

    Researchers: Medical errors now third leading cause of death in United States

    https://www.washingtonpost.com/news/to-your-health/wp/2016/05/03/researchers-medical-errors-now-third-leading-cause-of-death-in-united-states/

    I wonder if junior doctors not getting sleep has anything to do with this.

    Oh, I see, up above, Scott has found some study that says doctors lack of sleep or heavy work hours don’t matter. However, someone also commented that when hours were reduced in the study, workload was not reduced. So that’s a confounding factor there. If your hours are reduced but expectations of how much work you do are the same, then there’s no reason to expect fewer errors, as you are still not doing a reasonable amount of work in a reasonable amount of working hours. Still a crazy situation, likely to make a person prone to errors.

    • Randy M says:

      This makes me think of malpractice insurance. Do Insurers have any leverage via rate differences to get doctors to work fewer hours? Or are they convinced by those studies? I would think that they have a concrete incentive to study it in depth.

      A quick search shows that the NHS pays billions of pounds in malpractice fees. One site says 18, but it’s unclear if that is settlements or malpractice insurance costs.

      NHS employs 149,808 doctors (2015). Say it costs around 140,000 pounds for 1 doctor per year. (salary of a specialist, doubled to account for taxes, benefits, etc.) If all of the malpractice payouts went instead to hiring specialists, they could get about 128,000 doctors, assuming pounds paid in malpractice is 18 billion. An increase of 86%, which would nearly cut in half hours worked.

      But of course, the assumption that all errors are due to overworked doctors is way wrong, even disbelieving the aforementioned study results. But it looks like roughly x% decrease in malpractice payoffs could get x% more doctors, without paying them less. Is there a point where this would be feasible?
      Naturally, someone needs to come up with a system to make sure patient care is uninterrupted by shift changes. It seems like the kind of thing that they are often talking about (“computerizing medical records”), so I assume the easy answers are taken.

      • Murphy says:

        I think the NHS is large enough that malpractice insurance, unless through a subsidiary, isn’t really worth it. Insurance only makes sense when you can’t absorb the cost.

        You’d also probably want to spread that around with nurses as well as doctors.

        But yes, your central thesis that perhaps investing in extra permanent staff might actually cut costs if it reduces errors moderately I think is reasonable.

        I have strong negative feelings about some of the NHS’s “computerizing medical records”. Every trust has it’s own insane little system and suffice to say, they gave the doctors what they asked for rather than what they actually needed. There’s thousands of inept doctors who will only give up their biros when they’re pried from their cold dead hands no matter how many errors it causes in records.

        They’re “computerised” in the sense that the records are in fact technically on computers yet every other part of the workflows remain the same so instead of usable data you have terabytes of pictures of scans of photocopies of faxes of illegible handwritten scribbles.

  35. Rhand says:

    I forgot the difference between nephritic and nephrotic syndromes about 5 hours and 5 drinks after STEP-1.

    To my chagrin, it came up again for the IM Shelf.

    God I hate IM.

  36. Mariani says:

    So, Australia is clearly better at healthcare (in addition to other stuff). Do they allow more room for markets to work there?

  37. Urstoff says:

    Is there a modern rationale behind junior doctors working so many hours (mostly speaking of the US; conditions and incentives in single-payer countries are probably different)? My impression is that it’s just a historical holdover that is being reinforced by macho posturing. Is the current justification to cram three years of on the job training into one? Is it to weed out those who would actually make bad doctors, even if they were given the same amount of training across a more reasonable timespan? Is it just to save money?

    • onyomi says:

      As a junior professor, I can say that there seems to be a similar phenomenon in academia (and, if I understand, law firms, financial services industry…) where junior professionals are basically just expected to sacrifice everything for a few years as they “break into” the profession.

      Some of it is just getting used to all the new demands, but I think part of it is a sense that what they (senior professionals) have is experience; what they lack is time and energy. What you (junior professionals) have is youthful energy and (assuming you give up all your hobbies) time, and what you lack is experience. The best way to remedy this imbalance…

      And yeah, as others have mentioned, it also serves as a kind of hazing; weeding out those not fully committed and indoctrinating you into the culture.

      Apparently research shows people who were hazed value their fraternity membership more highly.

      • Jill says:

        That’s true about the Fraternity Initiation Effect. However, that doesn’t mean that hazing is a good thing, especially if it sometimes causes death or serious injury.

      • Anecdata:
        In my experience in a fraternity and running a pledge education program for a semester, the reason for that study’s higher value perception is highly, highly due to selection effects. The stronger the hazing, the more likely people who aren’t super crazy gungho drop out. Any higher loyalty/value was usually in spite of hazing, not because of it.

        Not to mention the vicious circle it creates of people only getting value out of a hazing organization because hazing is all that is in it. Hard workers and empathetic people avoid frats that haze like a plague, so if you haze, you actually scare away the best part of being in a fraternity, having a network of awesome and diverse people you can fall back on or learn from.

        • John Schilling says:

          It would seem to me that a fraternity that selects for loyalty among its members, which excludes from its ranks the insufficiently loyal, would genuinely be more valuable than one which does not. Even when assessed from a dispassionate outside view.

          • It depends, you could and many certainly do… but you tend to get a lot of useless dudes that flake out on things or are worse than dead weight.

            Surviving fraternities have/had a base-level of loyalty you needed, but no more than the typical range of loyalty-requirements for any other organization though.

            Thriving fraternities do and did so by having awesome individual members. Anything that selects for just loyalty tends to be a net-negative, even if some places survive in spite of hazing rituals.

            Grain of salt time, this is just my opinion on the matter and I fought with lots of older brothers in my tech school fraternity to get rid of the last vestiges of hazing. Maybe it was timing/general improved school freshmen, but after we got rid of those things and focused on our values (education, networking, community engagement, etc) we did much better with higher achieving people. This had a nice positive feedback loop.

          • Dice Without Rulers:

            You beat Goodhart’s Law! Congratulations!

          • @Nancy
            Time to go drink and haze some pledges to celebrate! ?

    • Adam Casey says:

      Given that a lot of the extra hours are paid as overtime it seems like this isn’t saving that much money.

      • Randy M says:

        Versus hiring more doctors to fill those positions, it probably is; or at least it would in the states due to benefits and payroll taxes. Not to mention training costs.

    • Scott Alexander says:

      I still think the idea of dualization is really relevant here.

      My father is a senior doctor and he’s very pro- long residency hours. He says that it’s impossible to train good doctors in a 40 hour week (or 50 hour week, and possibly 80 hour week). He says part of the point of residency is that you need to literally be able to perform procedures in your sleep, and then you’ll never mess them up again. There is a lot more medicine than most people expect there to be and it takes a long time to learn. Keep in mind that if residency lasts 3 years and we take the “10,000 hours to be an expert” factoid seriously, then you need to work about 60 hours/week to be an expert in your specialty by the end of residency.

      • Urstoff says:

        Is there an endless supply of potential residents?

        And what’s the downside of simply extending the residency a couple of years? In selecting for people that are willing to put up with a couple years of 80-hour weeks, are we actually selecting for better doctors? I remain dubious.

        • JuanPeron says:

          Residency inflicts substantial overhead on hospitals. You have to pay residents decently (annualized, not hourly), but you can’t let them go off and act as extra doctors – you have to pair them up with an attending physician who’s losing more time to training than the’s gaining to convenience. They’re basically a massive money sink that governments have to subsidize to keep the program going. Since you aren’t paying residents hourly, you save money by overworking them.

          As a result, you say “We can afford three years of residency per new doctor on these subsidies. It takes 10,000 hours to make you qualified. Therefore, you’re working 3,300 hours/year and wellbeing be damned.”

          As I understand it, it’s a mix of traditionalism and sheer budget practicality.

          • vV_Vv says:

            If I understand correctly, doctors in the NHS can remain “resident” or “junior” essentially for their entire career.

      • Could you make up for that in the US by not requiring a 4 year degree before starting medical school?

  38. naath says:

    Jeremy Hunt is a slime ball. He thinks people die on Saturdays because there aren’t enough doctors on Saturdays… and he solves this by making doctors work more hours, as if noone is going to die because their doctor had had no sleep in 48 hours (sleep deprivation is very effective torture…). We need MORE DOCTORS but of course, there’s no money, because plutocrats avoid paying tax.

    • Shieldfoss says:

      You don’t actually need more doctors, you just need to stop wasting their time on petty bullshit, and stop working them so hard they burn out early.

      EDIT: In particular, the problem definitely isn’t the amount of money involved – you can run a good health service on the amount of money. It is the aggravated misspending of the money on government-mandated silliness that is wholly unnecessary to the running of a good health service.

      • Jill says:

        Very true. When you set up a system, it won’t work if it’s set up in clunky ways that gum up the works and are counter-productive. But it is very hard for people to face and be aware of the incentives and power relationships involved in setting up and maintaining a system, as I’ve mentioned above.

        I think one thing in the U.S. that would help us out a lot would be to have more school teachers, accountants, engineers, scientists etc. in government positions e.g. in Congress. Nothing against lawyers, but when you have too many lawyers in government, as the U.S. does, it’s lopsided. You have everybody thinking all one way, and not even realizing how narrow that perspective is.

        • Corey says:

          That can backfire though depending on how you do it. For example, my home State of NC has a part-time legislature (they don’t meet all year), which sounds great for getting citizens involved.
          This means they make $14000 a year, though, so if, say, I was able to win a seat, wanted to, and could do a good job of it (all false in reality) I couldn’t afford to.
          Also in such legislatures, since you have turnover, the legislators get dependent on lobbyists to write legislation, which predictably causes problems.

          • Jill says:

            It seems like legislators depend on lobbyists to write legislation, even in full time legislatures. I didn’t mean that Congress should be a part time job though– maybe a 2nd career.

          • Nornagest says:

            Lobbyists don’t write legislation — that job usually goes to the legislators’ staffers. (A congressperson usually employs several full-time staffers, many if they’re important — Washington has a large office park’s worth of staff offices, and that’s just the federally run ones.) What lobbyists do is provide information — usually information slanted toward whoever’s paying them, but usually not outright fabrication, because the whole point of keeping lobbyists around is to have a credible source on their field.

          • Edward Scizorhands says:

            If you want a law changed, you often get much better results proposing the specific changeset rather than “it sucks, change it.”

          • Nornagest says:

            I’m willing to believe legislators sometimes adopt lobbyist suggestions. But “helped write this one bill, according to a Times article from 2013” doesn’t get you to a pattern of dependence.

        • “I think one thing in the U.S. that would help us out a lot would be to have more school teachers, accountants, engineers, scientists etc. in government positions e.g. in Congress.”

          Once they are in Congress, they aren’t school teachers etc. any more. You are, I think, assuming that the problem is congressmen trying to do good but not knowing how. I think the fundamental problem is that doing good isn’t what is in the interest of a congressman. Getting reelected and getting various benefits from his power are.

          Consider parts of the private market that you think work badly. Is the problem that the CEO of a firm doesn’t know how to serve the customers or that, for one reason or another, serving the customers isn’t the best way of maximizing profits and pleasing the stockholders? If your answer is the latter, apply the same approach to government.

          A good deal of the libertarian argument hinges on the idea that in both private and governmental systems individuals act to achieve their own objectives, and that individual objectives are less badly aligned with the general welfare in the private system.

          • Chalid says:

            I think the assumption is that the typical congressperson has a different definition of “good” than e.g. a schoolteacher.

          • Jill says:

            I don’t think that having a variety of people of various backgrounds in Congress would completely solve the problems. But it would make for less Group Think. Of course, individual objectives do need to be aligned with the general welfare.

            I actually don’t believe that individual objectives are necessarily less badly aligned with the general welfare in the private system than in government. Or at least they do not have to be. Our current system of government needs to be overhauled to get the Big Money out of politics. If that happened, it would be far easier to design a governmental system where individual objectives are aligned with the general welfare.

            I think a lot of things should be done by private industry. But when private industry creates a huge expensive dysfunctional mess, as it has in American health care, then giving the government a try at it seems well warranted. The big problem here is the politics is still full of Big Money. So instead of single payer, we got something less good than that, with a big component of crony capitalist welfare queens in medical insurance and the pharmaceutical industry feeding at the public trough.

            But at least we got rid of the pre-existing condition mess and got health care available to more people than before..

          • Jill says:

            Yes. Now we need 70% of them to not be lawyers.

          • HircumSaeculorum says:

            @David Freidman, Chalid, Jill

            I think that corporatism needs to be moved into the Overton Window ASAP. Not only would it increase the diversity (of viewpoints, modes of thinking, etc.) of the legislature, it would get rid of the whole issue of gerrymandering and increase the visibility of huge issues that only people in certain professions are aware of (for instance, Scott’s complaints about the FDA; I’m generally in favor of health and safety regulations, but these sorts of unhelpful rules need to be eliminated). It might also increase confidence in democracy and democratic institutions by making them look a little more representative of the actual diversity of the nation. Lawyers are pretty similar (I imagine; correct me if I’m wrong) across the geographic expanse of the nation, but they’re pretty dissimilar vis a vis a schoolteacher from the geographic constituency they represent.

            I’m not saying its a panacea, but it should at least be talked about.

  39. Alsadius says:

    Medical residency has always sounded like a hazing system to me. It’s ostensibly there to toughen people up, but mostly it’s there because all the people who finished it are in charge now, and they look back on it with vague nostalgia. That said, the fact that doctors consider health ministers to be evil surprises me not at all – everyone thinks their boss is evil, especially when the boss in question is a distant, faceless bureaucracy(which are all pretty inherently stupid and evil to begin with).

    Would not the natural solution to paying doctors a ton of money and treating them like crap be to pay them less and treat them better?

    • Salem says:

      But doctors, and especially junior doctors, aren’t paid a ton of money in the UK. Considering their level of education, they are paid very little. See here for a general idea of the pay, or here for something slightly out of date but possibly more informative.

    • Shieldfoss says:

      Would not the natural solution to paying doctors a ton of money and treating them like crap be to pay them less and treat them better?

      You’d think so but no.

      “Treat them better” means “work them less individually.”
      “Work them less individually” means “hire more individuals to maintain the amount of work being done.”
      “Hire more individuals” means “pay them more.” (This line is false in an interesting fashion)

      If you need the same work done in less time, you need more people. That should be completely obvious. If you lower the pay, you’ll get fewer people. That part should also be obvious.

      And yet you’re completely right, but your focus is in the wrong place. You can hire more people for less pay – if they’re less qualified. This is the correct decision. Since I love to harp on the Danish GP, I will do it some more. The archetypical GP’s Clinic has one GP and one secretary plus contracted cleaning services (There is not enough that needs cleaning to hire full-time cleaning staff) and one part-time nurse. In the most well-run GP’s Clinic I am familiar with, five GPs have [old data now] a service staff of: Three secretaries, six or seven nurses, three or four lab assistants and I believe four full-time cleaning staff. Due to various efficiencies they have found, the Clinic can handle a volume of patients as if each of those various staff members counted as 3/4th of a doctor each – because 3/4ths of what a GP does actually does not need you to be a trained GP but can be handed off to others.

      There are so many things that you really shouldn’t use doctors for – or nurses for that matter – wastes of the precious resource that is their time. Every minute a doctor wastes is a minute more the doctor must be at work to do doctorial duties. I’ll quote The Do-Operator from upthread:

      Junior doctors in Ireland (and presumably the UK) spend most of their time doing routine jobs that are handled by nurses or phlebotomists in almost every other civilized country. This includes recording ECGs, inserting venous lines, taking arterial blood gas samples and giving the first injection of any newly prescribed intravenous antibiotic. They also have to do a lot of stuff that should be handled by non-medical staff, such as tracking down old X-rays or old handwritten patient records. (It is possible that they have since moved into the 21st century and digitalized this, but if so this happened during the last 4-5 years).

      I’ll interpret “most of their time” as if it means “at least half”

      Hire non-doctors to do this work and you can cut doctor shift length in half.

      I suspect a lot of the problem is status games. A Junior Doctor is not yet high enough in the game to have a personal secretary, no matter how much of an economic benefit this would be in the “tracking down old X-rays” department. You get some of the same nonsense in software development and engineering – I have yet to work for any company, neither when Salaried nor as a Consultant, where my work efficiency could not have been well increased with a part-time secretary – or possibly better, a single full-time secretary for each four developers/engineers. But secretaries are status symbols for management, so none of that.

      I recall especially an office I worked in once as a consultant. The manager had twenty employees under him, all engineers, and zero secretaries (because this department was not so important.) It was the number one improvement I suggested to him, but he couldn’t get away with it. Spend two hours of a senior engineers time to courier a folder to elsewhere? Absolutely – the folder has to get there and engineers are all we have. Secretary? Not on your life.

      And this brings me back to the Five-man GP team. No paperwork above, nobody else responsible for their decisions

      Non est salvatori salvator,
      neque defensori dominus,
      nec pater nec mater,
      nihil supernum.

      They’ve hired the appropriate number of secretaries. And nurses. And lab assistants. And they are, the five of them, making more money than God but they have, by God, earned it.

      • Jill says:

        Thanks for this, and for your other informative comments on this issue today.

        Status and power games often rule the world, in wasteful ways. They need to be rooted out and let go of, in order for human systems to be productive rather than wasteful.

        • “They need to be rooted out and let go of, in order for human systems to be productive rather than wasteful.”

          What would you use as a non-status-driven method for rooting out status games?

          • Jill says:

            That’s a big question there, that will require some thought. It may be another day before I come up with much.

            But, like Socrates, I believe that observing situations and the problems inherent in them, and asking questions, can be useful, even if I don’t immediately have the answer.

            It occurs to me that the very first step, which is almost never done in the mostly power blind U.S., is to simply observe and point out the status and power games and “gaming the system” that are occurring. Just pointing those out to one another is a LOT more than is usually done in the U.S. Heck, even seeing them is a LOT more than is usually done in the U.S., due to our cultural power blindness.

            Sometimes thorough and clear observation of a problem reveals the solution automatically. Sort of like a Sherlock Holmes strategy.

            With regard to human systems, you see what the incentives are, and then you figure out how to change them so that individuals in the system are motivated to do things that are in alignment with the beneficial purposes of the system.

            E.g. you figure out a campaign finance reform system where Citizens United is repealed by a Constitutional amendment. And perhaps you limit election campaign duration, and the amount each individual can contribute to a candidate, and have it be a matter of public record how much was contributed by whom– not a secret. Things like that.

            Transparency can solve a multitude of problems. There are a lot of things that people will do in secret, that they would not do if everyone could see what they were doing.

          • John Schilling says:

            It occurs to me that the very first step, which is almost never done in the mostly power blind U.S., is to simply observe and point out the status and power games and “gaming the system” that are occurring. Just pointing those out to one another is a LOT more than is usually done in the U.S.

            It’s done quite often, as a matter of fact, but it is usually done poorly.

            One of the perks of real status or power is that it makes people reluctant to call out the powerful out on their misdeeds or even their privileges, out of a combination of fear and respect. But throwing accusations against people of modest status or power is safe and fun even if the accusations are false.

            As is speaking truth to some safely-distant power, but if the power is too culturally distant to retaliate or command respect, it is probably too distant to be much affected by the truth.

          • CatCube says:

            @Jill,

            Allowing that this is just my personal observations, but we don’t seem to be notably worse in the US than in other countries. People not calling out the powerful is a problem everywhere.

          • keranih says:

            but we don’t seem to be notably worse in the US than in other countries. People not calling out the powerful is a problem everywhere.

            I’d suggest that a representative from a minor province calling out the chief executive as a liar during a major televised speech is exactly an example of “calling out the powerful”.

            But I don’t expect everyone to agree.

      • Anonymous says:

        You can hire more people for less pay – if they’re less qualified.

        Or if you make the job more attractive, for example by reducing the hours demanded.

        • Shieldfoss says:

          Not fast – there’s no real competitor with a large pool of qualified junior doctors you can headhunt from (barring Scott’s previosly mentioned immigrants) so you’re going to need to cut hours, then keep them cut for five-six years, while retaining your grip on government in the face of voters who suddenly cannot see a doctor.

      • I remember a complaint online from an American interns’s wife that a good bit of his very long shifts was spent on paperwork because it was cheaper for the hospital to overwork interns than to hire secretarial staff.

        It occurs to me now that paperwork errors can be deadly.

  40. Phil says:

    Could any of this be solved by making it not so hard to get into Medical School?

    Last time I looked through the acceptance stats it looked like even low ranked Medical Schools are harder to get into than some of the top ranked Law Schools.

    I get that no one wants unqualified doctors running around, but judging from the people I know who’ve washed out of weeder courses for med school, seems like we could greatly expand the pool of people who get to say they’re doctors, and still only have really smart people in the pool

    Personally, I’d rather be treated by a marginally less qualified Dr not exhausted from working 100 hours

    ————————

    unrelated (or maybe only tangentially related) – how does the quality of medical school applicants now compare to the quality from the 60s or 70s?

    I’m more familiar with law school acceptances, but the spots at top law schools have mostly remained constant, while the quality of the pool has gone way up

    most of the people who got into top law school in the 60s and 70s, wouldn’t get in there based on their qualifications now

    I wonder if a similar thing is going on medical school admissions

    • sweeneyrod says:

      In the UK, the limiting factor for doctors is the number of clinical placements. Entry requirements aren’t too high in my opinion — about 10% if people studying pre-university qualifications (A-levels) achieve the grades required to study medicine.

    • AlphaGamma says:

      Note also that “medical school” means very different things in the UK and the US. In the UK, most people who want to be doctors apply to study medicine at university when they finish high school. They then spend five or six years only studying medicine (plus other subjects like anatomy, pharmacology and biochemistry to the extent that they are needed for medicine) and then graduate as doctors- though most British medical doctors only have the title of Dr. by courtesy, the degree which licenses you to practise medicine in this country is technically a Bachelor’s.

      (Essentially all British university courses are specialised in this way, not just vocational ones. Courses other than medicine are usually shorter- the standard for a Bachelor’s is 3 years. Some medical students are given a “pre-clinical” BA or BSc halfway through their course as well as the MBBS that makes them a doctor.)

  41. Murphy says:

    There are private hospitals in the UK.

    They often pay better, have higher staffing though don’t tend to invest nearly as much into training their staff as the NHS does.

    They tend to attract staff out of the NHS but career progression within the private hospitals tends to be sluggish (after all, they can recruit senior people who’ve had lots of expensive training in the NHS)

    I could go get health insurance tomorrow and it would even be crazy cheap by american standards and thus go to one of those private hospitals where they have twice as many staff per patient if I get sick. Though if I get anything really weird or expensive to treat that will still ultimately fall back on the NHS. (hence why the insurance is so cheap)

    I do in fact go private for my dental care (again, pretty cheap, I pay about 150 per year to cover normal stuff) though if I fell on hard times I could still stick with the same dentist and get covered by the NHS, I’d just have to wait slightly longer and probably get slightly cheaper fillings.

    From the service users point of view the NHS works pretty well, they have internal markets with the trusts bidding against each other to provide services to councils who buy services for their region which apparently works pretty well.

    That being said, I’m very aware of how junior doctors are treated. The minister gets the backlash but a lot of the crap junior doctors endure is freely inflicted upon them by senior doctors who control a lot of how the hierarchy works. They take the view that they had to endure abusive conditions and so they don’t have any problem inflicting those conditions on their juniors. (senior doctors were surprisingly quiet about the junior doctors strike for a long time)

    I think there’s a large element of false economy:

    junior staff like junior doctors and nurses suffer abusive conditions so they are likely to leave quickly. It costs a crazy amount to train doctors and nurses and that money is effectively lost in an attempt to save money. If doctors worked 40 hour weeks you can bet there would be far more who would be content with lower salaries long term but they either have to climb up or leave taking their hundreds of thousands of pounds worth of training with them or else get abused forever.

    The average turnover of nurses in the NHS is between 3 and 5 years. a few stay for decades but most do not. If you look at a graduating class of nurses on average they’ll work less than 5 years on wards. It costs a staggering amount to train them to the point where they can run a ward and that money is lost in an attempt to cut costs by understaffing wards.

    My SO is a nurse and 11 months after graduating she’s been in the situation where she’s been the only permanent members of staff on her ward, then found she’s the only permanent nurse currently present in her chain of command (there’s supposed to be someone coordinating staffing and senior nurses you can call in case of emergency) and had to organize agency staffing for ~ a dozen wards which really really isn’t something which is supposed to fall to a nurse less than a year out of university. (oh and the on-call doctor was also agency and had no idea what was going on)

    In that trust she was working 5-8 hours beyond her shift end most days and she stopped taking holidays because every time she did someone died. That was a really bad Trust.

    Those kinds of conditions burn people out. One of my friends from uni (who may have been a year or so behind Scott in the same place) qualified as a doctor but had a mental breakdown and eventually quit entirely after realizing one night that 25+ hours into a shift she was equivalent to drunk due to exhaustion while having to make medical decisions that could kill people.

    Both myself and my SO think that the nursing unions should be striking too. It’s tough to run things for a day or so without doctors but when nurses strike … well there’s an example of when the canadian nurses union went on strike. 7 minutes. The nurses went on total strike for 7 minutes before the state went to the bargaining table.

    Nursing unions are far too submissive most of the time.

  42. Jack V says:

    I don’t have a lot of first hand knowledge, but I live in the UK and my partner works in a UK medical school (as a biologist, not a doctor).

    I automatically believed the doctors even before I looked into it very much. Doctors (at least to start with) hate the idea of striking, if they even considered it, I assumed they were really serious (see also british barristers).

    AFAIK the “government screwed up the statistics because they’re idiots and don’t listen to professionals” is basically correct.

    I also have heard — enough I take it quite seriously — the current government has taken against the NHS, either because they want to cut money (even if it costs more indirectly) or because they ideologically believe a partially or completely privatised health service would be better, so are starving it of funds. Again, I trust the doctors.

    My impression of labour disputes is that if the union (or lack of union) is too weak, the company eventually ends up taking advantage of everyone, and if its too strong, it’s easy for it to itself become ossified and grind things to a halt. And ideally (as with any contractual relationship) you have a relationship between company and workers where both need each other and negotiate a “fair” contract, but both have a nuclear option (laying everyone off vs going on strike) that it’s best if we never resort to, but being there keeps the other party honest (most of the time). It doesn’t always work out like that.

    • “AFAIK the “government screwed up the statistics because they’re idiots and don’t listen to professionals” is basically correct.”

      I know nothing about this particular case, but why do you prefer that interpretation to “because doing the statistics wrong gave them the result they wanted”?

      A very long time ago I spent a summer in Washington as a congressional intern. I was working on one project one day a week for my congressman, on another four days a week for a group of academics producing a fact book on state and local financce. In both cases it was clear that the material I was looking at, produced in one case by the agriculture department and in the other case by a group of academics working for various governmental customers, reflected deliberate dishonesty, not stupidity.

      Details on one of the two cases here, on the other available if people are sufficiently curious.

      • Jill says:

        I like transparency in general. There is a problem in democracy though, in that you don’t get elected if you don’t give people what they want. There are plenty of politicians who have lost elections because they told the truth. And the people elected a liar instead. Most voters are not at all fond of the truth.

        So, if you live in a democracy, you are going to be having politicians who lie. There are people running for office who don’t lie, but they usually don’t get elected. Does anyone see a way to change this?

        • Anonymous says:

          You get rid of elections and set up a government that has incentives to provide good government.

        • Squirrel of Doom says:

          To me, this is a good argument for getting as much of society as possibly out of this deeply flawed system. That is, I see it as an argument for libertarianism.

        • Skivverus says:

          Truth and plausibility have never been perfectly correlated variables, and the resulting danger shows up in every form of governance. For example, in your second sentence, substitute “democracy” with “dictatorship”, “get elected” with “stay out of prison”, and “people” with “the current dictator”; I submit that the resulting sentence is approximately as true (and as plausible).
          Possible solutions to close the gap show up here, especially #7 on that list. Truth in a foreign vocabulary sounds much less plausible than truth in your own.

          • “Truth and plausibility have never been perfectly correlated variables”

            True. And the more my welfare depends on the truth of what I believe, the stronger my incentive to try to distinguish them. In the context of voting, my welfare does not depend on the truth of my beliefs. In the context of market choice it does.

          • Skivverus says:

            @David Friedman

            “[T]he more my welfare depends on the truth of what I believe, the stronger my incentive to try to distinguish them.”

            A very good point, and one I generally agree with.
            I disagree (or perhaps differ on emphasis) that voting and personal/societal welfare are entirely unlinked – highly blurred due to causal distance and other actors, certainly, but it’s not that there’s no link.
            Also, there’s approval voting, which doesn’t really work with physical goods (and thus money) as well, but allows a voter to say “I think these candidates/policies are acceptable” instead of just “I think this candidate/policy is the best”. StackExchange does seem to work.

          • “I disagree (or perhaps differ on emphasis) that voting and personal/societal welfare are entirely unlinked – highly blurred due to causal distance and other actors, certainly, but it’s not that there’s no link.”

            I live in a country with a population of three hundred million–I don’t know about you. The chance that my vote will alter the outcome of a presidential election is well under one in a million. That’s “no link” to social welfare for all practical purposes.

            There is a link to personal welfare. If I support the candidate and policies that the people around me approve of they will think better of me, which is to my benefit. But that link doesn’t depend on whether that candidate and those policies are actually better but on whether other people think they are, so it’s a link to plausibility not truth, so has the opposite of the desired effect.

            There is a reason that most public discussion of trade issues is put in terms of an economic theory that is at least two hundred years out of date–but easier to understand than the correct theory.

          • Skivverus says:

            @David Friedman

            Last I checked there were more things to vote on in America than “president”; I do take your point about plausibility being the more salient, and that is a problem. In theory, that’s what secret ballots are supposed to prevent; in practice, well…

          • @Skiverrus:

            There are more things to vote for than President, but one chance in ten thousand is still pretty close to zero.

            We have a secret ballot, but most of us are not very good liars, so are not likely to tell all our Democratic friends that obviously the Democratic candidate is the good guy and the Republican a villain, then go vote for the Republican.

  43. Shieldfoss says:

    A Method For Generating Good Outcomes through Correct Incentives in the Medical System

    One of the worlds absolutely best run medical services is the General Practitioner’s private clinic in Denmark. I don’t have my cites nearby but it receives top marks in both level of service (including quality of medical care) and in efficiency (That is, level of service for the amount of money paid in.)

    The cause of these top marks is that the Danish GP has a very good incentive structure. The details are not simple, but I will present a simplified explanation that should serve to illuminate quite well. Expect every single paragraph to contain at least one lie. Some paragraphs will be wholly false.

    This post is specific to the GP’s private clinic. I will not cover specialist practitioners (e.g. dentists) who are run on a different scheme. Nor is it a claim that the GP’s private clinic is magically amazing – there are still problems, particularly in low-density rural areas and in inter-clinic coorporation.

    I will cover the background facts, the incentive structure and then some of the positive and negative knock-on effects this incentive structure has. I will briefly compare and contrast with state-owned hospitals, which are staffed by equally skilled doctors, trained in the same medical schools, and yet receive lower marks in both service and efficiency due to different incentives.

    Background facts.
    *The GP’s Private Clinic is just that: Private. It is not the state but the GP who owns, or co-owns with other GPs, their own clinic. As a result, a GP is not salaried but paid from the surplus their clinic generates.
    *A citizen of Denmark has a right to some levels of free medical care. Additional levels of care can have some degree of subsidization. Further care can be purchased out of pocket or with private insurance.
    *For all non-emergency medical care and for some emergency medical care, your GP is your first point-of-contact with the medical system.

    Incentive to Keep the Service Level High
    The naive way for the government to grant free medical care at private clinics is to reimburse any receipt for a covered consultation. This is actually a terrible solution.

    Instead, the government has created two schemes for covering medical care, Medical Insurance Groups 1 and 2. You, as a covered citizen, freely decide between groups 1 and 2 (There is paperwork involved. The vast majority of people are in Group 1, literally everybody I know is in Group 1.)

    Reading my description of Group 1, you will notice it has some superficial similarities to a Taxicab Medallion Scheme. Taxicab Medallions are known to be terrible. Group 1 is not terrible. The reason is Group 2. Group 2 is the kind of magical edge-case solution you’d never have expected state bureaucrats to have invented. Until I get to the explanation of Group 2, Group 1 will look like it has all the same terrible incentives as Taxicab Medallions.

    Group 1 rests on a piece of private property called a Provider Number. Provider Numbers trade at hundreds of thousands of dollars. This is because any GP who wants to get paid to service Group 1 patients (Again: Group 1 is almost, but not entirely, the whole population of the country) needs a Provider Number. The state does not pay any GP. The state does not pay any clinic. The state pays a Provider Number. A GP does not provide medical services. A Clinic does not provide medical services. A Provider Number provides medical services. Typically, the ownership goes like so: A GP or group of GPs own a Clinic, and the Clinic has a Provider Number.

    Every citizen in Group 1 is assigned to a Provider Number. For each assignee, that number receives an annual payment Basis Fee. If an assignee needs a consultation, the Provider Number gets an additional Consultation Fee. You can do some fairly simple statistical math to the number of assignees and their age groups to calculate how many consultations you’re going to need to provide. If you provide fewer, your patients may become impatient and switch to a different GP with a different Provider Number.

    Much like Taxicab Medallions, this means that Doctors would get more money if there were fewer numbers (Service being poor everywhere patients won’t change provider, so you can accept more patients for Basis Fee losing patients.)

    One of the main reasons Provider Numbers are less terrible than Taxicab Medallions is that there are enough Provider Numbers. Unlike Taxicab Companies and Medallions, Doctors cannot succesfully lobby to artificially limit the number of Provider Numbers, because of Group 2.

    Group 2 is for any patient unsatisfied with Group 1. If you are in Group 2, the state does not pay a Basis Fee for you to anybody. Instead, it reimburses you – up to a certain amount – for consultation fees you incur. Any Clinic can accept you, you can select any clinic, and then the fee is whatever amount you agree on.

    Group 2 solves the incentive problem twofold, at both the Clinic and the State level. First, it improves service levels – Patients unsatisfied with Group 1 switch to Group 2, removing their basis fee from the GP they were unsatisfied with and adding a significantly higher consultancy fee to a GP who provides better service, solving the problem at the Clinic level. Second, it causes a floor on the number of Provider Numbers – because a G2 consultancy fee is higher than a G1 consultancy fee (and the state is paying), the state is incentivized to keep people in G1 by improving G1 service. If service is bad due to a too high patient/Provider Number ratio, it is trivially easy to create new Provider Numbers, solving the problem at the state level.

    Because of this dual layer of solutions, issued Provider Numbers are rarely too few – the state doesn’t want to provide too few since that costs them money, and doctors don’t lobby for fewer because they won’t capture the overflow anyway.

    Incentive to Keep the Efficiency Level High
    GPs are private business owners who operate businesses called Clinics. Any gains caused by improvements they create are captured by themselves. If a consultation used to take half an hour and now takes twenty minutes, that’s 50% more consultations in a day. That gets you 50% more consultation fees and allows you to accept more Group 1 patients, securing their Basis Fee as well. This, in turn, incentivises the Clinic to hire the efficient number of secretaries, lab assistants and nurses.

    Far more important, though: This incentivises a pushback against unnecessary bureaucracy. The previously mentioned Basis Fee and Consultancy Fee are not declared from on high. They are negotiated between the government and an organization representing the GPs. If the government wants to, for example, create a mandatory monitoring regimen for some disease (Perhaps in response to a recent scandal that was in the papers), the GPs are going to respond with “What an interesting idea for a service you haven’t paid us to perform.” When the state wants to impose paperwork on a private clinic, the bill is presented up front. The state, being the legal monopoly on force, can still impose such paperwork wihtout paying, but in turn nothing prevents a clinic from selling its Provider Number, going 100% private and referring all patients with that disease to other clinics.

    Comparison with a State Run Hospital in the Same Country
    When the state imposes paperwork on a state-run hospital, studies are needed to assess how much that increased costs (or, if budgets are locked, decreased service). This removes the immediate disincentive to impose paperwork while preserving the incentive to impose paperwork (That is, getting your face in the paper after somebody died due to lack of paperwork) Additionally, unlike the GP system, there is no Group 2 where you go to a private hospital if the service at your local state run hospital is poor. (Recent policy changes have slighlty mitigated this. Slightly.)

    Second, nobody is properly incentivized to improve efficiency. Sure, administrators get a salary, but as state employees they get the same salary whether the hospital is run well or poorly. Much like the politicians in charge, it is far more important to them to stay out of the papers – and they cannot, unlike the private clinics, refuse to comply with regulations that don’t make sense.

    Postscript
    I spent a lot of words on the Provider Number, mainly because it is complex. The important part, though, is the paragraph on bureaucracy pushback. David Friedman, in Machinery of Freedom (also other places) writes that the problem with good government that works for everybody is that it is a public good, and thus underproduced, while bad government that works for special interests (or in the service of the bureaucracy) is a private good and lobbied for. The magic of the system is that the incentives have been aligned so that bad law (unnecessary bureaucracy) disproportionally impacts a single actor (The organization of GPs) who therefore has a powerful incentive to resist, while good law (less BS paperwork) has become a private good with serious positive externalities.

    • Shieldfoss says:

      Addendum: Doctors, in general, have been known for being unwilling to strike what with people literally dying whenever they do. The Danish GP has the same problem. Fortunately, if they do not reach an agreement with the government, they do not go on strike, they just stop accepting the state medical insurance card and require payment from the patient.

    • Jill says:

      “The magic of the system is that the incentives have been aligned so that bad law (unnecessary bureaucracy) disproportionately impacts a single actor (The organization of GPs) who therefore has a powerful incentive to resist, while good law (less BS paperwork) has become a private good with serious positive externalities.”

      What a brilliant solution to the problem. It does seem that some combination of private businesses and public regulations or requirements is good. But the overall system has to be structured in some way that doesn’t inevitably lead to corruption or waste or a generally screwed up outcome.

      Perhaps people give too much thought to ideological concerns e.g. Libertarian all private business orientation vs. socialist everything should be done by the government orientation. Perhaps the BIG issue here is how to set up the system so that the power relationships and the way the business is carried out do not lead to corruption, waste, and generally screwed up counter-productive outcomes.

      To do that, you have to look at how the system is going to work, and who is rewarded or incentivized for doing what. But it’s almost unheard of to look at that.

      And it’s unfortunately very heard of to look at such situations solely in terms of ideology e.g. Libertarianism vs. socialism– which will blind you from seeing how a particular system actually works. Because many Libertarians assume that leaving everything private and unregulated always works great in every instance and industry, ignoring any evidence to the contrary. And people who are totally socialists– I guess they must be in Europe because it doesn’t look like we have many in the U.S. today– would assume that government control and/or regulation would work great in every instance and industry, despite any evidence to the contrary.

      Taking the ideological blinders off to look at actual situations would be quite helpful, but it’s hard to do, especially in the U.S.

      And looking at who actually has power in a system and what they do with it, is important too. But awareness of power is a blind spot in the U.S. psyche. We like to believe that people are much more equal than we are, financially and politically. E.g. everyone in the U.S. seems to see themselves as “middle class”, except for maybe Bill Gates and people on welfare.

      So systems are actually set up or maintained with power blindness– with little attention to who has the power over whom and what they are likely to do with that power. Almost everyone hates power politics and wants little to do with it, doesn’t even want to think about it — leaving a huge amount of control to the few sharks who are willing to face the facts of power and play the game.

      • Salem says:

        Because many Libertarians assume that leaving everything private and unregulated always works great in every instance and industry, ignoring any evidence to the contrary.

        Oh Jill, don’t ever change.

        Even doctrinaire libertarians don’t think that the market is perfect. Just that government intervention is worse. I believe the slogan is “Markets fail. Use markets.

        • Corey says:

          For healthcare, it’s different, since it’s difficult to get even an approximation of a free market. My experience is with the US system, which is the worst in this regard – for example, nobody knows how much something will cost until after it’s done!
          With markets unable to control costs, that leaves politics, which can make bad choices like the ones under discussion (“we’ll fund 1/3 of the doctors we need and make them work 3x as long; what could go wrong?”)

          • Alliteration says:

            There is the cosmetic surgery market and the medical tourism market which can be used to approximate a free market.

        • My view of why market failure is a problem for private markets but a worse problem for the alternative: Recording of a talk. Book chapter.

      • It really is important to look at what’s going on.

        It turned out that people who weren’t married to ideologies were better an prediction than people who had strong ideologies.

        https://slatestarcodex.com/2016/02/04/book-review-superforecasting/

      • Joe W. says:

        On the other hand, it seems implausible to me that there really are no general overarching trends at all – that the best approach to providing each good or service is utterly unpredictable, can’t even be reasonably guessed in advance.

        That isn’t to say that details don’t matter, but I think calling someone an ideologue for believing that similar situations tend to work similarly is unfair.

  44. keranih says:

    Two not connected thoughts:

    Firstly, “The July Ward” by S. N. Dyer (1991 Nebula novelette nominee) is recommended. Much less SF than F or…well. Great story.

    Secondly – My biases are against centralized medicine, against wasteful systems, and against professionals in unions. I think that collective bargaining has a place, but that is for low-skill workers who can be replaced in ten minutes. It should be assumed that anyone with a certification or college degree has both the mental ability and mature judgement to accurately assess the potential working conditions prior to signing a contract, find redress to issues that arise thereafter, and buggering off to greener pastures – including brand new careers – if redress fails. Setting up a system where medical professionals are cogs instead of individual actors should have been seen as a major error.

    (This is also my issue with primary education in the US. Teachers shouldn’t be in unions either. Janitors? Sure. Not teachers.)

    A third thought – anyone know how we came up with 40 hours as the ideal amount of time to spend earning room and board for one and ones’ family for a 168 hour week?

    • CaptainNemo says:

      That a work day should be 8 hours’ work, 8 hours’ sleep, 8 hours’ play. I think that was before they had 5 day weeks though, maybe it stuck when we moved from a 6 to a 5 day week.

    • caethan says:

      Fun story: American doctors are explicitly forbidden to organize in any way. My wife is an endocrinologist and went to a professional conference last year with about half of the total endocrinologists in the country attending. One of the presentations was by a lawyer who offers to review employment contracts for endocrinologists, and has a ton of experience with it. He apparently reviews so many contracts, that he has to avoid giving accept/don’t accept advice on contracts lest he be construed as attempting to organize the profession.

      • Jill says:

        That’s unfortunate. What we have is a system where some people are super organized e.g. special interest groups of corporate crony capitalist welfare queens like the military industrial complex. And other people are forbidden to organize. Often the people who are allowed to organize end up eating everyone else for lunch.

      • Devilbunny says:

        This is not exactly true; doctors can and do organize (a famous example being residents in LA County in, I think, the late sixties). The catch is that doctors cannot do so when they are independent practitioners, because doing so is forming a cartel. If doctors who are employees want to unionize, they can. I have often thought of this as the break-out-the-popcorn moment of Obamacare, which has a number of provisions that strongly incentivize doctors to become hospital employees.

  45. Vidur Kapur says:

    The NHS is suffering problems at the moment, due to six years of this government being in charge. As experts at the King’s Fund have noted, when spending as a proportion of GDP on health in the UK was brought up to the EU average under the last Labour government, outcomes did significantly improve in many areas. Under this Conservative government, we’ve seen the most austere period for the NHS perhaps in history, despite claims of funding increases. Britain spends less on its healthcare than virtually every other developed country, which is good because it means that it’s quite an efficient system, but when outcomes start lagging, there should be significant spending increases.

    As for the junior doctors’ strike, they’re striking because of patient safety, not because of pay (the pay issue matters only insofar as Saturday pay is inextricably linked to Hunt’s plans for a seven-day NHS). The health secretary, Jeremy Hunt, wants to create a ‘seven-day NHS’, where all forms of care are available seven days a week (at the moment, junior doctors only provide emergency care on weekends). However, Hunt has not pledged any extra resources – money, staff, and so on – to make this seven-day NHS happen, so instead he’s trying to spread existing resources which are already stretched as it is over seven days.

    Hunt claims that this is to address a ‘weekend mortality’ effect, where patients admitted on weekends are more likely to die. However, he is misrepresenting the studies on weekend mortality, as the authors of the studies he is citing have stated, as well as the editor of the BMJ, and of course as the junior doctors have been pointing out all along. A fully seven-day NHS is a noble aim (although one does wonder whether Hunt is deliberately trying to dismantle the NHS in order to get increased support for privatisation), but without the extra resources required to make it happen, it should not be carried out. A good majority of the British public continue to support the junior doctors.

  46. Anonymous says:

    Some people don’t like visiting hospitals because of all the sickness and death.
    I don’t like it because of the guilt attacks.

    “Sorry I brought more work for you! Maybe I should’ve stayed home and let it heal by itself! I’m sure my problem is not a big deal anyway!”

    • Magnap says:

      Ditto. I put off getting a referral to a psychiatrist for ADHD testing for so long, because surely my local doctor had better things to do than hear me complain about my concentration problems. And sure enough, I have ADHD.

  47. Who wouldn't want to be anonymous says:

    I have always found it extremely bizarre that all the people you don’t want making mistakes due to sleep deprivation–doctors, air traffic controllers, and what have you–always seem to have insane shifts. I mean, a hundred hours, seriously? The fuck are they people thinking when they write the schedule?

    • CatCube says:

      The fuck are they people thinking when they write the schedule?

      They’re thinking, “I have X number of employees I’m allowed to have and Y hours of work to be done. I’ll be fired if Y hours of work isn’t done.”

  48. “”” You read the press releases and they sound sort of reasonable, and then you talk to the doctors involved and they tell you all of the reasons why these policies have destroyed the medical system and these people are ruining their lives and the lives of their patients and how they once shook the Health Secretary’s hand and it was ice-cold and covered in scales.”””

    Without wishing to defend the Health Secretary, the “people involved” are most often a terrible source when it comes to the effects of policies on the overall system.

  49. amoeba says:

    This is a great post.

    Regarding the last two paragraphs; I lived (for some years) in Germany, Russia, UK, and Portugal. Germany appears to have *by far* the best medical system among these countries (and is pretty good overall). And it is fully state-run.

    But I have a question to anybody who is a German doctor: is the situation there similar to the UK horror described in this post?

    • Germany’s healthcare system may be great, but it is not state run at all.

      There is heavy regulation (as there is in the US, where calling it free market is a bit ridiculous when hospitals can only open or expand if they demonstrate to the regulators that there is a societal need to do so).

      As many European countries, though, Germany does regulate medical prices leading to a moderate shortage of doctors, which is mostly a problem in rural regions.

    • heiner says:

      Judging from my German junior doctor girlfriend, the situation is similar if not quite as extreme. The “sweet summer child” look if you ask about the legality is just as much a thing as Scott describes, and senior doctors do scream, intimidate, etc without repercussions because they are the ones who in the end acknowledge the completion of a list that can’t realistically be completed (more ops of a certain kind per junior doctor than the hospital had in total, etc)

  50. Anonymous says:

    Not exactly related to the strike situation, still…

    Why not teach everyone a little medicine, mandatory, in every level of education below X?

    Obviously not meant to replace specialists, I’m usually opposed to having to teach everybody something but the situation is apparently beyond ridiculous. Not even a nurse can give an injection? I think giving an injection or sewing a wound could be taught to pretty much everyone.

    Is the risk of amateur pseudomedicine so bad as to make teaching people the basics not worth it? Could it be made to decrease the risk instead?

    Optimizing specialization is one thing, optimizing credentialism and monopoly is another, doing the latter to make more money instead of out of “concern for the plebs” is another entirely.

    Where I live, I shit you not, people go to one kind of doctor that tells them what kind of doctor has to see them later, and that’s all this first doctor does. And you can’t avoid this by going to the appropiate doctor directly for some reason. Then the second charges you money and asks you to go take some laboratory tests (Blood, Shit, X Rays etc.) No, you can’t do any of those without the second doctor’s authorization. So you go to the lab a few days later and the lab people get you your results, they are forbidden from telling you what the problem is at this point, even if its something a kid could figure out. So there you go to the second doctor again, so he can give permission one last time. But only for a few months. Most doctors are pretty happy with this situation where I live. As are most people, now incapable of the level of self care you would expect from a mammal… I once saw a not mentally retarded man get scurvy in the modern world. He just ate the same every day.

    You know shit’s fucked up when going to your complicit local veterinarian and getting your drugs from the black market starts sounding like a reasonable idea.

    • Rhand says:

      We already have that with WebMD, and now they have to teach us in medical school about how to talk to a patient who is convinced he has a subarachnoid hemorrhage.

    • arbitrary_greay says:

      It’s less the risk of pseudomedicine, as a part of the war on drugs. The current proposed solutions to the opioid addiction thing are mostly putting up more hoops to jump through. Because clearly no one would go to their complicit local veterinarian and get their drugs from the black market in reaction to such measures!

    • If you don’t mind, where do you live?

      Considering that diabetics are taught how to give themselves injections, I can’t see any reason why everyone shouldn’t be taught how to give themselves injections.

      • Ninmesara says:

        Most drugs that require injections are not injected the same way insulin is (insulin is the most common drugs diabetics are injected with). Insulin is injected into the fat just under the skin. Mos other drugs are injected deep into the muscle, usually into the buttocks. It is harder to inject yourself into the buttocks, it is much easier to inject someone else. And to be properly done, it requires a little more technique. It CAN be taught to everyone, but it wouldn’t be my priority in health education for the general public.

    • Adam says:

      What you’re describing is mostly the fault of the insurance company. I don’t have to do a lot of that on Blue Cross Blue Shield, but when I was still on Tricare, I did. They wouldn’t pay for a diagnostic unless a specialist said I needed it and they wouldn’t pay for a specialist unless my primary care manager said I needed to see a specialist.

    • Ninmesara says:

      I’m geting the impression that you’re neither a nurse nor a doctor, and will answer accordingly.

      Why not teach everyone a little medicine, mandatory, in every level of education below X?

      What is a little medicine? What would you propose to teach? Where I live (Portugal), my anecdotal impression is that most people are not able or wiling to put up the effort of learning “the basics” not related to their own needs (or their children’s needs). Most of what the general public need to know reduces to “Don’t get fat. Stop smoking. Exercise a little”, and this is already hard enough for many people.

      Not even a nurse can give an injection?

      This is usually their job… Here you're more likely to find a doctor that doesn't know how to give an injection. Where do you live? Honest question, I’m curious about nurses not giving injections.

      I think giving an injection or sewing a wound could be taught to pretty much everyone.

      Giving an injection? Sure, but it is probably not as easy as you might think. You often have to use some suction to make sure no blood comes out, which might take some practice. You don’t want accidentally to inject intramuscular drug into a systemic vein, do you?

      Sewing a wound? Probably not… You should use sterile material, which is not trivial to do properly (some medical students have a pretty hard time with this). How do you know whether you should sew a wound? Should you cut the devitalized border of the wound? Can you even recognize devitalized skin? How do you handle tar tatoos on the wound? How do you apply anesthesia the wound? Do you really need anesthesia, or will it be more painful than just applying one or two stitches to the wound? You better know how to explore the deeper tissues looking for serious muscle, tendon or nerve injury, as well as troublesome blood vessels you might have to ligate. Which kind of dressing do you apply afterwards? Sure, these hard cases can be deferred to a real doctor, but do you have the discernment to distinguish them? Also, do you need to take antibiotics? Was the wound contaminated? What about tetanus risk? Do you need to administer prophylaxis? Which kind? Vaccine or Immune Globulin? What are the risks of tetanus immune globulin? Can the average person handle all of this?

      Is the risk of amateur pseudomedicine so bad as to make teaching people the basics not worth it?

      It’s a mix between high risk, inability to understand enough of the basics and the illusion of knowledge. Source: I love talking to amateurs about medicine, and I talk a lot.

      Optimizing specialization is one thing, optimizing credentialism and monopoly is another, doing the latter to make more money instead of out of “concern for the plebs” is another entirely.

      Sure, but you really need specialization if you want the best possible quality of care. Medicine is just that complex, unfortunately, and keeping track of all relevant knowledge is very hard.

      Where I live, I shit you not, people go to one kind of doctor that tells them what kind of doctor has to see them later, and that’s all this first doctor does.

      This is shitty primary care… It is unfortunate that you have to deal with it. I do not endorse this.

      And you can’t avoid this by going to the appropiate doctor directly for some reason. Then the second charges you money and asks you to go take some laboratory tests (Blood, Shit, X Rays etc.)

      the lab people get you your results, they are forbidden from telling you what the problem is at this point, even if its something a kid could figure out.

      Many lab technicians might be unable to interpret your results. Even the doctor in charge of the lab might be unable too without talking to you and performing a normal physical examination. Yes, medicin is just tha complex.

      As are most people, now incapable of the level of self care you would expect from a mammal…

      Mamals live fast and die young. I’d prefer people to display the self care of a turtle. Barring that, getting doctors to take care of them is a pretty good decision. Again remember the basics: Don’t be fat; Don’t smoke; Exercise a little.

      I once saw a not mentally retarded man get scurvy in the modern world. He just ate the same every day.

      Not eating the same thing everyday is something I consider basic enough to teach everyone. You can add it to my list.

      You know shit’s fucked up when going to your complicit local veterinarian and getting your drugs from the black market starts sounding like a reasonable idea.

      As in having your veterinary choose the right drugs for you or just prescribing the drugs you researched online? In any case, it doesn’t sound too reasonable to me…

      As I said, I don’t know your level of knowledge about these issues, but even if you know a lot, please remember that MOST PEOPLE DON’T, and probably never will. The takeaway is that medicine is REALLY complex and hard to get right…

      You can live your whole life while knowing only the basics, but someday (quite often actually) something will come up that requires actual deep knowledge.

      Please do not be offended by my comment. I just think most people with such strong opinions about medicine should read a real medical textbook on some of the topics they write about and took some kind of test about that knowledge (written assessment, oral examination).

      • Why do you think “don’t get fat” is good advice?

        As far as I can tell, the odds for sustained weight loss aren’t good, and efforts at weight loss can go wrong, ranging from regaining all the loss weight plus more to seriously damaging eating disorders.

        People say “it’s hard to lose weight, but people should keep themselves from getting fat”, but I’ve seen no evidence beyond the anecdotal that the latter is generally feasible.

        • satanistgoblin says:

          Is weight acausal magic?

          • jaimeastorga2000 says:

            No, weight is like temperature and your body is like thermostat that automatically returns to the target temperature. If your obesity set point happens to be at a weight that makes you fat, you’re SOL; your body will make you hungry, lethargic, cold, and pretty much use every trick in the book to make you gain weight. See Scott’s review of Good Calories, Bad Calories.

          • satanistgoblin says:

            If that was the case, why is average weight increasing? Cannot be genes because they cannot change so fast. And that is not my experience having lost weight.

          • jaimeastorga2000 says:

            You are correct that genetics do not change that fast; whatever increased our set points lately, it was clearly environmental (though genetics is probably the reason some lucky people were able to resist this change and retain their low set points, thus remaining thin while everybody else got fat). But nobody knows what the orange soda is.

          • Anonymous says:

            Personally, I’d blame dietary changes from 100 years ago to now.

            Is building muscle a good countermeasure against obesity, what with the set weight theory? I mean, muscles weigh more than fat. Should be possible to appear thinner (and more fit) while retaining the same weight.

          • “Is weight acausal magic?”

            There are a lot of possibilities, including less sleep, rebound from dieting, the low fat fad (eventually government supported, infection….

            Found my list, and add changes in microbiome.

            Default weight can change due to a lot of factors.

          • Randy M says:

            Is building muscle a good countermeasure against obesity, what with the set weight theory? I mean, muscles weigh more than fat

            Most likely, it isn’t a “weight set point” but a “fat retention in adipose cells” set point or something similar. More muscles may help, as that increases basal metabolism.

            I’ve heard interesting theories that a possible cause is having access to seasonal food at any time, as, say, sweet berries or other autumn foods might have been a trigger to gain fat for winter. Of course, different populations would surely be expected to react differently to modern diets.

          • onyomi says:

            Food is cheap and fancy and people are inactive.

            Imagine this is all you have to eat and it’s really, really expensive. Also, there’s nothing fun to do in your house. I think your “set point” would go down.

        • Anonymous says:

          Staying fit is actually much easier than the pathologically intellectualizing models out there would make you think. The trick is to be active in general and take a “holistic” and self-aware approach to nutrition, exercise and metabolism.

          You are correct in practice though, effectively taking this approach seems to be outside the realm of possibility for most people, as it requires abandoning the comfortable idea that a single and simple solution exists.

          The best way to describe the pathetic state of nutrition science (At least at the public level) is to remember that Ayurveda, an irrational system based on bullshit like food being categorized by “element” (Fire, Water, Earth, Air and so on) ends up being more useful to a lot of people in practice.

          Many people get stuck at an atrophy (Yes, you can atrophy and get fat at the same time) stage where your body has pretty much abandoned all hope of you being an active human being, switching your metabolism back to “normal” is hard but not impossible. It requires a usually drastic lifestyle change and can take a pretty long time (years) and is full of plateaus and apparent (in the short term) setbacks.

          This is all based on ample anecdotal data.

          • I thought I was in more agreement with you than I turned out to be, but have the previously planned comment….

            Some very moderate exercise is good for people, but if the standard of virtue is being thin, then some fat people give up on most movement. It doesn’t help that they are likely (how likely? I’m not sure, but I’ve seen a lot of anecdotes) to be taunted for exercising in public.

            I believe there’s a cultural problem– people get the impression that the choices are to be impressive or give up.

            When you said “fit”, I thought you meant having a good capacity for physical movement, but possibly you meant “not fat”. There are fat athletes and thin sedentary people.

            As for ample anecdotal data, I’ve got plenty about the damaging effects for many of trying to lose weight.

          • Anonymous, the reason I thought you might have bought into the”everyone should be very lean” cultural construct was that you mentioned people getting “great bodies” and I thought you might have meant great looking bodies with no regard for long-term effects.

            I’ve been wrong in this direction before– expecting the worst of people who recommend weight loss– and I should work on being less hair-triggered. On the other hand, the culture really is pretty awful in the direction I’m seeing, so calibration is tricky.

            I had no idea sit-ups could be dangerous for knees. Details?

            The standing/Posture yoga you describe sounds like it’s got overlap with Taoist standing meditation– and information about that isn’t rare. I’ve found Lam Kam Chuen’s The Way of Energy to be a good introduction.

            I agree about the possibilities for change, and it wouldn’t surprise me if there are people who can gain more than a cm if they un-hunch. I also agree that it needs to be a respectful process.

          • Anonymous says:

            @Nancy Lebovitz

            I had no idea sit-ups could be dangerous for knees. Details?

            I meant squats instead of sit-ups, english is not my native language. Sorry.

            The standing/Posture yoga you describe sounds like it’s got overlap with Taoist standing meditation– and information about that isn’t rare. I’ve found Lam Kam Chuen’s The Way of Energy to be a good introduction.

            Kind of, a lot of stuff you can find completely ignores the physicality aspect. They are still useful if you want to delve into the other things but good eastern physical tradition is really hard to find. I can comfortably say that from 100 Yoga schools, at least half are harmful (Standing on your head can be dangerous and is not trivial to teach) and from the other half, most are no more useful than exercising intuitively.

          • As I was typing that, I was wondering whether you might have meant squats.

            I have no idea what you mean by physicality, so I can’t tell whether the Taoist stuff I’ve studied leaves it out. If you’d care to expand on the topic, I’m definitely interested.

          • Anonymous says:

            By physiciality I meant not leaving out the hard physical work that is required (And should be personalized for every student)

            You should sweat and do really hard stuff that leaves you exhausted some times. Push the limits of your body, not just standing meditation. A lot of schools never push (Or push horribly wrong) their students and focus on the meditative aspect only. I have little experience with Tao, no idea if they get serious or how often. The problem is that pushing like this is when problems (Physical and psychological) start to appear if mistakes are made, but is really necessary if you seek real progress.

            Old school yoga teachers use a stick to hit students during poorly done postures, serves a dual purpose, as a ritual and for hitting specific muscles to bring the practitioner’s awareness to those muscles.

          • Lam Kam Chuen has methods for gradually increasing the physical effort– some of the arm positions are more difficult than others, or (in The Way of Power) there’s lifting your heels just a little off the floor.

          • Anonymous says:

            https://www.youtube.com/watch?v=8pIgs03TYo4

            This is B. K. S. Iyengar at 60 years old and with a pretty respectable belly. Techniques have obviously improved with time.

            https://www.youtube.com/watch?v=Ki9qos7dWTg

            Some footage of the classes with students and so on. Pretty nice.

        • Ninmesara says:

          That particular piece of advice is the one I am less knowledgeable about.

          It is consensual that being fat is generally bad for yor health (independently of other risk factors) and people who are fat are should be encouraged to lose weight.

          IF they do lose weight, they usually became more healthy. Many people won’t, though… Some lifestyle interventions do work for prevention and treatment of obesity, but results are generally modest and the lifestyle modifications can (anecdotically) take a toll on patents’ emotional wellbeing. Obesity is complicated, and I should refrain from giving advice over the internet, as I can’t put hard numbers on it’s effectiveness (because of my ignorance, the numbers must be around somewhere)

          On the other hand, smoking is not complicated. Stop smoking. Now.

          • Anonymous says:

            This is a perfect example of the core of our disagreement.

            Consider my comment above, I surely have less knowledge of nutrition, metabolism and obesity in all their complexity than you do, yet I offered that advice. Why? I’ve seen a lot of people overcome all kinds of physical problems and get really awesome bodies following similar advice, and the current state of affairs on the matter is a tragedy. Even if I don’t have the hard numbers or anything like that, it makes sense to me. You can ask me not to trust myself and my experiences but I would need really good reasons. How much damage could it really do?

          • Anonymous says:

            Obesity on its own is pretty obviously unhealthy. The afflicted have reduced mobility, endurance and the body in general is under strain to support so much excess mass.

          • keranih says:

            Obesity on its own is pretty obviously unhealthy.

            When epidemiologists run the numbers, people who are overweight are healthier than people who are an equal degree under normal weight.

            While the mobility and structural issues you name are issues for the obese, it is apparently the co-linked lack of physical exercise that is really damaging. Because the degree of physical activity varies widely between people, it is not possible to say of two specific people that the obese one is in worse health than the less heavy one.

            Most of present society’s rejection of overweight people is aesthetics, not health.

            I’m not saying that obesity is good, just that its harms are not what everyone says they are.

          • https://danceswithfat.wordpress.com/2015/05/20/fat-people-and-our-knees/

            This one surprised me– a lot of the joint problems which are attributed to fat can actually be treated effectively with the same PT that works for thin people.

          • “I’ve seen a lot of people overcome all kinds of physical problems and get really awesome bodies following similar advice, and the current state of affairs on the matter is a tragedy. Even if I don’t have the hard numbers or anything like that, it makes sense to me. You can ask me not to trust myself and my experiences but I would need really good reasons. How much damage could it really do?”

            Here’s the reason. Your data set is incomplete. You’ve got information about what is possible for some people. You don’t know enough about whether weight loss/exercise can backfire badly– it can–or what proportion of people it backfires for.

            Have some information about backfiring– women who exercising hard but not eating enough to prevent or heal injuries. Many of them are in the “normal” weight range.

            At this point, you might be thinking “but I meant that people should have some common sense”. The thing is, we are living in an anti-common sense culture about fatness, health, and virtue. People who are dying of cancer get told they’re looking good because they’ve lost weight.

            With the ideology of virtue through effort, people just aren’t going to have good judgement about what body signals to ignore.

            As sort of a point for both our sides, I’ll recommend Scott Sonnon. He has high athletic ambition and a congenital connective tissue problem. As a result, he’s much more meticulous about preventing injury than the vast majority of people who recommend exercise. (He also believes it’s good and possible for people to not be fat. I have no strong opinion about whether he’s getting that part right, but I expect he’s probably causing less damage than most people who believe that.)

            He doesn’t say compete with yourself. He says (with detailed advice) go for what you need to be better that day. Don’t expect that you can necessarily do today what you did yesterday. Pay attention because what you can do on one side of your body may not be what you can do on the other side.

          • Ninmesara says:

            @Anonymous:

            This is a perfect example of the core of our disagreement.

            Yes, maybe it is

            I’ve seen a lot of people overcome all kinds of physical problems and get really awesome bodies following similar advice

            I’ve seen a lot of people that didn’t. I believe people have the right to know their odds of succeeding, and it feels irresponsible of my part to give that kind of advice without knowing the odds myself.

            I believe almost everyone who is overweight should try to lose weight, I’m just not sure what kind of impact this advice has. The possible damage of saying that anyone can lose weight if they try hard enough is having lots of frustrated people who fail, but I think the positives probably outweigh the negatives.

          • Ninmesara says:

            @keranih

            When epidemiologists run the numbers, people who are overweight are healthier than people who are an equal degree under normal weight.

            I don’t really understand your phrasing. Do you mean that a person 10kg underweight has the same mortality of a person 10kg overweight? People who are underweight are pretty obviously less healthy as a group. You have to be very careful with your confounders, as part of that effect that can be attributed to the fact that many diseases (much worse than obesity) cause you to lose weight (e.g. almost all gastrointestinal cancers, many [most?] advanced cancers, some forms of heart failure, autoimmune diseases of the gastrointestinal tract, anorexia nervosa, some forms of depression, demencia). Which studies have you read? Do they control for confounders? This is an area I haven’t read a lot about, and I’d really like some solid references if you know some.

          • As far as I can tell (casual research and asking around), information about the effectiveness of weight loss efforts in general doesn’t exist. There has been no grand survey of what people tried and how it worked out.

            “The possible damage of saying that anyone can lose weight if they try hard enough is having lots of frustrated people who fail, but I think the positives probably outweigh the negatives.”

            The down side isn’t just a lot of frustrated people. It includes people who’ve dieted themselves heavier and it includes people with eating disorders and exercise injuries.

            I don’t know how to do the utilitarian calculation of some people losing weight and being more comfortable and maybe living longer vs. people (a smaller number, but I don’t know for sure) who’ve been miserable and obsessed for years and may have caused themselves permanent physical damage.

          • Anonymous says:

            @Nancy Lebovitz

            Answering your previous comment here too.

            When you said “fit”, I thought you meant having a good capacity for physical movement, but possibly you meant “not fat”.

            I don’t. What gave that impression? I think the current image of “Fit” is pretty distorted to the “thin” side of the equation, to the point where I often end up giving similar advice to skinny people who are atrophying too. This is particularily bad in the case of women, they themselves being allergic to functional physiques for supposed aesthetic reasons. Note that I do think Fit = Not fat in a strict sense.

            I also think that the process should explicitly NOT be approached as a “losing weight” thing, or optimized for that.

            I agree with you on the dangers of misguided exercise, funnily enough I also have a connective tissue condition* and athletic aspirations. Managed to turn it into an advantage for some stuff.

            It is why I said that the process takes years and needs to be done for real, lifestyle change. Forget about lifting weights or abusing your knees doing sit-ups and so on.

            I had the privilege to study serious yoga for real… First thing the teachers taught us was that the whole thing was about building and refining conscious and otherwise control of our bodies. It was emphasized that the proper way to do an asana (Posture) is something that even 100 years old people in wheelchairs can and benefit from doing, with aid and props like pillows, belts, suspension ropes if need be and so on. And that the most basic asana of all, that is, to simply stand straight with joint rotation, muscle relaxation/activation, breathing and state of mind optimized, is the most difficult asana of all and pretty much impossible to master. And it shows in every other posture or motion. Sadly my advice is to stay away from yoga entirely because people have no idea what they are doing and it ends up being harmful and useless mystical bullshit. Swimming, btw, is a very good exercise if you worry about joints. The water holds you, and you exercise a lot of stuff even if you just play in the water.

            Diets are usually a terrible idea. You should slowly and naturally change your diet over time, as your metabolism changes too. For most people this is as simple as eating what they want when they are hungry, put the effort and time to cook what they really feel like they want instead of eating the easiest choice etc.

            The whole point of “Holistic approach” is that people ought not to stop eating or start training in shitty ways. You should eat more if you start to do serious exercise, not less. Even if you are overweight imho, in most cases. There is no simple rule however so common sense is required.

            I not only believe it is possible for people not to be fat, you can actually change your skeletal structure slightly over time, gain half a CM of height and broaden your shoulders etc. And you can do even more crazy shit when you start delving into conscious or otherwise control of the parasympathetic nervous system and so on, sadly this is still considered impossible magic by most people.

            There is no method that teaches holistic knowledge about taking care of one’s body in the west, it is a tragedy. Even professional athletes and most trainers do some things very wrong because they got too focused.

            My fear is that most people just don’t have the time, energy, motivation or opportunity to do something like this. We optimized physicality away. I mean, the way institutions work is entirely counterproductive. If a kid stands up unquiet and wants to remain standing up for a while and maybe straighten his shoulders and raise his arms, what is a teacher going to do? Probably suspend him or something. They didn’t even let me sit properly when I was a kid. We are missing so much.

          • keranih says:

            @ Ninmesara

            This study isn’t the one that I read at most depth, but it’s a starter:

            http://www.ncbi.nlm.nih.gov/pubmed/15840860

            You are absolutely correct that there are confounders – that was the point of the discussion regarding this (mongst the people who were talking about it.) One *can’t* say “fat = unhealthy” and “thin = healthy” – even across large groups, a little bit of extra weight was of no significance. It was far more useful to look at the confounders (blood sugar, cardiovascular condition, etc) than to do a judgement off weight for a majority of the population.

      • Anonymous says:

        One clarification: The comment about nurses not being able to give injections was regarding comments I read on this thread. Nurses do give injections where I live.

        I agree that medicine at that level should not expected from everyone, real doctors obviously have a place. We need more of them if anything, however, a saying comes to mind: “Perfect is the enemy of good”

        The ugly implication is that people are going to get suboptimal care in order to reduce the load on the system, and this wouldn’t be “fair”. I think until we can extend that optimal care to everyone for free without enslaving our doctors or ignoring people’s freedom and preferences well, perfect is the enemy of good.

        Ideally people would go to a doctor as soon as their own knowledge is not enough, and they would be well trained in assessing this. Perhaps this is indeed impossible but I doubt it, people are not that stupid and knowledge is not that hard to synthesize into a simple system of simple heuristics. Perhaps allowing some freedom without incentivizing this behaviour could be a decent compromise?

        Doctors and healthcare specialists in general obviously have better insight into this than I do, so I ask: How many people in your opinion go to the healtcare system over “bullshit”? My uninformed guess is “A lot”. A better way to phrase this, do you think the healtcare hierarchy is optimized well enough, or do you get a lot of patients with “obvious” problems (for you) that you feel someone else should deal with so you can focus on the non obvious situations that do require your time and knowledge? Perhaps if this hierarchy had 10 imaginary levels you could “outsource” the lower 2 or 3 to the patients through education and so on.

        Don’t worry about offending people over bullshit… My own level of knowledge is not even relevant to the subject at hand, as you said.

        • Pku says:

          There’s also the nontrivial issue that unknowledgable patients might not be able to tell the difference between important and obviously (to doctors) bullshit.

        • Ninmesara says:

          however, a saying comes to mind: “Perfect is the enemy of good”

          I worry about this almost everyday, when I have free time to worry about things.

          How many people in your opinion go to the healtcare system over “bullshit”

          My experience in the ER mostly in pediatrics. In my opinion, parents overvalue value episodes of vomiting, diarrheia or fever. If the child looks fine, these are not worrisome findings. Some special kids must absolutely be brought to the ER with any of these symptoms, and their parents are educated accordingly, but generally this is not worrying. Some teenagers present with chest pain and fear that it might be a symptom of a heart attack. Pain usually comes from a sore muscle, which can be proven by palpating the muscle and eliciting pain.

          In a GP office, adults might be problematic for other reasons. They often ignore symptoms such as chest pain (from heart problems), fatigue (too many causes to list; when insidious people adapt remarkably), pain during sexual intercourse in post-menopausal women (not serious but usually very easy to treat), urinary incontinence (the same). When people get into denial they can ignore some pretty amazing things, such as an individual who managed to ignore extreme fatigue, dark-brown urine, yellow eyes, and vomiting of blood (sequentially, not all at the same time).

          In any system you’re going to have false positives and false negatives, and optimizing for the best outcomes seems very hard. I think the best possible result would use short phone consultations (which we have) and patient education in the ER or GP office (which is already done in many situations, but could be done more often). Also better electronic record systems (the ones I’ve used are a joke) and clearly defined guidelines for common situations (which we already have, but could use more).

    • Psmith says:

      This has generally been my experience, especially w/r/t orthopedic injuries. After the third or fourth time in a row getting a non-diagnosis like “shoulder strain” or “shin splints” and being told to take 3200 mg of ibuprofen 4x/day for 5 days and rest until pain-free (or being written a prescription for equally pointless physical therapy), you start to realize that you’re not really getting anything from the doctors that you can’t get just as well from an old edition of Netter’s atlas and some aggressive googling.

      • Noumenon72 says:

        The Googling actually works better than the physical therapy because you get your information from someone who’s actually passionate about the subject of scapular retraction or nerve tension. The P/T people just made me do a workout, Google sold me on the worldview that exercises are supposed to reconnect your brain and your body.

      • The Nybbler says:

        One thing going to the doctors gets you is documentation when it DOES turn out to be a zebra. If you just treat it conservatively yourself and it doesn’t help, when you go to a doctor they’re going to ignore anything you did on your own and start you over on the conservative treatment.

  51. hlynkacg says:

    There’s a bunch I want to say, but at the same time I don’t really think it would add anything to the conversation.

    I used to half joke that my 18 months working in a metropolitan ER had done more damage to my mental health than the 8 years I spent as medic in the military. I’ve occasionally felt guilty that I made it through as much as I did only to fall apart while working a job that was ostensibly “normal”. In find it both depressing and somewhat life-affirming to hear that I’m not the only one who burnt out.

    • Jill says:

      Yeah, we are so individually oriented sometimes in the U.S. that tons of people are having the same horrendously difficult experience and they all think they’re alone, and so they don’t organize together to solve their common problem usually.

      • If you’re interested, I could try to dig up libertarian and anarchist writing that is in complete agreement about that problem, albeit with diverging solutions of people organizing together without government rather than organizing through it.

        EDIT: For reference, I became an-cap from the left side of things, enjoying reading things like Ecology and Politics or the Story of B. So I very much support the DIY/get together with your community directly to fix stuff approach.

        • Jill says:

          I wonder how people could become open to doing more of the the DIY/get together with your community directly to fix stuff approach. That seems to have been nearly extinguished.

          • It’s hard to say, but my experience has led me to believe that you just have to find the other people willing to do stuff and just start doing. As it gets successful, other people will happily jump on to keep it going. (like the student community garden I kickstarted after years of languishing as a wishful dream of various architecture students).
            People rationally want to wait for seeing how any given system or thing works. So, if I want people to start doing more gardening, entrepreneurial activities, or community projects, I’ve got to start doing them and show that they work.

            It is a thin spark of flame, but even if we find our saves in a place dark save for a single light, we can still use that flame to light others until the whole world is illuminated.

            Or at least the surrounding area wherever I live, but I can’t do everything… jeez. Also, look up maker-spaces and there is a whole flowering of DIY communities springing up on youtube and elsewhere. I can send you some of those too!

          • Jill says:

            Yes, please do. I am looking up maker spaces.

            I don’t see any real close to me, but perhaps I will start one.

          • CatCube says:

            This is the second place I’ve seen “maker space” in the last week or so. What’s the daylight between that and the perfectly serviceable term “workshop?”

          • Eggoeggo says:

            “Workshops” are where uneducated, unwashed men do horribly gauche manual labour.
            “Maker-spaces” are about self-actualization for enlightened urban professionals.

            It’s like the difference between a “supermarket” and a “farmers market”.

          • Nornagest says:

            At least it’s not an atelier.

          • Pku says:

            @Eggoeggo: I don’t know how to tell you this, but there exist terminologies which are not based on a desire to insult your ingroup.

          • Woah, I only used ‘maker-space’ because that’s what I’ve heard them called, so assumed that you’d want to google search that word to find the same thing. I mean if you search workshop, you’ll likely just get your local tap-and-die or cnc shop instead of a place where hipsters pool together to rent a space for tools. Much as I find machining super cool and the experienced machinists basically Hephaestus, I doubt they’d be happy to just let you come in and use their stuff.

            As for crafting links, what would you want to see? I’ve got woodworking, blacksmithing, gardening, and tabletop terrain crafting channel links I could send.

          • John Schilling says:

            This is the second place I’ve seen “maker space” in the last week or so. What’s the daylight between that and the perfectly serviceable term “workshop?”

            If a place is described as a “maker space”, it is almost certainly filled with nifty tools that you can come in and use for your private projects without too much trouble. If it is described as a “workshop”, that might still be the case but it isn’t the way to bet.

            And while it is certainly possible to set up and advertise “workshop where you can come in and use our tools, not to be confused with someone else’s private workshop that they weren’t really advertising but showed up in your Google search anyway”, that requires about 3100% more words – which means people increasingly don’t bother, and “makerspace” becomes an increasingly reliable way of distinguishing open-access workshops from the other sort.

          • CatCube says:

            @John Schilling

            *shrugs* I don’t know why they don’t call them “public workshops” or “membership workshops” or something. “Maker space” sounds so unbelievably twee I can hardly believe an adult would willingly use it.

            TBH, my comment asking about it was originally going to be something along the lines of “Maker space? Is that hipster for workshop or something?” Then I thought that might be unnecessarily combative and maybe there was history I didn’t know, so I deleted it and posted what you saw.

          • Nita says:

            I think ‘makerspace’ is an extension/rebranding of ‘hackerspace’, hence the similar term structure.

            And ‘workshop’ often means something like ‘seminar’ or ‘master-class’ these days, so that would be confusing.

          • MichaelM says:

            @John Schilling

            So why aren’t they just called open-access workshops?

          • HeelBearCub says:

            Language is constantly changing. Synonym is a useful term because of this fact.

            The portmanteau makerspace looks synonymous with workshop, but has a subtly different meaning or implication. That is one of the drivers of changing language since, well, something similar to the beginning of language.

            Edit:
            “Workshop” is, itself, a portmanteau of work and shop. Dating from 1580, it appears this is an archaic meaning of shop, meaning a booth or a shed. So even in the word itself, we can see how language changes.

          • John Schilling says:

            So why aren’t they just called open-access workshops?

            Because why use six syllables when three will do?The people who actually establish and use “open-access workshops”, and who consequently have to use the term an order of magnitude or two more often than you do, are going to converge on a term that A: doesn’t have more than two or three syllables, and B: isn’t “workshop”.

            Nita has explained the etymology behind the term they have chosen. And, being the ones who made the actual institutions and then everything made in those institutions, it’s their choice what to call them.

          • I think there is a second reason. “Work” has negative connotations, “maker” has positive connotations.

          • CatCube says:

            @David Friedman,

            Now that I think about it, for me it’s actually the opposite. If I heard someone in person refer to themselves as a “maker” because they were building hobbies in a rental workshop, I’d want to pinch their cheek and say “Awww, you adowable widdle urbanite.”

            I grew up in a rural area where it was very common to have at least a small shop for some basic carpentry. Of course, you had a few people with welding, machining, electronics, gunsmithing, etc. It just grates on my ear to take something that was so common where I grew up and attach a twee synonym (“maker”) to it.

            I don’t have any objection to what they do, BTW. It’s actually really important that people are willing to work on building things on their own! It’s just the coinage that I don’t care for. Like I said, I had never heard of this before last week. I don’t know if this is something that’s been going on for years under my radar, or a very recent neologism.

          • Matt C says:

            At least here, a makerspace means a workshop that is available by joining a club, with membership open to pretty much anybody.

            Ours has an explicit idea of including computery people and fine arts people as well as your traditional woodshop or metalshop folks.

            There’s also an ideal of community sharing that is actually upheld pretty well. Members routinely give classes to each other and various internal improvement projects are planned and carried out by volunteers.

            Yeah, “makerspace” is kind of a cutesy/pretentious name, and there is a bit of a hipster vibe (more noticeable from the outside than the inside in my experience), but these aren’t important failings. The place itself delivers on what it promises. If there used to be things like makerspaces going by different names, I never knew about them.

          • CatCube says:

            @Matt C

            I guess I don’t know what they would be called either. If I ever needed to use a tool or shop I didn’t have, I’d just ask a buddy if I could borrow his. Granted, I don’t do much woodworking or machining, just simple repairs or small electronics projects.

            To go back to Jill’s point about DIY, I think that’s both a generational thing and urban/rural divide. I had some outlets in my apartment where the plugs were loose-fitting. I told my apartment manager about them, but the repair guy apparently just verified that you could still get electricity out of them and left a “Your apartment has been entered” note on the door. I went to Home Depot the next day and replaced them myself. I’m not going to spend an hour quibbling with somebody over 68¢ in parts and 10 minutes of work, especially when it’s a fire hazard.

            My brother-in-law is frustrated with his kid, who had a broken guitar. My BIL asked him if he tried to take it apart to figure out what was wrong before coming to him. My nephew replied that he was afraid of breaking it more and making his dad mad. This baffled both me and my BIL, when we talked about it later; we both had our dads pissed at us for taking things apart when we were a lot younger than the nephew in question. His older sister is putting off getting her driver’s license, despite by sister and BIL having already purchased a car for her–nobody in my or my parent’s generation can figure out what her deal is. We all had our licenses on the day of our 16th birthday. There’s some sort of generational thing going on, but it’s not coming from the parents in this case.

          • houseboatonstyx says:

            @ Matt C.
            Yeah, “makerspace” is kind of a cutesy/pretentious name

            Which may be a useful feature, keeping out disagreeable people.

          • Matt C says:

            I think being a homeowner and being cheap helps in pushing you toward do-it-yourself. There’s an awful lot of things that you can fix with $10-20 in parts and an hour or two of time that will cost you $100 or more to have a pro look at.

            If you live in an apartment, these kind of issues aren’t supposed to be your problem. If you already know how to change a broken plug, it’s not a big deal, but if you’ve never done it before it will seem kind of scary, and do you really want to get pushed around by your landlord?

            Also, lots of people these days don’t feel like $100 is a very significant amount of money. Giving up X hours to save $100, where X is probably about 1 but maybe more like 4, isn’t an attractive tradeoff to them.

          • Matt C says:

            Initially I guessed that we would feel out of place and unwelcome at our local makerspace. It was promoted in a way that made it seem like a place for young, cool people to show off for other young, cool people.

            I don’t think feeling like you’re not going to fit in with a bunch of 22 year old cool kids means you’re a misanthrope than nobody should want around anyway.

            Fortunately ours isn’t a cool kids’ club, at all. Plenty of old and uncool people there, but you’ve got to get in the door to realize this.

            Presumably in time “makerspace” will lose its hipster connotations and greybeards like CatCube (and myself, I guess) won’t feel put off by the name.

  52. Jim says:

    I want to be sympathetic to the doctors, but I struggle to square the tales of woe with the fact that medical degrees, and indeed foundation posts, are massively over-subscribed here in the UK. All these prospective doctors are presumably aware of how arduous the training will be. They know exactly what they are getting into, and like many highly intelligent, driven people will tolerate fairly extreme working conditions for a number of years for the chance of a secure and lucrative career at the end. (Yes, jobs in the NHS are very, very secure, and NHS consultants are also able to build a private practice.)

    As a British taxpayer I also appreciate it when the government plays hardball when negotiating wage contracts, given the recent disaster when the government rolled over on GP contracts. Strangely there is little noise coming from GPs in the media about the “final straw”.

    • Murphy says:

      It’s a tournament. Winner takes all.

      Much like careers in science.

      http://www.johnskylar.com/post/107416685924/a-career-in-science-will-cost-you-your-firstborn

      There’s a small number of well paying good jobs (GP’s, consultants) but to get those you have to endure massive abuse. Some other careers which have similar distributions are actors and models. Many at the bottom of the pile get endlessly abused because abusive people take advantage of their hope that they can get to the top.

      If you feel happy about abusing the majority of junior people on the basis that a fraction of them will get to become senior people then have fun.

      Personally I’m more a fan of trying to treat people reasonably and fairly no matter where they are on the totem pole.

      • Jon M says:

        This simply isn’t true in medicine. Almost everyone who qualifies as a doctor in the UK can become a GP or a consultant if they want to do so (and most of them do).

        The reason so many people go in is precisely because it doesn’t have a tournament structure. Junior doctors get a fairly poor package early on in their careers, but almost all of them will end up in senior positions a decade later. You cannot say the same thing about actors, sports players or even academics.

        • Eggoeggo says:

          Well, the junior doctors who don’t quit or leave the country, which appears to be well over half from Scott’s statistics.
          Nowhere near as bad as actors or athletes though, true.

          • Jon M says:

            A few things here:
            1) The figure of not continuing training is still under half. Still surprisingly high historically but not a tournament payoff structure
            http://www.theguardian.com/society/2015/dec/04/almost-half-of-junior-doctors-left-nhs-after-foundation-training

            2) many of the ones who don’t immediately train come back and do more training later.

            3) locum positions in the UK pay extremely well. This article shows that the hourly rate is usually at least 2x the standard junior rate http://www.theguardian.com/society/2016/feb/11/are-locum-doctors-and-nurses-really-bankrupting-the-nhs. However that actually underplays it because the NHS’s real hourly rate is lower because they make the doctors work longer than legal hours. As a result being a locum is not necessarily an unattractive option for a few years. I have one junior doctor friend who spent five months working as a locum in a year, then went on a round the world trip for the rest of the year on the money he made in the first half. He’s now back in GP training.

            4) as you can see from the article, the NHS is deeply concerned about even a 50% rate of juniors not continuing their training, the issue here is not that there are many people running after a few jobs, but that the training period is unpleasant and a significant number of doctors consider other options as a result.

            5) the structure of medicine is an apprenticeship not a tournament. This structure also puts the lower downs in unpleasant working conditions and lower pay, but this is because there is a long period of human capital accumulation not because the number of high paid jobs is an order of magnitude lower than the number of people wanting the jobs.

  53. Salem says:

    Just to correct a misapprehension in this thread; the NHS is neither single-payer nor single-provider. There is plenty of private medicine in the UK, and it is growing as a share. The NHS provides free health care to anyone who wants it, but competition is allowed. Most of the consultants I know moonlight in the private sector.

    I think Scott is making a very strange argument here. Yes, being a junior doctor means hellishly long hours. But this is not a state secret! Everyone knew, or had ample opportunity to find out, about this, going in. They still chose to go down that path. And they are free to change paths at any time, and find a job either in the (admittedly artificially constrained) domestic medical private sector, or work as doctors overseas, or indeed stop being a doctor altogether. The fact that they don’t quit suggests that, all things considered, this isn’t such a big deal. They consider it their best option, after all.

    Now, maybe the way they are being treated is mean anyway. But government resources are limited. If we should give them more money – because let’s be clear, theit demand is not to reduce the workload, it’s for more money – then that has to come from somewhere. It is a hard road to hoe if you want to claim that junior doctors are the most deserving cause on a pure “hardship” basis. Their expected prospects, and their options, are so much better than most, that it’s genuinely scary to see them described as exploited.

    And bear that in mind if you want to argue “Oh, the other jobs they could get would be even worse, so they don’t really have options.” Well, the people actually doing those kind of worse jobs right now are then presumptively much more deserving of your sympathy, right?

    Scott tries to vaguely suggest that if we don’t treat the junior doctors better, we won’t be able to find anyone to do the jobs, but his heart’s not in it and he knows it’s not true. There are loads more people who want to become doctors. There is a genuine shortage of nurses, mind you, but because they aren’t quite of the same social class, it’s not on the leftist agenda.

    This is pretty much exactly the same as the “Madjunct” situation in the USA – people in objectively stressful conditions, but who nonetheless chose that situation, have lots of other options, and are better off than most of the population, demanding special treatment because they are comparing themselves not to the population at large, but to their peers who went into finance. And they get listened to purely because they are middle-class (in our sense, not the American sense). However, our junior doctors are far worse, because they are endangering lives, whereas if someone didn’t give a seminar in Grievance Studies I am sure society would somehow stagger on.

    Now if Scott was saying that the problem here is the new contract specifically, I could maybe see some argument, but the truth is no-one believes that. The new contract is a small change and he is quite right that this is all about “camel’s back” issues.

    • Andrew Sabisky says:

      agree with all of this, apart from the “endangering people’s lives” bit – mortality falls during doctor’s strikes pretty much always, largely because, I suspect, a lot of procedures of dubious necessity get postponed/cancelled. I talked about this a bit here http://www.ibtimes.co.uk/doctors-strikes-have-taught-us-that-were-too-reliant-healthcare-1554819

      • Murphy says:

        short term mortality falls, that doesn’t say much about long term. If you suspend all operations in a hospital for a day then that day will have low mortality no matter what the procedures were or how dubious. Even if you restrict it to definitely necessary surgery mortality on that day drops. (of course it just gets spread out over the following months)

        • JuanPeron says:

          This is a big thing to remember whenever you see a headline about “People who get this procedure have lower expected life span than people who don’t!”

          Even when true, that’s not always an indictment of the procedure. If you’re performing a surgery with high mortality, but great outcomes in the successful case, it may be that people are choosing a risky shot at returning to health over a guarantee of a slow-and-miserable decline.

    • James James says:

      The junior doctors knew about the long hours going in, but they didn’t know that their pay was going to be cut. And they can’t do anything about it (except strike).

    • Civilis says:

      Yes, being a junior doctor means hellishly long hours. But this is not a state secret! Everyone knew, or had ample opportunity to find out, about this, going in. They still chose to go down that path. And they are free to change paths at any time, and find a job either in the (admittedly artificially constrained) domestic medical private sector, or work as doctors overseas, or indeed stop being a doctor altogether. The fact that they don’t quit suggests that, all things considered, this isn’t such a big deal. They consider it their best option, after all.

      There’s one thing that bothers me reading this that I haven’t seen mentioned elsewhere. I work for an American IT company. Having a friendly relationship with our HR person, I’ve spent time discussing things with them. My impression was that, for corporate America, the average 40 hour work week is basically inviolable. Any discussion of workers being expected to work more than 40 hours a week (or, alternatively, 80 hours in a two-week period, to account for occasional odd shift schedules) gets corporate lawyers really nervous, and labor law lawyers virtually salivating with anticipation. And I have it easy as a salaried position; I know hourly workers that have to be forced to take lunch to avoid any perception that their employer may be in violation of the law. I also know that America isn’t unique in this regard; the German military had to pull out of NATO exercises recently because they hit their overtime limits.

      Why is it that the medical profession seems to be able to completely ignore the law? I can understand why individual doctors and nurses see it as their duty to their patients or career, and hospital administrators need to keep their ERs staffed. What I can’t understand is why nobody in the legal industry has gone after the medical profession, unless there are specific exceptions for medical practitioners.

      I lean somewhat libertarian, however I understand the reason for a 40 hour week labor law and would need to investigate the ramifications of changing it before I could unconditionally support changing it. Still, the idea that employees know what they’re getting into when they agree to a labor contract should be applied universally or not at all. I know a few people that would love a longer workweek if the pay was commensurate; for example, an IT support tech that works for $50,000/year for 40 hours/week may be worth paying for $100,000/year for 60 hours/week when you take into consideration the cost of insurance and other costs not directly in salary.

      Again, what I’m seeing might not be correctly applied. I’m in a region where most contracts are government, and having direct government supervision of your business practices makes you much more careful to stay in compliance with the relevant regulations. I know lawyers themselves have a reputation for overwork, so it’s not just medical people. Still, I’ve heard enough stories of fanatical-seeming business practices to keep people at 40 hours to know I’m not alone.

      • keranih says:

        It’s not just medical – all of the professional (non-academic) classes do this – lawyers, engineers, etc. (And the American military does it as well – there is emphasis on making sure lower ranks get time off, but that’s out the window for leadership levels.) Small businessmen and management of all stripes also regularly break 40 hours.

        And farmers have never worked 40 hour weeks.

        I don’t understand it either – the best idea I can come up with is a means for unions to ensure the maximum size of a workforce at a particular factory, and that somehow spread to the rest of the economy. To me, it doesn’t seem optimal for society.

        • arbitrary_greay says:

          The jobs where supervisors very carefully make sure their employees take their mandated breaks and lunches are jobs where the employees clock in and clock out, so that there is a relatively objective record of their hours.
          These are mostly lower-level jobs that are, well, hourly wages.

          Salaried workers rarely participate in such a system. Even those that involve timecards are often submitted at the end of the week, so no outside system verifying hours worked. This means that such practices as “assign X hours shift, 3X hours work” are possible.

          So the solution is…make more jobs not salaried, but hourly, and institute an entrance/exit-based punch-in/punch-out clock? Maybe verified with surveillance of the entrance/exit? (hah, good luck getting companies to sign on)

          • Paul Carbone says:

            Most of the salaried workers I know would hate that. It’d be a loss of control over their working life, and make time management at work utterly inflexible.

            A strict hourly system is perfectly appropriate if you need everyone to be working on the same machine or assembly line at the same time. That isn’t true for most salaried professionals, who are more apt to have a wider set of discrete tasks or projects to work on which are handed off to a client or someone else when complete.

            Or to put it more crudely; “Get out of my way, I’ve got shit to do!”

          • arbitrary_greay says:

            @Paul Carbone:

            I agree. I still marvel at how much laxer time management is at the company after that one, and there are definitely times of greater productivity at the latter. Wherever you set the time deadline, people will dawdle the 15 mins before “in preparation” of leaving. With a flexible finish time, people are more likely to finish their task, in stead of lining up to punch out.

      • John Schilling says:

        My impression was that, for corporate America, the average 40 hour work week is basically inviolable.

        There are two very different rule sets for corporate America, depending on whether a worker is a “manager”. In quotes because basically any white-collar professional work counts as being a “manager” – hey, there’s a secretary or a nurse or someone you could tell to do things for you, right?

        For non-managerial work, every hour of work has to be rigorously tracked, as does every break. Anything past 40.0 hours gets paid at 150% nominal rate, with other premiums for extra-long shifts, holiday work, etc. And any hint that someone is being asked, encouraged, or even allowed to work an untracked hour, e.g. allowing your employees to take lunch at their desks where someone might thoughtlessly ask them to do something, is good for fines and lawsuits and the like if a regulator finds out.

        This encourages corporate employers to carefully track and make sure nobody is working more than 40 hours unless absolutely necessary. And, yes, to chase them away from their desks to make them eat lunch in the cafeteria. It also, because of the premium overtime pay, encourages the workers to try and arrange to work 50 or 60 hours a week, which can be an interesting dynamic.

        “Managers”, which as noted means any professional, get paid a fixed salary nominally based on a 40-hour week but with no requirement to track which hours are actually worked. It may be against the rules to say “We expect you to work sixty hours completing these tasks next week”, but there is no bar to saying “Here are the tasks we expect you to complete next week, and you are not authorized to put more than forty hours on your timecard” even though the tasks will actually take sixty hours to complete.

        This incentivizes real management to assign more than forty hours per week of work to their not-really-management white-collar professionals. The best employers are careful not to do too much of this and/or to reward it with promotions, bonuses, and other benefits. The worst employers, keep losing their best people to the best employers.

        • Randy M says:

          When I’ve been promoted to salaried positions, it has come with the joke “You’re salaried now, which means we don’t have to pay you overtime, ha ha.”

        • arbitrary_greay says:

          The only place I saw that gave the option of overtime pay to salaried workers was a company that had clocking in/out as a requirement for security concerns. (they had military contracts, the clock operated the gate)
          So the hours of even salaried workers were recorded.

          Salaried workers automatically “donated” the first X number of overtime hours for free, before they started getting overtime.

        • Civilis says:

          I guess then it’s the high competition for qualified workers plus government oversight that keeps the local corner of the IT industry at 40 hours a week actually worked. ‘Better treat staff as non-managerial whenever there’s a doubt’ is a good rule of thumb when dealing directly with the government where a finding of violating the regulations can cost you your ability to do business with the government, and hence, your business.

          What would it take then to get most medical professionals qualified as non-managerial, and what would the effect be? Well, the effect would be a disaster for American medical care, unless the time limit is enough to basically import enough medical professionals from elsewhere, in which case you’ve just moved the problem…

        • Brian Donohue says:

          Does this apply to government workers? People I know who work for the government say they are shoo-ed out at 5:00. I know most of these jobs are unionized, so maybe the work rules are different.

          • John Schilling says:

            If it’s unionized, there will definitely be management oversight to make sure no union member does anything beyond what the union contract allows, because that way lies lawsuits and NLRB intervention. But management or non-union white-collar government people mostly set their own schedule like management and white-collar people everywhere in the US economy.

            Since actual government employees are exceedingly difficult to fire, if they work more than 40 hrs/wk it is because they actually like their jobs, or because they are angling for a promotion or the like.

        • As more anecdata, I am a late 20s white-collar professional, with all white-collar professional friends.
          Not one of us actually works a 40 hour work week. The average tends to be around 46 (rough estimate).
          It’s standard fare to work around 70 hours at least one week a month.

          Working only 40 hours is 100% guaranteed to involve huge misses on key deliverables and will get you fired. I generally work 45 hours a week at minimum and estimate I would have to work around another 15 hours to meet every deliverable.
          Unfortunately, the incentives are quite perverse, because the department is always seeking to “optimize.” Through attrition, we’ve eliminated 3 out of 17 positions in the last 2 years. Meeting every deliverable is a great way to encourage upper management to find more savings.

          I remember missing one key deliverable the Friday before Labor Day, which was supposed to be a half-day. I had already worked 12 hours, my Access database (lol, we care about efficiency and use Access) could not handle a certain query, and I decided to leave. Which resulted in massive beratement from my Team Lead.

          For certain emergencies, you will be expected to call in on your personal time off. Myself? Usually not. But I did call one person on her vacation, expecting to reach her voicemail. Instead she was complaining she could barely hear me because she was at the top of the mountain and had quite poor reception.

          I will say, not all of Corporate America is structured this way. There are plenty of individual employees, departments, and companies that do not seem to do jack shit.

          Corporate America culture in general varies greatly from department to department. My office was empty on Christmas Eve, except for my Department, which had meetings scheduled until 5 PM (?). My company also removed all the water coolers because they encouraged excessive fraternization.
          Now, my Father-In-Law’s company. He received a company-wide email from their CTO saying to report to the warehouse for an emergency. He got there, and saw March Madness projected on the warehouse wall. That was their entire afternoon.
          One of my friends works 70-80 hours week on average, but once a month his department head takes his department of 10 or so people to a bar and they run up a $2000 bar tab which is charged to the corporate account.

          • HeelBearCub says:

            Assuming you are a programmer, go find a different job. Because, unlike many people there, you have job skills which are greatly in demand.

            I have spent time working very long hours. All programmers do, at some point. I recently had a period where I worked 7 days a week for about 6 months straight. But it wasn’t because management was playing bullshit games. The attitude you are describing sounds like a company that will eventually implode.

          • Dahlen says:

            My company also removed all the water coolers because they encouraged excessive fraternization.

            I don’t even know what the heck people use a water cooler for (yes, I know it’s right there in the name, but I have genuinely never used one), but this sounds positively dystopian.

          • Ahhh, were only I programmer….

            I’m in Accounts Receivable for a healthcare company. I am searching for new positions, but it’ll be a stretch to land the kind of job I want.

            Our company is pretty restrained, but even within our company, our department has a reputation for corporate dystopian affairs. It’s amusing walking through the campus at Christmas, seeing decoration after decoration, until I arrive at my department. Gray walls, as far as the eye can see! Not a branch of mistletoe in sight!

      • Corey says:

        Huh? As a programmer, in most jobs I’ve had, if I left after working only 8 hours that day, it was considered roughly equivalent to defecating on the boss’s desk.

        • Civilis says:

          I’ve perhaps internalized the very screwed up local dynamics as being standard. We have the Federal Government as basically the number one local employer (if you’re working for a company, that company is billing most of its hours to the Federal Government one way or the other) with all the regs that entails, and the number two local employer feels like it should be the legal industry, with enough employment law experts that employers not dealing with government regs aren’t seemingly willing to risk the army of employment lawyers.

        • Edward Scizorhands says:

          Those jobs suck. Are you in the video game industry? If not, there is no need to put up with that. Go home, and spend the time job hunting if you think you will get the axe because you have self-respect.

          • Corey says:

            Ordinary embedded Linux stuff. I eventually fell into this job, which doesn’t need a lot of hours. In the older jobs I actually did only work about 40 hour weeks, which is how I knew the reception it got. OTOH I cared less because it seemed like India was going to eat the whole industry (and all knowledge work) anytime, so job loss was just a matter of time no matter what (nowadays I know better).

          • I cared less because it seemed like India was going to eat the whole industry (and all knowledge work) anytime

            Among my reference group, I cannot find a single person who will speak highly of work quality from that country.

            I wonder what the impression is among SSC readers.

          • brad says:

            Forget India, even outsourcing programming to Indiana doesn’t seem to work very well for very many companies. I could speculate, but I don’t think anyone knows for sure why outsourcing / remote work in software development is so often a disaster. If you could crack that nut you’d be a billionaire.

          • Maybe the reason that even fairly local outsourcing of programming doesn’t work well is that there are fewer opportunities for casual contact than there are in an in-person environment.

            See also Jane Jacobs for why there’s a lot of invention in cities.

            On the other hand, my impression is that open source is a lively and creative environment, and it’s almost all virtual contact. If virtual works better in that environment than in companies, there’s something else to be explained.

          • Corey says:

            @Beta & replies: keep in mind the difference between outsourcing and offshoring. Both my problematic job and my current one got around a lot of the typical India-developer problems by opening offices there and hiring direct. (In the older job this fed my despair – we got decent-quality work at 1/3 the price. In my current job, we actually have the opposite problem than typical – instead of programmers who only know Big Data systems struggling with embedded Linux, we have truck-transmission-controller programmers who aren’t comfortable in multiprocess C++ with a gigabyte of RAM).

            Outsourcing, whether local or remote, causes lots of problems due to misaligned incentives. In programming this tends to manifest itself by throwing piles of barely-literate bodies at any project.

          • brad says:

            @Nancy Lebovitz
            The common wisdom is that open source is good for highly technical code (for lack of a better term, think linux kernal), terrible for UX (GIMP), and a mixed bag in terms of security (openssl vs libressl).

            Inasmuch as that translates back to outsourcing/offshoring/remote work in the private sector I’d expect that the embedded space Corey is talking about would be closer to the ‘highly technical’ side of things.

        • Saint Fiasco says:

          Your boss sounds like he deserves to have his desk defecated on.

          Alternatively, if defecating on a desk is too unsanitary, consider leaving for the day after working 8 hours. It’s apparently the same for them.

      • Adam says:

        The actual hours you work billed to a government contract do have to be kept under the limit the contract specifies. I’m not an attorney, but I worked for the Comptroller’s office last time I was still on active duty and we had to be certified in fiscal law. The basic idea is the agency you’re working for is paying for a certain number of hours worked and if you work additional hours for free, you’re donating to that agency, and they aren’t allowed to accept donations because then they’re exceeding their appropriation from Congress. You can donate money to the government if you want, but it has to go directly to the Treasury. You can’t donate to a specific agency.

        My wife experiences this and it was weird to see when I first saw it. She can work more than 8 in a day and more than 40 in a week, but she has to be comped and can’t exceed 80 in any pay period because 100% of her hours are billed to the Navy. Of course, if you’re actually a uniformed servicemember, you can work 15 months without ever getting to go home while getting two hours of sleep a night if you’re lucky, not only with people dying all around you, but with people trying to kill you at the same time. It’s a little counterintuitive that that’s fine, but a contractor can’t work a minute over 80 hours or it’s illegal, even if they’re a professional and even if they’re a manager. But that’s the way it is. I’m sure that’s part of the reason no government project ever finishes under budget. Purchase outputs instead of outcomes and you’ll get outputs instead of outcomes.

        • John Schilling says:

          I’m assuming this is just for blue-collar non-management work. I’ve worked for several government contractors, and run one myself, and never seen anyone even attempt to enforce a rule against white-collar professionals working unpaid overtime on a government contract. Some contractors de facto assign and require such work, some merely allow it if you’re sufficiently motivated, nobody tries to stop it.

      • Joe W. says:

        I lean somewhat libertarian, however I understand the reason for a 40 hour week labor law and would need to investigate the ramifications of changing it before I could unconditionally support changing it.

        I’m curious: what, in your view, is the reason for a 40 hour week labor law? And, by ‘reason for’, do you mean ‘reason it exists’ or ‘argument for why it is a good idea’?

    • Those very long hours might be a trap because they leave people with not much in the way of mental resources or time for job-hunting.

    • grort says:

      because let’s be clear, their demand is not to reduce the workload, it’s for more money

      I notice that I am confused.

      I have trouble imagining what these doctors are thinking. Hundred hour weeks, thirty-six hour shifts, and they’d rather have more money than fewer hours? How can this be?

      • The Nybbler says:

        “More money” is easier to enforce. If you demand and receive a 20% raise and no extra 20% appears in your paycheck (or mystical fees appear making it go away), you can point to that and cry foul. If your nominal hours are reduced but the actual number of hours you’re expected to be working doesn’t change, that’s harder to show.

        In general, when making deals with an untrustworthy counterparty, making sure all their concessions are verifiable is vital. Otherwise you’ll likely give up something for nothing.

        • Eggoeggo says:

          And a simple demand for higher wages is hell of a lot easier to do through strikes and union organizing than

          “What do we want?!”
          “Structural changes in the workplace that allow junior doctors to coordinate to improve working conditions!”
          “When do we want it?!”
          “Once we all have a vacation to read and approve the 3000 page negotiated contract!”

    • Protest Manager says:

      Differences:

      1: The abuse of the “junior doctors” is literally criminal, in that their employer is violating the law WRT work hours. “You should have know they gov’t would violate the law and abuse you! Suck it up!” really isn’t a winning argument.

      2: Doctors provide a lot more value to society than adjunct professors in queer studies. So they’re more valued, and get more sympathy.

      3: NHS may not be a complete gov’t monopoly, but it’s close. Universities are not. Unless there’s someplace else they can reasonably go, their employer gets less “benefit of the doubt”.

      4: It appears the British Governing classes wish to sell a lie: “We can get excellent NHS service at the current level of funding.” They are telling that lie on the backs of the “junior doctors”.

      I see no reason to support gov’t lying.

  54. The Do-Operator says:

    I also attended medical school in Ireland, and I agree fully with this description.

    I just want to point out that there is a major contributor to this situation which is easily fixable: Junior doctors in Ireland (and presumably the UK) spend most of their time doing routine jobs that are handled by nurses or phlebotomists in almost every other civilized country. This includes recording ECGs, inserting venous lines, taking arterial blood gas samples and giving the first injection of any newly prescribed intravenous antibiotic. They also have to do a lot of stuff that should be handled by non-medical staff, such as tracking down old X-rays or old handwritten patient records. (It is possible that they have since moved into the 21st century and digitalized this, but if so this happened during the last 4-5 years).

    If they just hired trained nurses or something to do those tasks, there would be much less of a need for junior doctors to work those ridiculous hours. At the very least , they would be much more likely to get sleep while on 36-hour call if they weren’t constantly woken up by nurses who need them to give a routine injection.

    • Anonymous says:

      Or, as Shieldfoss suggests, remove the people who have financial incentive to permit as few people to be doctors as possible from deciding how many people get to become doctors.

    • Jill says:

      Sounds like a good idea to hire trained nurses.

      • keranih says:

        But you can’t get trained nurses without starting with untrained nurses.

        • Nornagest says:

          Doesn’t matter in the short term, if the supply of nurses is less constrained than the supply of doctors. I have no idea whether it is or not in this case, but the nurses aren’t striking.

          In the long term you’ll probably need to make some adjustments, but at least you have two supply streams now.

    • Scott Alexander says:

      Yeah, I’d forgotten about that!

      It seems weird that a cash-strapped system would use more-trained professionals in a case where they could get away with using less-trained professionals, but I wonder if junior doctors’ desperation and inability to go anywhere else actually means they can get away with treating them worse than nurses. I guess I’d need to hear from a British or Irish nurse to know if that’s true.

  55. Andrew Sabisky says:

    A number of other relevant facts:

    Medical school admissions are heavily limited to keep supply of doctors tight. There’s no shortage of British-born youngsters wanting to become doctors! There are 12.5 applicants for every medical school place. In 2008, naturally, the British Medical Association (doctors’ union) voted to restrict places and ban new medical schools from opening. http://www.bmj.com/content/337/bmj.a748

    standard cartel behaviour.

    Secondly, one issue that no one is really addressing honestly is the changing nature of the medical profession, and by that I mean that increasingly high numbers of female doctors. In the old days, the structure of “work yourself like mad to qualify as a consultant for big £££ further down the line” worked reasonably well, but women are naturally quite prone to taking career breaks in order to have babies, which means they are much less likely to wind up qualifying as consultants and earning the £££ to justify all the early-career craziness. The whole system needs a rethink, accordingly. This also has implications for general practice and a shortage of GPs willing to become partners.

    lastly, the entire strike has been conducted with an extraordinary quantity of lies on both sides. The government have tried to make their case on the basis of a somewhat dubious weekend mortality effect, and the junior doctors have tried to argue “oh we’re not striking about pay, this strike is about patient safety” – as Scott points out in the comments above, this is completely bogus, there seems to be no relationship between junior doctor hours and patient death rates.

    • Jill says:

      How to have honesty emerge in such situations is a good question.

    • Douglas Knight says:

      Your comments about women make sense for America, where all doctors quickly move on to the $$$ stage, but not in Britain. If the woman never gets the £££, then it doesn’t justify her decision to become a junior doctor. But if she spends enough years working long hours as a junior doctor, it justifies the government’s investment in training her. It may create a shortage compared to training a man, but if it is cost-effective to train one woman, it is cost-effective to train two. (Yes, it is probably more cost-effective to train a man, but maybe not if the woman spends more years as a junior doctor, even though her total career is shorter.)

  56. metalheadcatbus says:

    This article in the NYT is from a few years back- I wonder what you think of it? http://www.nytimes.com/2011/08/07/magazine/the-phantom-menace-of-sleep-deprived-doctors.html

    • Thanks.

      A major point is that handoffs from one doctor to another are dangerous because doctors aren’t trained in how to do handoffs well, and their need to have time and focus for handoffs isn’t respected.

      Also, there’s a lot which could be done to handle information better, like keeping track of drug interactions.

      • Wrong Species says:

        Even if doctors were more trained in handoffs, it still seems like it would be a loss in productivity though. The time spent explaining all of the doctors mental notes would be less time used for helping patients.

  57. Siah Sargus says:

    Okay, I’m not an expert on the inner workings of becoming a doctor in every single country in the world; hell, I barely understand how some parts of the American system work. But I think the problem that Scott described also affects people’s trust in the system. (And solidified my choice to not become s doctor).

    I know this is going to sound arrogant, but I don’t think I would ever see a general practitioner for medical advice. Odds are, even if it’s a complex and serious problem, I can find out what I need to know with a couple of searches and a pdf to a textbook that’s only one edition out of date. I’ve done my own bloodwork through services on the internet. I can set up an IV on my own. Drugs can be bought without prescriptions, and usually for slightly cheaper. The only routes of administration I can’t do are rare and redundant, like IO. Taking care of my health is something that I have to do by myself, because the current system otherwise is too expensive, too prohibitive, and too credentialist.

    It would be great if doctors had shorter hours, could study more and more thoroughly, had more residencies open to them, and didn’t have to worry about the politics of a detatched batch of asshat bureacrats, but I have no idea how to create that utopia. Western medicine is amazing, the wealth of information contained in it is tremendous, but the route of administration definitely needs some work.

    • Jiro says:

      I am skeptical that you could do that without screwing up in corner cases, but even if you could, it’s clear that the vast majority of potential patients can’t.

    • I think you’re overoptimistic about the quality of the information that’s out there and also about how badly things can go wrong with your health. You haven’t considered the possibility of a injury or illness severe enough to keep you offline.

      This being said, I wouldn’t be surprised if your methods are enough to handle a pretty high proportion of problems.

      • Rhiannon says:

        I think he has considered the possibility of an injury severe enough to take him offline. It’s the general practitioner he won’t seek advice from, not necessarily a specialist if something goes really wrong.

        It’s a shame that there are no cheap insurance options which cover only emergency care and specialist advice in the case of serious injury and illness.

      • Nornagest says:

        When I’ve tried to figure out my own health problems, I’ve usually been able to find out what it could be pretty readily. What I haven’t easily been able to find is info on relative frequency and differential diagnosis, which leaves a pretty big horses-versus-zebras problem.

    • Nornagest says:

      How much is your time worth? Even assuming you do as well as a GP would, that sounds like it would take a lot of it.

    • Rusty says:

      I love this thought and I love Dr Google. But then I remember going in to see my GP with what I thought was a really painful insect bite and she said no, that’s actually shingles and as I’d come in right away the drugs they could prescribe might make the attack a lot less severe than it would have been otherwise. So maybe I won’t give up on the real thing just yet.

  58. James James says:

    “I sort of sympathize with the government’s complaints that they don’t have enough money to make a system where doctors don’t have to work a bunch of 36 hour shifts, but I feel like if you don’t have enough money to run a health system that treats its employees like human beings, maybe you shouldn’t be running your country’s health system.”

    This reminds me of someone once saying “if you can’t afford to pay the minimum wage, you shouldn’t be running a business.” It’s a bizarre assertion.

    The US spends twice as much on healthcare as the UK as a percentage of GDP. Trying to increase the percentage in the UK would be a… challenge, and it wouldn’t improve outcomes (see Robin Hanson).

    One good way to increase junior doctors’ pay and decrease their hours would be to decrease consultants’ pay and increase their hours.

    I have little sympathy for junior doctors who support the NHS. If you support a monopsony, it’s churlish to complain when it cuts your pay and your only alternative is to emigrate.

    If we didn’t have a monopsony in the UK, they could more effectively negotiate their pay by moving jobs.

    Even with a National Health Service, having national pay scales is crazy. Letting hospitals set their own pay would be an improvement.

    • James James says:

      We should also move away from the situation in the UK where the government pays for your training but pays you very little and then you move to Australia. Better to make medical students pay for their own training by debt (perhaps the government could lend them the money), pay them more to enable them to service that debt, and if they move to Australia at least they still have to pay the debt.

    • suntzuanime says:

      I think the implication would be that when you stopped running your country’s health system, you would permit other people to take it over, rather than outlawing healthcare altogether. Although even if you did, it wouldn’t hurt outcomes (see Robin Hanson).

  59. Sun Kitten says:

    Just to clarify, while the junior doctors are on strike, emergency care is being covered by the consultants, who are 100% behind their junior colleagues. It’s the regular clinics and appointments which are being cancelled over the strike periods – which sucks if you’ve waited for an X-ray or something and now you have to reschedule, but at least the emergency care is fully covered. I am not a doctor, and I do support their cause (but I am also fortunate enough to not be waiting for any appointments).

    • g says:

      Right. If you’re going to be taken to the hospital with sudden-onset chest pains, the day of a junior doctors’ strike is pretty much the best possible time for it to happen.

      • Leit says:

        On the other hand, I have a brother in the UK whose appointment for dental surgery was cancelled, and is now dealing with a tooth cracked so badly that it’s cracked another tooth. It’s apparently extremely painful, but doesn’t rise to the level of emergency.

        Kind of sucks to be in that bracket.

    • Eggoeggo says:

      Ahh, I still remember my mother going in for some routine tests when she got sick. It took months to get the results back, and by then the cancer had already spread too far for anything to be done.
      Comforting to know some things about the UK never change.

  60. Rusty says:

    I must admit to finding this post pretty disappointing. It didn’t seem to amount to much more than ‘I don’t know anything about the situation but I expect the doctors are right and the employer is a villain.’ I expect more rigour from this blog. Despite living in the UK I understand this dispute even less than Scott but I’d like to have some of the following addressed:
    1. How long do junior doctors actually work? How has that actually changed with the 48 hour week. Does time spent on call but in bed count toward the 48 hours?
    2. How many doctors does Australia even need? It’s population is prett small vis a vis the UK’s. Surely they can’t take all our doctors??
    3. What kind of shape are the UK’s finances in? Is there plenty of money in the NHS so we could send some the doctor’s way? My impression is that funds are super tight and the quality of service is declining.
    4 what was the impact of the new contract the last Labour government signed? My impression was that it made a lot of doctors very well off though I’m not sure how that squares with what I gather is a severe recruitment crisis.
    And so on. Anyway I feel there are a ton of interesting questions to address and the idea that the government is being wilfully difficult strikes me as unlikely. But, as noted, I don’t really know.

    • JDG1980 says:

      What kind of shape are the UK’s finances in? Is there plenty of money in the NHS so we could send some the doctor’s way? My impression is that funds are super tight and the quality of service is declining.

      Does it matter? If being a doctor is a crappy job, fewer people will become doctors, and those who are already in the system will become more and more disgruntled and start looking for other options. Pleading poverty doesn’t change that. We hear such claims all the time in the US from both public and private employers – “we can’t afford to pay decent wages”. Well then, don’t expect decent employees or a decent quality of work.

      • Rusty says:

        Well that sort of begs the question. If your premise is that the doctors have right on their side then that would be the conclusion also. Anyway the point I was trying to make is that Scott comes across as a partisan in the debate and not a very well informed one at that. As I say I am even less informed than he is but I found the post a bit of a disappointment.

    • JBeshir says:

      The UK’s finances are good enough (and the NHS currently cheap enough) that it could afford to pay more. It has a deficit, but it’s a relatively small one by international comparisons, and they’re talking seriously about closing it by 2020 (although most people don’t expect it to actually happen).

      Unfortunately the reason those finances are good is that there’s an austerity push, with top-level budget squeezing used to force lower level government to become more efficient, against the natural behaviour of bureaucracy. This is a very blunt tool, and makes the government bad to work for in a lot of parts, and even causes blips in service functioning here and there. It does seem to work, and is the kind of tactic which can be used when the right-wing political party outright wins elections and can act fully on their policies without compromise.

      The NHS is not literally facing cuts, the Conservatives pledged to “ring fence” its budget in order to win the election, because they’re viewed suspiciously when it comes to the NHS and the NHS is very popular- but it’s facing roughly inflation-indexed funding at a time of an aging population and rising expectations to provide more expensive, new treatments, so it’s got much the same budget pressure. So long as having local doctors leave and immigrant doctors replace them is a functioning release valve for that pressure, it’s likely to be used.

      Combine with the latest push for a “seven days a week” NHS service for the public, and you have the current situation.

      A take away: Don’t just blame the Secretary of State for Health, this one goes all the way to the Chancellor of the Exchequer and the Prime Minister, and not just because they appointed a lizard.

      • Furslid says:

        That’s actually a common ploy when faced with budget limitations. Cut essential services rather than pork. Then plead necessity. Get more money because essential services are threatened.

        It’s from the lizardman playbook, but it works.

  61. suntzuanime says:

    Wow, I had no idea things were so bad over there. I’d been trusting the socialists when they said “well, other countries have state-run healthcare and it’s not a catastrophe”.

    • seladore says:

      Well, it’s becoming a catastrophe because the person in charge (Jeremy Hunt) is ideologically opposed to state-run healthcare.

      Before taking office as health secretary, Jeremy Hunt co-authored a book describing how best to dismantle the NHS and replace it with a US-style insurance-based system. And all his actions since being put in charge are consistent with this.

      http://www.independent.co.uk/news/uk/politics/jeremy-hunt-privatise-nhs-tories-privatising-private-insurance-market-replacement-direct-democracy-a6865306.html

      So, conditions deteriorating in the NHS is a direct result of his plan. The ‘destroy the NHS’ playbook basically goes “cut funding and push junior doctors to breaking point; NHS standard of care goes down; point to decreasing standard of care as evidence that the private sector needs to step in to make things more efficient”.

      So what we’re seeing is not a socialist healthcare system in crisis. It’s a socialist healthcare system being actively sabotaged by someone ideologically opposed to socialist healthcare systems.

      • Eggoeggo says:

        Jeremy Hunt has been health minister for the last 3 and 1/2 years.
        He must work fast to have caused this problem while Scott was in Ireland.

        • seladore says:

          I was mainly talking in the context of the current doctor’s strikes — they aren’t striking over general bad working conditions, they are striking specifically to oppose contractual changes being imposed by the current government.

        • Scott Alexander says:

          I was in Ireland during their giant economic collapse, which I think had something to do with it. And the party in charge of health care at the time was a pretty rightist/libertarian party for Ireland.

          • JDDT says:

            To clarify — were you in the Republic/Ireland/Eire, or in Northern Ireland/British Ireland?

          • LaochCailiuil says:

            Afaik he studied in University College Cork which is in the Republic of Ireland. My maxim for health care in Ireland and my relation to it is: don’t get sick! By my experience of healthcare in Ireland is it’s a mess of bureaucracy with a poisonous mix of Catholic attitudes to well being and morphological freedom.

        • He must be especially powerful given that Ireland is a separate country from England.

      • suntzuanime says:

        Yeah, that’s a really good argument against letting democratically-elected governments run things.

        This sort of strategy of “let’s make this terrible so people will beg us to kill it so we can kill it” seems to pop up in all sorts of contexts. I wonder if there’s a good way to defend against it.

        • Andrew says:

          Make it much easier to kill things.

        • satanistgoblin says:

          I do not expect that is a big problem because politicans probably care more about being reelected than achieving preferred policy as fast as possible.

        • Jill says:

          One solution is to get more pragmatic, and less ideological, people in government. And more variety in elected officials. But many people believe that ideology is the important thing to look at in voting for officials. Not necessarily so.

          • Wrong Species says:

            Ideology does become more important when there is more disagree on core values though. Would you vote for a competent Hitler over a less competent progressive? What if he promised to be bipartisan and work across the aisle? Being less ideological isn’t always a good thing. I wouldn’t want someone to make a deal with competent Hitler in the name of bipartisanship. I would want that person to be stubborn and refuse to negotiate over my core values.

          • Jill says:

            Hitler was not competent. He was insane.

            Values are indeed important. But ideology is more constraining than values. It’s more like a secular religion.

          • John Schilling says:

            Hitler was not competent. He was insane.

            You understand it is possible to be both, right?

            Hitler’s empirical success argues strongly for his competence. But consider Niven:

            “I don’t shoot a man for being incompetent in the Devil’s work. I shoot him for being competent in the Devil’s work. Admiration for his technique is part of the process”

          • Jill says:

            I guess we’re into semantics here. I was thinking about competent in governing. Perhaps you were thinking of competent in killing people.

          • Nornagest says:

            The guy took over a country and then most of Europe. You don’t get to do that without being exceptional at something related to the business of politics. He was not a good guy, we know he’s not a good guy, but it behooves us to understand how a stunt like that can be accomplished. If only because it might be attempted again.

            Refusing to look too close at the man because of his evident evil is about the least pragmatic response to it that there is.

          • Wrong Species says:

            “I was thinking about competent in governing. Perhaps you were thinking of competent in killing people.”

            Lets say our hypothetical Hitler was good at both. He was good when it came to infrastructure, running the economy, providing the right mix of government intervention and a free market. But he also thought jews were evil and should be exterminated. I assume you would pick an incompetent progressive over this evil.

          • Tracy W says:

            I think the Nazi’s atrocities tend to (very naturally) destract us from how terrible their policies were for Germans generally, no matter how ‘Aryan’ the Germans were.

            Hitler’s policies led to the death of about 10% of Germans, Germany being militarily overrun and unable to defend itself against anything its enemies choose to do (eg the firestorm of Dresden, the Russian army’s raping of German women), and the deaths of most of the top politicians at the time, by suicide or judicial execution. German cities were bombed out ruins and much of the population was on the verge of starving. As governments go, that’s about as incompetent as you can get.

            Hitler’s early successes seem to be down to a combination of Germany being a very large already somewhat industrialised power with a lot of population, so really in Europe only France, Russia, or Britain could match it militarily, the strong desire of British and French politicians to avoid a repeat of WWI, and Field Marshal Romney (sp?) being both competent and prone to aggressive over-interpretation of orders (eg “provide forward scouting” as “if you see a weakness, invade!”)

          • Samuel Skinner says:

            “As governments go, that’s about as incompetent as you can get. ”

            You could say the same thing about Napoleon.
            https://en.wikipedia.org/wiki/Napoleonic_Wars_casualties

            Failing to conquer the world doesn’t mean you are incompetent. It is a really hard thing to do.

            “Hitler’s early successes seem to be down to a combination of Germany being a very large already somewhat industrialised power with a lot of population, so really in Europe only France, Russia, or Britain could match it militarily,”

            I think you are underestimating the task Hitler accomplished. The German Army was capped at 100,000 men under the Treaty of Versailles (for comparison Poland put together a million men to fight in 1939). Rebuilding the armed forces and more importantly arming them was a monumental task. Wages of Destruction goes into the details, but essentially no one is going to be able to pull it off- you need someone willing to take Germany far past the brink of financial ruin (and then be willing to resort to looting other countries) in order to rebuild their armed forces to the level Hitler did.

            “the strong desire of British and French politicians to avoid a repeat of WWI, ”

            The French invaded Germany in 1923. Given the state of the German military, there was no practical way the Germans could replay WW1 at the start of Hitler’s rule.

            “and Field Marshal Romney (sp?) being both competent and prone to aggressive over-interpretation of orders (eg “provide forward scouting” as “if you see a weakness, invade!”)”

            If you are referring to the Battle of France, it was a host of happy accidents for the Germans. The original plan was found by the allies, so they went with a new one involving striking through the Ardennes… I’m sure you are probably aware of the details.

          • Tracy W says:

            @Samuel Skinner: indeed I have said similar things about Napolean. Although he was good at winning battles and the Napoleonic Code was kept for quite a while, so I do think a bit more highly of Napoleon’s competence as a leader than Hitler’s.

            My criticism of the Nazi’s incompetence is not based on their failure to conquer the world but on that their policies led to the deaths of millions across Europe, including Germans, and to Germany being invaded and occupied by its enemies and numerous atrocities were committed against German citizens. The Nazis managed to get Britain, the USA and Russia united against Germany.

            By persecuting the Jews the Nazis also managed to move the centre of scientific work to the USA, kinda the opposite of a Golden Age.

            As for rebuilding the army, the British during WWI managed to go from starting the war with 400,000 to an army of 4 million at the end. Note that was during a war famous for the scale of its slaughter, and in Britain which historically relied on its navy. So I very much doubt that rapidly rebuilding an army is that tough a task.

            I have read the Wages of Destruction. The author accumulated an impressive amount of statistics, but I’m not so impressed as he was by the Nazi war regime, from the author’s data it consisted of squeezing German workers living standards (and working Jews, Slavs, etc to death). The British were producing on a level equivalent to the Germans without squeezing their population’s living standards to the bone.

        • Chalid says:

          “Those contradictions won’t heighten themselves, comrade!”

        • Jill says:

          “This sort of strategy of “let’s make this terrible so people will beg us to kill it so we can kill it” seems to pop up in all sorts of contexts. I wonder if there’s a good way to defend against it.”

          That’s an excellent question. In the U.S. and perhaps in England too, we’ve had heavy propaganda for decades now, persuading many or most people that government is always the problem, never the solution. So voters are actually voting for the candidates who seem to hate government the most, and who are likely, when in office, to make sure government does not work.

          A large part of Trump’s appeal is his outsider status, in addition to his billionaireness, in our money worshiping culture. His supporters think it’s wonderful that he has zero experience in government.

          To combat this situation, perhaps we would have to combat the propaganda, so as to persuade voters to elect candidates who are at least willing to give government programs a try, and try to make them work as planned, rather than destroying them.

          Being destructive is such an easy job though, that everyone seems to want it. Voters want to bash politicians and the government in general. And the victorious “outsider” politicians who are elected by these voters, want to destroy the government, once they get into office.

          It’s the ultimate self fulfilling prophecy. Government doesn’t work. Vote for me and I’ll prove it.

          • Randy M says:

            His supporters think it’s wonderful that he has zero experience in government.

            What about having more school teachers, accountants, engineers, scientists etc. in government positions?

          • Jill says:

            Some people think Trump has something to offer, in spite of having no experience in government. I don’t. Many school teachers, accountants, engineers, scientists, even some real estate developers do. Of course, opinions may differ on this. And I was thinking mostly of Congress members, not the president.

          • Randy M says:

            That’s fair, I guess. For what it’s worth, I really think Trump is the last example to go to when discussing doctrinaire free-market advocates who would want to have their government perform poorly on his watch to make a point.

          • Anonymous says:

            It’s the ultimate self fulfilling prophecy. Government doesn’t work. Vote for me and I’ll prove it.

            Yet more evidence that you never step out of your echo chamber.

            Trump is about the opposite of “government doesn’t work, and I’ll stop it from doing things” – he specifically runs on the platform that he can make government do things better. Build a wall on the Mexican border, exercise quality control on Muslim immigrants (note his statement was (paraphrased) “stop them from coming in until we can figure out how to not let in terrorists also”, i.e., he thinks that with proper management government is capable of exercising good judgement), negotiate trade deals to benefit Americans, etc.

            All of those are active things that Trump promises to do and his selling point is that he’s competent to get them done because he’s both experienced dealing with government and in the private sector and he’s personally observed that the people running the USG are both incompetent and corrupt.

            But go back to the talking points, please.

          • “we’ve had heavy propaganda for decades now, persuading many or most people that government is always the problem, never the solution.”

            You don’t find it odd, in that case, that government has continued to grow, not shrink? If your account is true, wouldn’t you expect lots of reforms in the direction of privatization–school vouchers replacing public schools, individual retirement accounts replacing social security, a reduced role for government in medical care? Which hasn’t happened.

            I think a more accurate account would be “many people have argued for less government than Jill thinks desirable, but have not persuaded enough voters to actually move the U.S. in that direction.”

            “Propaganda” meaning “arguments Jill disagrees with.”

      • Mary says:

        “So what we’re seeing is not a socialist healthcare system in crisis. It’s a socialist healthcare system being actively sabotaged by someone ideologically opposed to socialist healthcare systems.”

        False dichotomy. It is exactly its socialism that permits his actions. You do not put the system in the hands of politicians without the risk of politics.

        • hlynkacg says:

          You do not put the system in the hands of politicians without the risk of politics.

          Exactly.

          If you don’t want something to be politicized don’t put politicians in charge of it.

    • JDG1980 says:

      Wow, I had no idea things were so bad over there. I’d been trusting the socialists when they said “well, other countries have state-run healthcare and it’s not a catastrophe”.

      The NHS system (single-provider, with the government directly employing doctors) is pretty unusual among First World countries. More common is single-payer, which is like the US Medicare system but covers all citizens, not just those over 65. Some European countries also use heavily regulated systems of compulsory private insurance, similar to PPACA.

      It appears that the single-provider method has some serious problems – though it’s hard to tell just how much of this is inherent and how much is limited to the implementation in the UK. However, most left-leaning Americans (i.e. the kind of people who vote for Bernie in the primaries) aren’t in favor of an American NHS, but rather “Medicare for all”. Under that proposal, doctors and hospitals would still operate independently, but private medical insurance would be replaced by a single-payer national system.

      • JBeshir says:

        It works really well from a user’s perspective; it gets results comparable to the most expensive in the world for a lot less.

        It’s just that it turns out it’s crappy to work inside something with so much pressure to be cost-effective; working in the NHS as a doctor is like working in an Amazon warehouse. This would be mitigated by the need to stop doctors going overseas pressing in the opposite direction, except apparently immigration of doctors is working to diminish that pressure.

        • Is it reasonable to assume that the world will equalize enough that there will no longer be a flow of doctors and nurses into the UK?

          • JBeshir says:

            I certainly hope so; at which time conditions would probably improve. I think it is probably good to try to make conditions improve somewhat sooner than that, though.

    • TheAncientGeek says:

      The NHS is so unbad that the level of approval for it has been described as religious. The right wingers have been seizing on the junior doctors dispute, an isolated data point, as proving some sweeping point about socialsm. Well, you can’t prove things with single data points, and Cameron’s Britain isn’t socialist in any meaningful sense.

      • Joe W. says:

        The level of approval religious believers have for religion has also been described as religious. And I would expect them to spend more effort thinking about it. A religious person can leave their religion; a British person who decides to weigh up the pros and cons of socialized medicine cannot opt out of the NHS.

        • sohois says:

          This is false, and I’m surprised hasn’t been mentioned in any comments so far. Britain has privately run health care systems and private insurance if people wish, however few do since the NHS can provide without the additional cost of the insurance.

          There was a bit of a brouhaha a quite a few years ago about people paying privately for access to certain drugs not available through the NHS, and subsequently being denied further NHS treatment, but I’m not sure if that policy still exists. Thus it is entirely possible to opt out of the NHS. One might make the argument of the extra tax burden, but then taxes go to all kinds of services that an individual may never use.

          • Furslid says:

            Of course you can opt out of Catholicism. You still have to tithe to the Church, that’s not an option. If you want to get married, better get married in the Church. No one’s forcing you, you have the option to stay single. Of course we’ll still ostracize you for any relationship you have. Extramarital sex is wrong.

            I think that still having to pay, and being punished for trying to use alternatives mean that opting out of Catholicism isn’t much of an option above.

            They also mean opting out of the NHS isn’t much of an option.

          • Joe W. says:

            One might make the argument of the extra tax burden

            That’s exactly the argument I would make – more precisely, the fact that you are obliged to pay for the service whether or not you actually use it.

            but then taxes go to all kinds of services that an individual may never use.

            Right. And you can’t opt out of those either. (Whether you should be able to do so is a separate issue, obviously. “X is not optional; therefore, X should be optional” is an absurd argument and not one I’m trying to make.)

    • sweeneyrod says:

      Bad for some doctors maybe, but at least we have universal healthcare, like pretty much every developed country! That’s not to say that the NHS is better than non-nationalized systems in most European countries, but it does do a better job than the US system.

    • anonymous says:

      Suntzuanime, healthcare being good/bad is usually refers to it being good/bad for the *patients* and for the taxpayers, not for the doctors.

      Scott’s post tells us zero-zilch-nada about how *good* British healthcare is.

      Maybe (and maybe not, I don’t know), their ruthless exploitation of doctors is cost effective for taxpayers and patients.

      • Nornagest says:

        I’d like to unveil my proposal for a healthcare system funded through a nationally televised deathmatch tournament fought by orphans.

        Patient outcomes in my model are great!

      • suntzuanime says:

        Yeah, there’s something to be said for locking society’s best and brightest in an Omelas torture chamber and wringing as much value out of them as possible so the rest of us can live lives of comfort and ease. That may be more or less what the socialists explicitly have in mind, even, substituting “best and brightest” for “wealthy kulaks”.

        • Jiro says:

          Heretic! Omelas is supposed to be about social responsibility! We’re the filthy oppressors whose great society is built on the backs of the suffering like the poor child down there.

          We’re not supposed to identify with the child and treat Omelas as about how other people’s attempt to build a great society is oppressive to us. If we think along those dangerous lines we might even conclude that we shouldn’t have to sacrifice for the good of society, and become selfish capitalists instead.

          • Mary says:

            eh, the first thing to note about Those Who Walk Away From Omelas is how utterly useless they are. One kind word to the child would bring the whole house of cards down.

          • keranih says:

            But then they’d be stuck fixing it. Which sounds an awful lot like work.

            I’d bugger off to the wilderness, too.

          • onyomi says:

            I just realized that the film Snowpiercer may have been loosely based on that story.

          • hlynkacg says:

            One kind word to the child would bring the whole house of cards down.

            As I recall the story tries to head off that objection at the pass by claiming that the child is to far gone to save. That any attempt at rescue or relief would only result in them lashing out in fear and confusion.

          • Loquat says:

            @hlynkacg –

            The story might be set at a particular point in time when that child is too far gone to save, but it’s presented as an ongoing issue with their society, something all citizens are told about when they’re old enough – presumably the child has to be replaced from time to time, and then there’d be a window of time when the new one could reasonably be saved.

            I’m pretty sure “the child is too far gone to be saved” was more of a rationalization common among citizens than an actual assertion by the author, though.

          • Mary says:

            If the system is so corrupt and evil that you can’t stand to live under it, it should be brought down regardless.

        • anonymous says:

          They aren’t locking anyone up; people become doctors in Britain willingly, and they know what awaits them.

          I’m not a cheerleader for socialism or the UK system; I’m just pointing out a logical mistake.

        • TheAncientGeek says:

          How strange. Libettopia looks like Omelas to me, because the weakest suffer horribly in the absence of safety nets.

          • Everything not mandatory is forbidden.

          • Geek:

            In other contexts, as discussed in other threads, we distinguish between harming someone and not helping someone. Even if you are pretty sure there are things you could have done that would have saved a life somewhere in the world, not doing them doesn’t make you feel like a murderer.

            So even if it were true that, in libertopia, people without skills valued in the market did very badly, that would not be equivalent to a system where someone was deliberately mistreated in order that others could have a happy life.

          • TheAncientGeek says:

            @David

            I ddnt previously say anything that hinged on the omission/comission distinction and
            I don’t think I care that much about it now.

            I don’t think that a society is just if the condition of the poorest person in it is horrifying, and not merely undesirable…at least if there are altenatives, and there are.

            I also don’t want to be that person, irrespective of the delibarateness if the situation…. and it can happen to anyone.

            In one of our previous discusons you said you wouldn’t mind if everyone started discrimnating against people like you. You didnt offer an argument for the attitude and it seems irrational to me. Its not in your rational self interest to be massively discriminated against, so why is it in your interest to a back a system that allows it?

            @Dice

            ????

          • Jiro says:

            Being an unlucky person in such a society would lead to him being discriminated against, but allowing such a society to be created would be beneficial to him in the vast majority of possible worlds.

            That’s like saying that it’s not in his rational self-interest to have a politician he doesn’t like win an election, so he shouldn’t back a system that allows that.

          • “Its not in your rational self interest to be massively discriminated against, so why is it in your interest to a back a system that allows it?”

            Because the alternative system has much worse down sides.

            The basic choice is between having decisions such as who employs me, sells to me, rents to me made on the principle of “it happens if both parties are in favor of it, otherwise it doesn’t”–freedom of association–or on the basis of “it happens if the government is in favor of it, otherwise it doesn’t,” although there are obviously intermediate positions.

            Under the first system, I suffer serious costs from discrimination only if almost everyone wants to discriminate (assuming the group I am part of is a fairly small minority). Under the second, I suffer serious costs if enough people support discrimination to control the decisions of the government.

            There are other disadvantages to the second system as well, but that’s the most relevant one.

          • TheAncientGeek says:

            @Jiro

            Playing Russian roulette for money leaves me better off in 5/6 worlds, but I wouldn’t do it. I make an expected utlity calculation, not an expected value calculation, and I put a very high negative utility on my premature death. Who doesnt?

            @David

            Nonlibertopias include countries with strong
            constitutional constraints against discrimination , so the 99℅ can’t duscimiate against you, and the 51℅ cant either.

          • @Geek:

            Constitutions don’t enforce themselves. The U.S. constitution had the same constraints against discrimination at the point when all west coast citizens of Japanese ancestry were rounded up and put in concentration camps, and the Supreme Court accepted the action.

            Canada had essentially the same constraints at the point at which the children of native Americans were taken away from their parents, shipped across the country, and put in establishments where they were forbidden to speak their own language.

            The circumstances in which private discrimination imposes large costs on a relatively small minority are ones in which a large majority of the population wants to discriminate. Under those circumstances, maintained for a while, the constitutional constraints may not be worth the paper they are written on. If it’s a 99% majority, or anything close, they almost certainly are not.

            To quote a past president of the U.S.

            “John Marshall has made his decision; let him enforce it now if he can.”

          • Jiro says:

            Playing Russian Roulette for money may be a scenario where you never want to take the risk, but that is because you value life a lot compared to money. It’s a lot more plausible that someone could value (advantages from having a government free enough to allow discrimination) to a 1/6 chance of becoming the victim of discrimination.

  62. JDDT says:

    I totally agree that everything you describe is horrible and terrible and should be fixed.

    And I think it is a terrible mistake that doctors haven’t chosen to strike about their awful working hours and conditions which would undoubtedly gain public support.

    Instead they’re striking about pay — which seldom elicits public support.

    • suntzuanime says:

      The stereotype is that you don’t go into medicine because you want an easy job, you go into medicine because you want a lot of money.

      • Siah Sargus says:

        You go into medicine because you want to heal people, and money and job conditions are a secondary concern. That’s why doctors and nurses get so fucking chewed up by all of this shit.

        • Vox Imperatoris says:

          My father’s a doctor (radiologist), and he certainly didn’t go into it because he “wanted to heal people”.

          He went into it because he wanted to make a lot of money.

          • Jiro says:

            The LW idea that you can have a “true objection” is spreading and mutating too much.

            Most people don’t have a single reason for doing everything. Wanting to make money is part of the reason why people become doctors, but wanting to help people is another. If wanting to help people is only part of the reason, then it has a partial effect on salaries.

          • Vox Imperatoris says:

            @ Jiro:

            Let me rephrase: I think that the pay was the primary reason he chose being a doctor over the many other jobs that also involve helping people in one way or another. Which, as I see it, is pretty much all jobs except those involving criminal activity and vice.

            But sure, to whatever extent being a doctor is more satisfying non-monetarily than other jobs, it will carry a lower salary, holding all other factors (like the number of people qualified to do it) constant.

        • Rhand says:

          Meh, if I wanted to help people, I’d have gone into nursing, teaching, or social work.

          I’m a 4th year medical student, and I went into medicine for the same reasons Scott Alexander and everyone else did: power, money, prestige, and women.

          • Garrett says:

            Women?
            I’m 34 and single. I’ll switch careers if it will mean I can start a family, even if it is a net financial loss.

          • Vorkon says:

            Obviously, the real reason to get into medicine is to crush your enemies, see them driven before you, and to hear the lamentations of their women.

          • Randy M says:

            Well, there’s certainly the lamentations

        • keranih says:

          You go into medicine because you want to heal people, and money and job conditions are a secondary concern.

          For some people, yes. For others, no. There is an imperfect but readily identifiable break between the two populations along gender lines.

        • Squirrel of Doom says:

          The underlying assumption for this argument is wrong.

          In reality, people go into medicine for a lot of different reasons.

    • Scott Alexander says:

      I don’t know that much about this issue, but I got the impression they were specifically striking because the NHS wanted to remove overtime pay for Saturday work while giving them a general pay raise.

      I think the doctors’ position was that the overall result of the changes would that, whether or not their pay was constant, it would remove a lingering disincentive to making them work Saturdays.

      • JDDT says:

        I think we need to distinguish between the players here to say anything sensible:

        The union:
        They are advocating as hard as they can for the best contract they can get for junior doctors — and they are institutionally suspicious of the Tories so they may be giving them a harder time. (Under a Labour government, privatising schools, say, may be stupid but it isn’t regarded as the thin end of the wedge like it is under identical Tory policies — perhaps that’s totally fair, I don’t know.)
        One of the union’s most powerful tools in negotiations is a strike — but to do that it has to convince its member that their is just cause for a strike over this issue. The union has been criticised for lying to its members about the content and context of the deal. Speaking to people close to the union and doctors who are mere members, I think the union has been over-demonising the deal to its members to get them to feel upset and strike: union negotiators seem to list various nuanced clauses and changes in balance here and there as reasons for the deadlock; whereas union members tell me its because the government hates them and is trying to destroy the NHS (and I am not even slightly exaggerating).

        The government vs the hospitals:
        The government writes the contract, but its actually the hospitals that implement it; the government says “xx hours are legal” and the hospitals apparently ignore it.

        Hospital policy is to game any contract with the government as much as is possible — and I think the civil servants who set policies don’t even understand how they’re implemented and what goes on.

        For example (true story), my local hospital told me that they are no longer doing procedure X due to budget concerns, and only doing procedure Y. Given that I really care what procedures are done unto me, I had taken a deep interest into the pros and cons of X vs. Y when they were first offered — and one of the things I know is that procedure X is orders of magnitude cheaper and safer (mainly cheaper because it is safer: for procedure Y hospitals end up doing a lot of follow-on care because people are often very ill as a result). I mailed my Member of Parliament to ask what was going on. He got in touch with the head of the hospital who helpfully explained: the hospital invoices the government for procedures X and Y — it is very hard to cut corners with procedure X; but easy with procedure Y — so the hospital can improve its bottom-line by creating a margin between what they spend on procedure Y and the amount they invoice the government for — yes, from a global perspective this is a disaster: the NHS ends up spending orders of magnitude more (for this specific treatment) than it would otherwise, but the hospital is optimising for itself. And the civil service is none the wiser.

        The same guys who created the invoicing agreement that incentivises the hospital to offer me the worse, more expensive treatment, are the same guys who are drafting the new contract for junior doctors.

        Scary!

        The doctors:
        Every doctor I have met has been intensely critical of the government and intensely loyal to the NHS — therefore they’re (in my experience) unwilling to take action (or raise a voice) against hospital management — who are actually the menace here — and instead focus everything on government.

        That’s my impression anyway.

        PS. I think overtime is a terrible thing because it encourages people into working patterns that are bad for their health (and in the case of doctors: for the health of their patients); but I think doctors under the current regime have become rather dependant on the section of the income they get from working ridiculous hours — and if tomorrow the government said “we have learned things are awful and you’re working illegal hours — that’s terrible — we are making sure you only work legal hours from now on” then suddenly many (perhaps most?) junior doctors wouldn’t be able to service their debts because they made them assuming an income including crazy-amounts of overtime.

        • Thanks for writing that all up.

        • Jill says:

          “Hospital policy is to game any contract with the government as much as is possible — and I think the civil servants who set policies don’t even understand how they’re implemented and what goes on.”

          Bingo. A huge part of the problem here.

          It’s hard for citizens to keep track of what government is doing. Which is a reason for overall a smaller government rather than larger. However, government needs to fulfill some functions. And in those cases, civil servants who set policies need to START understanding how they’re implemented and what goes on.

          Part of the solution may be to have more varied people in government, as I’ve mentioned elsewhere. When most people in Congress or state legislatures are lawyers, you get a narrow lopsided view, where people have no clue that it is lopsided, because they’re all on the same lopped side looking inward.

          Who would be good at this? Systems psychologists? Organizational development experts? Maybe some accountants or engineers? Maybe psychologist researchers who specialize in game theory research should be part of the team too.

          • “It’s hard for citizens to keep track of what government is doing. Which is a reason for overall a smaller government rather than larger. ”

            Correct.

            But the other half of the problem is that it isn’t in the interest of the individual voter to keep track of what government is doing because, in a large polity, his vote has almost no effect. If I spend time and effort researching cars before buying one, I end up with the car I have decided is better for me. If I do the equivalent before voting, the chance that the better candidate gets elected goes up by one part in several million.

            ” However, government needs to fulfill some functions.”

            That is where we disagree. I’m curious as to your view of the general issue–what things have to be done by government rather than by non-governmental arrangements and why.

          • Jill says:

            If something is being done by private industry well, and people are fine with it, there is usually no call for the government to get involved. If private industry is causing huge expensive problems or polluting the atmosphere a lot, then people want to do something about it. And the industry usually won’t do anything to solve the problem on its own, so the people go to government for a solution.

            Health care, for example, was a monstrosity, with skyrocketing costs and pre-existing condition issues and numerous other problems. So that’s how we ended up with Obamacare.

          • Nornagest says:

            Speaking as an engineer, engineers aren’t good at debugging social systems. I won’t venture an explanation, but usually what I see my colleagues doing is rounding society off to the totalizing model closest to what they grew up with (if they were more or less comfortable with it), or occasionally to its opposite (as a reaction to dumb people and frustrating systems). That’s about the opposite of what you want in a national-level politician.

            My own opinions, of course, are flawless. [/s]

          • Jill says:

            I think lawyers are no better than engineers are at debugging social systems. Right now we have mostly lawyers and that’s at least as bad as having almost all engineers. But when you put a team together of people with different backgrounds, the engineers, the accountants, the game theory researchers etc. each contribute a part to the team thinking. And it comes out better overall because of the diversity.

          • Nornagest says:

            Diversity can be better in some situations, but it’s not a universal good. You don’t want a team of three bricklayers and three cardiologists doing open-heart surgery.

            Drawing most of our legislators from the same profession has its own problems, and I do think our political class could use more awareness of e.g. economic theory. But the law is a very complex and often counterintuitive beast, and lawyers do spend a career interpreting it, which is about as good an apprenticeship for a job that’s all about manipulating it as I can think of.

          • Cerebral Paul Z. says:

            “And the industry usually won’t do anything to solve the problem on its own, so the people go to government for a solution” — That’s certainly understandable enough. So perhaps it shouldn’t surprise us too much if, whenever government won’t do anything to solve a problem on its own, people go to industry for a solution. I would argue that a lot of the “government-bashing” which some of us want to condemn, root and branch, came about in exactly this way.

          • Jill says:

            Cerebral Paul, I don’t think so. This political scientist points to persuasion by political propaganda since Newt Gingrich in the 1990’s, persuading people that government is bad and should be bashed, especially government by members of the Democratic party. He said that this made the eventual rise of someone like Trump inevitable. I believe him.

            The political scientist who saw Trump’s rise coming

            http://www.vox.com/2016/5/6/11598838/donald-trump-predictions-norm-ornstein

            A huge percentage of the bashing of government is simply political propaganda. Obama has been bashed since he began running for president, for the smallest of reasons– and for non-factual reasons like being Muslim and not being born in the U.S. constantly. Hillary has been bashed for decades. There is no reason too small and no conspiracy theory too ridiculous for Right wing media to bash Hillary with.

            Bush got a free pass to invade Iraq on the basis of lies about weapons of mass destruction. But Hillary’s emails are made out to be the worst deal in the world.

          • suntzuanime says:

            lol yes no one has ever complained about Bush’s invasion of Iraq. come the fuck on.

          • Joe W. says:

            @Jill

            What is it about arguments for smaller government that makes you see them as ‘bashing’, ‘propaganda’, and so on? Do you think there are no reasonable arguments for why governments will tend to do a poor job of running things, and that therefore anyone making this kind of argument must be a mindless idiot? Or is it just that you think that these arguments are reasonable, but mistaken?

            EDIT: Or, third possibility: do you accept that there are reasonable arguments for this position, and are instead describing only the unreasonable arguments as bashing?

          • Cerebral Paul Z. says:

            Jill, I’ve already ridiculed you once for suggesting that political propaganda was an invention of Newt Gingrich’s. Please don’t make me do it again. Better to consider the possibility that propaganda is always with us, and that if a particular flavor of it starts being persuasive at a particular point in time, there may be a good reason for that. Especially since the bar you implicitly set here– that a shift in public opinion only counts as authentic if the electorate arrive at it completely on their own, without anyone propagandizing them on the subject first– is one which few, if any, of the shifts you approve of would clear. (Was there really no one out there, pre-PPACA, trying to convince people that the existing health-care system had to go?)

          • keranih says:

            Bush got a free pass to invade Iraq on the basis of lies about weapons of mass destruction.

            No, Jill, this is not correct.

            Bush did not originate the idea that Iraq had WoMD. That pov was widely and publicly shared by multiple figures in American politics, including Clinton (and Biden.)

            The statements about suspicious of WoMD may have been shown to be incorrect. This is not the same as lies.

            Bush was roundly criticized for both Afghanistan and Iraq by people from both the right and (even more so) from the left.

            You should update your priors.

          • “If something is being done by private industry well, and people are fine with it, there is usually no call for the government to get involved. ”

            What is your definition of “well?” I could argue that health care is not being done well anywhere, since people still die.

            It seems to me what you need is comparison not to an absolute standard of how well things should be done, which doesn’t exist, but a comparison to how well they would be done under an alternative system.

            So how do you decide which things government will do better than private arrangements?

            “Health care, for example, was a monstrosity, with skyrocketing costs and pre-existing condition issues and numerous other problems. So that’s how we ended up with Obamacare.”

            Prior to Obamacare, about half of all healthcare expenditures came from government, and all of the industry, both provision and insurance, was heavily regulated. How do you figure out whether the things you disapprove of were due to too little government involvement or too much?

          • Pku says:

            Compare to places where there’s slightly more/ slightly less government regulation? Countries with slightly more government intervention seem to have more efficient healthcare.
            Granted this doesn’t rule out marginal benefit but loss in a wide difference (or confounders).

          • Edward Scizorhands says:

            Compare to places like . . . Singapore?

            Germany’s system is privately run. How do they do?

            There is this assumption that

            1) every other country has awesome health care, and it’s government run

            2) the US has poor health care, and it’s privately run.

            There are as many types of health care systems as there are countries, and many of them are more free-market than America.

            America is the outlier only in how much it spends. Otherwise if you were to look at a unlabelled chart of countries based on any per-capita metric, you wouldn’t be able to pick out the US.

          • Vorkon says:

            You don’t want a team of three bricklayers and three cardiologists doing open-heart surgery.

            You’re right, cardiologists are just the worst. Seriously, what’s wrong with those guys?

          • Furslid says:

            @Jill

            Your position seems to be that there are some things that government shouldn’t do, and other things it should. People should find the correct role for government by getting feedback from society and making adjustments accordingly. If something is broken, give it to the government to fix.

            I hope that this is an incomplete position. The only adjustment allowed is moving things from private to government. To find the right role of government, you also need to be able to move things from government to private. Otherwise the feedback system is broken.

            A much simpler example. If I turn up my thermostat when I feel cold, but can not turn it down, I will end up sweltering. If we move things from private to government without ever moving them back, we will end up with too many things being done by the government.

            So, what are your criteria for removing government from an industry or service?

          • BBA says:

            As I see it from the opposite side of the world, Singapore is a single-payer system cleverly disguised as free market health care. Between the price controls on private providers, the government ownership of several major hospitals, and the fact that everybody’s required to contribute to health savings accounts at a fixed proportion of income (and will get catastrophic coverage once they’ve exhausted their HSAs) there’s very little room for market forces to do their work.

            But you get a bill for everything and you pay the whole thing with money that’s theoretically yours, so the appearance of free market health care is kept up.

    • Pku says:

      I wonder if there’s a status signalling thing here – maybe if you ask for better conditions you’re signalling to the other doctors that you can’t take the heat, but asking for more pay signals high status, since you think you’re worth more. And since the higher-status doctors end up setting the agenda, it’s the people saying the second thing that end up getting heard.

      • Jill says:

        Interesting. Yes, that theory would certainly be consistent with the values of American culture– proud work-aholism and achievement orientation, and worship of money so intense that we may be about to elect someone president because they are a billionaire, despite their knowing nothing whatsoever about how government works.

        Cultural blind spots and values and “de-values” are really interesting, and revealing in just about everything that every sector of a society does.

        • “we may be about to elect someone president because they are a billionaire”

          We probably are not going to elect Trump president, and if we do it won’t be because he is a billionaire but because he is a very able demagogue.

          Which gets back to my point about one of the reasons government works badly. If you know your vote has no significant effect on the outcome, it’s natural to treat political partisanship as something more like cheering for a football team than buying a car–so you support the team it is most fun to support, not the one that will do the best job of running the country.

          • Part of Trump’s demagoguery is his claim that being very rich helps qualify him to be president.

            In a culture that didn’t value money so much, a demagogue would have to make different claims.

          • Randy M says:

            A frequent critique of politicians is their reliance on donor money. Given that, touting being independently wealthy is not entirely an appeal to mammon.

          • John Schilling says:

            A frequent critique of politicians is their reliance on donor money.

            Politicians like Donald Trump?

            Trump may or may not be a billionaire on paper. He does not have the cash or liquid assets to finance a competitive Presidential campaign through November, and he isn’t going to try. He is going to keep saying things that cause millions of people who ought to know better that he is so massively rich that we ought to consider him above temptation or corruption, and also a winner, because of the winning.

            Hence David Friedman’s comment.

          • Randy M says:

            Is that intended to be a rebuttal to me or an agreement? My comment did not depend on anyone’s words being in correspondence with reality to any degree.

            Can either of you point to a Trump quote where he says his money is in and of itself worthy of respect versus appealing, however falsely, to peoples suspicion of the corrupting power of campaign finance?

            It’s weird to be arguing that American’s don’t idolize money. Sure they do–but this isn’t great evidence for it.

          • Jill says:

            The way people view politics has a lot of origins. There is lots of propaganda telling people how to look at elections and politics. And the memes that are repeated the most tend to be picked up by the most people. So that has a lot to do with it too.

            We are a very entertainment oriented society. Our news has disappeared and has been replaced by entertainment. Bread and circuses rule people. And bread here and now is fairly easy to get, so circuses rule us.

          • Jill says:

            Randy M, billionaires like Trump don’t have to say that they think their money makes them attractive to Americans. It’s obvious and goes without saying.

          • Randy M says:

            Yes, but it makes them attractive because we think it makes them less susceptible to bribes, not because we all have dollar signs in our eyes Scrooge-McDuck style.

          • Loquat says:

            Also, a very rich person who can claim to have earned most/all of their money by their own efforts (as opposed to inheriting it) can point to their wealth as proof they’re competent at something. Being unusually competent and successful at one’s chosen line of work is generally attractive to Americans – I suspect Trump would be much less popular if he’d just inherited a fortune and then spent his life having fun and doing no work whatsoever.

        • Joe W. says:

          I’m not sure how relevant the values of American culture are when we’re talking about junior doctors in the UK, though.

          • Jill says:

            The U.K. is our cultural ancestor. We have a lot of overlap. And the discussion here today is often veering into U.S. doctors and the U.S. medical system too.

          • Furslid says:

            As an American, I think in an American framework. If I see something that doesn’t make sense in another culture, I try to explain it. This necessarily is an explanation that makes sense to me, as an American. This explanation is not necessarily wrong. It does need for me to check to see if it applies though. The first check is to see if the values that make the explanation work are part of that culture.

            It does look like British culture has the values that make this explanation work. “Not wanting to signal weakness.” and “Not going into a profession that everyone knows has long hours and then not accepting that aspect of the profession.” seem to be British values as well. So the explanation likely works.

        • SJ says:

          and worship of money so intense that we may be about to elect someone president because they are a billionaire,

          I know that HIllary Clinton churned a lot of money through the Clinton foundation (and into her pockets, it seems), but I didn’t know that turned her into a billionaire.

          Or are you talking about someone else?

  63. Anonymous says:

    Technically European law caps junior doctor work weeks at 48 hours a week. Then again, technically American law caps junior doctor work weeks at 80 hours a week. My first week on a non-psychiatry service as an American junior doctor, I worked a bit over 100 hours – and so did everybody else I encountered. When I asked about the law, everyone just gave me that “oh you sweet summer child” look.

    Is it just me, or does this imply a gigantic shortage of doctors just about everywhere in the west?

    • Jason says:

      You can model the market as a cartel where medical associations make medical school hard to get into (very high marks required, etc) in order to cap supply and raise prices.

      The people who suffer are patients and junior doctors.

      • Scott Alexander says:

        I’m not sure this is quite right. My father is friends with a senior doctor who’s trying to open a medical school, and he tells me that the main bottleneck is residency positions.

        Residency positions are legally mandated to involve lots of high-ranking doctors spending a lot of time teaching residents, and they also have to pay residents a pretty decent salary. Since these high-ranking doctors don’t come cheap, they’re a huge financial loss and the government has to subsidize them out of a national interest to have there be a next generation of doctors. But there are a lot of reasons the government doesn’t want to (number 1, they’re expensive, number 2, a lot of this is left to local governments, but it’s cheaper for local governments to recruit doctors from elsewhere than to train their own) so there are never really enough residency spots. The medical school cartel is (genuinely, for the sake of their students) worried about producing more new doctors than the residency system can train, so they hold back (I’m not sure who is enforcing this or how) on making new medical schools until the number of residency slots can catch up to them, which they never do.

        • Randy M says:

          It must be mind-boggling complex to start a new medical school from scratch.
          In support of the cartels, I have heard that lawyers are currently way oversupplied, leading to people with big debts and low prospects, to say nothing of any mischief an oversupply of lawyers may bring.
          Doesn’t look like doctors are near that boat. Well, at least the desire for much more of them is there, even if the demand (ie, ability to pay) is not.

        • Cliff says:

          What a joke. “Medicine is the only field in the world where people cannot be trained without government subsidies.” I’m sure doctors are lobbying sooo hard for more residencies, it’s just coincidence that they fail to get rid of this bottleneck which gives them $400,000/yr salaries. I’m sure it’s complete coincidence that the AMA is sooo good at keeping down the number of doctors in order to accommodate this extremely constrained system.

          The government should eliminate all residencies. Then the question would become, would the AMA be willing to kill a lot of people to make a political point so they can go back to suckling at the government teat? I have no doubt the answer is yes. But you will never convince me that magically doctors are unable to train new doctors without massive amounts of government pork.

          • Anon says:

            The government should eliminate all residencies.

            I don’t know enough about any of this to claim my opinions as fact, but I think you’re going further in your opposition than the evidence allows. Hands-on experience in a lot of fields (medicine, law, enterprise software, aerospace) teaches far more than you’d learn in college, takes a while to accrue before you can go without training wheels, and will generally be done at the expense of the company or institution which takes on the fresh graduate. This is especially true of medicine; while certain professions like piloting can be adequately simulated outside of the field, and legacy software development can be practiced outside of a company, it’s really hard to simulate a human body to practice surgery in a low-risk environment. This means that an aspiring surgeon’s first attempt at a surgery after watching how it’s done will be on a patient, with all the risks that entails. Having residencies as a requirement may be a bit strict (it might be better if they were just “strongly recommended” and only places which were short-staffed or desperate for hires would take someone who hasn’t performed a residency, much like how internships in tech work today), but deciding that hands-on experience is unnecessary runs contrary to the evidence and is overcorrecting in response to the current setup.

            But you will never convince me that magically doctors are unable to train new doctors without massive amounts of government pork.

            There’s a massive opportunity cost incurred when a doctor with 20+ years of training and experience spend his time watching over residents and students instead of practicing himself, especially when that doctor’s services are valued above $200K. That “government pork” is necessary to incentivize professionals who can make that kind of money through a private practice to spend some time training more people so that the knowledge doesn’t die out. It’s not that they’re unable, it’s that they wouldn’t want to and would have much better things to do with their time.

          • “That “government pork” is necessary to incentivize professionals who can make that kind of money through a private practice to spend some time training more people so that the knowledge doesn’t die out.”

            I don’t follow that. You are saying that training doctors is expensive because a major input is the time of trained doctors, whose time is valuable. But the result of being trained is to become one of those trained doctors whose time is valuable.

            So the doctor in training ought to be willing to pay the doctor who is training him the market value of his time–whether directly or by providing his services to the hospital that employs the trained doctor at a low price in exchange for the training.

            How is this different from any other situation where producing something valuable requires a prior investment?

          • God Damn John Jay says:

            This means that an aspiring surgeon’s first attempt at a surgery after watching how it’s done will be on a patient.

            Question: What is the largest primate that is still dumb and shallow emotionally?

          • Publius Varinius says:

            Question: What is the largest primate that is still dumb and shallow emotionally?

            Humans?

          • hlynkacg says:

            don’t feed the troll PV.

      • In the U.S. system, restriction of supply by the medical association to hold up wages pretty clearly used to be the case–I don’t know to what extent it still is. During the Great Depression, the AMA sent a letter to the medical schools telling them that they were graduating too many students and they all cut back. Not surprising, given that getting licensed required graduation from an approved medical school and the AMA had de facto control over the approval process.

        Part of the subject of my father’s doctoral thesis–which took a long time to get approved.

      • sweeneyrod says:

        In the UK at least, I think clinical placements are the limiting factor.

    • Shieldfoss says:

      Almost as if the people deciding how many people are allowed to become doctors are the people whose salaries are inversely proportional to the number of doctors. Not a problem, thank God, in my native Denmark.

    • thirqual says:

      In some countries, more obviously manufactured that in others. In France, the number of places in medical school (from second year) is strictly limited (with a competitive exam at the end of the first year). There are many justifications, from the left to the right, all self-serving, counter-productive and unable to resist analysis.

      During the 70s that number was ~8500, the population was 50-55 millions. It dropped to ~4000 during the mid-80s and stayed there until the turn of the century, where people in charge started to panic and raise the number.

      Right now the numerus clausus is ~7500, and the population is ~66 millions.

      Of course wealthy students just go get their diploma in another European country, and we import doctors from Eastern Europe and North Africa (1/4 of the new doctors in France have obtained their diploma outside of France, 10% of all the doctors were born in either North Africa or the Levant (mostly Syria and Lebanon).

      • Eggoeggo says:

        The French do that for teachers too, don’t they? And then assign them to schools to ensure full employment. Do they also have a teacher shortage?

  64. Anonymous says:

    Imagine having to decide between going to the bathroom or getting a bag of crackers from the vending machine because you don’t have enough time between cases to do both. Imagine having to remember the difference between nephritic syndrome and nephrotic syndrome (two totally different things) after ten hours of work, after getting three hours of sleep the night before. Imagine that you’ve just admitted a neurotic old woman to the hospital and you know in your heart that you should take her hand and explain to her in a soothing voice that everything is going to be okay, except that you already feel like every nerve of yours is beaten raw and you have three patients left to go before you can so much as sit down for a few minutes. Imagine your attending yelling at you because you got something wrong and saying you need to spend more time studying, and you trying to keep your mouth shut instead of telling him that you literally have only a half-hour in the day that could be considered free time by even the broadest stretch of the imagination and you are damned if you are going to spend that studying endocrinology.

    I would quit after the first week to become a subsistence farmer.

    • Andrew Ticviking says:

      Where is permitting you to do that?

      • JBeshir says:

        I think you’re allowed in most places- provided you can afford to buy the land, of course, and you don’t want anything you can’t fabricate yourself and would need to trade for.

  65. Pku says:

    How easy/hard do the older doctors have it? Would there be a way to improve things overall by shifting some of the workload up the ladder?

    In retrospect, it seems like my dad’s worked something like 70-80 hour weeks his whole life (and this is the stage for which I was around, which is past his junior doctor days), in the Israeli system, which I don’t think is quite as bad as what’s described here. So I’m going to guess the shifting thing wouldn’t easily work.

  66. FacelessCraven says:

    Weren’t we just discussing positive rights?

  67. Dr Dealgood says:

    So can Deiseach or someone else sufficiently Irish and/or British explain how the British Isles managed to get a Reptilian-majority government?

    Not one to cast stones here, America has one hell of a horrible government right now, but it seems like a lot of policy decisions in the UK only make sense from the perspective of actively trying to destroy or drive off their own population. I mean, how did things get to this point?

    • JDDT says:

      Can you give a concrete example to work with?

    • Eggoeggo says:

      They got lizardmen because they voted for Kang instead of Kodos.
      Also it’s easy to forget just how insulated the British civil service is from actual politicians. A lot of the policy decisions make perfect sense from the perspective of a Permanent Secretary who sees ministers come and go.

    • Anonymous Colin says:

      In the late 1970s a great statesman came along by the na