"Talks a good game about freedom when out of power, but once he’s in – bam! Everyone's enslaved in the human-flourishing mines."

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 All of this may be misunderstood or outdated.]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. Vaniver says:

    I, for one, can’t wait until we have software doctors, and can put this foolishness behind us.

    • Scott Alexander says:

      I feel like the sort of civilization that let software do doctor stuff would be the sort of civilization that would let highly experienced and well-trained nurses whose outcomes have been proven in study after study to be equal to or better than those of doctors do doctor stuff. Needless to say, we are not in that civilization.

      Our only hope is that maybe Google will lobby for the software or something in a way that nobody is lobbying for nurse-practitioners.

      • Randy M says:

        What about nursing schools? Any reason they don’t lobby for an expanded role for nurses? Possibly that nurses go to do their post grad work at schools with various programs versus the medicine specific schools of doctors? We hear at times in the states about nursing shortages (though it doesn’t sound quite as bad as it is with the doctors you mention).

        • Scott Alexander says:

          I don’t know. I doubt that the power of nurse practitioners affects number of application to nursing school that much. Maybe some nurses here can say more?

        • Murphy says:

          The doctors unions fight with the nurses unions to keep things in doctors controls and unfortunately the former is made up of people used to giving orders and the latter is made up of people more used to taking orders from people exactly like the former people without complaint.

          • Tom Hoffman says:

            I would say the difference is not so much being accustomed to giving or following orders as the amount of money and prestige one side has compared to the other. Unionized nurses can be pretty feisty.

          • Murphy says:

            They can be but I know a few senior nurses who are constantly frustrated by how utterly subservient a large fraction of nurses are.

        • JamesBarney says:

          Yeah AANP lobbies congress for increased responsibility and reduce regulatory burden on the part of nurse practitioners. The AMA lobbies against them.

          The AMA is the 3rd largest lobbyist in the country, many senators come from elite circles so they probably are friends with many more doctors than nurses, and represents doctors who command an enormous amount of respect.

          The AANP only has a bunch of evidence on their side.

          • Donny Anonny says:

            I dimly recall reading an article about ten years ago that claimed the AMA poor a lot of effort in to controlling the number of doctors entering the workforce in order to ensure that they could command high salaries and other benefits.

            Does anyone know if there’s any truth to this?

          • XVO says:

            @Donny

            Just an example I found quickly:
            http://www.forbes.com/2009/08/25/american-medical-association-opinions-columnists-shikha-dalmia.html

            Yes, the AMA is one of the biggest sources of rot in the American health care system. It hardly ever gets into the public consciousness because it’s not cool to believe in freedom. The entire reason our medical system is so expensive is because of a lack of freedom, socialists can ration things and cover up the blemishes for a while, but it always ends up like every other socialist system. Humans don’t work the way socialists want them to, we aren’t ants.

            We need freedom to practice medicine, freedom to compete with existing hospitals and the medical industry, freedom to build medical devices, freedom to spread medical knowledge etc. The general public has been cowed into fear everywhere though. What if unqualified people practice medicine? Well, in some ways isn’t that exactly what we have now? And how much money are we losing? And how many lives have we lost? And how much suffering has it caused? Trillions, millions and millions. It’s all unseen suffering though, no one can be blamed, whereas if someone sells a medical device that kills people that is on the front page of the newspaper.

            The consequences for fraud and incompetence need to be high, but what we have now is an evil corrupt system.

          • Squirrel of Doom says:

            You can think of the AMA, ABA and other high status professional organizations as very successful trade unions/guilds, that control their fields very strongly, at the expense of society in general.

        • pneumatik says:

          My wife recently finished getting her BSN (Bachelors of Science in Nursing), the new replacement for a nursing associate’s degree. The school was relentless in promoting more responsibility and more education for nurses. The correct response when asked what you wanted to do when you got out of school was more school, either a Masters in something like Nurse Leadership or a DLP to become a Nurse Practitioner. There wasn’t a push to be equal medically to doctors, but OTOH they were told that they should never say they were “just” a nurse.

          I was interested to learn from my wife that not all that long ago nurses were trained by hospitals and were functionally only able to work at the one hospital that trained them. It meant that they couldn’t go work anywhere else without starting their training, and therefore payscale, all over again. Nurses (I guess AANP) pushed to standardize the RN certification and to promote formal schooling like the BSN to “professionalize” nursing so that nurses could take their experience and go work anywhere. It seems to have worked well so they just keep going, creating more advanced degrees and certifications.

          If the number of doctors doesn’t grow like it seems like it needs to then eventually nurses will end up filling all the gaps in care. My grandmother was a nurse when she was younger. She said that everything my wife learned and did in nursing school were things that only doctors did when my grandmother was a nurse.

          • SJ says:

            I know a few people (of my mother’s generation) who were, or still are, nurses.

            I’ll have to ask them how accurately this describes their experience: not all that long ago nurses were trained by hospitals and were functionally only able to work at the one hospital that trained them.

            Most of the people I’m thinking of began nursing in the 1970s and 1980s in the United States. One that I know of attended a school-of-nursing that was attached to a major metro hospital, and later spent about a decade working as a nurse at a different hospital in another metro area.

            I don’t recall hearing about major re-training being required at the new hospital. (But I don’t think anyone asked.)

            Which region/time-span are you thinking of?

          • Garrett says:

            Much of what the public thinks of as nursing is now done by CNAs – Certified Nursing Assistants. Also having standardized credentials, but generally only about 200 hours of training. They do most of the traditional nursing work, but have a lot less authority and power, making burger-flipper wages.

          • Wency says:

            My mother is an RN who graduated with an AA in Nursing from a community college in the early 1970s and never earned a higher degree. She has probably worked at ~10 hospitals in the Southeast, Midwest, and Northwest over the last 40 years. Her skills have always been in high demand, she has never been fired, and she has never had difficulty landing a job more or less immediately after looking for one.

            A generation earlier, things might have been different. Though I think in that generation, working for the same company for your entire career was more the norm in any case. My grandmother worked for the same hospital her entire career, just as my grandfather worked for the same company for effectively his entire career. Could she have switched hospitals? I don’t know, but I don’t know if the thought ever occurred to her.

          • pneumatik says:

            Sorry about the ambiguity about the date range I was referring to. My understanding was that nurses were more tied to their hospitals back pre-WWII. … Wikipedia has some supporting information in their article on nurses.

            However, I’m being informed as I type that some hospitals have “hospital nurse programs” where nurses are still only accredited at their specific hospital. I can’t find any Internet references, though, so who knows.

        • Ninmesara says:

          Portuguese med student here, I have no idea what the nursing school curriculum is in other countries.

          The moment you expand nurse’s roles enough, you stop having nurses, and start having “doctors” that didn’t go to medical school. Simple as that. Either you change nursing schools’ curriculum or you have “doctors” without the proper formal education, depending on ad-hoc self-study and “workshops” to get the relevant knowledge. You can doubt the value of much that is taught in medical school, but between classes and residency we are in fact taught something, and that something seems very important to me. I have nothing against expanding nurses’ roles, but there needs to be proper formal education in place.

          There are no nurse practitioners in my country, but the nurses I know are NOT prepared for the kind of appointments patients have with a doctor. I have no doubt they would be prepared with proper training, but not now.

          • Garrett says:

            I’m a little out of my field, but most nurses in it for the long haul start off with a Bachelor’s degree in nursing (BSN), which is 4 years of training. Here’s an example curriculum from one of the first links I found through search.

            They are then hirable and may go into standard practice at most institutions.

            Then you’re looking at another few years to become a nurse practitioner in a specific field. Example curriculum.

            These usually require several years of experience first.

          • Ninmesara says:

            @Garret

            The curriculum for the nurse practitioner seems really good, but in my opinion is probably lacking in history taking and physical examination. These might be unnecessary, if nurses are only expected to diagnose very simple stuff, though. In any case, the emphasis seems to be in physiology, pharmacology and practical matters, which is great.

            I also like the fact that education specific to the nurse practitioner is not part of the standard nursing curriculum, but something interested nurses can take afterwards.

        • Miranda says:

          Nurse speaking here. I’ve worked in several deeply short-staffed hospitals, and it has never been anywhere near as bad as what Scott describes for junior doctors (although I’ve heard of hospitals in Quebec that were possibly as bad – coercing newly graduated nurses into working 80 hours a week with the threat of firing them if the didn’t, and there ended up being a scandal when a bunch of nurses committed suicide.) I think it’s possible nursing is harder (physically, emotionally, and cognitively) on an hour-by-hour basis than medicine, but my shift is 12 hours and at the end of it I leave regardless of whether all the work is done (although if I regularly leave a lot more work undone than my colleagues I will get snarky looks and eventually get yelled at by the manager.) This makes a huge difference. Also nursing positions are 40 hours a week and you only work more if you want to.

        • Miranda says:

          Re: the “power for nurses” thing – as a nurse, I have approximately no desire for “more power” intrinsically, and I think this is true of almost all nurses. I like my job a lot, I feel valued and respected, and I’m not at all sure I would like it more or feel more respected if I were also responsible for prescribing my patients’ antibiotics. (Note: in ICU many nurses and doctors who know each other have agreements that the nurse can put verbal orders in under the doctor’s name and just let him know later – this is mostly for bloodwork, X-rays, and some extremely routine medications. I have this with several doctors, and with a number of doctors I’ll alert them to a problem and say “okay I’m assuming you want X, Y, Z?” and they will say “yeah, whatever” without really listening because they trust me. This seems like a kludgy and unstandardized way of minimizing the doctor’s need to apply cognitive effort to nurse-solvable problems, and I’m not sure what an intelligent standard is, since there are many nurses I work with who *shouldn’t* be trusted to do this.

          • Ninmesara says:

            Most nurses I know seem to share your opinion in relation to “more power”. Responsibility for human lives can be pretty heavy at times if you’re not a total psychopath and I can see where you’re coming from.
            It is good if you like power, though, and can stomach the responsibility. I always advise people who consider medicine as a career to not even think about nursing (some people view nursing as a backup plan if their med school application fails), as both professions are so different. I don’t need to discourage people the other way around, as most people who can choose medicine can also choose nursing.

          • SolipsisticUtilitarian says:

            Maybe the ol’ adage of “Giving power to people who want it is a bad idea” applies here.

      • Eggoeggo says:

        In certain parts of the US aren’t 4 and even 2-year associate degree holders–such as dental technicians–taking on more and more of the grunt work?

      • Rhiannon says:

        I didn’t realize there were such barriers to nurse practitioners operating as primary care providers here. Makes sense why I haven’t seen one since I moved to Austin from the UK 5 years ago, which is a shame as I liked seeing a nurse practitioner at my GP surgery. If lobbying for nurse practitioners is too remote, I wonder if there’s any way to legally challenge the extent of the occupational licensing restrictions?

        • Garrett says:

          It varies State-by-State. A lot of the “doc-in-the-box” services where there’s a provider in a pharmacy(chemists’s) are nurse practitioners throughout the US. Texas may be one of the funny States, though.

      • vV_Vv says:

        I feel like the sort of civilization that let software do doctor stuff would be the sort of civilization that would let highly experienced and well-trained nurses whose outcomes have been proven in study after study to be equal to or better than those of doctors do doctor stuff.

        And whose fault is that?

        I bet it’s the doctors lobbies that use their political clout to erect these barriers to entry, creating artificial scarcity of medical labor. But then they have to work inhumane shifts. It looks like they have been hoisted by their own petard.

        • rockroy mountdefort says:

          I bet it’s the doctors lobbies that use their political clout to erect these barriers to entry, creating artificial scarcity of medical labor. But then they have to work inhumane shifts.

          The doctors/lobbyists who do the lobbying and have the political clout aren’t the doctors who have to do the 24 hour shifts.

          At best, they’re doctors who at some point in the past had to do 24 hour shifts.

          • Hlynkacg says:

            Yes, that is an important distinction.

          • baconbacon says:

            Its the same reason almost every sports league ends up with a rookie scale for contracts- those are the guys that don’t get to vote.

      • pneumatik says:

        We’ll get there. Nurses have much more responsibility than they used to and it continues to increase. There simply aren’t enough doctors being produced by med schools to meet the demand. I expect doctors to go more and more into management and oversight positions, with nurses getting certifications that allow them to make more and more decisions. The AMA will never allow doctors to not be in charge, but there’s no reason nurses couldn’t get more authority to make medical decisions in a manner similar to what paramedics are allowed to do.

        • rockroy mountdefort says:

          There simply aren’t enough doctors being produced by med schools to meet the demand.

          no wonder, when they engage in such an unbelievable degree of hazing.

      • Ninmesara says:

        Could you link to some of those studies and to what kind of training they undergo? There is nothing like that in my country, and I’m curious.

      • Squirrel of Doom says:

        The US won’t formally allow it, but web servers in other jurisdictions will slowly chip away at the problem and slowly become software doctors.

        Or at least that *could* happen.

    • Eggoeggo says:

      I, for one, can’t wait until we have software doctorates and National Programming Service bureaucracies.
      Bet you we’ll get that before AI doctors. How else will we stomp out problematic meritocracy?

      • Joe W. says:

        A fun exercise to try: list all the issues that might theoretically arise with a software industry that is left mostly to the free market, as ours is now. For each issue, describe how well-designed government interventions – regulation, licensing, state funding, perhaps full state control – could improve outcomes.

        The challenge is to do this and not come away with the conclusion that the software industry obviously ought to be nationalized tomorrow.

        (I’ll start if you like. Software is non-rivalrous and mostly non-excludable. Some software performs roles that are critically important – controlling medical devices, safety equipment, etc. – which we cannot allow incompetent quacks to introduce bugs into. There are too many programming languages, and the most popular ones are popular not because they are the best, but because of network effects. Software developers are sometimes subjected to ‘crunch time’ as a project nears completion, in which their employer forces them to work dangerously long hours. Software projects are notoriously difficult to plan and schedule, so firms will consequently be less efficient than you might otherwise expect.)

        • voidfraction says:

          What about the history of government IT rollouts (healthcare.gov, for example) makes you think that a nationalized software industry would be even marginally competent?

        • Vorkon says:

          For each issue, describe how well-designed government interventions – regulation, licensing, state funding, perhaps full state control – could improve outcomes.

          Emphasis mine.

          That’s the crux of your problem right there. Of course a “well-designed” government solution could improve outcomes, if it were designed well enough. The problem is actually getting a government to design such a solution well enough, which has been shown time and time again to be difficult to pull off.

          You might as well be asking, “list all the problems we could solve if we solved all our problems.”

          A better question would be, “list the potential solutions to these problems, which will simultaneously fix the problem, fail to create greater problems, and which we can actually manage to implement” and if you have any suggestions on that front, I’m sure the entire industry would love to hear them.

          • TheAncientGeek says:

            I kind of agree with that, but there is some low hanging fruit, notably in copying good solutions from over countries. There is a lot of not-invented-here bias in politics.

        • Aegeus says:

          Some software performs roles that are critically important – controlling medical devices, safety equipment, etc. – which we cannot allow incompetent quacks to introduce bugs into.

          But most does not, which means that the current model, where the NSA spends millions training developers to be paranoid perfectionists who write unbreakable software, and everyone else just hires whatever devs can get the job done, is a better model. You may be correct that there’s an advantage to nationalizing the software for critical national systems, but what’s the advantage to nationalizing, say, Ubisoft?

          There are too many programming languages, and the most popular ones are popular not because they are the best, but because of network effects.

          First, there’s no one-size-fits-all programming language. Python is good for ease of development, not so much for performance. Second, the government is not a cure-all for network effects. Even if you could wave a magic wand and make every developer on the planet use the best programming language (which doesn’t exist), you’d still have years of legacy code to contend with. And unless you have a very well-funded government, you aren’t rewriting all that legacy code to meet your new language standards.

          Software developers are sometimes subjected to ‘crunch time’ as a project nears completion, in which their employer forces them to work dangerously long hours.

          You’re commenting on an article where hospitals in a nationalized health system are forcing doctors to work dangerously long hours, so I don’t see why you expect the government to help with this.

          Software projects are notoriously difficult to plan and schedule, so firms will consequently be less efficient than you might otherwise expect.

          This only is an argument if you expect governments to be more efficient at planning and scheduling, and I don’t see why they would be.

          And I can think of a very good reason why the industry shouldn’t be nationalized, which is the fact that the software industry has its tentacles in every corner of the economy and there is no way to cleanly pull it out and roll it into a government bureau. Tons of companies use custom software that’s tailored to their needs, and that means that you would have millions of companies knocking on the Bureau of Software’s doors to get their code written. It would also create massive potentials for abuse, because said Bureau could pick winners and losers in the economy by deciding which companies they give support to.

          • Nornagest says:

            I think Joe W’s point was more about how easy it is to make an argument for nationalization than an actual call for nationalization. The issues he brings up are all real ones (though some of them are not quite what they appear), but they’re hugely outweighed by other issues, some of which you’ve found.

            Maybe I’m wrong, though.

          • Joe W. says:

            @Nornagest

            You’re not wrong.

            In short, I’m trying to demonstrate that arguments along the lines, “This industry has market imperfections X Y Z, therefore we should have the government step in and solve them”, prove far too much, unless you actually do want to argue for a fully centrally planned economy.

        • Thomas Jørgensen says:

          .. honestly, I have on occasion contemplated that some major government ought to allocate a sufficient number of billions to have an entire operating system and a standard package of utility software (an office package and a few sundries) written to “Formal Proof Of Correctness” standards. Then give it away. Because this would almost certainly be a net economic win, just from less labor lost to bugs. And the market is never, ever going to do it.

          .. The problem is, of course, that if say the EU were to do this, they’d likely never be able to stop. Because now there is a horde of programmers with expertise not very much in demand by the market, and hell, the voters are always going to want more software that doesn’t crash. Ever.

    • vV_Vv says:

      The same thing is starting to happen to software engineers. What do you think all this “more women/minorities/otherkin in STEM” is about?

      Of course, then you could have software software engineers, provided that Big Y and his followers don’t go FAI Akbar 🙂

  2. E. Harding says:

    “and the rest will have to stay sophomores”

    -Freshmen.

  3. dinofs says:

    It’s interesting that you seem to be suggesting Britain’s socialized health care system to be part of the problem here. Not that it isn’t (I wouldn’t know), but my experience with socialized medicine in Denmark and Germany has been very positive. Service has always been prompt, effective, and cheap even as a non-resident — a good deal better than what I’ve gotten in the US, and with more humane hospitals to boot. From the other side, my brother, his wife and many of their friends are doctors in Denmark, and they make it sound as though working in a hospital is stressful, and they do work long shifts without breaks, but never anything like what you describe here. They all have plenty of time to read, have hobbies, meet with friends, etc. I’m wondering if the difference is that the UK and Ireland are particularly bad, or Denmark and Germany are particularly good, or if the doctors I know have been brainwashed to protect their lizard overlords. Does anyone know if there are significant differences between the British and German/Nordic medical systems?

    • DanielLC says:

      I don’t think he’s saying that Britain’s socialized healthcare is why it’s so bad. It’s that that’s why the libertarian solution won’t work and they’d have to resort to something like strikes. It’s sort of like how in a dictatorship the leader can be good or he can bad but if he’s bad you’re not going to be able to vote him out of office.

      • Anonymous says:

        From Scott’s post, it seemed like the specific way in which Britain’s healthcare is socialized is the problem.

        • Ryan says:

          Another variable to consider is the overall level of public health. My off hand knowledge is that Danes are especially healthy people, while Britain has major problems with obesity, substance abuse, etc.

        • scav says:

          There’s another data point. Scotland (for historical reasons) has a separate NHS under the budget and direction of the Scottish parliament rather than the UK one.

          It’s doing better in various ways and has no junior doctors striking, and it’s more socialised rather than less.

          The problem seems to be top-level “lizard-person” mismanagement as described.

      • Jason says:

        He seems to be positive about Australia’s healthcare system which is also socialised.

        My experience of the Australian system (based on living in the same house as a couple of junior doctors here in melbourne) is that they worked 100 hour weeks and were on the brink of despair at all times before quitting…

        But at least it’s worse in Britain!

        • Simon says:

          The right wing government in Britain has used the fallout from the world financial collapse to drive through a huge number of ideologically driven policies in disguise as necessary austerity measures. In the last year, for example, they have sold of more state assets than in any other year and at bargain basement prices to their wealthy mates. (Check out the way shares in our previously national postal service were apportioned and vastly under-priced.)

          The underlying intention is to demonstrate that the NHS is broken and needs a good dose of outsourcing on the road to an insurance based model. Despite nothing mentioned in any manifesto huge chunks are already being run by privateering topslicers in no-ones best interest but their own. The current health secretary, that well known piece of cockney rhyming slang, Jeremy Hunt, is on record before he got the job as calling for the break up of the National Health Service.

          Apparently the ideal man for the job.

          • Alex Trouble says:

            Putting something like health care under the auspices of politics is exactly the sort of thing that many of us warned about when the US was having this debate in 2007-2008. You can’t just assume another party will never be in power, or never run the system poorly–those are inherent features of any democratic-ish system of government.

          • Wency says:

            I’m just looking at this for the first time now (as I’m American), but it seems to me the day-1 price rise for Royal Mail was high but within the normal range for IPOs. I would expect government to underprice its IPO somewhat relative to a corporation for the same reason that I would expect worse customer service at the DMV than at the bank, but I don’t think there’s enough here to suggest extraordinary corruption.

            2/3 of the shares went to institutions, though in a normal IPO, that number would be 100%. Were some institutions with links to the Conservatives explicitly favored? The participation of individuals in IPOs is risky for both parties and there are good reasons why IPOs shouldn’t rely on them.

            All that said, I don’t know if privatizing Royal Mail was a good idea, just that there doesn’t seem to be much rational inquiry in this comment, and Hanlon’s Razor may be adequate to explain any sub-optimal results from the IPO.

        • William O. B'Livion says:

          Australia has a mixed system. When I lived there everyone I knew/worked with had private health insurance they paid for, and while both private insurance and government provided care happened at the same *hospital* some doctors (like here in the US) would only take private insurance, some would only take cash and you had to get reimbursed.

          When I had to have surgery there (down in Adelaide at a hospital without emergency generators) my insurance company was dunned…a LOT of money for what was admittedly pretty reasonable care.

          And they used a lot of junior labor for the petty stuff. You know, the coming in and waking you up at 2:30 in the morning to see if you’re sleeping well…I mean take your vitals.

          Oh, and the Doctor pissed off to NSW for a holiday the day after my surgery leaving a drainage tube in my neck that had stopped draining, but they nurses wouldn’t remove it w/out his say so. Which was really annoying.

          All in all my experiences with Australian medical care more or less mirrored my experiences with US Health Care. The care in Alice Springs was polite, but desultory. The service in Adelaide was…less polite (for Australian values of polite. Got to adjust for culture), mostly because they were busier/more harried.

          However in both cases I had to pay a bit and the insurance company, not the government, picked up the rest.

          I do know that some percentage (Aboriginals for certain, plus other segments of the population) of the Australian population has their health care paid for/covered by the Government, which is to say the tax payers (corporate and otherwise), but I was never able to fully understand how the lines were drawn.

          • Cheese says:

            I gather from your comment you’re not an Australian citizen? If so you would not have your healthcare paid for by Medicare (the payment/re-imbursal side of the public health system).

            A few notes on how it works:

            As a broad statement, as an Australian citizen (or a UK citizen via the NHS reciprocal agreement), you get completely free medical care within limits.

            ED visits, urgent care and care for diseases that require hospital treatment is free. Primary care via GP is free, however the reality is that without a health care card (available only to low income earners, welfare recipients and pensioners) you will pay a co-payment ranging from between a quarter to a half of the consult price. Ambulance calls will cost you but, again, this is dependent on your ability to pay.

            Where the line starts to blur is non-urgent care and ‘elective’ procedures. Non-urgent and non-life threatening procedures are free in the public system, BUT there is a significant waiting list. This list is modified due to need (i.e. higher severity first) in addition to length of wait. Examples would be things like ACL reconstructions or hip replacements where it is possible but uncomfortable to live relatively normally.

            Why do people get private health cover/insurance?

            A few factors, the main ones of which are:

            -Getting ‘elective’ procedures done at private hospitals with essentially no waiting list that would otherwise cost in the thousands to tens of thousands.

            -Private hospital stays for chronic illnesses or recovery after elective/smaller procedures. Private hospitals are less crowded, nicer and you get your own room

            -Cover for things like dental, physiotherapy, optical and other stuff medicare either does not cover or covers minimally.

            So people who can afford private health cover tend to pay for it. However it’s not really good value for money in many cases. Care for life threatening stuff is far, far superior at public hospitals as they are bigger, have more top specialists and are set up for it. Private hospitals will actually turf you to a public one for severe emergencies (and the government charges your private insurer I am pretty sure). Ditto chronic disease stuff, although that depends. Personally, I only have private health because I play a bit of sport and have popped knee ligaments before – basically I want to be able to skip the queue there (although if my injury is severe enough then there’s really no queue anyway).

            There are also tax incentives for people to take up private health insurance, which kick in at income levels over about 90k for individuals. The government also pays some of the cost of private health insurance irrespective of income level

            A lot of the stuff i’ve said here is contradicted in certain circumstances but that’s broadly how it works. Sure i’ve got a few things wrong as well.

    • AnonymousCoward says:

      Not to mention that the comparable paradise all these doctors are moving to—Australia—has a single-payer system too.

      • Anonymous says:

        Australia doesn’t have a single-payer system. The government sets fixed fees for given services. However doctors can (and many do) charge (sometimes much) more than this, and either supplemental private insurance or out of pocket payments need to make up the difference. The government encourages all permanent residents to have private insurance via an extra income tax (maybe 2%) on everyone who doesn’t have it.

        It’s actually still more complex than this where the cost or waiting time of a procedure depends on if it’s coded as emergency. So it’s more of a crazy messy hybrid system somewhere between the UK and the US.

        • Jason says:

          Well, that’s true of GPs and outpatient services, but once you are admitted to a hospital the government is on the hook for literally everything

          • Schoma says:

            Not at all; in addition to the public system, private medical insurance and private hospitals exist in Australia. So you may choose to attend a private hospital or clinic (usually for reasons of improved service and/or shortened wait times) and your medical insurer foots the bill, though rarely all of it. That’s, of course, if you’ve taken out a policy with a private insurer. Woe betide the fool who didn’t but attends a private hospital or clinic anyway.

            In addition to that, dentistry and ambulance services are not covered by the public health (Medicare) system. Uninsured patients get hit with the full fee.

            Finally, if you are over the age of 31, earn over a certain income (I forget exactly what the bar is) and *don’t* take out private health insurance, your costs to use the public system (i.e. as a portion of your taxes) increase (Medicare surcharge).

            It’s an odd, hybrid system but it gives a lot more choice to both patients and healthcare workers.

          • Schoma says:

            Having said that, a taxpayer *can* claim a Medicare rebate on private health insurance payments. So I guess you could argue that the government is still on the hook even there.

      • Gunther says:

        Australian reporting in, we have universal health care but we certainly don’t force doctors to be government employees for “ten or twenty years”. It sounds like that might be the underlying problem here.

    • creative username #1138 says:

      In the British system doctors are government employees. They aren’t in Germany. Also Germany does not have a NHS. There are multiple competing insurances, both public and private (private insurance gets you better treatment and faster appointments).

    • Arilando says:

      Hmm. I’m danish, and for the last several months there have been several scandals about poor quality of care at hospitals, especially in hospitals in and around Copenhagen. There’s quite a bit of criticism of the healthcare system coming from several sides.

      • Shieldfoss says:

        Fra lægesiden kan jeg afsløre at det er præcis det samme problem som det er for det faldende service-niveau alle andre steder: Flere og flere og flere krav om dokumentation gør at færre ressourcer kan bruges på patient-hjælpende arbejde (Men Shieldfoss! Dokumentation er patient-hjælpende! Sagde næsten ingen læger men mange af de bureaukrater hvis job er afhængige af at nogen skal håndtere al den dokumentation). Service-niveauet er langt højere hos den Praktiserende Læge, for de er ikke ansatte ved staten og derfor bliver betalt per konsultation. Hvis en gennemsnits-konsultation tager længere tid pga. mere papirarbejde, så forlanger PLO flere penge af staten per konsultation, så papirarbejdet hos de praktiserende stiger meget langsommere end hos de læger der er månedslønnede af staten.

        (Find/replace staten/regionen)

    • Shieldfoss says:

      The Danish equivalent of the “General Practitioner” (“Praktiserende Læge”) is typically not a government employee but a private business owner with their own clinic. This gives them far more leeway in negotiations for what the government pays them in return for their services, because if no agreement is reached (and therefore the government no longer pays them to handle the patients the government is obligated to make sure get treatment) the patients instead have to pay on their own and then get it reimbursed by the government.

    • Neanderthal From Mordor says:

      In Germany inpatient medical care is provided by independent hospitals. There is no single medical employer like the NHS.
      The german system has a mix of compulsory and private insurance but this is not about insurance or “socialized” medicine (whatever that means). Is about the NHS having a hiring monopoly and using it to overwork doctors.
      Another advantage of german doctors is that fewer foreigners know the german language compared to english, so there is lesser pressure from immigrants. My cousin is a foreign doctor in Germany and he had to know the language really well to be allowed to work there.

    • dinofs says:

      Thanks everyone. So it seems like the general consensus is that the problem is in the government being the sole employer of doctors, as well as not particularly caring about their well-being or where they come from. I’m still a little confused why, even with the power to make them, the NHS wants its doctors to work 36 hour shifts — but maybe that’s a separate issue?

      • enoriverbend says:

        “the problem is in the government being the sole employer of doctors”

        This is the prime cause, I think. I never understand why the current left vehemently accuses companies like Wal-mart of monopsony but fails to recognize that government is often a much better example of monopsony.

        • Mary says:

          Because the purpose of the accusation is to attack, not to be just. You only need principles if you want to treat people justly.

        • Mario says:

          “the problem is in the government being the sole employer of doctors”

          No, that isn’t the problem. The problem is that overeager MDs always worked more than they should have, literally ruining market prices. That, and that there isn’t any infrastructure at gov. level to rescue MDs from themselves on the long run. Keep in mind that the same situation does not exist to the same degree in any other category of government employee, not even at universities.

          The result of MDs outcompeting each other to death is that resolving the situation now would require doubling the number of doctors hired, AND a crackdown on egos and ambitions. But nowadays no one want’s to see government spending the necessary amount of money on anything. That, and “freedom” and shit. That’s why the problem is never really solved, and why lizardmen tend to have that job of managing health care (no one else has the stomach).

          Also, notice that people just quietly go and work under these ridiculous conditions.

          And this is the other side of the coin: Why is anyone in Blighty working 100+ hours a week? Can’t they find a different, more reasonable job, say, as a janitor or whatever? It boggles the mind that someone who definitively isn’t terminally stupid puts up with that kind of workload in a country in which you can have far more comfortable careers. Of course we know why this is so: personal attachment to the profession, and surely a good dose of narcissism. And hubris and irresponsibility (performing surgery after more than 16 hours without sleep is just plain irresponsible).

      • Ano says:

        “I’m still a little confused why, even with the power to make them, the NHS wants its doctors to work 36 hour shifts — but maybe that’s a separate issue?”

        Because the NHS is underfunded compared to other health services in the OECD, and Britain is grappling with an aging population. The NHS is also not very well run, since it is run by well, politicians (who are always cooking up poorly thought out reforms and projects that waste time and money). Under the Labour government of 1997-2010, this took the form of strict and inflexible targets that led hospitals to fiddle their numbers when they proved impossible to meet. Now, it’s the 7-day NHS. Another scandalous example of waste is the Private Finance Initiatives which were designed to keep hospital debt off the government’s balance sheet, allowing the government to claim they were being fiscally responsible while hospitals have had to divert billions to servicing costly loans.

    • Adam Casey says:

      It’s not that we in the UK have a socialised system like most of Europe. It’s that we have rigidly centralised command-and-control system. Basically all doctors are given a contract by the government and told to sign it. If you don’t like it find a new career path because medicine in the UK is not for you.

    • Hackworth says:

      I have no particular insight into the realities of our health care system in Germany, but from what I hear in the news, we are facing very similar issues, though I’m not sure if they’re on the same scale as described here. Doctors and nurses getting overworked, medical and retirement care getting subjected to strict time budgets (x minutes to wash a patient, y minutes to dress, etc.) without room for individual needs, and so on.

      Also, an interesting data point: The staff at the Berlin Charité hospital started an indefinite strike in June 2015 for better working conditions:

      https://www.wsws.org/en/articles/2015/06/22/stri-j22.html

      So far, strikes in hospitals have happened only for better wages. However, for the first time in German hospital history, the agreement in the end (end of APril 2016) also included mandatory numbers of personnel, such as nurses and care staff per patient:

      http://www.tagesspiegel.de/berlin/mehr-personal-fuer-berliner-uniklinik-die-charite-schreibt-tarif-geschichte/13518510.html (only found source in German)

    • eqdw says:

      Disclaimer: My only source for this is a random reddit comment written by a seemingly well informed Redditor named HealthcareEconomistN (he keeps making new accounts), that I am half remembering reading a year ago.

      Germany has socialized medicine. It does not have single-payer medicine. This is probably a much larger distinction than we here in the US realize, given how these discussions are always framed

      • Joe W. says:

        This is probably a much larger distinction than we here in the US realize, given how these discussions are always framed

        Similarly in the UK. In my experience, a substantial proportion of people in this country are under the impression 1) that every developed country that is not the US has an NHS, and 2) that in the US, healthcare is totally laissez-faire. The dichotomy is seen as being between “socialized medicine” versus “letting everyone who isn’t rich die in the street”.

    • JB says:

      Yes, there are important differences between these countries. From what I understand, the British system is one of the few in which doctors are actually government employees (or effectively via contract? I’m not completely sure about this) . What’s more common in other countries with socialized healthcare is for the government to pay for health services, but the hospitals/doctors themselves are either private or a mixture of private and state-run.

      • gww says:

        I’m not sure of the distinction you’re making. In the British system the hospitals (which employ the doctors) are run by trusts, which are given income by CCGs, which are funded by central gov’t. UK hospitals aren’t (in general) private, but are a few steps removed from actual government, doctors aren’t really gov’t employees in the same way that – say – a civil servant would be. They’re more similar to (non-private) teachers.

    • Deiseach says:

      What I remember from years back over these arguments, before the (notional) limitation on working hours due to European directives, was a lot of senior doctors and consultants arguing that junior doctors had to work these kinds of hours to get proper training and experience, that you couldn’t hand over a patient halfway through treatment when your shift ended and another doctor started because this led to all kinds of mistakes and information not being passed on, and that basically this was how they were trained, everyone had to do it, the long hours meant you got a lot of exposure to all kinds of cases and so much more hands-on experience and that it would not be physically possible to train doctors to the necessary degree with shorter hours.

      So while I endorse everything Scott says about Ministers for Health (here in Ireland and the UK), the higher branches of the doctors’ profession aren’t without blame, either. The medical profession is about the last example of a guild existing and retains a lot of the attitudes: there is an artificial limit on the numbers who are permitted to qualify (as Scott says) and consultants make tidy sums with private and public practices running in tandem – that is, they can work in the public hospitals under the national health system and get paid for that, and are also able to have private practices.

      This is why the huge difference in waiting times to see the same consultant: go public on the medical card – six months. Pay as a private patient via health insurance (or you’re just that rich to afford to put your hand in your pocket) – is three weeks time convenient for you?

      • Adam says:

        That handing off the patient thing makes sense. I think it’s the same basic reason they haze the fuck out of us in military training to get used to never sleeping and being stressed and overworked all the time. It’s not like you can just clock out in the middle of a battle and hand it over to the next shift.

        However, that seems like it only applies to ER doctors and certain types of surgeons that perform longer than 8-hour surgeries. Otherwise, for a normal office visit, I’m rarely with a doctor longer than 10 minutes. Even when I’ve had to go to a hospital, I’ve rarely seen an actual doctor more than 2 minutes and most of my time is spent with a nurse and I’ve never been at the hospital itself longer than 8 hours.

        I guess maybe that’s part of the issue, though? Do junior doctors exclusively work at hospitals and never in small practices? I know I’ve seen my orthopedic surgeon with an intern before and at her practice, not at the hospital.

        • FJ says:

          Wife is a nurse-practitioner in an intensive care unit. Continuity of care is a major concern there. Treatment is a constant balancing act, and figuring out whether you should use this drug on this patient requires careful judgment (read: wild-ass guessing) about whether he seems more likely to die of Ailment A or Ailment B today. Every change of shift requires an extensive debriefing session with your replacement, and at least some of the diagnostic criteria are things like “This test result doesn’t feel right.” Weekends, in particular, are a huge problem because you tend to see a *complete* turnover in the medical team on Friday night and Monday morning.

        • Devilbunny says:

          Something not often appreciated by those not in healthcare: while most people think of “going to the doctor” as seeing a GP in a clinic, that is really not what most doctors spend most of their time doing.

          And that is where the problem arises: patients in the hospital must be seen and cared for daily. The way this is carried out is that the patients are assigned to one fully-licensed doctor (whoever was on call when the patient was admitted). Each one of them will usually have their own team of junior doctors and medical students to assist and learn. (In unusual cases, the same team of underlings will serve multiple bosses, but let’s keep it simple.)

          When I was on call, I was required to be in-house for the entirety, even though I only lived about five minutes away from the hospital. I had a collection of patients that I was responsible for all night long. Some of them were mine, some were primarily seen by other members of the team, and some belonged to other teams that just gave me the bare-bones of what was wrong and what to watch for so that I could address any acute issues that happened overnight (in addition to taking care of any new admissions). Sometimes there were four people on the list; sometimes there were twenty or more. Per team. And, because call happened every fourth night, there were four teams. You could have eighty patients, most of whom you had never met, under your aegis.

          That is why you end up with the situation where you can’t clock out: nobody wants to work every night. And everyone will be back at 0700, so you just have to keep them alive until then. (Although that’s sometimes an adventure in itself.)

          Also, @Mark Atwood, as an anesthesiology resident I routinely did cases lasting 6+ hours (I think my record was 14), although someone would let me get bathroom and meal breaks. And I certainly had a lot of nights where the end of one case meant only that I was assigned to the next one, and worked 24 hours straight without sleep. The American Society of Anesthesiologists was one of the first groups to call for hour limits, so we could not work more than 24 hours when on an anesthesiology rotation (if we worked in an ICU, or something else, the usual 30-hour rules applied).

    • Thomas Jørgensen says:

      It’s not that it’s socialized. It’s that it’s socialized and cheap and mean. My brother is currently doing residency in Denmark. Which is as socialized as medicine gets. And he is thriving. The problem is that the people running the show in the UK are.. insane. You can’t work people like that and get decent performance. It pretty much has to be killing patients through increased error. In quite high numbers. (And I’m wondering exactly how much modafinil they’re importing..)
      Cut the workweeks, they’ll likely make most of it back by working more efficiently when there, to the extent they don’t *hire more doctors*.

  4. DanielLC says:

    > so the top fifty percent of freshmen can go on to become sophomores, and the rest will have to stay sophomores until more money comes in.

    You mean stay freshmen.

    > This is why I find libertarian ideas like letting competition among firms determine people’s pay and conditions so attractive.

    That’s exactly what’s happening here, except with countries instead of firms. Let us hope that Ireland realizes that a 100% socialized industry run as a government monopoly is in fact one of the situations that libertarian ideas work under.

    • Deiseach says:

      It’s not 100% socialized; private practices and hospitals and clinics run in tandem. This is why the heated arguments here and in Britain over a two-tier health system.

      It is a thankless job trying to run the health service; it eats money, constantly runs over-budget and if you try cuts, somebody dies and you get heartstring-tugging stories in the media. It’s legendarily the graveyard of political careers and often (annoying) ambitious young wannabes are put into the job by the Taoiseach in order to put manners on them; to quote from Wikipedia on Ireland’s health service:

      In recent years, and especially since the tenure of Michael Noonan in 1994–1997, being appointed as minister has become somewhat of a “poisoned chalice” in government circles and a portfolio to be avoided by aspiring politicians; during his tenure Brian Cowen famously referred to the Department of Health as Angola due the fact that there were landmines everywhere.

      That said, I wasn’t one bit sorry to see Mary Harney go, and I think a lot of people shared the same schadenfreude; she was the party of Business, a right-wing party (by Irish standards) and was going to import the practices of successful commercial entities into the health care system, get rid of inefficiency, run it like a business, and of course stand up to the consultants. Scott’s anecdote tells you how well that went over 🙂

      Whatever about junior doctors going on strike, consultants’ strikes are sort of the ultimate weapon; you can always get another medical student in the door but if your consultant nephrologist tells you stuff it, they’re going to concentrate on their private practice, and good luck trying to import scab labour from abroad to fill the positions, their association’s lawyers are poised to take you to court the second you try that – ministers generally cave in and sign the contracts.

  5. Julie K says:

    Even someone who doesn’t have sympathy for the doctors ought to be wondering what kind of care the patients will be getting from someone who has been working for 36 hours straight.

    • Randy M says:

      Indeed. Does this really mean working 36 hours straight, or include time on-call lightly sleeping somewhere for eight of that? If awake, are drugs a problem for doctors?

      (Anyway, Scott, appreciate the medical posts you do, always interesting)

      • hlynkacg says:

        Assuming the experience of junior doctors mirrors that of nurses, EMTs, etc…

        Work for 4 – 5 hours take a short break/nap work a few more hours, rinse, wash, repeat.

      • Scott Alexander says:

        When I work my longest shift in my US hospital (24 hours, though on paper it’s a ten hour shift which just so happens to have an unrelated 14 hour shift afterwards) I get a lot of nice breaks and hopefully I can sleep the night if nothing’s too busy.

        My friends in Ireland told me that there were 36 hour shifts there with no breaks or sleep time whatsoever, sometimes not even enough to eat meals.

        • Mary says:

          My record was 40. In college. I carefully did all my homework on Saturday because I was staying up all night at a party (long story).

          I remember that the worst was 3, 4 AM. After that I was more alert, until I felt sleepy earlier the next evening. I could not, however, write fiction at all. (Though that day has been heavily overused as research material since.)

      • ReluctantEngineer says:

        My father (U.S. military doc) said he routinely went 30+ hours without any sleep when he was in residency (several decades ago). One time when I was in high school I complained about having been awake for 28 hours, and he helpfully informed me that his record was 52 hours.

        • William O. B'Livion says:

          I was in the military as a firefighter.

          One week, at least on paper the entire unit was “awake and on duty” for 140 hours. Reality was a bit different, but 3-4 hours a day snatched in 1 to 3 hour increments is a bit rough.

          Oh, and we weren’t doctors, but we were emergency responders. And yes, we did have at least one emergency.

        • James Picone says:

          My record is around that number too; I don’t remember precisely for some reason.

          (yay insomnia)

    • Scott Alexander says:

      I agree this makes sense, but the best research I know suggests it isn’t true in real life. I have no idea why not.

      • drethelin says:

        It seems to me like the actual work of Doctoring is mostly very simple. A lot of things are obvious, if you’re trained how to react to them you can do it on autopilot. The thing that makes Doctoring hard to master is that you’re expected to have a grasp on EVERYTHING. But 99 out of 100 cases are things like “I broke my leg.” or “I drank too much.” and there’s a certain floor below which it’s hard to go when dealing with those cases.

        • Scott Alexander says:

          There’s some truth there (though maybe not as much as you think – a lot of doctoring is remembering to double-check the really easy cases to make sure they’re not secretly something sinister – one out of every X broken legs will produce a compartment syndrome).

          But these studies are comparing medical errors with the new duty hours to medical errors without. The “easy” cases are a constant, but medical errors do happen, and frequently. The question is why they don’t increase.

          • anonymous says:

            Isn’t it because the limit on working hours exists only on paper, as you told us yourself?

            I didn’t read them throroughly but those links say that cutting the working hours didn’t improve the sleep of doctors in training.

            So it remains probable that sleep deprivation causes medical mistakes. The qustion is why limiting working hours doesn’t make them sleep more. So isn’t it because the limit on working hours exists only on paper?

        • Deiseach says:

          A lot of things are obvious, if you’re trained how to react to them you can do it on autopilot.

          Not necessarily; the out-of-hours doctor I went to when I had the inconvenient side pains outside the office hours of my GP told me “It’s only a kidney infection” and wrote me a prescription for antibiotics to get them when the chemist opened in the morning.

          And that’s how I ended up in A&E of my local general hospital at 3:00 a.m. the morning of Good Friday – hint: it wasn’t a kidney infection.

        • Ninmesara says:

          If you think “breaking a leg” is simple, then I think you don’t know a lot about medicine… Almost all broken bones are a significant challenge, that require radiological studies (which one? X-ray? CT?), neurovascular examination for complications of teh trauma (“A fracture is a soft tissue injury in which the bone has to be broken”). Some might require a specialist observation (usually an orthopedist), sometimes with urgent surgery in the same day to handle some of the complications of the trauma. Also, why did the patient break his leg? Would the trauma break the leg of a normal human, or do you have to look for a disease that might have made him susceptible to the fracture? Which test do you ask for in this case? What about a patient on blood thiner medications? Or a patient with a wound to the skin? Is the patient’s story consistent with the findings? If the patient is a children/dependent adult could he be victim of abuse? What do you do in that case?

          I do not want to come off as smug or offend anyone, but I’d really like it if fewer people went around saying that medicine is “mostly simple”… It might seem simple to a medical doctor after years of study and practie, but it is not “simple” by any other meaningful definition of the word…

          • John Schilling says:

            Almost all broken bones are a significant challenge, that require radiological studies [etc ad infinitum]

            I believe that almost all broken bones treated by 19th-century British or American doctors, who generally lacked those capabilities, eventually healed with minimal long-term disability. So “require” is looking kind of fuzzy here, and could benefit from a more rigorous definition.

          • Murphy says:

            @John Schilling

            If you consider a teenagers limbs to have significant value then it’s probably best to have someone check rather than simply accepting 18th century levels of limb-loss. They were really really Amputation-happy back then.

          • This doesn’t sound particularly unique to medicine, or even the diagnosis side of medicine. What about medical billing?

            Don’t even get me started on what it takes to keep a roof over your head and your toilets flushing…

          • Ninmesara says:

            @John Schiling

            I believe that almost all broken bones treated by 19th-century British or American doctors, who generally lacked those capabilities, eventually healed with minimal long-term disability.

            The likely outcome was very often pretty far from “minimal long-term disability”. Fractures of the forearm that are not left to heal perfectly aligned will lead to disability. With compound fractures (fractures in which the bone tears through the skin and becomes exposed) likely outcomes were death from infection or loss of the limb. These kinds of fractures were less common before the spread of cars, though.

          • Ninmesara says:

            @A Definite Beta Guy

            Sure! Everything is complicated nowadays, not only medicine! To be clear, the human body has always been complicated, but the more we know, the more knowledge you need in order to handle diseases or injuries according to the state of the art.

            This is true in crafts and sciences.

            Don’t even get me started on what it takes to keep a roof over your head and your toilets flushing…

            I don’t seem many people saying that engineering and sewer management are “mostly simple” and you only need professionals for the hard stuff. Plumbing might be something you do yourself, but be ready for some setbacks and suboptimal results unless you know a lot about it.

      • Ghatanathoah says:

        If I recall my reading on the subject, the decrease in errors caused by better-rested doctors is cancelled out by the increase in errors caused by doctors constantly having to hand their cases over to new doctors when their shift ends, and forgetting to tell the new doctor something important.

        • Douglas Knight says:

          That’s just a hypothesis, right? No one has actually studied the specific classes of errors, have they?

          Another hypothesis suggested in one of Scott’s links is that reducing the hours of interns without reducing their caseload isn’t good for their patients. This hypothesis blames the total hours, while your hypothesis is about short shifts.

        • pozorvlak says:

          Scott’s experience (that working-hours caps seem to be honored more in the breach than in the observance) suggests that hours worked may not actually have decreased in the “treatment group”.

      • Murphy says:

        ok, perhaps I’m misreading that but those links don’t seem to support that statement.

        The first seems to say the exact opposite, that they had fewer attention failures.
        The second includes this:

        How could fewer hours lead to more errors? For one, interns reported that while they weren’t working as many hours, they were still expected to accomplish the same amount that previous classes had, so they had less time to complete their duties.

        While noting that doctors weren’t sleeping any more in the “reduced hours” group than in the other.

        So it sounds like the “reduction” was a fake reduction confounded by doctors still being given just as much work and it’s self reported and , well, who wants to official report that they’re not getting their work done in the time they’re supposed to.

      • enoriverbend says:

        “I have no idea why not.”

        It’s entirely due to the presence of good nurses.

      • baconbacon says:

        If you design an entire system around overworking doctors then shifting to limited hours probably won’t have immediate effects since you have made expensive portions of the system redundant and worthless (and you are assuming that during the switch everyone adjusts quickly and well and no other random group of employees are getting dumped on and making mistakes that cause problems).

    • Mary says:

      Not to mention state-dependent learning. the infamous all-nighter study session at college meant that information was best remembered when running low on sleep.

  6. It seems to me that a lot of management gets to coast because the of the conscientiousness of subordinates.

    • Hawkice says:

      This is both true and surprising, because conscientiousness is not priced into the wages of hardly any workers. It is easy to measure, and other-report is reasonably accurate, so you might not even need a test. A lot of jobs have high turnover, so it can’t just be managers wanting a sticky wage discount. Managers are largely unaware of problems they don’t have to deal with, but anyone who has been a manager for long knows that there is an infinite stream of problems. So this is something normal humans would likely notice, prefer, have the ability to purchase and yet do not. Conscientious employees often leave to get better jobs, frequently. Why?

      • Jiro says:

        Is it easy to measure? This sounds like a classic case of managers not caring about something because it’s *not* easy to measure. You certainmly can’t put a number on it without some sophisticated analysis.

      • “Conscientious employees often leave to get better jobs, frequently. Why?”

        Lack of conscientious managers.

      • rockroy mountdefort says:

        conscientiousness is not priced into the wages of hardly any workers.

        it seems more the case that non-conscientiousness is priced into the wages of lots of workers, and that people continue to be conscientious in the face of continual demands and incentives from their superiors that they stop.

  7. Anthony says:

    Thanks for this. I trust your objectivity a lot, and it’s very valuable to me on this sort of issue.

    • Scott Alexander says:

      This is not a case where I’m likely to be good at being objective. All my friends are on one side and a lizard person is on the other.

      • Hawkice says:

        ‘Lizard people’ is perhaps unlikely in a literal sense, but given the rationing of bathroom breaks it’s not hard to imagine they are Tayloristic assholes. It could be that saying, one side makes huge sacrifices to save other people’s lives and one side is a penny pinching inhuman suffering factory IS ACTUALLY the non-biased statement.

        • Scott Alexander says:

          Bathroom breaks aren’t officially rationed. It’s just that when three people are having heart attacks around you and there’s nobody else there to help, taking some time out to go to the bathroom isn’t really an option.

          • baconbacon says:

            But you have unlimited access to catheters and things, can’t you just go in a bag strapped to your leg?

          • Inserting a catheter takes time and is a pain. And wearing one has some negative consequences.

          • John Schilling says:

            Inserting a catheter takes time and is a pain. And wearing one has some negative consequences

            One of the benefits of introducing women to the NASA astronaut corps was that, with catheters being the only other option for women to pee in a spacesuit, it became socially acceptable for health young adults to start wearing adult diapers in that context. To the quiet but uniform approval of the men, whose previous solution to the peeing-in-spacesuits problem was nothing to write home about either but nobody wanted to be first to break ranks on the matter.

            Though if it really does come down to diapers vs modified working hours and break policies for medical residents, let’s look real hard at the shift structure first.

          • Who wouldn't want to be anonymous says:

            Relevant.

            Speaking of which, also relevant.

        • JuanPeron says:

          One of the strange things I’ve encountered about learning to be less biased and more analytical about debates is that I totally forget this possibility.

          Every so often, I’ll get deep into trying to understand someone’s position, telling myself “there are no one-sided debates, there are no one-sided debates…” and getting nowhere. And then they’ll casually say something like “And that’s why those people are worthless and I want them to suffer!” And I’ll realize that holy shit, sometimes people have suffering as a terminal goal! (Not suffering of like, mass murderers. I’m talking about thinking rude waiters shouldn’t be able to afford heat in the winter.)

          This tends to be weird and shocking to me, and despite “never attribute to malice…” I find myself constantly having to adjust for the fact that malice is totally a thing.

          • +1 for this happening. It is rare, but so jarring when it happens that I am usually at a loss for words when it does.

          • Nornagest says:

            Malice totally exists, but we’re way too prone to assuming malice when dealing with systems or ideologies we don’t like. Pretending like malice doesn’t exist in these types of situations creates a few false negatives but prevents many more false positives.

            Sure, this leaves you poorly equipped to deal with e.g. actual Nazis. But there aren’t very many of those, and there are lots of people who want to convince you that random people they don’t like fall into that category.

            (Indeed, I don’t think the NHS here is actually being malicious. It’s just that it’s following an enormously perverse set of incentives.)

          • rockroy mountdefort says:

            This tends to be weird and shocking to me, and despite “never attribute to malice…” I find myself constantly having to adjust for the fact that malice is totally a thing.

            I try to bear in mind that stupidity never rules out malice

            If anything, one tends to compliment the other

        • Deiseach says:

          This is the lizard person in question’s name: he used to be Culture Secretary, then was promoted to be Secretary for Health.

          Many newsreaders, some very experienced, mysteriously mispronouncing his name and blaming it on “spoonerism” striking out of the blue!

  8. AnonymousCoward says:

    I feel like the answer to making libertarian job markets work is a strong safety net in the case of unemployment. If being unemployed for even a short time would mean you starve or become homeless (or have to move to where housing is affordable on unemployment payments in order not to starve or become homeless), then your employer really has you held at ransom.

    If on the other hand we paid everyone half the median wage as a basic income, and allowed companies to pay as little as they want, then employees would be negotiating from a position where they could actually afford to walk away without their lives being destroyed. Many of them would choose not to work at all, and work conditions would have to be enticing enough to get skilled people to actually work.

    Sure you’d have to massively increase tax to fund it, but it seems to me that not having your housing and meals at stake is pretty much the condition you want to make a capitalistic job market efficient.

    • Shieldfoss says:

      Wouldn’t work for doctors.

      There are other lines of employment that are exactly as critically important as doctors yet without these same issues, and they do not get any safety net the doctors don’t.

      The problem, as far as the doctors close to me have analyzed it, is that the government has a monopoly on training you to be a doctor. You cannot go elsewhere and become a doctor, so the government has no incentive to avoid making you want to leave. This is not as true now as it has been (witness this entire post about doctors moving to other countries) so possibly it might change, but it hasn’t so far.

      • Scott Alexander says:

        Yeah. One reason I think things might be better in the US is that there’s a lot of levels of obfuscation between the government and the people doing the training. I work for a Catholic hospital. The hospital gets money from the government to train me, they are legally mandated to conform to training rules set out by a body which, while not officially governmental, probably might as well be, but they’re not officially part of the government, and they’re competing for status and employees with all the other hospitals in the region.

        More important, the government gets no direct benefits from overworking me. Since the government doesn’t run the health system directly, it’s not like they can make every doctor work twice as hard, then halve the amount of tax money they spend on health. So their incentives are to regulate job conditions in the same way they do with other industries, not to carve out an exception of convenience.

    • TheAncientGeek says:

      I had a similar thought recently. People are, contra Caplan, rational to fear free markets, because being an unwanted resource in a free market is pretty horrible. Safety nets are therefore a good way of gaining popular support for markets….an idea which is taken granted in some parts of the world, but unthinkable in goers.

      • Vox Imperatoris says:

        being an unwanted resource in a free market is pretty horrible

        Maybe so, but the point people like Caplan make is that, under free markets, people aren’t “unwanted resources”. Everyone has a place, due to the law of comparative advantage.

          • Salem says:

            Gwern is overselling the case there, as is typical of him.

            But a more modest claim is certainly true: Ricardian comparative advantage doesn’t guarantee that the wage you command can pay for your subsistence. The motor car didn’t entirely eliminate horses’ comparative advantage – they’re still great fun to ride, but the cost of their upkeep means they’re not worth it for most of us, so the number of horses has collapsed.

            It’s not impossible for the same to happen to some, or all, people.

          • Vox Imperatoris says:

            @ jaimeastorga2000:

            I’m really getting tired of refuting you on this point.

            @ Salem:

            But a more modest claim is certainly true: Ricardian comparative advantage doesn’t guarantee that the wage you command can pay for your subsistence. The motor car didn’t entirely eliminate horses’ comparative advantage – they’re still great fun to ride, but the cost of their upkeep means they’re not worth it for most of us, so the number of horses has collapsed.

            It’s not impossible for the same to happen to some, or all, people.

            Technological progress, made it cheaper, not more expensive, to feed and house horses. It just decreased the incentive to breed new horses. They didn’t send all the perfectly healthy horses to the glue factory.

            Comparative advantage does not guarantee that people will be able to purchase their subsistence. But the only way you get a situation where people are unable to purchase their subsistence is one where the supply of goods necessary for subsistence becomes lower, driving the price up.

            That is the exact opposite of what is caused by technological progress.

            If we should ever get to a point where material goods are so abundant that there is nothing worth hiring people to do, that would necessarily mean that the goods required for subsistence must be in virtually costless. The hypothetical where labor is worthless but subsistence goods too expensive to buy, is simply self-contradictory.

          • Salem says:

            @Vox:

            Like you, I don’t think we’re in any danger of people not being able to earn subsistence (crazy labour market regulations aside). But your reasoning seems faulty to me. Specifically, you are neglecting opportunity cost.

            You are right that the cost of feeding horses went down, due to technological progress. But the cost of housing and caring for them went up, because technological progress meant that alternative uses for the land and the stablehand now had higher marginal productivity, and you have to outbid the other uses to employ those resources to the horse. Meanwhile the marginal productivity of the horse went down.

            In economic terms, the combustion engine was a complementary technology for land and people, so their productivity went up, but it was a rivalrous technology for horses, so their productivity went down. But horses rely on land and people as scarce factors of production, so the surplus from owning a horse (which we can model as their “wage”) went down across the board, and they’re now just pets for rich people.

            It is not self-contradictory for labour to be worthless but subsistence goods too expensive for most to buy, because labour alone cannot make goods, it needs to be mixed with other factors of production (e.g. land). If the opportunity costs of land are high enough, then the supply of food will be low, regardless of how many people are willing to work as farmers for a low wage.

            So people could go the way of horses, if we were to invent a technology that was both strictly rivalrous with people, and required scarce factors of production that people rely on. E.g. an AI/robot that could do everything a person can do but a million times better, is infinitely cheap to replicate, but requires 0.01 square metres of land to be put aside for its permanent use. Soon the globe becomes blanketed with the things, and food can only be afforded by the few.

            Now I agree that this is vanishingly unlikely, because we have become very versatile in the factors of production necessary to produce human subsistence, and it’s hard to believe that any technology wouldn’t work out in reality to be complementary to humans, but it’s far from contradictory.

          • Eggoeggo says:

            “They didn’t send all the perfectly healthy horses to the glue factory.”

            My father grew up on horse, whale, and rabbit during and after the war. There were about one million working horses in the UK in 1900 but only 20-25 thousand by 1914. They went to the dinner table and the glue factory.

            BTW, the opposite of “complementary” in econ is “substitute”.
            Rivalrous/non-rivalrous is used for distinguishing between types of goods (limited number of video tapes from a store vs TV broadcasts any number of people can tune into)

          • Anonymous says:

            To inject a little lit here, we have good reason to think that automation will be more complimentary to labor than a substitute, and good reason to think that it won’t eliminate jobs.

          • Julie K says:

            Ricardian comparative advantage doesn’t guarantee that the wage you command can pay for your subsistence.

            For example: *lots* of working parents would love to have a private nanny watching their kids. (Which happens to be a career that doesn’t require college.) Very few of them, however, can afford to hire one.

          • Vox Imperatoris says:

            @ Julie K:

            For example: *lots* of working parents would love to have a private nanny watching their kids. (Which happens to be a career that doesn’t require college.) Very few of them, however, can afford to hire one.

            Which is exactly the point: the limiting factor is not the amount of work to be done, but the number of people available to do it.

            If the costs of the things the working parents buy are reduced by automation, that “unlocks” the demand they have to hire a nanny.

          • jaimeastorga2000 says:

            @Vox Imperatoris:

            You can stop any time you like.

        • JuanPeron says:

          But not everyone has a place which is worth the price of food and shelter and necessities.

          I’m sure this has been deeply analyzed and discussed, but I see a lot of basic claims that “everyone has value!” in things like the minimum wage debate. It’s true, but if your ‘value’ doesn’t stop you from starving to death it’s going to be pretty cold comfort. You still have a good reason to fear the free market, even if it will hire you.

          edit: This has been hashed out at length in the rest of the thread. I’m not sold on some of the claims made, but I’ll take my point as addressed.

        • TheAncientGeek says:

          “Maybe so, but the point people like Caplan make is that, under free markets, people aren’t “unwanted resources”. Everyone has a place, due to the law of comparative advantage.”

          So why did anyone ever starve?

          “Ricardian comparative advantage doesn’t guarantee that the wage you command can pay for your subsistence”

          yep.

          • Vox Imperatoris says:

            So why did anyone ever starve?

            Because the productivity of labor used to be so low that there was often not enough to go around to feed everyone.

            This is no longer the case. Because of capitalism.

          • baconbacon says:

            Because the productivity of labor used to be so low that there was often not enough to go around to feed everyone.

            More recently (last few centuries) the answer has been because the government took 20% of the harvest and then banned imports.

          • Samuel Skinner says:

            “So why did anyone ever starve?”

            Because often there wasn’t enough food to go around. Remember that transporting food eats it up (since you need to feed the draft animals) so if a wide enough area has the crops fail, they die. This is exacerbated by war, disease or natural disasters.

          • TheAncientGeek says:

            @Vox

            Increased productivity means no one has to starve, but only in the sense that there is enough to go around, not in the sense at it necessarily goes around.

            Remember that the context of the discussion is safety nets …welfare and minimum wages. Safety nets ensure that production goes around sufficiently that no one starves.

            Increased productivity , absent redistributuon, doesn’t guarantee that every individual has enough to live on, it only guarantees that the average individual does. Having a place doesn’t guarantee subsistence either, so the original point stands.

          • baconbacon says:

            @AncientGeek,

            Nothing guarantees that everyone has enough. Some of the worst famines in history occurred in places that guaranteed basics like food to their populations while basically none occurred in strongly capitalist societies.

      • Garrett says:

        Doesn’t this apply to the dating market as well? Where someone who is unwanted for a relationship finds themselves with a horrible experience? If so, why isn’t there a bigger call for a relationship safety net where someone randomly chosen of compatible orientation need to provide you sexual services once a month or some such thing?

        • jaimeastorga2000 says:

          The traditional way to redistribute sexual access is early, monogamous, lifelong, benevolently patriarchal marriage.

          • Dahlen says:

            *looks at the original post*

            *looks at your comment, read in isolation from the discussion that preceded it*

            I can’t believe that, on a blog post concerning the work conditions of residents in the UK, you people still somehow find a way to shoehorn in your hobby horses, which, just as a daily reminder, the Western world outside SSC believes to be somewhere between antiquated and abominable. All roads lead to (N)R(x)ome around here… Am I the only one around who thinks this space could use less obsessing over culture war topics?

          • It seems to me that the point that traditional institutions now somewhat out of favor can be seen as a solution to a modern problem being discussed is relevant.

            More generally, one response to “here is a problem” is “what should we do to solve it?” A slightly different response is “what are we doing that causes it?”

        • NN says:

          If so, why isn’t there a bigger call for a relationship safety net where someone randomly chosen of compatible orientation need to provide you sexual services once a month or some such thing?

          Decriminalizing prostitution would pretty much accomplish that, at least for anyone who can scrape together a couple hundred bucks once a month.

        • TheAncientGeek says:

          Because coercing some individuals to have sex that they don’t want is much less acceptable than coecing working people into paying a portion of their salary to be spent on socially useful things.

          • John Schilling says:

            @Geek: Seeing you assert that so bluntly, kind of makes me want to see you support it. Rape seems to be considered less acceptable than armed robbery, but not by a huge degree. And it’s not clear where rape stands as compared to slavery on the public acceptability scale.

            Why can’t the formula which transforms criminal theft and/or slavery to benevolent taxation, ever be applied to the sex trade?

          • John, in response to your first paragraph, slavery is reasonably likely to include rape.

          • sweeneyrod says:

            @John

            Which formula transforms transforms slavery into benevolent taxation? Also, you seem to be equivocating between “armed robbery” and “criminal theft”.

          • “Why can’t the formula which transforms criminal theft and/or slavery to benevolent taxation, ever be applied to the sex trade?”

            A novel where it was.

          • Joe W. says:

            @TheAncientGeek

            Stating that taxes are spent on ‘socially useful things’ as a given strikes me as assuming the conclusion.

            In any case, a sexual safety net wouldn’t need to mean unwilling partners picked from the population at random, any more than a state army requires conscription.

          • sweeneyrod says:

            @Joe

            “In any case, a sexual safety net wouldn’t need to mean unwilling partners picked from the population at random, any more than a state army requires conscription.”

            True, but the proposal TheAncientGeek was replying to was “someone randomly chosen of compatible orientation need to provide you sexual services once a month”, quite different from government subsidised legalized prostitution.

          • John Schilling says:

            @sweeneyrod: I’m the libertarian here; don’t ask me to distinguish between taxation, various forms of theft, and slavery. But I am assured that there is a magic formula by which the process of taking my stuff or my labor for the good of the state is somehow acceptable in a way that it wouldn’t be if I were the one doing the taking.

          • TheAncientGeek says:

            @John

            Taxation is more acceptable than sexual servitude, de facto, because many more people accept it. That is presumably not what you are getting at. Presumably you want some kind of principlesd argument.

            Libertarians work off an axiom that any kind of compulsion is absolutely unaccpetable, meaning taxation is just as bad a sexual servitude. Libertairian conclusions follow from libertarian premises.

            Non libertarians don’t share libertarian premises. They are not stupidly failing to see which conclusions follow from premises shared by everybody.

            Nonlibertarians don’t hate freedom or love compulsion. They might even assent to the idea that compulsion is bad….but what they mean by that is something much more fuzzy and less absolute.

            Someone who accepts taxation in is someone who knows it is compulsion,, but willing to trade that off against the useful things the system provides … useful in their view, or they would not support the system And they dont support sexual servitude because they don’t see the same nett benefit. In particular, they see the level and nature of the servitude as much worse, which is something that you can do if you dont see all compulsion as infinitely bad.

            There isn’t a magic formula in the sense of an absolutist, bright line algorithm that tells nonlibertarians what to think. I’m afrid that you have to accept that the people who aren’t libertatians,Marxists, or some or kind of dogmatists are running off fuzzy logic and heuristics, not absolutes and bright lines.

          • Joe W. says:

            @TheAncientGeek

            Libertarians work off an axiom that any kind of compulsion is absolutely unaccpetable, meaning taxation is just as bad a sexual servitude.

            I don’t think that’s fair. Libertarians who believe in negative rights consider compulsion bad, but usually not absolutely unacceptable. And they tend to also believe that libertarian approaches produce better outcomes than non-libertarian approaches – as do libertarians who don’t believe in natural rights at all.

            I think that if libertarians shared your belief that laissez-faire leads to sickness, oppression, and misery for everyone but the rich, most of them would stop being libertarians.

          • Psmith says:

            Libertarians work off an axiom that any kind of compulsion is absolutely unaccpetable, meaning taxation is just as bad a sexual servitude. Libertairian conclusions follow from libertarian premises.

            This is undoubtedly a live strain of libertarian thought, but Michael Huemer and our very own David Friedman are pretty good about avoiding it.

          • John Schilling says:

            @Geek: Taxation is more acceptable than sexual servitude, de facto, because many more people accept it. That is presumably not what you are getting at. Presumably you want some kind of principled argument.

            I’d prefer a principled argument, but I’m not seeing anything at all beyond “Right now, most people agree with me that it’s OK to force people to do X but not to do Y, and yay me, it turns out that I want to force people to do X and don’t want anyone forced to do Y!”

            Great. Two hundred years ago, people thought it was OK to force people to pick tobacco and/or cotton eighty hours a week for no pay, so long as they were black. A hundred years ago, or even fifty, people thought it was OK to force people to join the army and serve as cannon fodder for the war du jour, so long as they were poor. Now people think it’s OK to force people to bake cakes for gay weddings, or to work hundred-hour weeks for subminimum wage (but only if they were fool enough to pursue a medical career).

            Imagine what they’ll think it’s OK to force people to do tomorrow.

            Now imagine it’s Donald Trump supporters who decide.

          • TheAncientGeek says:

            If Libertarians don’t think that all compulsion is unacceptable, why do they call it slavery? Even Friedman does that.

            @John

            If you want to come up with some principles I dont find horrific, be my guest. I’m not against principles, I’m against your principles. The various problems with an unprincipled approach don’t mean that any arbitrary set if axioms is better.

          • Joe W. says:

            @TheAncientGeek

            If Libertarians don’t think that all compulsion is unacceptable, why do they call it slavery?

            Because they believe it is slavery. But that doesn’t automatically override all other considerations.

            People who hold that there are such a thing as rights can, and I think generally do, believe that rights violations are one possible bad thing among many. That a particular action would involve the violation of rights counts against it, but if (for example) the associated utility gain is high enough, it might still be the best option available.

          • Agreeing with Joe:

            I’ve argued that there are imaginable, although unlikely, circumstances in which a military draft would be the least bad alternative. It’s still slavery.

          • HeelBearCub says:

            .. but some slavery is more slavey than other slavery?

            Come on, the reason you use the word slavery, and not simply compulsion, is that slavery sounds awful and compulsory x, where you have to be clear about what x is, doesn’t sound anywhere close to as bad. That’s fallacious argument.

          • houseboatonstyx says:

            @ several

            Um … steelmanned version. Alice paints for the love of it and also gets paid for it. If taxed, she has to paint more instead of sleeping late. I guess you could say she is being forced to paint.

            But calling that ‘slavery’ is ridi sill a non-central use of ‘slavery’. She could earn the extra money some other way. Or she could eat less steak and pay the tax without extra income.

            When people start stretching ‘theft’ or ‘slavery’ off its central meaning, I scroll past. So I don’t know whether they mean tax is ‘slavery’ when the money goes to someone else’s ‘positive right’ (including fire and police protection) — but in other cases, only ‘theft’.

          • Hlynkacg says:

            houseboatonstyx:

            That’s a pretty weak steelman. I think a better one would to be to ask whether or not the doctor’s right to get paid (or work less than 96 hours a week) is greater than your positive right to healthcare.

    • @anonymous coward
      Isn’t the safety net for unemployment in a free market supposed to be your friends, family, community, your own savings, and any unemployment insurance/disability insurance agreements you have set up?

      Why would we expect people to be any better or worse at planning for possible unemployment in systems with or without safety nets? People would adjust to the presence of safety nets and so would reduce their investment in other places that they would turn to if they have economic problems. If Social Security is a thing, people stop expecting to live with their kids in old age and reduce their retirement savings. With welfare and disability payments in place, people reduce or change the direction of their charitable giving to their community/church/local people with disabilities.
      @theancientgreek
      I’d agree with a safety net if that was the actual bargain offered, but as with any compromise for supposedly freer markets, it gets coopted by lobbysts. The safety net part gets implemented poorly/inneficiently/corruptly and then any failures get blamed on the free market part, and that part gets repealed or further legislated in a feedback loop of nastiness.

      • TheAncientGeek says:

        Can you show that this always happens…becuae it sounds like US specific problems to me.

        • I freely concede that I am not knowledgeable enough to show that. I believe the incentives of governments and people line up to work that way in general, but theory is weak or no evidence of anything. I guess country projection fallacy?

      • TheAncientGeek says:

        friends, family, community, your own savings, and any unemployment insurance/disability insurance agreements you have set up?

        How did that work out in thirties?

        Your suggestions all presume that things arent too bad…the individual has managed to save some money , or is an acceptable risk to an insurer, or comes from a family or co,mmumity that is not completely impoverished. Given the perfect storm of an individual who has always be poor in a community that is poor, it doesn’t work. It has a hole in it that a rights based universal welfare system desmt have. So it s less fit for purpose.

        And how is the minimum wage problem addressed?

        And we know how the market solution works because it has been tried. It worked so badly that almost everyone who could afford it went for state welfare.

        • John Schilling says:

          friends, family, community, your own savings, and any unemployment insurance/disability insurance agreements you have set up?

          How did that work out in thirties?

          Well enough to prevent starvation, as I understand it.

          Which leaves lots of room for improvement, but not so strong an argument for coercive improvement. And we’ll point that out every time you make an argument that looks like it implicitly includes, “…or else people will starve”.

        • “How did that work out in thirties? ”

          When the government had set up a safety net for banks, to provide them a lender of last resort in case of a bank run, and then when the run happened pulled the net out from under them?

          “And how is the minimum wage problem addressed?”

          At present, by making it illegal for people who are not worth at least the minimum wage to any employer to have a job.

          And the government dealt with the starvation problem by intervening to reduce agricultural output and push up the price of food.

        • TheAncientGeek says:

          Who says that the benefits of a safety net don’t outweigh the disadvantages of compulsion? If you have both democracy and a safety net, it is clear that the majority think they do. Are you putting forward a fuzzy logic, subjective judgement, or are the nonlibertarian majority contravening some absolute objective principle?

          It is of course not the case that no one has ever starved to death throughout, history, nor is it the case that starvation to death is the only negative outcome prevented by safety
          nets. Niggling about specific cases doesnt address the general point. If you want me to write ‘starvation, nonfatal malnutrition, suicide, debt, etc’ each time, I can.

          In context, the point about minimum wages related to the flaw in Caplans adversion to the principle of comparative advantage. The flaw was that the jobs so generated would not pay enough to live on. Complaining (yet again, the point really doesn’t need repeating) that minimum wage policies may reduce the jobs offered doesn’t address the issue with Caplans claim, because the issue of survivable wages isn’t addressed.

          • “In context, the point about minimum wages related to the flaw in Caplans adversion to the principle of comparative advantage. The flaw was that the jobs so generated would not pay enough to live on. ”

            At the risk of introducing the real world to the argument …

            The average real income in the developed world today is about twenty to thirty times what it was for most of history. Figure someone on the current minimum wage is making five to ten times what the average person made in most times and places in the past.

            Your “live on” is “live on in something not too far below normal developed world life style.”

          • ” If you have both democracy and a safety net, it is clear that the majority think they do. Are you putting forward a fuzzy logic, subjective judgement, or are the nonlibertarian majority contravening some absolute objective principle?”

            Neither. Voters are rationally ignorant in their political decisions, so the fact that certain policies are politically successful is very weak evidence that they are correct.

            Do you disagree? Consider any issue where you believe law is or was wrong. The decision to invade Iraq was made by a democratic government. The war on drugs was created by a democratic government. The decision to imprison the Nisei during WWII was made by a democratic government. The decision to put power in the hands of Hitler was made by a democratic government–he didn’t get a majority in the legislature, but he got his position through the democratic institutions of the Weimar regime.

            On what grounds would you object to any of those decisions?

        • Skivverus says:

          It does not seem to me that a safety net somehow becomes sturdier because it has the “government” label attached to it instead of the “community” label; for that matter, there’s no reason the perfect storm you postulate could be stopped by any safety net, governmental or otherwise (Argentina, Venezuela, Zimbabwe, and the Weimar Republic come to mind).
          Scale lessens the frequency of overwhelming shocks, but cannot avoid them entirely: to (ab?)use probabilistic imagery, you’re using a lot of dice to cover the ones with the sixes (and maybe the fives, and the fours); adding more dice to a given pool does not, in fact, make you immune to rolling too many ones, regardless of how many dice you add or whether you label the pool “government”.

    • Vox Imperatoris says:

      If being unemployed for even a short time would mean you starve or become homeless (or have to move to where housing is affordable on unemployment payments in order not to starve or become homeless), then your employer really has you held at ransom.

      That would be true if wages were determined by negotiation merely between the employer and the employee. But they are not. They are determined mainly by competition among employers.

      Also:

      starve or become homeless (or have to move to where housing is affordable on unemployment payments in order not to starve or become homeless)

      One of these things is not the same as the others.

      • Jiro says:

        That would be true if wages were determined by negotiation merely between the employer and the employee. But they are not. They are determined mainly by competition among employers.

        Exactly what determines the wages is irrelevant here. The point was that if becoming unemployed leads to you starving to death, you can’t quit. If you become unemployed, you don’t have any wages to be determined by competition or anything else.

        • Vox Imperatoris says:

          The argument was that working conditions (which are effectively part of the wage) are bad because people can’t afford not to work.

          My point was that whether or not people can afford not to work is irrelevant to the determination of wages and working conditions. The relevant criterion is the level of competition among potential employers at whatever time you were choosing your line of employment.

          For instance, in the military, it’s illegal to quit, and trying will get you thrown in jail. But so long as people aren’t drafted and have a choice between military and non-military careers (even if they don’t have the choice of “no career”), then competition will force the military to offer competitive wages and benefits. They can “alter the deal” for people already in, but then new potential recruits will take that into account.

          If, on the other hand, people were hatched from eggs in basements under corporate headquarters and couldn’t quit their jobs for one millisecond without starving to death, then it would be true that wages and working conditions would be set at minimum subsistence.

          Or, more realistically, wages and conditions may go down if government labor regulations restrict competition among employers for labor.

        • Joe W. says:

          If you become unemployed, you don’t have any wages to be determined by competition or anything else.

          If you become unemployed, what you have is your labor, which you can sell elsewhere.

          • Jiro says:

            If you become unemployed, what you have is your labor, which you can sell elsewhere.

            The stipulation was that becoming unemployed for a short time leads you to starve. If so, you won’t be able to sell your labor elsewhere because you’d starve before actually getting the job.

            It doesn’t do much good to have a job market where you can quit and be hired in a year if you can’t survive more than two months.

          • Joe W. says:

            As I said to TheAncientGeek elsewhere in the thread, this risk is greatly mitigated by having a flexible labor market.

          • John Schilling says:

            It also doesn’t do much good to have theoretical discussions based on stipulations that are grossly at odds with reality. Where are the real job markets where people are likely to be dead two months after they lose their job? And how do they dispose of the corpses?

          • Edward Scizorhands says:

            Wage subsidy. Everyone has tasks they want done for $2 / hour.

          • Jiro says:

            The stipulation is a hypothetical. It’s meant to elucidate a principle by postulating a situation that is clearer than normal.

            In the real world you probably won’t starve, but you might have a percentage chance of becoming homeless, or of getting into a debt spiral, or of just suffering a big loss that you can’t risk, etc.

          • Mary says:

            That would call for a very different policy response than starving in two months.

          • keranih says:

            but you might have a percentage chance of becoming homeless, or of getting into a debt spiral, or of just suffering a big loss that you can’t risk, etc.

            Yes, but we have a chance of those things happening all the time. What we need is the ability to model the depth and likelihood (and penetration in the population?) of negative events under situation X vs situation Y.

            Which in our case we have not got.

          • TheAncientGeek says:

            @JohnSchllng

            The place is the past.

          • TheAncientGeek says:

            @Joe

            Mitigation is not as good as a guarantee.

          • Jaskologist says:

            Serious question: Did we actually see people starving in the street in the past because they couldn’t find a job, as opposed to because there really wasn’t enough food to go around?

            I realize that may be a tricky distinction to make, but it seems important to me. We have larely solved the problem of famine (where somebody is going to starve no matter what we do). Discussions of welfare often call up the specter of the unemployed starving, but I’m not convinced that this actually happened absent famine.

          • brad says:

            I’m not really sure how to draw that distinction. But if you look at the Irish famine in the 1840s, Ireland was exporting food at the same time people were starving. If the starving Irish could collectively have outbid the English, presumably the food would have stayed there and at very least fewer would have starved.

          • keranih says:

            famine vs poverty

            This is a difficult distinction, as there is almost never absolutely no food in a region. It was not typical *at all* for all animals or crops of a region to fail at the same time. If it was too wet for barley, the wheat did fine. If it was too cold for young goats, the cows had more grass.(*) The people fortunate enough to have more food than other people – and the physical capability to hold onto the foodstuff – could and did sell it to other people.

            And they would buy it from other regions – once sea transport was going, which was prior to The Founding of The City. (Before that, the people would move to where there was more food – but other people would already be there. Trade was better.) If there were political issues with moving food from one place to another – France had an extraordinary system of local grain markets that didn’t welcome imports from other regions of France, much less Germany or the low countries – then it might be that outside imports could not fill the vacumn.

            And of course, the people with more money were better able to make sure their kids got fed than were the kids of people with less to trade. Poor people had colder homes, less protective clothes, and worse/less food. This is what it meant to be poor. When the price of food went up in a region, poor people felt it first and worst.

            So, pretty much, yes – while there have been isolated times when *everyone* in a region was starving, and winters/dry seasons have historically been not fun times(*) (**)it has been the pattern that in times of food shortage, some starved outright (but more likely died of other illnesses brought on by depressed starving systems) a lot were hungrier and weaker than they could have been, and some did pretty ok.

            (*) Region-wide droughts in dry grazing areas that affected nomadic people and their herds are somewhat different, but still, there were still places within those regions with some water, some fodder.

            (**) Places with more people than the local farm economy can support do exist – and in some of them, like Afghanistan, where a significant amount of family support comes from seasonal, out-of-region labor by some men of the family, wealth is definitely a factor in keeping the weakest family members from dying over the winter – particularly in the late winter/early spring “starving time.”

          • arbitrary_greay says:

            @Jaskologist:

            Someone else is probably more qualified to talk about this, but around 1930, the rice market had a huge deflation due to increased productivity. So even though the harvest was good, Japan went into an economic depression. Attempts to change products were limited by the need for starting capital, but due to aforementioned depression, most all farmers were deep in deb, and without leverage to even get useful rent reductions. (Analogue to some of the oil-dependent nations today?)

            Other:

            https://asiancorrespondent.com/2012/02/starving-to-death-in-wealthy-japan/

            The physical results of increased productivity are not making it to the people.
            http://theweek.com/articles/461606/why-asia-letting-millions-tons-extra-rice-waste

          • So far as moving the discussion closer to the current real world, it’s worth noting that average real wages in the developed world at present average twenty to thirty times as high as they were through most of history. We are a lot farther above subsistence than most of us appreciate.

            And in a market economy without extensive government regulation of the labor market, it doesn’t normally take a year to find a job, although it might take a year to find the job you are best suited to. One downside of laws making it harder to fire employees is that they make it riskier to hire them.

          • houseboatonstyx says:

            / Just dipping in here, ignore if it’s a derail. /

            @ Jiro
            In the real world you probably won’t starve [in two months’ unemployment], but you might have a percentage chance of becoming homeless

            Or rapidly less and less employable. As in losing cell phone use, being unable to repair ones car, etc.

          • Joe W. says:

            @TheAncientGeek

            Mitigation is not as good as a guarantee.

            Part of the argument for libertarianism is that there are no guarantees. It’s not reasonable to make your comparisons between a market system, in which such-and-such bad outcome might happen, versus a government with the specific laws you prefer, which by assumption guarantees the outcomes you want. Government is itself an system, which produces outcomes based on its own internal logic. It’s not an all-purpose ‘whatever I want to happen’ device.

      • Furslid says:

        Yes moving isn’t the same as starving or being homeless. It can still be pretty bad.

        Lots of poor areas are high crime. Moving from someplace where being a victim of crime is something you don’t consider beyond locking your doors and not leaving your laptop visible in the front seat of your car to someplace where it’s a constant concern isn’t something you shrug off.

        It can also cripple your career. If you move someplace cheap and rural, especially without reliable transportation, you may not be able to get to a new job. So moving can keep you unemployed.

        • keranih says:

          It “can be” pretty bad. It almost always isn’t bad at all.

          Moving to a new place for better employment/living standards is part of basic human behavior, and absolutely should not be conflated with starving.

          • Furslid says:

            Yes, but moving someplace really cheap based just on affordability without a job set up beforehand sounds really terrible.

  9. Ghatanathoah says:

    I’m not normally one to be nostalgic for the Good Old Days. But if a feudal lord tried to work his peasants as hard as this system works its junior doctors, his head would be stuck on the business end of a pike by the end of the week.

    Just saying….

    • Dr Dealgood says:

      Actually this, like many other bits of news from across the pond, makes me think of Britain’s gun ban.

      Now in an analogous situation in the US I seriously doubt things would escalate to the level of “watering the tree of liberty with the blood of lizardmen” so to speak. But if the USPS is any indication, overworking civil servants to the point of suicidal desperation is much less workable when they have the option to snap and go postal. Mass shootings might play a useful role in limiting how far the government can push it’s employees.

      I wonder how much of what British people put up with from their government comes from the fact that they can’t really do anything when it oversteps.

      • Going postal is so rare I don’t think it has much effect on working conditions, and I believe going postal which kills bosses is even more rare.

        • Eggoeggo says:

          Well, the US postal service did institute reforms around that time (with The Simpsons joking by 1999 about Postal Sprees not happening any more), and wiki only lists one major one between ’97 and now.
          So maybe something in the internal culture changed around that time?

      • In my model, the likely effect of a mass shooting in the health service would just be “government installs copious amounts of security in the hospitals and business continues as usual”. Why would that not happen?

        • Shieldfoss says:

          Security doesn’t prevent mass shootings, they prevent mass shootings past the security line. What you do is, you instead shoot/blow up the people waiting in line.

        • NN says:

          Security costs money. Good security costs a tremendous amount of money. Airport security in the US has a 7 billion dollar annual budget and misses 95% of smuggled guns and bombs in field tests. Israeli airport security is actually effective, but it costs 8-10 times as much per passenger as American airport security.

          It would almost certainly be more cost effective to just give junior doctors saner working conditions, perhaps with a bit of added security theater to reassure patients.

      • TheAncientGeek says:

        Armed doctors leada to better outcomes how, exactly? Are the weapon supposed to be a deterrent, or do doctors have to use them now and again to show they mean business ? If so, do their victims get factored into the overall utility equation?

        • Eggoeggo says:

          Yes, we all know you can’t stop frothing at the mouth about this subject. Let it gooooo

          • TheAncientGeek says:

            I know it seems crazily wrong to 99℅ of us, it if it seemed wrong to 100℅ of us, the comment would never have been made. There’s something about the topic of guns that makes people say the stupidest things.

          • hlynkacg says:

            @Eggo
            That was uncalled for.

            @TheAncientGeek
            I would say that weapons, get factored indirectly as part of the cost benefit analysis of the social prisoner’s dilemma.

            A stable “Cooperate – Cooperate” equilibrium is dependent on both sides having a “nuclear option” that will outweigh any benefit that the other side would get from defecting.

          • Eggoeggo says:

            At least the inevitable 50 comment argument about evil baby-killers won’t cause much disruption with the thread this large already.
            Enjoy yourselves (again)

          • TheAncientGeek says:

            The nuclear options in an industrial dispute are striking and sacking. You don’t need actual weapons.

          • Anon says:

            Striking and sacking are more like small brushfire wars–unpleasant for those involved but still limited in scope and not outside the basic rules of the game. The actual nuclear option–the option that is taken not to coerce but to annihilate–would be communist revolution.

            Like nuclear warfare, the capability does not need to exercised to be effective. Indeed, it is the threat of the nuclear option that helps set the rules and enforce them

    • William O. B'Livion says:

      If you tried to do that to “Junior Doctors” for 40 years you’d find your head on a (figurative) pike too.

      But for many of these folks there’s a light at the end of the tunnel that ISN’T an oncoming train.

    • Ant says:

      Disagree for the feudal regime. Lord did starve and work to death most of their subjects, they were frequent revolt (both at the local and national level), but most of the lord were sufficiently protected by their soldier to escape execution.

      • Ano says:

        That depends enormously on the specific time. “Feudal regimes” can mean anything from 1700s Russia to 800s France, and as with any era, there were rich times and poor. But most feudal serfs in the Middle Ages actually didn’t work constantly mainly due to a generous regime of holidays. In times when wages were high, peasants might choose to work even less.

        • Tracy W says:

          The holiday thing seems unlikely. If you have farm animals, they need looking after every day. Every single day.

          Plus how were those holidays counted? It may well be that the holidays meant you were exempt from your Lord’s service so you spent the time working on your own garden with the goal of feeding yourself.

  10. 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 name of Margaret Thatcher. She led a strong government elected with a lot of public support, and then did a bunch of horrific stuff that put her somewhere between Slenderman and Hitler in the public imagination. The opposition party had a bunch of unpopular policies for the time, and she remained in power for over a decade, until her own party replaced her with someone so bland that his most popular public caricature was being grey and eating peas.

      In the late 1990s a great statesman came along by the name of Tony Blair. He led a strong government elected with a lot of public support, (after getting rid of the whole nuclear disarmament and widespread nationalisation bits of his party’s constitution), and then manufactured evidence to take us into a hugely unpopular and drawn-out conflict in the middle east. He had a weak opposition party for much of his time in office, remaining in power for just under a decade, before stepping down and being replaced by his chancellor, who wasn’t really equipped to appeal to an electorate under 21st century media scrutiny.

      In 2010, still reeling from the financial crisis, we elected a hung parliament with no majority party, resulting in a coalition government between the Conservatives and centre-left third party the Liberal Democrats. We knew they were lizard-men. We could tell, because they’d clearly snuck up to Tony Blair one night in his sleep, licked his soft, sweaty skin, and absorbed enough of his DNA to look as much like him as possible without quite being able to pull it off.

      The coalition government was not utterly terrible, but the Lib Dems lost a massive amount of public support from the left for “letting the Tories in”. Meanwhile the opposition party struggled to find a leader with any kind of strong public appeal. In the next election, the Conservatives got the slimmest of slim majorities, and unrestrained by the Lib Dems (who went from 57 parliamentary seats in 2010 to eight in 2015), proceeded to grind their party axes like they have never been ground before. The opposition party, in a moment of constitutional madness, selected as leader someone who was in his youth a socialist firebrand, but in his old age is just a fussy old man.

      This isn’t the worst situation to be in. We have a very weak opposition, but also a very conflicted government. Many major pieces of controversial (and in some cases incredibly stupid) legislation or policy they’ve tried to implement has failed elsewhere for reasons of it being terrible, unworkable or illegal, and there’s hope that junior doctor’s contracts will be the next such item to be added to the list.

      Mostly, we’re waiting for the next great statesman to come along. They’re due any year now.

    • Adam Casey says:

      For the NHS in particular the story goes something like:

      After the war we were traumatised and wanted things to carry on in the command-and-control wartime economy path we’d been on so we elected some borderline soviets. They built the NHS, everything else they did was a terrible idea and was repealed quickly. But the NHS stuck because people like doctors.

      Now we’ve got a huge bloated bureaucracy designed by central planners, and which is protected from criticism by a near-religious reverence. (In the UK it’s common to believe that in other countries poor people simply die when they get ill). It is the largest single slice* of the government budget and reforming or abolishing it is impossible.

      Result: there are two types of government: those who massively increase the NHS budget in real terms, and those who screw the doctors so hard they bleed and *just* hold the budget level.

      *technically this is slightly cheating, largest slice if “pensions” and “benefits” count as different slices. But the point stands, it’s big.

      • Simon says:

        Actually the NHS is not that terrible financially-

        It’s just huge and unwieldy and currently being run, politically at least, by people who actively oppose and hate it.

        • Adam Casey says:

          “Not that terrible”. Kind of depends on your baseline.

          It’s very large and very hard to change. Which means when budgets are cut you have to give it preferential treatment and even then it ends up reacting very poorly. That’s not a sign of a healthy department.

          • Simon says:

            Just because something is hard to change doesn’t mean it should be thrown to the wolves. And a lot of the things done by post-war Labour were only given up under Thatcherism so not that quickly. And now we are apparently incapable of the engineering required to build our own infrastructure and have to pump public money into France and China for our nuclear power stations

            Many nationalized institutions ticked along sufficiently well that a cross-party majority of UK citizens want utilities and railways renationalised

            The fact that the East Coast Mainline ran at a profit until unnecessarily forced back into the hands of the pirates and thieves suggests they may not be entirely wrong

            Despite the beliefs of Ideologues there are things big government can do better than the free market.

            Get the feeling we won’t see eye to eye here though.

          • Simon says:

            There were a couple of links in there but they seem to have vanished for reasons beyond my limited skills. I’ll see if they’ll appear here

            http://www.theguardian.com/uk-news/2015/mar/01/east-coast-rail-line-returns-to-private-hands

            https://yougov.co.uk/news/2013/11/04/nationalise-energy-and-rail-companies-say-public/

          • Salem says:

            Get the feeling we won’t see eye to eye here though.

            In this thread, you have used such language as:

            “that well known piece of cockney rhyming slang, Jeremy Hunt”

            “people who actively oppose and hate [the NHS]”

            “pirates and thieves”

            Forgive me if I suggest you aren’t trying very hard to seek understanding.

          • Reading these very different pictures of the same history makes me wonder if there are any objective facts one could look at that would make the views of their authors converge, at least partially. How life expectancy as a function of income changed over time or varies across countries? Measures of how real income varied over time?

            Part of the problem is that each of us gets a filtered stream of information and the filters tend to at least in part reflect what we already believe.

      • Scott Alexander says:

        “There are two types of government: those who massively increase the NHS budget in real terms, and those who screw the doctors so hard they bleed and *just* hold the budget level.”

        This seems a lot like most American bureaucracies – the choices are “have its size constantly double every ten or twenty years until it becomes unmanageable” or “make it much worse, decrease services, anger everybody, and it stays about the same size”.

        I don’t understand why “keep it about the same, growing only matching inflation, and it gets neither better nor worse” isn’t an option, let alone “use technological progress and managerial acumen to make it smaller effectively”

        • Adam says:

          Not a complete answer, but some of it is most government service is labor-intensive and capital-light, making it subject to Baumol’s cost disease, though I think that’s more the case at sub-federal levels, especially law enforcement and education, and might arguably change as technology gets intelligent enough to replace labor in these sectors. Another part, though, is managerial salaries in government don’t have anywhere near the multiplier over employee salaries that private-sector managers enjoy. Ceteris paribus, I’d expect that to mean the managers aren’t as good. Plus, at the top level, they’re political appointees, and the politicians themselves are selected for ideological conformity, not leadership ability. Finally, there’s the ridiculous incentives introduced by the budgeting system. Bring in a project under budget in the private sector and you’ll be rewarded for that. Fail to spend every last cent you were allocated in government and whoever decides how much money you get will never again believe your budget estimate and will always give you less than you ask for.

        • Adam Casey says:

          One optimistic theory: diminishing marginal returns.

          It may be that the system has helped so many people so much that it’s now just not very cost-effective to help much more. All the cheap treatments are being done and we’re reduced to overpaying for dubiously effective drugs to try and wring out the last few QALYs.

          One pessimistic theory is that in the public sector incentives are not just misaligned with efficiency, they’re negatively aligned.

          So different hospitals and trusts and so on are working very hard to exhaust their budgets and then some. (We’ve recently seen several trusts going cap-in-hand to the minister saying they’ve spent all their budget for the quarter and haven’t paid staff yet … and being rewarded for this mismanagement with more money). In which case spiralling budgets are to be expected.

        • Salem says:

          I don’t understand why “keep it about the same, growing only matching inflation, and it gets neither better nor worse” isn’t an option

          In terms of spending, you are proposing the current government’s policies. In fact, they’ve raised NHS spending a little above inflation, so the “lizard people” (your words) are in fact more generous than you.

          The answers are, of course:

          1. It’s a false premise. Services are not decreasing. But they aren’t keeping track with people’s rising expectations, which requires ever-increasing sums.
          2. Rationing in the NHS isn’t done by price, it’s done by GPs and waiting lists. This creates terrible political pressures on the system.
          3. The NHS is a bureaucratic nightmare (5th largest employer in the world). If we were to make it more efficient, that might free up some funds to pay doctors more, but every set of efficiency reforms is bitterly opposed by the very same trade union that is now on strike.

          • TheAncientGeek says:

            Previous “efficiency reforms” have consisted mainly of hiring more bureaucrats. There isn’t good evidence that the NHS is actually inefficient, and there just because something is called an efficiency reform….

        • “I don’t understand why “keep it about the same, growing only matching inflation, and it gets neither better nor worse” isn’t an option”

          Presumably because the incentive structure within the organization produces changes that make it increasingly less efficient. For one entertaining picture of the process, see Parkinson’s Law.

          It isn’t all that surprising. Each individual actor in an organization is acting to achieve his objectives, not the objectives the organization was set up to achieve. Structuring an organization so that the individual decisions add up to the right group decision is a hard problem. On the private market, it’s in part done by a Darwinian process–firms that, by luck or good planning, come close to doing it prosper, firms that don’t go broke.

          That’s harder to do in the political context. Coase and Wang’s book on China suggests that they managed it to some extent by a system where local leaders were or were not promoted according to how well their locality was doing–but there’s an interesting book on corruption in that system which shows some of the failure modes of that approach.

          • Squirrel of Doom says:

            I came here to say what David Friedman had already said better.

            To paraphrase: All organizations drift toward achieving less using more money, unless being pushed hard in the opposite direction.

        • onyomi says:

          The obvious answer seems to be that government-run bureaucracies are not incentivized in any way to be efficient (in fact, they are incentivized not to be, since running under budget can be used as a justification for cutting your budget), so they gradually become less and less efficient, requiring more and more money just to do an equivalent job.

          The average cost per pupil at public schools in the United States is now $10,000/year… that’s a hell of a lot more than inflation, and I don’t think education is now 10x better than when everyone used slates and chalkboards instead of tablets and powerpoint.

          • Friday says:

            SmartBoards come to mind. I’ve never once seen them being used productively in ways that couldn’t be duplicated with a normal projector/whiteboard setup, but they’re at least a few thousand dollars apiece and pretty common.

          • jaimeastorga2000 says:

            I’m oldskool. There is nothing wrong with slate chalkboards and chalk made from chalk. If you are doing 1:N classroom lecture of complex topics, nobody has ever invented anything better, especially once longevity and operating costs are factored in.

            I prefer whiteboards because blackboards hurt my ears and chalk has an extremely unpleasant texture. Plus, the marker fumes smell nice!

          • Nornagest says:

            Plus, the marker fumes smell nice!

            You might want to check yourself for scales.

          • Eggoeggo says:

            My university went back to old-fashioned chalk boards in the new science buildings, because everyone hates whiteboards.

            Of course, they had to have two rows of sliding triple-layer 15ft boards hewn from living slate by swiss artisans, so they cost 10x as much as the white boards would have.

            The only organizations that can waste money better than rich public schools are rich private schools.

          • onyomi says:

            “The only organizations that can waste money better than rich public schools are rich private schools.”

            Whose students get government-subsidized loans to pay the tuition.

          • Hey! White boards are way better for mapping out D&D dungeons. A good portion of my teen years were spent around a 3’x4′ whiteboard one of my friends had punched holes into, spaced 1″x1″ apart.

        • mobile says:

          If you’re not growing, you’re dying.

        • TheAncientGeek says:

          A number of people are assuming that above-inflation cost rises can only be explained by inefficiency. Nope…consider a public education system facing a baby boom.

          You can’t make healthcare systems track inflation: they have to track demographics and drug costs. Did I mention that huge scletoric public health organisations have a huge bulk purchase advantage?

        • Chalid says:

          Some fraction of it is simply that our expectations grow higher.

          2000: “I have to stand in line for two hours to renew this license? This agency is terrible.”
          2016: “The online license renewal page is slow and ugly and only works with IE and Firefox? This agency is terrible”

          • onyomi says:

            In other words, government agencies can’t keep up with the private sector. (That said, I don’t find the DMV ANY better than when I first set foot in it almost twenty years ago now. Last time I renewed my license it took half a day, and I didn’t even need to take a test or anything. The cost for things like renewal, of course, does go up.)

          • CatCube says:

            @onyomi:

            What state? I’ve only ever used Michigan’s Secretary of State offices, and I don’t think I’ve ever spent more than about 30 minutes in one. I’ll be changing my residence to Oregon this year, so I’ll have to see how that goes.

          • onyomi says:

            Connecticut.

          • More anecdata:
            For the four or five Illinois DMV visits (to three different offices) I’ve made, all have been terrible and took forever.
            My two visits to the same Wisconsin’s DMV office were pleasant and quick.

            EDIT:
            Hmm, apparently, my experiences are abnormal, but Connecticut is right at the bottom:
            https://www.dmv.com/blog/best-worst-customer-satisfaction-520701

          • Nornagest says:

            Slow and ugly I deal with every day for enterprise software. I’d be happy if the online license renewal page loaded fully, didn’t go down for maintenance far more often than any computer system should require for maintenance, and didn’t fail a third of the time anyway for unexplained reasons.

          • Eggoeggo says:

            hahaha, online license renewal? Maybe they’ll have an adobe shockwave based renewal page in another five years or so.

          • Nornagest says:

            Hmm, apparently, my experiences are abnormal, but Connecticut is right at the bottom

            If Calfornia’s are some of the best, then I’d hate to see the worst.

            On the other hand, I’ve been to a number of California DMV locations and the ones in the country are actually pretty painless. It’s just urban centers that suck.

          • djw says:

            @Catcube

            I have spent considerably longer than 30 minutes in the Michigan Secretary of State office every time I go to renew my vehicular registration in person.

            The lady at the desk has always been pleasant, and has usually been helpful, but she has never been quick.

          • Chalid says:

            Huh, I renewed in NJ painlessly by mail a few years back. I had no idea the rest of you were stuck in the dark ages.

          • Mary says:

            I’m in Connecticut. I use AAA to renew.

          • Vorkon says:

            Connecticut.

            My apologies.

            That said, I can second what Nornagest said about California’s being wildly inconsistent. One of the ones I’ve gone to was, POSSIBLY, as bad as, if not worse than Connecticut’s (though, I’ve only been to that one once, while Connecticut is consistently bad) while the one I normally go to is… not GOOD, necessarilly, but mostly painless.

          • Illinois DMVs rank among the worst experiences I have ever had waiting in line. Changing my address took longer than seeing the Frozen Princesses at Disney World.

            The attendant then asked me for my birthday and home address because I don’t look like me. Apparently.

            My last two licenses were printed so terribly that most bartenders do a double-take when they see it. My last was blurry: even after 3 printings! This one distorted my face like a fun house mirror.

            Disgusting.

        • JBeshir says:

          It isn’t an option for healthcare, because of an aging population.

        • CatCube says:

          To add to many of the above, some of it is that the US Government is just old. As large organizations age, they tend to pick up more and more rules, intended to fend off mistakes and corruption that the organization has experienced in the past. For private firms, if these get too onerous, they’ll suck the company underwater and it’ll go out of business (for example, General Motors’ previous mismanagement resulting in an unsustainable pay structure–saved only by USG intervention.)

          To give a personal example, because this is what I was working on before I had to take a break: Government procurement rules prohibit just specifying a particular company’s product when it can be competitively bid. This rule generally makes sense, because they don’t want specifiers taking kickbacks.

          However, then you run into the situation I’m in, where we want to use a small purchased building–basically a shed. In a private firm, I’d just pick one that we have used successfully in the past and be done with it. I can’t do that here. But we can’t design what we’re going to put inside the building without knowing the building dimensions, which if it’s not chosen until bids come it, we can’t generate the construction documents needed to put the project out for bid! So basically, we’ve got a good idea of what building we want to use, because we’ve had them on various projects with good performance, but I’m spending days (and taxpayer dollars) doing a ridiculous charade documenting what criteria we want, instead of one sentence on the construction drawings saying “PLACE XX BUILDING FROM YY MANUFACTURER. SEE SPECIFICATION SECTION 13 ZZ AA.00 BB.”

          Of course, one of the reasons the Government has this rule in the first place is because it’s so difficult to fire people for abusing authority. Again, a private sector engineer could just pick a building and be done with it. And if he did it wrong his boss could just fire his ass and be done with it. But the reason a boss can’t do that is again, related to rules passed to prevent historical problems, where a boss used tax dollars to build a cronyist fiefdom. Nobody would care if somebody used investor dollars to build a fiefdom, but we very reasonably don’t want somebody using taxpayer dollars to do so.

          TL; DR: The Government has so much cruft from being around for years.

          • onyomi says:

            “The US Government is just old.”

            Sounds like it could use some competition from an energetic new startup.

          • Mary says:

            The problem is that we’ve discovered no real substitute for territorial sovereignty for the problem of choice of laws.

          • CatCube says:

            Sounds like it could use some competition from an energetic new startup.

            That would give a whole new meaning to “disrupting markets.”

          • “The problem is that we’ve discovered no real substitute for territorial sovereignty for the problem of choice of laws.”

            There have been quite a lot of past societies where what law you were under was not determined by where you were but by some version of who you were. In medieval Islamic societies, for example, the different peoples of the book (Muslims, Christians, Jews and, probably, Sabeans) were under different laws. Drinking wine was a serious offense for a Muslim but not an offense for the others, for example.

            To some extent, different Sunni Muslims were under different law depending on which madhab (school of law) they followed.

          • TheAncientGeek says:

            …and if course, ‘one law for me’ has often institutionalised abuses.

          • Anomaly UK says:

            The NHS is also just old. There are a lot of government-run health systems out there, but not many 70-year-old ones. In my opinion that is the root of the problem

          • onyomi says:

            “…and if course, ‘one law for me’ has often institutionalised abuses.”

            As opposed to the current system, under which no abuse occurs.

            Re. a system getting old: Stefan Molyneux made what I think is a good point: when you first nationalize something you get a big windfall of savings because now all the privately trained people continue to do things the way they did but under a system which is mandated to keep costs down. But eventually those people get old and die and/or become embittered by dealing with the new system, which requires half their energy be spent on paperwork or can only go on by importing new, foreign suckers. As with socialism in general, it tends to function like “eating your seed corn,” or, in this case, scaring off all your young talent.

          • John Schilling says:

            In medieval Islamic societies, for example, the different peoples of the book (Muslims, Christians, Jews and, probably, Sabeans) were under different laws. Drinking wine was a serious offense for a Muslim but not an offense for the others, for example.

            I’m going to guess that burning a Koran in public would get you tried, convicted, and executed by an Islamic court no matter what your faith, though.

            More generally, having a territorial sovereign decide that one group of people obeys one set of laws and another a different set, doesn’t change the fact that you are ultimately using the single-territorial-sovereign model to make it work.

          • “More generally, having a territorial sovereign decide that one group of people obeys one set of laws and another a different set, doesn’t change the fact that you are ultimately using the single-territorial-sovereign model to make it work.”

            In theory, and to some extent in practice, the decision wasn’t being made by the territorial sovereign, although it might be enforced by him. Part of the theory of Islamic law is separation of law and state. The law was deduced from Koran and Hadith by legal scholars.

            In practice, it wasn’t that tidy—there were parts of the law produced by the sovereign, supposedly to fill in gaps in the religious law. And the Ottomans pretty much took control over the legal system, with the kanun sometimes clearly inconsistent with fiqh and with the Sultan claiming the power to tell judges which of the legal interpretations of their school they had to use.

            But the view of at least one prominent scholar is that, in much of the Islamic world, there was an implicit deal between the (usually foreign) prince and the legal scholars under which he left legal matters to them in exchange for their supporting his legitimacy.

            Note also that, in the European middle ages, there was usually an effective division of legal authority between church and crown, and sometimes between king and nobles.

          • Mary says:

            That sounds tangential. The “single sovereign” can be – in reality will be — a body of people. If the association is informal rather than formal, as long as it can have a single voice for practical purposes, it’s a single sovereign.

        • Deiseach says:

          use technological progress and managerial acumen to make it smaller effectively

          Because “technological progress” n the NHS has meant massive government contracts for IT systems which were totally unfit for purpose and “managerial acumen” has mean more and more managers and trying to sell off the bits that private companies (which sometimes have been criticised for providing poor care and services in previous contracts) are interested in, while remaining caught with having to provide public health care for the rest of the system.

          Because every government which has come along has screwed around with it in order to cut costs; they’ve tried market solutions, etc. and ended up with extra layers of management (but not staff like nurses, doctors, technicians, other medical-related professions), half-finished schemes that have been abandoned when ministers were reshuffled/the party in power changed, etc.

          In Britain right now they’re trying to sell off chunks of it to private providers (a lot of them being American healthcare companies licking their lips at the notion of getting juicy contracts). This leads to cherry-picking – you can only sell off the attractive parts which are (or look like they are) profitable to private investment, which leaves the government still stuck paying for the unprofitable parts.

          It’s really the worst of every world: not completely socialised medicine, half-and-half private, and being constantly pulled about and broken down/built back up by different ministers.

          Here in Ireland we had regional health boards which ran the service in their territory, then all that was centralised (because “economy of scale” and efficiency) and now they’re talking about breaking it back into the separate health boards because the promised savings never materialised.

          Look at the National Children’s Hospital here in Ireland: I’m not joking when I say I was listening to news stories fifteen years ago by people promising that this time next year, it’d be up and running. The team back then promised it would work on their selected site, even when everyone was saying it was impossible. Fifteen years on, we may get it – on a new site – sometime. Next year for sure!

        • Ano says:

          “keep it about the same, growing only matching inflation, and it gets neither better nor worse” isn’t an option

          Because Britain has an aging population, because this government and the previous Labour government ruined the finances of many hospital trusts through PFI schemes, because every Health Secretary tries to implement some wonderful new reform to increase efficiency only to waste millions.

          “use technological progress and managerial acumen to make it smaller effectively”

          Every time a new Health Secretary shows up, this is exactly what they try to do. Results are mixed. Adding extra layers of management and expensive IT reforms sometimes just ends up diverting time and money that could be spent on frontline services. The NHS IT reforms ended up being a costly boondoggle.

      • TheAncientGeek says:

        The NHS delivers similar results to the US mish mashsystem at roughly half the cost. Also, all health care systems face rising costs because of aging populations and more expensive drugs. You hear a lot of wailing about costs, but you need to make the right comparison in the right way. The right baseline is not a flatline.

        • onyomi says:

          If the government had a monopoly on personal computers we’d now have computers that ran twice as fast and cost four times as much as they did in 1995. You think a doubling in speed comes without cost?

          • TheAncientGeek says:

            It sounds like you are trying to trump empirical evidence with a theoretical argument.

          • onyomi says:

            What’s wrong with that? Empirical evidence doesn’t mean anything without interpretation.

            Also, we have empirical evidence that things run by the government stagnate in quality while getting more expensive while things run by the private sector get both better and cheaper at the same time.

          • JBeshir says:

            We have specific empirical data about the operation of the various healthcare systems, and as one usually should expect it is stronger evidence than data indicating general trends.

          • Joe W. says:

            @JBeshir

            On the other hand, if what you want to know is not “Will this plane fly?” but “Will other planes that I make fly?” or “How can I make a plane that flies further/faster/etc?” or even just “Will this plane fly again tomorrow?”, then the calculations are once again important.

            If all you have is empirical evidence, and absolutely no theory underlying it at all, you can’t use it to make any predictions.

            If you have a theory that makes a prediction, and then you gather empirical data which doesn’t match the prediction, then maybe the theory is wrong. Alternatively, maybe you made a mistake when gathering the data.

          • JBeshir says:

            If all you have is empirical evidence, and absolutely no theory underlying it at all, you can’t use it to make any predictions.

            True only with a very broad definition of theory. “Reality remains consistent moment to moment unless acted upon” is enough of a theory to start making empirical observations useful for predictions, as is very vague implicit theory- people don’t routinely form formal theories about the contents of their fridge, but are fairly good at predictions about it.

            And you don’t need to pick a single theory, or even a demarked set of theories to act on; you can and should approximate adjusting weight on *all* theories based on their level of consistency with observations, and this should trigger change in predictions accordingly.

            Certainly, no one should need to start writing out any kind of formal theory for you to realise that the plane flying today makes it a lot more likely it will fly tomorrow, even if the calculations as far as you understand them seem to say otherwise.

            The space of theories in which the plane flies has gained weight, and a disproportionate number of those have it fly tomorrow as well.

          • TheAncientGeek says:

            Its completely true that evidence needs interpration , and that truth completely fails to imply that evidence should be trumped by theory.

            What makes theory true is evidence..the evidence..the evidence supporting it, and the lack of evidence against it. That’s a one way arro o w, meaning you can resolve issues and answer questions about what us the best theory,

            Adding a rule that theory trumps evidence gives you you arrows in both directions, making epistemological disputes circular and. unresolevable. You have a situation where someone can say ‘theoryT is wrong because it is contradicted by evidence E’, and someone else can say ‘no, E is contradicted by T’ leading to an impasse.

          • TheAncientGeek says:

            Coninued…

            Of course, we don; actually overturn well-confirmed theories on the basis of a single piece of contradictory evidence..the heuristic in that case is to re-examine and try to replicate the contradiction. So the refined version of the rule is “don’t causally trump evidence with theory”.

            “Also, we have empirical evidence that things run by the government stagnate in quality while getting more expensive while things run by the private sector get both better and cheaper at the same time.”

            But we don’t have data top the effect that that is an exceptionless law, since there are exceptions. Why not try to understand what makes the exceptions exceptional, rather than ignoring data that doesn’t fit our cherished ideology?

        • JBeshir says:

          The NHS is very, very good from a user’s point of view; it’s possibly one of the most cost-effective healthcare systems in the world. Just like Amazon’s distribution chain is remarkably cost effective.

          Being a component in a cost-effective system is not super fun and maybe we should be willing to let it be a little less cost effective so as to not be squeezing doctors so severely. But that’s not politically popular.

          This seems to be an example of one of those times where “yes, but squeezing people harder just makes them do worse enough that it isn’t worth it” isn’t true, and we need to use an optimisation process that actually cares about the people in the system.

        • Julie K says:

          The NHS delivers similar results to the US system at roughly half the cost.

          Higher salaries in the US are a prime component of that.

          • TheAncientGeek says:

            And the NHS is able to pay low salaries because it is seen as a religious institution, and working for it as a form of public service. In other words, *lack* of profit motive makes it more efficient! Is that not interesting from the perspective of the correctness of libertarianism?

          • Randy M says:

            Not really. How do you go from that to making every job useful to the society motivated by the same zeal? The utility of money is in that everyone needs it, so the profane, or even simply the secular, occupations get filled by someone for the right price.

          • TheAncientGeek says:

            I didn’t have the kind of non libertarian society that s all socialsed in mind…what I had in mind is more pluralistic. There is more than one kind of non libertopia.

      • Mary says:

        Also, that was the time when we had just learned to mass produce antibiotics. So it just happened that medical care vastly improved when it was nationalized.

      • AlphaGamma says:

        They built the NHS, everything else they did was a terrible idea and was repealed quickly.

        Not entirely sure how true that is. The railways remained nationalised for nearly 50 years and there is still widespread public support for their being renationalised, for instance.

        • Salem says:

          I agree that not everything else was repealed quickly – huge swathes of the economy remained nationalised into the 80s.

          But as for a terrible idea – c’mon. I remember British Rail.

    • The UK has been the country in the OECD whose economy has grown the fastest since 2008 all the while employment is at record-high levels; so, if the Tory’s goal is to destroy it, they are doing a terrible job at it.

      • Simon says:

        And that growth is still not saying much. Indicators seem to suggest things are beginning to look pretty bleak again. And the job distribution doesn’t fill one with confidence that the basics are being done well.

        Also, without looking at the extent of the selling off of large parts of the service you don’t get a clear picture of how much the Tories, (and to be fair Labour before them to some extent), are wrecking up the place.

        • Yeah, 2.x% growth is not spectacular per se, but given how the rest of the rich countries have been faring (with the exception, more recently, of Ireland), it’s pretty good.

  11. FacelessCraven says:

    Weren’t we just discussing positive rights?

  12. 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.

  13. 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.

  14. 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?

  15. 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?

  16. 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.

  17. 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.

  18. 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.

  19. 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).

  20. 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.

  21. 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.

  22. 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.)

  23. 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.

  24. 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.

  25. 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.

  26. 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.

  27. 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.

  28. 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)

  29. “”” 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.

  30. 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.”

  31. 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.

  32. 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.

  33. 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.

  34. 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.

        http://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.

  35. 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.

  36. 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.

  37. 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.)

  38. 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.

  39. 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.

  40. 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?

  41. Mariani says:

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

  42. 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.

  43. Jill says:

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