Book Review: House of God

I’m not a big fan of war movies. I liked the first few I watched. It was all downhill from there. They all seem so similar. The Part Where You Bond With Your Squadmates. The Part Where Your Gruff Sergeant Turns Out To Have A Heart After All. The Part Where Your Friend Dies But You Have To Keep Going Anyway. The Part That Consists Of A Stirring Speech.

The problem is that war is very different from everything else, but very much like itself.

Medical internship is also very different from everything else but very much like itself. I already had two examples of it: Scrubs and my own experience as a medical intern (I preferred Scrubs). So when every single personin the medical field told me to read Samuel Shem’s House of God, I deferred. I deferred throughout my own internship, I deferred for another two years of residency afterwards. And then for some reason I finally picked it up a couple of days ago.

This was a heck of a book.

On some level it was as predictable as I expected. It hit all of the Important Internship Tropes, like The Part Where Your Attendings Are Cruel, The Part Where Your Patient Dies Because Of Something You Did, The Part Where You Get Camaraderie With Other Interns, The Part Where You First Realize You Are Actually Slightly Competent At Like One Thing And It Is The Best Feeling In The Universe, The Part Where You Realize How Pointless 99% Of The Medical System Is, The Part Where You Have Sex With Hot Nurses, et cetera.

All I can say is that it was really well done. The whole thing had a touch of magical realism, which turns out to be exactly the right genre for a story about medicine. Real medicine is absolutely magical realist. It’s a series of bizarre occurrences just on the edge of plausibility happening to incredibly strange people for life-and-death stakes, day after day after day, all within the context of the weirdest and most byzantine bureaucracy known to humankind.

Just in the past week, for example, I had to deal with an aboulomaniac patient – one with a pathological inability to make up his mind. He came to my clinic for treatment, but as soon as he saw me, he decided he didn’t want treatment after all and left. The next day, he was back on my calendar – he’d decided he needed treatment after all – but when his appointment came around, he chanegd his mind and left again. This happened five times in five days. Every day he would phone in asking for an appointment. Every day I would give it to him. Every day he would leave a minute or two before it began. Unsure how to proceed, I sought out my attending. He ignored my questions, pulled me into a side office, took out his cell phone, and started playing me a video. It’s a scene from his musical, The Phantom Of The Psychiatric Unit, which he’s been forcing his interns to rehearse after rounds. I watched, horrified. It was weirdly good.

If I were to write a book about this kind of thing, people would criticize me for being unrealistic. The only way to get away with it is to pass it off as “a touch of magical realism”, and this The House of God does to excellent effect.

The story revolves around an obvious author-insert character, Roy Basch MD, who starts his internship year at a hospital called the House of God (apparently a fictionalized version of Beth Israel Hospital in Boston). He goes in with expectations to provide useful medical care to people with serious diseases. Instead, he finds gomers:

“Gomer is an acronym: Get Out of My Emergency Room. It’s what you want to say when one’s sent in from the nursing home at three A.M.”

“I think that’s kind of crass,” said Potts. “Some of us don’t feel that way about old people.”

“You think I don’t have a grandmother?” asked Fats indignantly. “I do, and she’s the cutest dearest, most wonderful old lady. Her matzoh balls float – you have to pin them down to eat them up. Under their force the soup levitates. We eat on ladders, scraping the food off the ceiling. I love…” The Fat Man had to stop, and dabbed the tears from his eyes, and then went on in a soft voice, “I love her very much.”

I thought of my grandfather. I loved him too.

“But gomers are not just dear old people,” said Fats. “Gomers are human beings who have lost what goes into being human beings. They want to die, and we will not let them. We’re cruel to the gomers, by saving them, and they’re cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them.”

This is where the magical realism starts to come in:

Rokitansky was an old bassett. He’d been a college professor and had suffered a severe stroke. He lay on his bed, strapped down, IV’s going in, catheter coming out. Motionless, paralyzed, eyes closed, breathing comfortably, perhaps dreaming of a bone, or a boy, or of a boy throwing a bone.

“Mr. Rokitansky, how are you doing?” I asked.

Without opening his eyes, after fifteen seconds, in a husky slurred growl from deep down in his smushed brain he said: PURRTY GUD.

Pleased, I asked, “Mr. Rokitansky, what date is it today?”


To all my questions, his answer was always the same. I felt sad. A professor, now a vegetable. Again I thought of my grandfather, and got a lump in my throat. Turning to Fats, I said, “This is too sad. He’s going to die.”

“No, he’s not,” said Fats. “He wants to, but he won’t.”

“He can’t go on like this.”

“Sure he can. Listen, Basch, there are a number of LAWS OF THE HOUSE OF GOD. LAW NUMBER ONE: GOMERS DON’T DIE.”

“That’s ridiculous. Of course they die.”

“I’ve never seen it, in a whole year here,” said Fats.

“They have to.”

“They don’t. They go on and on. Young people – like you and me – die, but not the gomers. Never seen it. Not once.”

“Why not?”

“I don’t know. Nobody knows. It’s amazing. Maybe they get past it. It’s pitiful. The worst.”

Potts came in, looking puzzled and concerned. He wanted the Fat Man’s help with Ina Goober. They left, and I turned back to Rokitansky. In the dim half-light I thought I saw tears trickling down the old man’s cheeks. Shame swept over me. My stomach churned. Had he heard what we’d said?

“Mr. Rokitansky, are you crying?” I asked, and I waited, as the long seconds ticked away, my guilt moaning inside me.


“But did you hear what we said about gomers?”


Someone once said that the point of art is to be more real than reality. The House Of God is way more real than reality. Reality wishes it could be anywhere close to as real as The House of God. This is a world where young people – the kid just out of school, the blushing new mother – die. Even normal old people – your grandmother, your grandpa – can die. But the most decrepit, demented people, the ones for whom every moment of artificially-prolonged life is a gratuitous misery and you pray at every moment that God will just let them find some peace – somehow they never die. They come into the hospital, they go back out to nursing homes, a few weeks later they’re back in the hospital, a few weeks later they’re back in their nursing homes, but they never die. This can’t be literally true. But it’s the subjective truth of working in a hospital. The Fat Man is right. I’ve been working in medicine for three years now, and I have seen my share of young people tragically cut off in the prime of life, and yet as far as I can remember I have never seen a gomer die. The magical realism of House of God describes the reality of medical professionals infinitely better than the rational world of hospital mortality statistics.

In the world of The House of God, the primary form of medical treatment is the TURF – the excuse to get a patient out of your care and on to somebody else’s. If the psychiatrist can’t stand a certain patient any longer, she finds some trivial abnormality in their bloodwork and TURFs to the medical floor. But she knows that if the medical doctor doesn’t want one of his patients, then he can interpret a trivial patient comment like “Being sick is so depressing” as suicidal ideation and TURF to psychiatry. At 3 AM on a Friday night, every patient is terrible, the urge to TURF is overwhelming, and a hospital starts to seem like a giant wheel uncoupled from the rest of the world, Psychiatry TURFING to Medicine TURFING to Surgery TURFING to Neurosurgery TURFING to Neurology TURFING back to Psychiatry again. Surely some treatment must get done somewhere? But where? It becomes a legend, The Place Where Treatment Happens, hidden in some far-off hospital wing accessible only to the pure-hearted. This sort of Kafkaesque picture is how medical care feels, and the genius of The House of God is that it accentuates the reality just a little bit until its fictional world is almost as magical-realist as the real one.

In the world of The House of God, medical intervention can only make patients worse:

Anna O. had started out on Jo’s service in perfect electrolyte balance, with each organ system working as perfectly as an 1878 model could. This, to my mind, included the brain, for wasn’t dementia a fail-safe and soothing oblivion of the machine to its own decay?

From being on the verge of a TURF back to the Hebrew House for the Incurables, as Anna knocked around the House of God in the steaming weeks of August, getting a skull film here and an LP there, she got worse, much worse. Given the stress of the dementia work-up, every organ system crumpled: in a domino progression the injection of radioactive dye for her brain scan shut down her kidneys, and the dye study of her kidneys overloaded her heart, and the medication for her heart made her vomit, which altered her electrolyte balance in a life-threatening way, which increased her dementia and shut down her bowel, which made her eligible for the bowel run, the cleanout for which dehydrated her and really shut down her tormented kidneys, which led to infection, the need for dialysis, and big-time complications of these big-time diseases. She and I both became exhausted, and she became very sick. Like the Yellow Man, she went through a phase of convulsing like a hooked tuna, and then went through a phase that was even more awesome, lying in bed deathly still, perhaps dying. I felt sad, for by this time, I liked her. I didn’t know what to do. I began to spend a good deal of time sitting with Anna, thinking.

The Fat Man was on call with me every third night as backup resident, and one night, searching for me to go to the ten o’clock meal, he found me with Anna, watching her trying to die.

“What the hell are you doing?” he asked.

I told him.

“Anna was on her way back to the Hebrew House, what happened – wait, don’t tell me. Jo decided to go all-out on her dementia, right?”

“Right. She looks like she’s going to die.”

“The only way she’ll die is if you murder her by doing what Jo says.”

“Yeah, but how can I do otherwise, with Jo breathing down my neck?”

“Easy. Do nothing with Anna, and hide it from Jo.”

“Hide it from Jo?”

“Sure. Continue the work-up in purely imaginary terms, buff the chart with the imaginary results of the imaginary tests, Anna will recover to her demented state, the work-up will show no treatable cause for it, and everybody’s happy. Nothing to it.”

“I’m not sure it’s ethical.”

“Is it ethical to murder this sweet gomere with your work-up?”

There was nothing I could say.”

After learning these medical secrets, Dr. Basch uses hook and crook to prevent his patients from getting any treatment. They end up healthier than anyone else in the hospital, and Basch becomes a contender for “Most Valuable Intern” – in typical House of God style, nobody knows if this award really exists or is just a rumor. His colleagues compete for another award, the “Black Crow”, which goes to the intern who gets the most autopsy consents from grieving families – and which the administration doesn’t realize incentivizes doctors to kill their patients. This is so reminiscent of the bizarre incentive systems in real hospitals that it hurts.

But as the year goes on, everyone gets more and more frazzled. One intern has a mental breakdown. Another commits suicide by jumping out of a hospital window (this isn’t dramatic exaggeration by the way; three junior doctors have committed suicide by jumping out of windows in the past three years in New York City alone). Dr. Basch runs through all sorts of interesting forms of neurosis. Finally, the end of the year approaches, the original crop of interns thinned-out but triumphant – and then they realize they have to do the whole thing again next year as residents, which is maybe a little less grueling but still in the same ballpark.

So they decide, en masse, to go into psychiatry, well-known to be a rare non-terrible residency. The author of House of God is a psychiatrist, so I guess this is only a spoiler insofar as you aren’t logically omniscient. When the Chief of Medicine learns that every single one of his hospital’s interns are going into psychiatry and there aren’t going to be any non-psychiatry residents in the whole hospital…

…okay, fine, I won’t spoil the ending. But suffice it to say I’m feeling pretty good about my career path right now.


House of God does a weird form of figure-ground inversion.

An example of what I mean, taken from politics: some people think of government as another name for the things we do together, like providing food to the hungry, or ensuring that old people have the health care they need. These people know that some politicians are corrupt, and sometimes the money actually goes to whoever’s best at demanding pork, and the regulations sometimes favor whichever giant corporation has the best lobbyists. But this is viewed as a weird disease of the body politic, something that can be abstracted away as noise in the system.

And then there are other people who think of government as a giant pork-distribution system, where obviously representatives and bureaucrats, incentivized in every way to support the forces that provide them with campaign funding and personal prestige, will take those incentives. Obviously they’ll use the government to crush their enemies. Sometimes this system also involves the hungry getting food and the elderly getting medical care, as an epiphenomenon of its pork-distribution role, but this isn’t particularly important and can be abstracted away as noise.

I think I can go back and forth between these two models when I need to, but it’s a weird switch of perspective, where the parts you view as noise in one model resolve into the essence of the other and vice versa.

And House of God does this to medicine.

Doctors use certain assumptions, like:

1. The patient wants to get better, but there are scientific limits that usually make this impossible
2. Medical treatment makes people healthier
3. Treatment is determined by medical need and expertise

But in House of God, the assumptions get inverted:

1. The patient wants to just die peacefully, but there are bureaucratic limits that usually make this impossible
2. Medical treatment makes people sicker
3. Treatment is determined by what will make doctors look good without having to do much work

Everybody knows that those first three assumptions aren’t always true. Yes, sometimes we prolong life in contravention of patients’ wishes. Sometimes people mistakenly receive unnecessary treatment that causes complications. And sometimes care suffers because of doctors’ scheduling issues. But it’s easy to abstract away to an ideal medicine based on benevolence and reason, and then view everything else as rare and unfortunate deviations from the norm.

House of God goes the whole way and does a full figure-ground inversion. The outliers become the norm; good care becomes the rare deviation. What’s horrifying is how convincing it is. Real medicine looks at least as much like the bizarro-world of House of God as it does the world of the popular imagination where doctors are always wise, diagnoses always correct, and patients always grateful.

There have been a couple of studies finding that giving people health insurance doesn’t make them any healthier – see for example the RAND Health Insurance Experiment and the Oregon Medicaid Experiment. I’ve always been skeptical of these studies, because it seems logical that people who can afford health care will get more of it, and there are ten zillion studies showing various forms of health care to help. Insulin helps diabetes. Antibiotics help sepsis. Surgery helps appendicitis. To deny claims like these would be madness, yet the studies don’t lie. What is going on?

And the answer has to be somewhere in the bizarro-world of House of God. Real medical treatment looks precious little like the House MD model of rare serious disease -} diagnosis -} cure. At least as often, it’s like the House of God model where someone becomes inconvenient -} send to hospital -} one million unnecessary tests. Everyone agrees this is part of the story. House of God is a brilliant book in that it refactors perception to place it in the foreground.

But it’s brilliant because in the end it’s not just a romp through hilarious bureaucratic mishaps. There is as much genuine human goodness and compassion in this book as there is in any rousing speech by a medical school dean. The goodness is often mixed with horror – the doctor who has to fight off hordes of autopsy-consent-form-seekers to let a dying patient spend his last few seconds in peace, or the one who secretly slips euthanasia to a terminal patient begging for an end to the pain because he knows it’s the right thing to do.

The question posed here is “what do you do in a crazy cannibalistic system where it’s impossible to do good work and everyone is dying all around you?”, and the answer is “try as hard as you can to preserve whatever virtue you can, and to remain compassionate and human”. The protagonist swings wildly between “this is all bullshit and I’ll just make fun of these disgusting old people and call it a day” and “I need to save everybody and if I don’t I should hate myself forever”, and eventually like everybody, comes to some kind of synthesis where he recognizes he’s human, recognizes that his patients are human, and tries to deal with it with whatever humor and grace he can manage.

It’s hard enough for a book to be funny, and it’s hard enough for one to be deep, but a book like House of God that can be both at once within the space of a few sentences is an absolute treasure.


I talked to my father about House of God, and I told him a few parts that seemed unrealistic. He told me that those parts were 100% true in 1978 when the book was written. I looked into it more, and ended up appreciating the work on a whole new level.

Uncle Tom’s Cabin is credited with kickstarting the emancipationist movement and maybe even causing the Civil War. The Jungle is famous for launching a whole new era of safety regulations. House of God has a place beside them in the pantheon of books that have changed the world.

The book’s “Second Law” is “GOMER GOES TO GROUND”: demented old people will inevitably fall out of their hospital bed and injure themselves. The book has a whole funny/horrifying scene where the senior resident explains his strategy for this eventuality: He leaves their beds low enough that patients won’t kill themselves when they fall, but high enough that they’ll probably break a bone or two and have to go to orthopaedic surgery – which takes them off his hands. Later, a medical student apes this procedure, a patient falls and breaks a bone or two, and everyone freaks out and tells him that it was a joke, that of course you don’t really arrange skeletal fractures for old people just to save yourself time, what kind of heartless moron could think such a thing? This is some nth-level meta-humor: the reader probably mistook it for real advice because it meshes so seamlessly with all of the other madness and horror, yet most of the other madness and horror in the book is easily recognizable by practicing doctors as a real part of the medical system. Actually, on the n+1st meta-level, I’m not at all sure that the resident wasn’t meant to be completely serious and then backtracked and called it a joke when it went wrong. For that matter, I’m far from sure this wasn’t a real medical practice in the 1970s.

I see enough falls that I wasn’t surprised to see them as a theme, but I thought the book exaggerated their omnipresence. My father said it didn’t – there were just far more falls back in the Old Days. Now hospitals are safer and falls are comparatively rare. Why? Because the government passed a law saying that insurance wouldn’t pay hospitals extra money for the extra days patients have to stay due to fall-related injuries. I am so serious about this. This, I think, is the n+2nd meta-level; amidst all its jokes-played-straight the book treats encouraging falls as an actual in-universe joke, and yet in the real world once hospitals were no longer incentivized to let patients fall the falls stopped.

How did people become aware of this kind of thing? How did the movement against it start? A lot of it seems to be because of House of God. Everyone in medicine knew about this sort of thing. But House of God made it common knowledge.

People were scared to speak up. Everyone thought that maybe they were just a uniquely bad person, or their hospital a uniquely bad institution. Anyone who raised some of these points was met with scorn by prestigious doctors who said that maybe they just weren’t cut out of medicine. House of God shaped medicine because it was the first thing to say what everybody was experiencing. Its terms like “gomer” and “turf” made it into the medical lexicon because they pointed to obvious features of reality nobody had the guts to talk about before.

Shem writes an afterword where he talks about the reaction to the book. Junior doctors and the public loved it. Senior doctors hated it. He tells the story of going to a medical conference. Someone asked who he was, and he said jokingly “I’m the most hated doctor here”. His interlocutor answered “Oh, don’t worry, I’m sure you’re not as bad as the guy who wrote that House of God book.”

But House of God gets credit for helping start movements to cut intern work hours, protect doctors from sleep deprivation, reduce patient falls, and teach empathy and communication skills. The moral of the story is: the courage to tell the truth is rare and powerful. More specifically: the courage to tell the truth is rare and powerful not just in Stalinist dictatorships and violent cults, but in apparently normal parts of everyday First World life. All of these differently loaded terms like “culture of silence” and “political correctness” point at a fear of rocking various boats with nothing but your imperfect first-person knowledge to go on. But a tiny crack in the wall can make a big difference.


In a closing scene, Dr. Basch and all of his fellow interns – interns who had broken into tears weekly, gotten burnt out, starting seeing psychiatrists, considered suicide, all this stuff, these interns who had smashed up against the unendurable horrors of medicine and held themselves together only by the promise that it would soon be over – the minute they graduate internship they change their tune:

It looked like all but two or three [interns] would stay. The Runt and I were definitely leaving; Chuck hadn’t yet said. The others were staying. In years to come they would spread out across America into academic centers and Fellowships, real red-hots in internal medicine, for they had been trained at the Best Medical School’s best House, the House of God. Although a few might kill themselves or get addicted or go crazy, by and large they’d repress and conform and perpetuate the Leggo [the Chief of Medicine] and the House and all the best medical stuff. [Eddie] had been praised by the Leggo that he could start off the second year as ward resident, with “a free rein” on his interns. And so, saying already that the internship been “not so bad,” he was preparing to indoctrinate his new charges: “I want them on their knees from day one.”

Shem’s author mouthpiece character Berry says:

It’s been inhuman. No wonder doctors are so distant in the face of the most poignant human dramas. The tragedy isn’t the crassness, but the lack of depth. Most people have some human reaction to their daily work, but doctors don’t. It’s an incredible paradox that being a doctor is so degrading and yet is so valued by society. In any community, the most respected group are doctors. [It’s] a terrific repression that makes doctors really believe that they are omnipotent healers. If you hear yourselves saying, ‘Well, this year wasn’t really that bad,’ you’re repressing, to put the next group through it. [But] it’s hard to say no. If you’re programmed from age six to be a doctor, invest years in it, develop your repressive skills so that you can’t even recall how miserable you were during internship, you can’t stop.

Shem’s thesis is that it isn’t just about not wanting to make waves or offend the Chief of Medicine. It’s about denying your own pain by identifying with the system.

This puts me in a weird spot. My internship (I find myself saying) wasn’t so bad. I can give you some arguments why this might be true – things have gotten a lot better since The House of God was published (with no small credit to Shem himself), a small community hospital in Michigan is less intense than Harvard Medical School’s training hospital, psychiatry interns sometimes have it easier than internal medicine interns since everyone knows this isn’t a permanent deal for them.

And yet I distinctly remember one night a long time ago, coming home from high school. I had noticed that all of the adults around me said high school was some of the best years of their lives and I would miss it when I was gone, and yet high school seemed objectively terrible. I wondered if there might be some bias or bizarre shift in memory that happened sometime in people’s twenties and gave them a localized amnesia or insanity. So I very distinctly recall telling myself “My current assessment is that high school is terrible, and if you ever find yourself remembering that high school was lovely, please be aware that your memories have been hijacked by some malevolent force.”

And God help me, but every single part of my brain is telling me that high school was lovely. I fondly remember all the friends I made, the crazy teachers I had to put up with, the science competitions I won, the lunches spent in the library reading whatever random stuff I could get my hands on. It seems like it was a blast. It’s hard for me to even trust that one memory as anything more than imagination or the product of a single bad day. But although high-school-me had a lot of issues, he generally had a decent head on his shoulders, and if he says my memories have been hijacked, then I grudgingly believe him.

So was my intern year a good learning experience? I have no idea and I’m not sure anyone else does either. It’s another type of figure-ground inversion: parade of horrors broken only by the occasional triumph, or clear sailing with a few bad moments?

On my last day of internship, one of my colleagues who was moving on said “I’m going to miss hating this place”. I’ve always remembered that phrase. Now I wonder if it’s some kind of weird snapshot of the exact moment of transition, the instant when “nightmarish ordeal” morphs into “halcyon days of youth”. This is why medicine has to be written as magical realism. How else to capture a world where people reliably go from agony to Stockholm Syndrome in the space of a day, and where the transition is so intermixed with the general weirdness that it doesn’t even merit special remark?

I found myself having more emotions reading House of God than I’ve had about anything in a long time. I don’t really know why. But I think it has something to do with this resignation to the general incommunicable weirdness all around anyone who works in medicine. Somehow Shem manages to avoid the normalization of insanity that happens to every young doctor, capture the exact subjective experience and write it down in a way that makes sense. And then, having put his finger right on the unbearable thing, he makes it funny and beautiful and poignant.

I tell her. Again I tell her about Dr. Sanders bleeding out in my lap, about the look in Potts’s eyes that night before he jumped, about my pushing the KCl into poor Saul. I tell her how ashamed I am for turning into a sarcastic bastard who calls the old ones gomers, how, during the ternship, I’d ridiculed them for their weaknesses, for throwing up their suffering in my face, for scaring me, for forcing me to do disgusting things to take care of them. I tell her how I want to live, compassionately, with the idea of death clearly in sight, and how I doubt I can do that, ever again. As I think back to what I’d gone through and what I’d become, sadness wells up and mixes with contempt. I put my head into Berry’s folds and weep, and curse, and shout, and weep.

“. . . and in your own way, you did. Someone had to care for the gomers; and this year, in your own way, you did.”

“The worst thing is this bitterness. I used to be different, gentle, even generous, didn’t I? I wasn’t always like this, was I?”

“I love who you are. To me, underneath it all, you’re still there:” She paused, and then, eyes sparkling, said, “And you might even be better.”

“What? What do you mean?”

“This might have been the only thing that could have awakened you. Your whole life has been a growing from the outside, mastering the challenges that others have set for you. Now, finally, you might just be growing from inside yourself.

He also frames all of it in the language of psychoanalysis, which is jarring and sounds preachy. I’ve ordered the sequel, Mount Misery, about his training as a psychoanalyst. Expect a review of that soon.

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153 Responses to Book Review: House of God

  1. Hal Dall MD says:

    I can’t remember for certain when I read the book, I think It was in 1980 as a 4th year student. I did not dissect it as Scott has, but I have long believed it helped me endure through my internship and residency. I think it somehow gave me a sense that what my peers and I experienced was not an isolated or local phenomenon. I also gained some perspective on the ordeal I had already (barely) endured. I have some selective memory with the post-grad years, but 35 years later I still avoid recalling the clinical years of med school.

  2. eqdw says:

    I can confirm that my highschool experience was objectively terrible and my life right now is orders of magnitude better than that one was.

    IDK how all the rest of you nerds got out of that hellscape with fond memories but I sure didn’t. Besides, now I can spend money on stuff. Go travelling. Live in a nice house without autocratic assholes telling me what to do. I get to play with technology. Learn new things that aren’t on the course syllabus. Meet people who aren’t the same age as me.

    Highschool was terrible and they should be burned down. Life in your 20s is much better

  3. luispedro says:

    “There have been a couple of studies finding that giving people health insurance doesn’t make them any healthier – see for example the RAND Health Insurance Experiment and the Oregon Medicaid Experiment. I’ve always been skeptical of these studies, because it seems logical that people who can afford health care will get more of it, and there are ten zillion studies showing various forms of health care to help. Insulin helps diabetes. Antibiotics help sepsis. Surgery helps appendicitis. To deny claims like these would be madness, yet the studies don’t lie. What is going on?”

    These studies show that the marginal healthcare has small value on average (their power is limited, so they cannot show that it has no value at all). The extra healthcare that these people were consuming was already well into the “diminishing returns” point of the curve. Add in uncommon, but catastrophic, failures of healthcare delivery (hospital acquired infection, for example) and the average effect of marginal healthcare may be zero even while healthcare as a whole is very valuable.

  4. garrettmpetersen says:

    Daniel Kahneman argues that our memories of an experience are disproportionately weighted towards the very end of the experience. If you have a miserable experience but the very end of it isn’t so miserable, you’ll remember it as less miserable than it actually was.

    I spent the last few months of high school clinically depressed. It coloured my whole memory of high school. I remember high school as a distinctly negative experience.

    However, for most people the end of high school is more positive than any other part. You have big grad parties and the excitement of moving on in life. The final months of high school are almost certainly better than the drudgery in the middle, so maybe that causes people to misremember the whole experience as more positive than it was.

  5. Quixote says:

    Reading people’s high school experiences it sounds like a lot of problems people have come from living in small places. When there aren’t a lot of people in a place high school just lumps all kids form that place together and all the outliers are hosed. When a place has high population they can have specialized high schools, art schools, trade schools, industry specific high schools etc. And anyone who is exceptional along any axis can go to a high school full of kindred spirits and have a good time finally being “among their people.”

    • moridinamael says:

      FWIW I went to a “special high school for smart nerds” and posted above about how I disliked the experience so much that I wrote my future self a letter.

  6. PB says:

    My favorite part of the not-very-good novel by Michel Houellebecq The Map and the Territory involves the protagonist’s father who had to undergo surgery to get an artificial anus. On the one hand, isn’t medicine amazing that we can have surgery to get an artificial, working anus? On the other, this old man had to undergo surgery to get an artificial anus. The father eventually decided to get “put down” in Switzerland.

  7. nestorr says:

    Another aspect I find is that younger people have keener sensibilities, my last year has been objectively awesome, but I don’t think I’ve enjoyed it all that much, and I’m not sure if it’s actual anhedonia or just being old and stuff not hitting you that hard. Yeah I distinctly remember teenage me hating hs but I’d also rate teenage me as a wimp.

  8. jiriki says:

    Reading the first paragraph made me wrinkle a bit. Given the older link where Scott linked to hunter/gatherer societies having happier people, and talk of Sebastian Junger. He gave great example how some Blitz survivors missed the air raids even there was death and everything, because of deep feelings, community and working together.

    As someone who has done military service, I can certainly understand why people appreciate the bonding etc.

    War movies can suck though. I don’t mean that. Military also attracts all kinds of crazy sociopaths and sadists. But I know many people from military, and I respect them greatly as human beings. Also many of us are here because of what people in military did.

    Also I haven’t seen the movie of Kwai-river, but I have read the story of labor camps. And it was one of the the best short stories I have ever read. First everything was turning into nihilistic hell, and later two corporals saved a captain’s life. Then life there turned upside down, people started helping each other, starting jungle “academy”, creating a jungle POW music group, setting up POW theatre, creating improv christmas dinner, treating the wounds of the returning enemy soldiers against guard’s orders. It was a story of humanity.

  9. Machine Interface says:

    Personally I do not experience the nostalgia-for-past-life at all, and that in spite of being unable to remember most of the bad things. I can think of mostly happy memory, then ask myself “would I like to go through this again?” to which my brain immediatly and clearly answer “oh hell no!”

    Though I believe this is partly due to awareness of how unsufferable present me would find past me (and probably reciprocally) and past me’s friends if they were to meet.

  10. liskantope says:

    I’ve noticed a similar phenomenon with nostalgia, where no matter how unpleasant or difficult a particular period of my life was, I find myself mentally flitting to certain scenes from it which could be pleasant or carefree but which are no longer possible in my current life. I guess our minds are just more inclined to go back to nice memories than to painful ones, especially when they are memories of doing things that are no longer part of our lives today. In recent months, this type of nostalgia has shot through the roof for me, I think not because my life today is particularly unpleasant or difficult, but because it tends to be rather drab and lacking in both great moments and miserable moments — my mind is a little bored and wants to relive something but would prefer not to relive anything painful.

    We see a roughly similar phenomenon in political attitudes. I’m too young to remember the Reagan era, but I’m pretty sure he was a pretty polarizing president and know that his policies made many feel miserable. Yet a lot of people seem to have been looking back on it fondly during the presidency of George W. Bush and also today. Meanwhile, around 2012, many were reminiscing about how great Bill Clinton was, and indeed I remember studies showing that he was more popular than Obama at that time. But I’m sure that back in the 90’s, those who liked President Clinton were probably lukewarm and a lot of people hated him. During this year’s election season, when we actually began to closely revisit the idea of the Clintons in the White House along with all the scandals involved, we didn’t exactly wind up giving them a ringing endorsement.

    • Matthias says:

      Clinton was reasonably popular. I remember that even during his scandal about his affair with Monica Lewinsky, his popularity endured.

      (But I only saw all of this second-hand from Germany.)

  11. FerdJ says:

    Feels like a case of what people see the most being their normal. I’m a normal, healthy person from a normal, healthy family, so for us, the hospital is a place you go once in a while when you get hurt due to some kind of trauma. You usually get fixed within a few hours, day or two at most, and go home. So we kinda assume that everybody who goes to the hospital has that experience.

    But what’s a hospital doctor’s normal experience? If basically healthy people tend to come in rarely and usually leave fast when they do, then we’re probably a small, forgettable part of the doctor’s experience. If their days are mostly spent dealing with Gomers who have ridiculously complex set of interlocking health problems that nobody really knows how to deal with, are probably never going to be close to anything we would call healthy again no matter what the doctors do, and have to deal with a bizarre bureaucracy probably designed around dealing with healthy people for anything involving them, then I can see it being easy to get depressed, crazy, cynical. Especially if you just spent years studying to get into medicine, probably with a vision of yourself helping basically healthy people get better again, because that was your world too before you got into this.

    • Murphy says:

      It’s not limited to doctors.

      Tech support hit the same problem. In the organisation there will be a lot of people who have IT problems.

      The self sufficient ones who solve their own problems the IT dept rarely ever see.
      The ones who aren’t nightmares to deal with take up a little time.
      Normal people with the occasional really weird problem take up a little more time.

      But the vast vast vast majority of their time gets eaten up dealing with a minority of utterly crazy morons who don’t google anything, don’t follow instructions, lie and fuck things up.

      As such their perception of the users at a company with 1000 people and 10 high-maintenance asshats (who somehow don’t get fired despite being unable to turn on their monitor) is going to be dominated utterly by the 10 asshats that they have to deal with every other day.

  12. watsonbladd says:

    On war movies: See Das Boot and Kanal, or A Bridge Too Far or Bridge over the River Kwai, for war movies that absolutely don’t fit that frame, at all.

    • keranih says:

      I would consider adding Kelly’s Heroes (and to a certain extent, Three Kings, which wanted to be the Gulf War Kelly’s Heroes) as anti-genre-type movies.

      But then again…

      …naw. Have to think on this. More thoughts on the next OT, maybe.

    • Matthias says:

      The author of Das Boot (the book) complained that the movie was far too upbeat compared with reality.

      Spoiler: the movie is pretty dark already.

    • Otzi Ozbjorn says:

      The Winter War, Finnish, 1989 directed by Pekka Parrika

      A war movie that shows the human cost and horror of war without glamorizing it.

  13. gardenofaleph says:

    It is strange that the most stressful times produce the closest friendships, and oftentimes the best memories.

    Part of it is the way we deal with boredom.

    In the moment, stress/responsibility/anxiety are subjectively quite negative experiences, but in the long run, the memory of it, at least for me, fade rapidly. All that’s left is what I’ve accomplished and the brief nice moments snatched between the Important Stuff.

    Boredom is pretty bearable in the moment but leaves you with precious little to remember after its gone. So my summer vacations, while idyllic in many ways, are forgettable. Service trips with my university or those delirious weeks during final exam time– those leave me with fond memories of trials overcome with friends/comrades.

  14. Deiseach says:

    There is also the English (Australian-English) doctor/comedian, Dr Phil Harris, who writes a regular column for “Private Eye” magazine and combines working as a doctor in an NHS clinic with stand-up comedy tours.

    “What do we want? Evidence based policy making!
    When do we want it? After systematic review and independent cost effectiveness analysis!”

    • zz says:

      This is the point where someone should mention the cost of delay, which is often overlooked but really important.

      It is, in fact, possible to try something that has only tentative evidence that it does what we want, and in using it, gather more evidence about whether it does what we want or not.

      That is, we want evidence-based policy making. And not only do we want it after systematic review and independent cost-effectiveness analysis, but if that’s not going to be finished soon, we also want it now. Along with the ability to admit that something we tried didn’t work and stop trying it.

      • Murphy says:

        If you set up the system to build in RCT’s whenever you’re not sure which of 2 options are the best then that’s not too hard.

        if there’s not enough good data to decide one way or the other then the sane thing would be to randomise people into one wing or the other. (not just in medicine, in everything from criminal justice to preventing speeding)

        but “research” is almost a dirty word to the public.

        lets say a government doesn’t know whether jail or treatment works better for drug addicts. They honestly don’t know which is more effective. (unless they’re politicians who feel certain they know but can’t prove it)

        If a government wants to send everyone convicted for heroin possession to jail: no problem!

        If a government wants to send everyone convicted for heroin possession to counseling and drug treatment: no problem!

        If a government wants to send some people convicted for heroin possession to counseling and drug treatment and some to jail based on whether the judge is pissed off and hungry that morning or even if he wants to: with a dice roll and collect no data on effectiveness: no problem!

        If a government wants to send some people convicted for heroin possession to counseling and drug treatment and some to jail based on a dice roll with strict data gathering a criteria so that in a couple of years you’ll know for certain and can make better choices for everyone from then on? UNETHICAL! EXPERIMENTING ON PEOPLE WITHOUT THEIR CONSENT! Generate new knowledge and suddenly everything is assumed to be evil by default.

        Adding science to scenarios which nobody would bat an eyelid at otherwise somehow makes it evil and unethical because the public have such a fucked up view of science. We’ve had so many decades of movies and shows about “evil scientists” that people are willing to continue hurting each other forever rather than finding out whether they’re harming people and stopping.

        • Deiseach says:

          I have to disagree with this, it’s not “Adding science to scenarios which nobody would bat an eyelid at otherwise somehow makes it evil and unethical because the public have such a fucked up view of science”, it’s the arbitrariness of the decision.

          If you’re really doing it by random selection, then people get disturbed/angry/concerned about Joe getting preferential treatment to Bill based on nothing more than a coin toss/dice roll. Maybe Joe gets sent to rehab and he’d really do better if he got a short sharp shock jail sentence. Maybe Bill needs rehab and support but you’ve sent him to jail based on “sorry, you were assigned the wrong random number for that”.

          Everyone gets sent to jail or everyone gets rehab at least means you are making no difference between Joe and Bill, everyone gets treated equally fairly or unfairly. Ditto with hanging/bleeding-heart judges – they’re supposed to judge based on the evidence and the rule of law and precedent, not if they have indigestion or don’t like the look of the defendant’s phiz or are suckers for a sob story. And if they’re blatantly biased in all their judgements, we can (in theory at least) notice this pattern and turf them off the bench.

          But where you’re talking about making a huge difference to someone’s life as part of a scientific experiment, people get antsy, because you’re talking about humans not rats (and I don’t think this is necessarily a bad thing, I’d be a lot more disturbed if the public attitude was “Hell yeah, do what you like, they’re sub-human scum who don’t deserve any rights and we, the public, might as well get some use out of them”).

          So then you have to intervene with judgments as to “Okay, Joe would do better from jail time and Bill from rehab”, which undercuts the impartiality of the experiment. Besides, I don’t see why you can’t do data gathering on the subjects as is; surely there must be some studies on “Montorgonia cracked down on heroin addicts and sent them all to jail, here are the results after five years” versus “Michilinexas set up a rehab programme instead of jail time, here are the results of that”?

          • Murphy says:

            Your response is exactly what I’m talking about. The references to “lab rats” in particular. It’s perfectly fine to do things just because or going with your gut but as soon as it’s turned into an RCT it’s evil by default because “lab rats”.

            everyone does not get the same treatment. everyone does not get treated equally or fairly.

            In reality sentencing largely depends on things as trivial as whether the judge has just had lunch.


            And they don’t get turfed off the bench. Your hypothetical perfect wise judges do not exist and the fair public who actually get upset about people spending years extra in prison because a judge was reminded of his schoolyard bully don’t exist either.

            At least if it’s a fair dice roll everyone gets a fair and equal chance at the different possible interventions without it being biased by their race, sex or whether the judge had a fight with her husband that morning. Using a human as your random number generator doesn’t magically make it fair. Quite the opposite.

            Currently we’re making huge difference to peoples lives in utter ignorance. But there’s a glorification of ignorance. If you don’t know whether doing X or Y actually hurts people more, you know that by doing the less good one you’re effectively hurting some huge number of people constantly but somehow it’s treated as morally acceptable as long as you keep yourself in ignorance and any effort to find out whether X or Y is objectively worse is shot down because it’s “unethical” because whim and feelings get a free pass on ethics.

            Data gathering without an RCT makes it almost impossible to judge the effectiveness of an intervention. Imagine someone offered you a new drug from pfizer that they claimed treated some problem you had. You found out they’d not done an RCT, instead they’d allowed each doctor to “go with his gut” sorry, use their wisdom and experience to go with their gut and decide whether to give the drug or the placebo. At the end of the trial the super-healthy, middle class, white people who made up the majority given the real treatment looked much healthier than the lower-class, sickly, mostly minority, mostly poor patients on the control because it happened that the doctors just felt that the drug would help them less. How much do you trust the effectiveness of the drug?

            “Following up” is close to useless when the intervention is not randomized, the 2 groups are utterly different to begin with so you can’t compare them at the end in any meaningful way and the few papers which try to do so tend to be complete shit.

            Not doing a proper RCT has all the ethical problems of running an RCT: putting people in interventions which are worse for them only they go on forever and ever and ever where the RCT ends after some reasonably short time period and then we get to stop hurting people so much out of glorified ignorance.

          • Jiro says:

            Many people think there’s a difference between intentionally treating people unequally, and having people treated unequally because of inevitable human failings.

          • Murphy says:


            In dictator games when people are explicitly told that they may or may not be hurting others in the case where they choose the maximum reward for themselves and where they’re told that they can find out whether they’re in the harm/no harming group before they make their choice by simply clicking a button, most will choose not to find out and then choose the option which maximises their rewards.

            I suspect that this is the same mechanism only with a fig leaf of “but if we admit that we don’t know which is harming people more it counts as bad” because people are quite happy to continue inflicting harm on others as long as they have the option of not being told about it.

            People seem happier to keep those exact human failings even if there’s an option to reduce them for the sake of not wanting to admit that those human failings can also count as bad.

          • Jiro says:

            In the real world, as opposed to in lab experiments, intentionally treating people unequally is very prone to motivated reasoning about when doing such things are really necessary, as well as creating bad incentives for people to not just use motivated reasoning, but actually be insincere about it. Treating people unequally in a random way is not as prone to such problems.

            That’s why Eliezer’s answer to the trolley problem is that it may be the right thing to do for perfect reasoners, but it is not the right thing to do for fallible humans. The same answer applies here. In theory, if the experiment won’t hurt the human more than doing nothing, it should be permitted. But unless you’re a perfect benevolent AI, and not a fallible human, you’d better limit yourself to experiments that can be performed after getting consent.

  15. Machine Interface says:

    For a war movie that is actually pretty distinct from the usual war movie formula, you can try The Thin Red Line.

  16. algorizmi says:

    If you like medical internship as a genre, consider Intern by Alan Nourse of The Bladerunner fame (pen name Doctor X). It originated as a daily diary and so captures much of the pathos that is otherwise lost with time.

  17. Tracy W says:

    The forgetfulness has a strong evolutionary function as it is the only reason any woman ever chooses to get pregnant a second time. I recall leaving the hospital and a midwife telling me “See you in two years time!” and me laughing at what a fool she was. And she was wrong, badly wrong, it was twenty-two months.

    Basically it’s a leftover, like nipples on men.

    Although I do recall that intermediate school (ages 11 and 12) thoroughly sucked, on a whole variety of levels, and I have never felt interested in repeating it.

  18. BBA says:

    My parents met in medical school, and their horror stories about their residencies convinced me at a young age never to become a doctor. (That and their endless complaints about work, but that’s everyone isn’t it?)

    Regarding the high school discussion – is EVERYONE miserable in high school or is it just that nerds seek out fellow nerds, and the vast majority of normies did just fine? As someone who was miserable myself due to circumstances I’m certain are entirely unique to me, I was under the latter impression, but it could just be atypical mind fallacy on my part. If everyone really is miserable, and everyone knows it, then what the fuck?

    • Matt M says:

      “That and their endless complaints about work, but that’s everyone isn’t it?”

      Is it? I feel like this is a cultural cliche that doesn’t really match my experiences at all. I’ve had almost entirely positive experiences with employment despite not having any particularly glamorous or highly coveted jobs. Both of my parents had fairly low-class low-status jobs and kept an almost universally positive attitude about them though – occasional complaints about certain annoying bosses or co-workers, but on net seemed to genuinely like and appreciate their jobs.

      “is EVERYONE miserable in high school or is it just that nerds seek out fellow nerds, and the vast majority of normies did just fine?”

      My perception is that everyone THINKS they’re miserable, but very few actually are. At least, that seemed to be the case in my upper-middle class white suburbia environment where virtually nobody had anything legitimate to be miserable about (nerds included). I think as we get older and experience more of the world, our threshold for what counts as “miserable” increases a lot.

      • carvenvisage says:

        Your two paragraphs seem seem to contradict your idea that work/later life is worse than school: on the one hand your parents were happy in ‘fairly low class low status jobs’, and you also had positive experiences with employment, while on the other, everyone at your highschool by your own report, ‘thought they were miserable’.

        You go on to say that actually they can’t have been miserable and/or that if they were it doesn’t count, -because they had nothing ‘legitimate’ to be miserable about, but, on the face of it, that makes no sense at all:

        (in descending order of importance)

        1. ‘illegitimate’ misery is still misery. They’re not parallel concepts.

        2. Throughout the world and its history there are and have been little 12 year olds and younger who are strong, reasonable, determined, kind…- -worthy to be seen as full citizens. Sometimes even eligible. -And you describing a whole school full of ridiculous whiners, but at the same time saying they have no reason to be miserable? Isn’t being a disgrace a reason to be miserable? Especially if somehow everyone at the institution that’s allegedly supposed to prepare you for life ends up the same way? Does experiencing molehills as mountains not hurt? Does it not cause a person difficulties and problems?

        3. the should-go-without-saying epistimelogical problem that people don’t always go announcing all of the things that might make them miserable for everyone to hear and know.

        4. You may be overlooking, but you may not, that some people have much weaker intelectual and academic proclivities and talents than others.


        This is ignoring the obvious difference in the nature of the work: school work and actual work are both work, but one of them makes you money, while the other burns your and your parents tax money at a prodigious rate.

        That schoolwork is compulsory while actual work is not: one is active interference, the other is the oh-so-terrible crime of not giving you free money, -except that if you really don’t want to work, in a lot of countries you can get free(ish*) money. *for some people it’s very painful, for others the bureaucracy and loss of status are nothing.

        That actual work often contributes in an immediate and visible way to something you are a useful part of: if you’re a dishwasher you know your chefs and restaurant are relying on you. If you’re a cleaner you make things clean, if you’re a binman you make the world go round. If you’re a bookkeeper you know your business and tax system are relying on you. Even if you work, god forbid, in retail, you’re playing your part in the competitive ecosystem your society uses as a pricing mechanism. (also- like a professional fighter is paid to be strong and healthy, you are paid to cultivate charm, charisma, and a welcoming demeanor, which are generally useful, -like strength and good health.)

  19. TomA says:

    The ethos described in House of God is what evolved over at least the past century and involved millions of people in the medical profession located at thousands of hospitals, and somehow became endemic despite being dispersed all over the country. There must be some fundamentals at work here that brought about that consistency.

    Is there any evidence for similarity or distinction for medical practice in other countries or cultures?

    It would be interesting to research what underlying fundamentals led to this outcome.

  20. Daniel Ford says:

    Your situation with memory shifts reminds me of how PIs would tell us that they really missed being in graduate school. And I could see they were all full of shit because they had the option of being a permanent postdoc (which is graduate school, forever) and yet they never chose to do that.

    But when I look back on my biology graduate school experience today there are a lot of things I miss about it. And then I realize that I have reoccurring nightmares about graduate school and no other aspect of my life.

  21. Matt M says:

    Count me among the many who as teenagers who reacted with a mixture of contempt and disbelief at every adult who said “Enjoy these years – they’ll be the best of your life” and yet now would probably strangle my own grandmother for a chance to go back to those times.

    Almost all of my best memories of life are from high school. The 13+ years after it have been nothing but a huge waste of time, for me at least.

  22. teageegeepea says:

    GOMERs actually die in Wiseman’s documentary “Near Death”. It just takes a very long time, typically with the doctors waiting for the family to agree to remove the breathing tube since the condition seems unlikely to improve.

  23. Immanentizing Eschatons says:

    My high school experience is a bit of a weird case: I enjoyed- or would have enjoyed- high school greatly, but I did a bunch of shitty things then had a mental breakdown (this then repeated several times until around a year ago, I am a senior undergrad in college now). But in terms of things that happened to me, I liked high school, I recall liking it at the time as well.

    Regarding the gomer discussion, there is always something about this kind of talk that bothers me deeply. I have no doubt that some patients really want to die, and they should then be able to do so. But others don’t, and the way people talk about this, they act like everyone in some sufficiently bad condition wants death, or should want death, and this makes me extremely uncomfortable.

    I’m pro-legalization of assisted suicide, but …I’ve seen people say the lives of others aren’t worth continuing with no regard for their personal preference on the matter often enough. IDK

    Edit: to be clear my position is basically “some people want to die, some people want to live, but don’t erase the preferences of either, and I think the average person would probably be surprised about the extent of what could be inflicted on them before they lose the desire to keep existing. Also no one should feel like they are a “burden” on others for living (something something state funded healthcare)”

    • AnonEEmous says:

      i personally feel that legalization of assisted suicide allows certain people to choose death to spare their family members, even though their family members don’t mind the burden at all. my entire family exhibits this behavior of wanting to spare others the trouble, which is incredible when both sides want to spare the other the trouble and fight over it…anyways, I’d selfishly prefer that the state didn’t enable this possibility

      • Jiro says:

        even though their family members don’t mind the burden at all.

        They “don’t mind the burden” because of the rule “if taking care of a sick relative is a burden, I am never allowed to admit it, not even to myself”. The burden is something which would, in pretty much any other context, be considered serious harm to them.

        (This is also a general problem with the idea of revealed preferences–it doesn’t account for self-delusion, avoidance of guilt, etc.)

        • Deiseach says:

          It depends on circumstances. For some people, it isn’t a burden. For others, it is. And often the level of support and help they get make the difference. Having to put Grandma in a nursing home because she’s too ill to look after herself independently any more is one matter; having to do it because you can’t afford and don’t get any help with aids to make things easier for her, when you could take her into your home and look after her with financial/community nursing assistance, is another thing.

          I tend to side with AnonEEmous out of personal experience: anecdote is not data, but here goes.

          When my father was 71, he had sudden and complete kidney failure, to the point where he simply collapsed one day, was brought comatose to the regional hospital, and was put into ICU because he was so bad. His heart failed and he had to be resuscitated, and the medical staff tactfully sounded us out about “If this happens again – and it will probably happen again – do you really want us to resuscitate him again, or will we simply let him go peacefully?” and it was fairly clear they were pushing gently but definitely for us to pick option B.

          Well, my mother said “Hell no,” and we backed her up. So all in all he had to be resuscitated three times, and when he finally woke up and was together enough to come home, he was in very bad shape and the medical staff’s attitude was again very visibly, if unspoken, ‘we’re sending him home to die’.

          My mother and myself nursed him back to health and he improved to the stage that, even though he had to have regular dialysis, the consultant nephrologist routinely referred to him as “my miracle man” when talking about his case to students. Our family attitude was “yeah, that’s only because we wouldn’t let you lot kill him off”.

          Ten years later, at the age of eighty-one, he had a stroke (I’m pissed about this because it was due to medical negligence, but that’s another story). This time round, when they said “Look, he’s going to continue to throw clots, do you want us to resuscitate him or let him go?” we said “Let him go”.

          But that was only because for the year up to that, he had been gradually but definitely fading. He was ready to die. The stroke was unexpected and a shock, but he hadn’t much longer to live anyway, just simply fading from old age.

          If we’d listened to the doctors first time round, he would have been deprived of ten years of life, and they were good years; he was active, he was happy, up until my mother’s death he was fine and it was only in the two years after her death that he started letting go and fading.

          So yeah. Legalised assisted suicide may be a panacea for some, but for others it may be a push towards “is it really worth the bother?” and you’ll be seen as selfish if you say “yes it is”, whether you’re the patient or the patient’s family.

          • houseboatonstyxb says:

            In haste, on the other side.

            At age 72, my husband collapsed, an hour’s drive from town. The ambulance crew asked me: “If he needs resuscitation, shall we do it?”

            Me: “Yes, he wants to live longer. If he wants to die, he can commit suicide later. Let’s keep his options open.”

            Crew: “The hospital will not allow that. This may be his only chance [to die].” That is, his only chance to escape what Scott has briefly described here, and at more length in “Who By Very Slow Decay”.*

            So here (as with late term abortion for medical reasons), it is the prohibition of later action, which presses for earlier action. There is no safe option of “wait and see if things improve, then decide”.

            (In fact, after a couple of years of resuscitations every few months, he was on the way to a nursing home with tubes for oxygen, septic catheter, etc, when the last resuscitation luckily failed.)


          • keranih says:

            Houseboat –

            When you have the chance, can you elaborate on that “the hospital won’t allow it”?

            I’ve had several elderly/terminal relatives hospitalized, and every time they’ve gone over DNR options with us. Every time, for every one of several re-hospitalizations.

            Do you know if this is a state-by-state difference? Or something where a medical POA kicks in at the hospital door?

            As I said, when you have the time.

          • houseboatonstyxb says:

            @ keranih

            I see I was very unclear; apologies.

            When I said Crew: “The hospital will not allow that” , it was suicide that no hospital will allow.

            As you say, DNR forms are often offered at hospital, and often followed.

          • keranih says:

            @ Houseboat –

            Thank you for the clarification.

            …I’m not sure what else to say here, except that “suicide is not permitted, but a request to be allowed to die must be honored” is exactly as how I would write it.

            And as always, it’s the edge cases that cause the most heartache.

  24. Tyrant Overlord Killidia says:

    High school for me was terrible. My best friend died, and I had to deal with years of teasing and social stigma around a particularly mortifying/embarrassing event (the early 90s version of radicalizing the romanceless). The schooling before that, and bootcamp/college afterwards were very enjoyable. As a matter of fact, I think college was probably the most fun I’ve had as a well defined portion of my life.

    There’s literally nothing I remember fondly about high school, other than the time spent with friends when we weren’t in school. Jesus fuck, there’s no way I would want to relive actually being in high school again.

  25. Sigivald says:

    Re. RAND/Oregon, and I assume you must know this, but it seems oddly eluded in your mention – health insurance/coverage and health care aren’t the same.

    IIRC one main reason more non-emergency care does so little is non-compliance; people won’t take their meds.

    Insulin and you’ll go blind and lose your feet without it? Who cares?

    “We’re why we can’t have nice things.”

  26. Ninmesara says:

    I’ve enjoyed you review of the book, and might read it based on that, even though I’ don’t think I’ll enjoy it.
    I’d like to offer some of my experience as a counterpoint to your review. As a recently graduated doctor who’s spent about 1.5 years in wards throughout training (not as an actual doctor, though) in Portugal, what you describe doesn’t match my experience at all.

    GOMERs (when defined as old people with dementia, incapable of self care, with difficulty with swallowing, pressure ulcers, etc.) certainly die. I’ve seen it happen a lot, and I’m honestly puzzled about how different your reality (or even your perception of reality) might be in the US. Maybe you’re just better at keeping patients alive, or we’re more liberal in switching to comfort care only?

    Despite complaining sometimes, doctors don’t seem to try very hard to offload patients to someone else, unless they honestly believe the patient should be treated somewhere else (e.g. trying to send the patient to the ICU because he’ll need mechanical ventilation soon, a surgeon trying to send stage IV cancer to internal medicine or oncology because he can’t offer surgical treatment, etc.). Sometimes they do offload care to inexperienced interns, but usually under supervision.

    Also, my anecdotal perspective is that medical care makes people better and not worse. In particular, sudden deteriorations of conscience in a demented patient can often be diagnosed and treated, and more or less invasive investigation is often worthwhile. I can’t recall anything even similar to this:

    After learning these medical secrets, Dr. Basch uses hook and crook to prevent his patients from getting any treatment. They end up healthier than anyone else in the hospital, and Basch becomes a contender for “Most Valuable Intern”

    I’ve seen very little falls, especially with GOMERs (which are often too sick to move or restrained so that they don’t get out of their beds). Doctors and nurses work pretty hard to prevent falls. In fact, I can only remember a single fall inside the hospital, and it was from syncope (the man had early onset dementia, but was quite capable of self care and certainly not a GOMER).

    Some family members have had the misfortune of needing more or less specialized medical care, and the interactions with the health care system (both private and public) have been largely positive (not always, of course). Bureaucracy does stand in the way, but it feels as rationing of expensive resources and not as bureaucracy for its own sake.

    This is my experience as a student (I didn’t spend as much time as you did in the hospitals), but I wonder if the health care landscape is legitimately different in our countries. Bear in mind that I’m not defending the Portuguese health care system, which certainly has its flaws, nor saying it is better than anyone else’s. I was just countering the “bleak” review with some of my own experience.

    Are there any other doctors from outside the US who can weigh in with their experience?

    • Matthias says:

      Just judging by Scott’s post, the US is much better about falls now than they used to be. And Portugal might just never had had the bad incentives (extra money from the insurance after every fall!) that lead to lots of the craziness.

      • Ninmesara says:

        Portugal is also much better than it used to be regarding falls (or so people tell me), it’s just that I feel like today it doesn’t even qualify as a problem, at leas in placed I’ve been.

  27. S/R says:

    The Condoleeza Rice mechanism strikes me as close but not quite right. The issue is that when we’re not familiar with a tradition, we see only its rules — the really blatant traits which make a genre or tradition stand out as its own category of thing. With the Rice look-a-like, this is “blackness” + “femaleness.”

    (It’s more accurate really to call these subcategories of the species category human — iterating infinitely upwards — and thus we can also define the Rice doppelgänger as a category which has many variants over time. The more familiar you become with the defining rules of “Rice Doppelgänger,” the more you can see past the rules and notice the transgressions: today she’s especially tired, or changed her hairstyle slightly, or is wearing more/less make-up.)

    The reason you probably don’t enjoy war movies is because you haven’t seen enough of them to understand their unifying stylistic features (narrative arcs, aesthetics, etc) to be able to appreciate their subtle differences. This strikes me as an issue entirely separate from your exposure to war itself. War doesn’t play by the rules of war movies.

    It’s the exact mechanism which leads people to perceive unfamiliar music genres as “all sounding the same.” I’m sure plenty of people on this board have thought as much of reggae, metal, country, or Billboard Top 40 pop. I don’t think this post, or the quote I’m excerpting from it, is entirely on-the-money — but it seems at least close:

    “Before I had really listened to any metal, my overwhelming impression was that it all sounded the same. The real issue was that I wasn’t yet familiar with the genre’s common elements, and therefore couldn’t appreciate different artists’ individual variation and individuality. It’s a bit like how, when I was younger, I always struggled to find my friends’ houses in the suburbs. They were always the same colors, the same general builds and models, the same sizes. Obviously they all had doors, windows, yards. Of course my friends themselves never struggled. They’d learned to spot the minor variations, the subtle differences. They knew what to look for. They knew which elements were all the exact same across the housing development, and they knew which ones owners were able to customize, the ones the contractors had given a bit more variation. Similarly, because we’re finely tuned to what a general, generic human being looks like, we can look past all the common qualities — the chest and limbs and shoulders, the way all humans have skin and ears — and appreciate variety, beauty, excellence, the specific ratios of cheek curvature or shades of irises”

    • AnonEEmous says:

      it’s difference theory, a theory which I have personally invented. Straight from competitive gaming, where basically as you get to know certain units or characters better, they differentiate themselves more and more; interestingly, they probably remain about as different on a percentage scale, but on a psuedo-numerical scale the number difference grows larger and larger; people seem to base “different” on a numerical scale rather than a percentage scale, which is why an expert in anything will be very outraged when an amateur calls 2 similar-seeming things “similar”, even if the expert and the amateur perceive them the same on a percentage-based scale.

  28. John Schilling says:

    I’ve always been skeptical of these studies, because it seems logical that people who can afford health care will get more of it, and there are ten zillion studies showing various forms of health care to help. Insulin helps diabetes. Antibiotics help sepsis. Surgery helps appendicitis. To deny claims like these would be madness, yet the studies don’t lie. What is going on?

    Insulin, antibiotics, and so forth are so obviously helpful that we consider it unconscionable for anyone to go without them. And they are cheap enough that even in pre-Obama America we could pretty much always find a way to get them to the people who needed them. There will never be a proper study of “hey, what if we don’t give diabetics insulin?”, except as a clinical trial for Something Better Than Insulin. If there’s a large population of diabetics in the field not getting insulin, it is because they are so invisible they can’t be effectively studied. The effect of this sort of health care, is going to be included in the base rate of any study of the effects of Health Care(tm).

    What we are studying, by process of elimination, is the sort of Health Care that is sufficiently expensive and/or uncertain in its effectiveness that we are willing to say to people, “this purports to treat what ails you, but we are not going to give it to you”. Both the people inventing new treatments, and the people deploying new treatments without rigorous empirical cost-benefit analysis, are going to be doctors or doctor-adjacent types whose cognitive biases are all lined up with “I do Health Care(tm), Health Care helps people, this looks like Health Care, this must help people”. So most of what makes the initial cut, at least, is of exaggerated effectiveness and some of it will be positively harmful.

    Subdivide “Health Care” into “Good Old-Fashioned Country Doctoring” and “Modern Fancy High-Tech Medicine”. The former helps people, is uncontroversially provided to almost everyone in Western civilization, and gets them out of the hospital quickly enough to not be a big part of anyone’s caseload. The latter is most of the workload of the modern (big-city hospital) doctor, but mostly a waste of time and money. Except that every once in a while, one of its newfangled ideas turns out to be a winner, and is incorporated into the GOFCD canon.

    If this happens while the idea is still new enough to be under patent and so can’t be cheaply commoditized on its way to GOFCD-land, we get stories like, well, you know. But that sort of thing is rare enough to not much affect the general cost-effectiveness of health care debate.

    • psmith says:

      What we are studying, by process of elimination, is the sort of Health Care that is sufficiently expensive and/or uncertain in its effectiveness that we are willing to say to people, “this purports to treat what ails you, but we are not going to give it to you”.

      I don’t know that I’d lean on this explanation too heavily. Both the RAND HIE and the Oregon Medicaid lottery used variation in cost-sharing schemes as treatment, not variation with respect to a particular procedure or set of procedures. E.g., pretty sure the copay group used fewer oral antibiotics than the no-copay group in RAND (and I remember that they spent a good deal less on corrective lenses), but oral antibiotics and eyeglasses are presumably closer to country doctoring than to arthroscopic knee meniscus surgery.

  29. Mr. Breakfast says:

    I had noticed that all of the adults around me said high school was some of the best years of their lives and I would miss it when I was gone, and yet high school seemed objectively terrible. I wondered if there might be some bias or bizarre shift in memory that happened sometime in people’s twenties and gave them a localized amnesia or insanity.

    I remember high school (at least the early part when I was still following the rules) as overwhelming pressure, pain, isolation, and stress throughout every waking moment. I don’t look back on it fondly, but neither do I think that it was objectively as bad as it seemed.

    I would make the case for the boring, conventional interpretation here: Non-extreme levels of hardship and suffering generally make people stronger, more capable, and more resilient. You can’t drown in the same river twice, “Pain is just the sensation of weakness leaving your body.”, and so on.

    Grade school was awful, but what was actually awful about it? Having to sit still for hours at a time, being condescended to by adults who were obviously less intelligent than the adults I was used to, social competitiveness/bullying, low level physical violence. These things were huge at the time, but as an adult I can take the equivalent experiences in stride.

    High school and college likewise. The things which were stressful or overwhelming then are still present in my life today: long hours of often tedious and repetitive intellectual work, the need to make often unrewarded additional effort in order to remain competitive, being subject to authorities who do not deserve my respect, the weariness of working on goals with multi-year horizons to payoff, the need to provide others with measurable value in order to be valued in return rather than be loved unconditionally. This is still part of adult life, just no longer noticeable.

    So it doesn’t surprise me that if one goes into medicine, there is a hardening process to be endured before they are able to deal with sickness, injury, and death competently. Neither is it surprising that the person who emerges with the competence to handle these things would look back some time later be less distressed by events during the hardening process than they were at the time.

  30. Randy M says:

    Judging by the responses, there’s a lot of interest in talking about.
    Scott, any chance you could take a sabbatical and spend in substitute teaching in a public high school?
    (entirely joking except inasmuch as I would enjoy the resulting essays)

    • Scott Alexander says:

      I was a teacher in a public elementary school. You can find the relevant blogposts on my livejournal.

      • Randy M says:

        I’ve probably read them years ago; memories going, I guess. Just take it as a compliment, then.

      • zz says:

        I found the ‘school’ tag. In addition to reading about your experiences teaching, I also read The Legend of Mr. Andy, which was fantastic.

        And don’t worry: I don’t think you’re a witch.

        • Nancy Lebovitz says:

          Thanks. I’m pretty sure I hadn’t read those entries. “Pretty sure” because all too often, I’ll read something that seems new to me, and then discover I’d commented on it.

          The one about asking and answering is like a breath of sanity from a time before politics became so dominant.

  31. Nancy Lebovitz says:

    My memories tend to not be very vivid, and I have no illusions about having had a good time in school, but that isn’t going to stop me from posting a theory.

    Perhaps the memories look better because people (with few exceptions, I think) are healthier when they’re younger. They have more mitochrondria. They haven’t taken nearly as much connective tissue damage.

    It isn’t a matter of health, exactly, but they aren’t as jaded– experiences aren’t blocked and blurred by as many similar experiences.

  32. Murphy says:

    For people who like this kind of story you might also like The Leaky Establishment:

    Similar theme only for people working in the british civil service and british nuclear industry with security audits for elderly slide rules and calculators and strict rules against typewriters so as to avoid angering the typists unions but casual misplacement of nuclear material because it’s easy to audit calculators and few understand the inventory system for the nuclear material.

  33. Tibor says:


    I wonder how many people are going to be convinced by the book (or just your review) that euthanasia should be legal. I am much more scared of being very old one day seriously ill just after reading your review. I also wonder how anyone can stand being a medical doctor in a hospital 🙂 I definitely have even more admiration for you people now!

    I’ll definitely pick that book up but maybe I’ll wait till summer when the weather’s better and the sunset is not at 5 pm or even earlier 🙂

    • Matthias says:

      Euthanasia (and other grave decisions) should work under something like the following system: you need to consent eg one year in advance, and if at any time you change your mind the clock resets.

      Not expressing an opinion on euthanasia here. Just conditional: if we have euthanasia, it should have a safeguard of this kind.

      Similar for people who want to buy cigarettes or other harmful drugs, that are often bought on impulse: register at least 24 hours in advance, but cancellable anytime.

    • chrism says:

      For goodness’ sake! You miss the point that this book (intended by the author or not) helped junior hospital doctors survive a year that seemed to be designed to weed out the weak (it wasn’t; no society that has trained a doctor very expensively can afford to throw any of them away.) Internship/housejobs were a rite of passage that told newly qualified doctors whether they were fit for the rigors of residency or whether they ought to be satisfied with primary care. I know: a wretched statement that even I can hardly agree with, but with some truth attached. For the uninitiated, in north america one used to do an internship year and then either become a GP/FP or progress to a residency. But starting in the UK, even becoming a GP required a form of residency which took the form of a year of housejobs/internship, followed by two years of hospital service as a senior house officer/resident and one year as a trainee in a general practice. Most of us who went through that system realised that we were not being trained along the way, but rather being used as staff to fill positions that had to be filled, and the cream on the cake was us being used as slave labour in a general practice in the final year, paid for by the government and not the practice. There was an extremely contentious article in the BMJ by a trainee at the same practice where I became a trainee about this, though I should say that the principal GP who was the author’s trainer was not my trainer – mine was a very decent Pakistan trained doctor who was the hardest working principal in that practice who was beloved by his patients and who taught me most of the important things I know. For whatever reason, I had to do a total of four years post-graduate training/practice before I could be let loose on the general public. Having done it, I, rather ungratefully, moved to Canada, and entered upon a career of 24/7 call. Stupid me. Medical graduates here who choose general – no, family – practice, as they don’t want to cope with 24/7 care or ER work, do their four years in med school, and then go straight into two years of ‘family practice residency’ and then they get loosed upon us. Well, god save us but they are dreadfully uninformed and inexperienced. It’s not their fault, but it shows, and it has effects on the care they provide. A ganglion on a flexor tendon on someone’s wrist? – order an ultrasound or an MRI! That costs us all a great deal of money, but if you don’t know what a simple ganglion is it might make some sort of defensible sense.

      Anyway, sorry to be distracted. Euthanasia? Nothing – NOTHING to do with gomers and their refusal to die on time. Medically assisted suicide, to give it its proper name, is a boon to people like me who happen to have developed a malignancy that will claim us as its own one day. I’d feel pretty pleased if someone would let me cheat my cancer of that particular victory a day or two before it would win it. Do you really mean to argue with me on that?

  34. Randy M says:

    Excellent post, posts like these are why I highly recommend this blog.

    I’ve had few and not universally positive experiences with hospitals, but the treatment my wife got when we discovered a sudden and very rapidly growing tumor was swift and effective, and on net compassionate, so I can’t be too down on it.
    Just wanted to say that if the system looks at times like a pointless bureaucratic tangle of suffering, at least occasionally miracles are pulled off.
    (Also, there was quite a bit of personal expense involved, of course, but the insurance likewise did what it was supposed to.)

  35. vpaul says:

    Another great post Scott. Let me tell you about my workplace, a government financial regulator. Nobody understand the extremely complex financial areas that they are regulating, because they are lawyers not financial experts. The type of big data analysis needed to uncover fraud (if it exists) is so far from the abilities of understanding of anyone at the office it is sad. Everyone is convinced the banks are evil and wants to get the biggest settlement to advance their own careers. Plenty of people do nothing in the office because you can’t get fired, and everyone jokes about how slow the government is at doing anything and everything.

    • Matthias says:

      I’ve been working in finance and at actual competent places (Google).

      I can not help but imagine how well banks or medicine would work if it was run by Google or Aldi.

      (They also have their problem. But at eg Google any problem that had an obvious technocratic fix that every sane person agreed on was usually fixed that way. The bank had lots and lots of bullshitting from management and people not speaking up.)

    • sscf says:

      Which regulator? If you don’t mind saying. I’m also curious if you think this particular one is an outlier or not.

      • vpaul says:

        I’d rather not say exactly which. It’s a federal agency, not the SEC or Federal Reserve. My impression based on minimal interactions with those agencies is that they are better at understanding complex financial regulatory issues because they hire somewhat based on financial expertise. I have worked in state government agencies too and that was super depressing, both federal and state agencies suffer from bad incentive problems and incompetence/ laziness but the state agencies I have been at were much worse.

        I don’t think it’s an outlier at all, lawyers in government (who regulate large chunks of the economy) tend to be liberal (not saying that’s necessarily bad but that intellectual diversity is severely lacking), close minded, and bad with data / quantitative analytical issues. Also financial regulation and large scale investigations are so complex that even under an ideal system finding the truth would be difficult

  36. chrism says:

    I read it on my three month elective in 1981 – my final year, and I can’t say it was a good thing to read in advance of the horror to come. It increased the dread, but in the end it saved me. Six months into the blur of a one in two rota I met Ieta, a tiny lady from Goa who had trained in Dublin and was a fan of the book. We cheered each other up with The Rules: “The patient is the one with the disease”, “You can reach any body cavity with an 18G needle and a strong right arm,” all the while remembering that we were the ones who were “Young enough to die”. There was an English equivalent story that was recommended to housemen, called The Houseman’s Tale (with sequels like Bleeders Come First) but it was thin watery stuff compared to the The House of God. And somercet: I still call a bed cranked up all the way as being at neurosurgical height.
    Later I found and read Shem’s psychiatry book, but didn’t care for it at all. Analytic psychiatry had already died in the UK, and it was barely readable to someone trained in the view that it was mistaken nonsense.

  37. Alsadius says:

    Also, if you want a quality source of med-school-grade cynicism, is an excellent place to get it. (Warning: Occasionally really gross, because ER)

  38. danarmak says:

    This seems like a well known phenomenon. People go through a miserable institutional experience (college, army, residency, tribal adulthool passage) to gain an official status and privileges (diploma, profession, rank, mating privileges). The experience is deliberately miserable to provide graduates with a costly signal, to limit their number, and to filter for dedication. Graduates consider it a badge of honor, don’t remember the misery vividly, and would not want the next generation to have it any easier. Even when the ostensible goal is learning (college), rather than providing a service to others at a cost to oneself (residency), prestige is correlated with difficulty and not with any objective measure of achievement.

    The details of medical residency are specific to the field, but on the outside view, I’ve always seen this as one of the prime examples of the trope.

  39. SolveIt says:

    Hi, this is the first time in my life that I bought a book immediately after reading a review and I just wanted to tell you that.

    • The Obsolete Man says:

      Same here! The excerpts sold it to me alone. My favorite posts of Scott’s are the ones where he is discussing medicine and psychiatry. I love anecdotes from insiders. This is a particularly favorite one here:

      I wish The Last Psychiatrist would surface and write something! I miss that guy a lot.

  40. somercet says:

    Looking back at 1978, you had a bunch of doctors and nurses so dedicated to their own God-like powers they lied and kept silent to protect them. How terrible it would be to them, how much human suffering they would have exposed themselves to, to have admitted that they had few answers, and none to old age, and they needed to have an honest, painful talk with the patients or their loved ones. (Including the admission that heroic action might add a few more years, but there was no guarantee, and indeed, the doctors were reluctant to force heroism out of themselves for people who, themselves, though kind, loving and forgiving, were not of heroic stature. Few of us are.)

    Much better than endless regulations about bed height, don’t you think?

    • Alsadius says:

      Thing is, regulations about bed height is something that can actually be accomplished under our system. Getting senior doctors to become more introspective isn’t.

  41. John Nerst says:

    Great article, makes me happy I’m not a doctor.

    The figure-ground (signal-noise?) inversion thing interested me in particular, have been thinking a lot about that lately. Doing that kind of inversion with things one believes as an exercise is probably a good habit since it might make it easier to understand how something looks to somebody else. That “government” example is one of the more important ones, but there are others.

    The tricky thing is that these signal-noise inversions can be tricky to spot, two people with political views like:

    “The market is extremely powerful and will work best as a rule, but there are a few outliers where it won’t, and we should have a social safety net to contain its bad side effects.”


    “Capitalism is thoroughly corrupt and rewards rapacious selfishness. An economy run for the people by the people would be morally superior, but planned economies don’t seem to work very well in practice and lead to a lot of abuses, so we need the market to fuel our prosperity, however distasteful it might be.”

    …have very different attitudes but may well come down quite close to each other in terms of supported policies. If you model it as one main signal (basic attitude) paired with a corrective to account for how the first-order attitude fails to match reality perfectly, then this kind of difference is understated when the conversation is about object-level issues (because then the signal+corrective is compared) but overstated when the conversation is about general principles (because then it’s only about the signal, and they are further apart than peoples actual opinions).

    The funny sad thing is that this supports the view that if we saw issues as singular and isolated instead of part of a Big Referendum on Everything then we would agree about things more and fight less.

    It also explains the kind of situation (which happens to me a lot) where you seem to switch sides based on who you’re talking to. If you talk to someone with the “opposite” signal to you, you’re mostly concerned about boosting your own signal and ignore your own corrective that actually agrees with the other person. However, when talking to someone who agrees with your signal you may instead start to argue for your corrective. Maybe if you talk to people who you agree with a lot you go into third or fourth order correctives.

    Note that not all people have correctives, they´re called zealots or ideologues.

    There are several of these “two opposite signals with correctives that form a balanced view”. The market economy is one, art-as-entertainment and art-as-social-commentary is another, the whole infected cluster we can call “biology” vs. “culture” is a third set.

    I thought a while ago that this kind of reversal is a reason why Ayn Rand is so divisive. “Capitalist-types” are usually the villains in fiction, and how the poor were oppressed and lived in squalor during early industrialism has been documented and dramatized so many times that the corrective (fiction often tries to send a coherent message and therefore tends to avoid correctives) – that entrepreneurship is crucial for building wealth and capital owners fill a very important function, will seem jarring when it is for once brought out and given full signal-treatment instead (with the corresponding corrective ignored). People will find it either perverse or liberating.

    • Jugemu says:

      Excellent comment. I’d add that bringing up correctives/nuance isn’t just for people who agree with each other, but can sometimes happen with people who disagree but who trust each other not to go too hard on the attack.

    • Alsadius says:

      That is a really good description of a lot of political debates.

    • Skivverus says:

      I tend to think of this as “approximation via binary search” (or, in less math-y language, “split down the middle, pick what seems closer to reality, repeat”); definitely a useful common approach, but it does tend to break down if reality’s at, say, the 1/3 mark.

    • shakeddown says:

      I don’t know if this applies to most people, but the thing about Ayn Rand that raised my hackles wasn’t the brave capitalist part (I can totally eat up a book about a badass architect), it was the “all friendship is evil and corrosive to the soul” bit.
      After I read Scott’s “all debates are bravery debates”, I thought about it more and realized that I actually agree with this in the bravery debate sense – there are plenty of places, like high school and the military (seriously, being in the military seems to give people a +5 to liking Ayn Rand), that crush your individuality and self-fulfillment in the way she was saying and do need to be fought.
      But having this as the conclusion to the fountainhead was bizarre, because the fountainhead is a story about a guy who disdained friendship his whole life, and failed as a result, finally succeeding because he found friends who genuinely helped him instead of holding him back. And then she says “and this is why self-reliance is the one true virtue”, and it’s jarring. If she’d had correctives, maybe I would have taken it better.

      • John Nerst says:

        Oh I’m sure there’s more stuff in her philosophy. I haven’t read any of her books, just the Spark Notes on Atlas Shrugged because I wanted to use it as an example of just this kind of thing.

        • shakeddown says:

          There are other parts (some of them, like her taste in architecture, I even agree with). I was just mentioning the parts that made her unpalatable for me.

  42. YehoshuaK says:

    HoG sounds like a book worth reading. Maybe I’ll get to it eventually.

  43. gh0stard says:

    Hi, first comment here, but long-time lurker from France. My favorite blog.

    Concerning the topic raised by this essay… I am not a doctor or nurse, but I have relatives who are, and went myself a few times to the ER. It is eerie how much the US medical system seems similar to the French medical system. Which tends to indicate all the bad stuff described above is an emergent property of organized healthcare, not some odd national peculiarity. I wonder how it can be fixed, and if it can be. The easiest (and probably wrong) solution would be to encourage euthanasia, especially on old people, taking a very liberal approach of the Judeo-Christian “thou shalt not kill” (which apparently was badly translated from “thou shalt not murder”). The best solution would probably be to abandon the human body altogether and upload ourselves onto computers.

    I doubt politics, law,, internal management changes (beyond facilitating euthanasia) or even the progress of medicine can ever solve any of this. But I would welcome the views of actual doctors/residents on the subject.

    • Tibor says:

      I’m not a doctor but why don’t you believe that progress in medicine cannot solve this eventually? Probably not completely within our lifetimes. But I think that if the humanity manages not to annihilate itself in the next 200-300 years, there won’t be any terminal diseases or permanent disabilities any more (there will still probably be tragic accidents). The medicine has made an enormous progress over the past century and it’s not like that progress has stopped or seems to be hitting a ceiling soon. A real problem seems to be that the costs of treatment are also skyrocketing, but the technologies that are extremely expensive today will be much cheaper in a decade or two, so in the worst case the progress will be a bit delayed for financial reasons.

    • shakeddown says:

      Not sure if this is completely true – My Israeli medicine friends seem a lot more likely to say this book is exaggerated.

  44. Douglas Knight says:

    What’s up with -} ? Is that supposed to be an arrow? Why not the same ascii arrow -> everyone else uses? Or copy and paste a unicode arrow → ?

    typos: personin, chanegd, bassett → basset

  45. tcheasdfjkl says:

    Re: retrospective idealization – I find I sort of do the opposite thing sometimes. When I’m in a situation, I try to make the most of it by downplaying the downsides, focusing on the upsides, and generally telling myself the situation is pretty good, because that helps me stay motivated. After I leave I can more honestly evaluate the ups and the downs because that assessment no longer affects my day-to-day motivation and well-being.

    Is anyone else like me in this?

  46. FeepingCreature says:

    I have a crazy hypothesis.

    On the next LW survey, can we please check if “I remember High School as mostly pleasurable” correlates with “I have a job” or some other measure of general productivity?

    I suspect the degree to which one drops bad memories may relate with motivation. (The assumption is that high school suckiness for nerds is approximately constant.)

    • shakeddown says:

      That assumption seems highly variable, depending on whether you went to Stereotypical American Public School, special science program school, or some other country’s school system.

    • Aninhumer says:

      The assumption is that high school suckiness for nerds is approximately constant.

      As a nerd who had a fairly positive experience in secondary school, I’m finding this assumption (both as stated, and implied by this thread) kind of confusing, especially since so few people are actually saying what exactly was bad about it.
      I know a lot of people talk about alienation or bullying, and I can believe that happens, but is my experience of having good friends and only a few brief attempts at bullying really that unusual?

      Maybe my memories have been hijacked, but I don’t think I ever hated school.

      • There’s got to be a major difference before and after Aspergers was a thing, and before and after Cool Geek was a thing.

        • Rachael says:

          It also makes a difference whether the school was big enough to have more than one geek.

        • Matthias says:

          Another point is that geeks can get pretty good jobs these days. Compared to working at Google, high school sucks. Compared to your average person’s job, high school looks like the best days of your life.

          • John Schilling says:

            Male geeks could always get pretty good jobs. Well, living-memory always, at least. In olden times, male geeks could almost always get the girl, eventually, just by having the good job. Since that didn’t generally happen in high school, another reason to look back less than fondly on the experience.

            Female geeks, until recently, had a more restricted set of options – not sure whether than on the whole makes them look relatively more fondly on high school.

    • Deiseach says:

      On the next LW survey, can we please check if “I remember High School as mostly pleasurable” correlates with “I have a job” or some other measure of general productivity?

      Well, I liked secondary school, but I imagine a small town single-sex school where a couple of hundred students tops were attending is a very different animal from an American high school.

      I wasn’t bullied, I wasn’t sporty by any means and hated P.E. classes but nobody bullied me there, I liked my classes well enough in general (maths always excepted) and got average grades, and the day had structure to it which I didn’t mind. So I have no reason to have bad memories and I can see why people go “These are the best days of your lives”.

      But I think that sentiment applies as much to childhood/youth as a whole, rather than to high school as such; the notion behind it is that you don’t have the responsibilities of adult life yet, and (unless you’re very unfortunate) the losses of growing up and getting older haven’t happened – no deaths of anyone close to you, no big romantic failures, no setbacks or sickness or suffering. Your travails seem very big and important to you but (again, unless you’ve very misfortunate) they’re smaller troubles when seen from an adult perspective.

    • SpaghettiLee says:

      Yeah, I was gonna pop in and tell Scott I felt pretty much the same way about high school, except that I never really hated it to begin with. Imagine my surprise to see all the ‘what are you talking about, it was a nightmare’ comments. Also, I was a nerd (though more of a lit nerd than a STEM nerd) AND I went to (horrors!) a public high school. I must have just really lucked out with my teachers and classmates.

      Sorry to confound your hypothesis, but I haven’t really been ‘productive’ in the societally-approved ways since I left high school, and I still remember it fondly. I suspect it’s because that’s the last time my skillset matched up with what people wanted me to do.

  47. switchnode says:

    I got to the part where you said you liked it, said “Really?” out loud about six times, and read the rest of the review in increasing perplexity over our apparently irreconcilable impressions. Then at the final paragraph I stopped thinking I’d gone nuts.

    Seriously, that didn’t bother you? “Jarring” and “preachy” are exactly the right words; I found it almost unreadable.

    Of course, I’m now very curious what you might have to say about the sequel.

  48. Tim Martin says:

    “When I lived in Japan, I had a black neighbor who would always get told that she looked like Condoleezza Rice. She looked nothing like Condoleezza Rice.”

    I got told a few times that I looked like Tom Cruise. Aside from being white and having brown hair, I look nothing like Tom Cruise.

    Ah, Japan.

    • Tibor says:

      Reminds me of the British sitcom The Extras where Ricky Gervais (as a struggling actor who is desperate to get a proper role) meets Samuel Jackson and tells him he was great in the Matrix 🙂

  49. The word “gomer” wasn’t invented by this book, and it probably wasn’t originally an acronym. Before the book was published, I heard it from a longtime hospital nurse in Duluth, Minnesota; she had been using the word for years as condescending term for old demented men.

    The review, and the book, reminded me of this hospital training video.
    (Warning: I cannot watch it without sobbing.)

    • keranih says:

      Stupid allergies. Always kick in at the bit with the dog. I need to go spray that ragweed.

    • Tibor says:

      That’s what I don’t get. How can anyone who’s neither autistic nor a sociopath be a medical doctor (I suppose there are some exceptions such as being a general practitioner who mostly treats people for non-serious diseases) without having a mental breakdown? Or rather how can you retain some kind of compassion as a doctor without committing suicide by jumping out of a hospital window?

      • hlynkacg says:

        The horrible bastard answer is that they don’t.

        In my own experience the ones who go a whole career on the floor without loosing a good chunk of their humanity in the process are a rare breed.

        • shakeddown says:

          An anecdote: My dad recently added (to being a full-time hospital pediatrician) working part-time at a clinic. He is so much happier with this part of his job. All you get there is worried mothers bringing their healthy kids who have the sniffles, not the kids who are actually really sick.

      • Ninmesara says:

        By the standards of non-medical people, most doctors have certainly lost “part of their humanity”. What exactly is lost is probably different from one person to the next, but we do lose something.

      • Ghatanathoah says:

        I’m wondering how anyone of any neurotype at all could be a medical doctor.

        If younger me had started down the path of being a doctor, and then heard that interns, residents, nurses, and junior doctors work the hours they apparently work and have the experiences they do, I would make absolutely sure to never be one. If I had student loans I’d default on them and declare bankruptcy. I wouldn’t regret that because not only does the money a doctor makes not seem worth it to me, I would actually pay money to not be a doctor.

        If someone forced me to choose between being a doctor and taking on the level of loan debt medical students take on take on without being a doctor, I’d take the latter. A damaged credit score is well worth the price of never having to work at a hospital.

        Who are these people who are smart enough to learn all these complicated facts about anatomy, but are somehow unable to realize what kind of working conditions they are in for? How are they smart enough to prescribe medications, but not realize that there are lots of jobs that are more pleasant than being a doctor. Like being a cesspool worker, to name just one example.

  50. Patrick Merchant says:

    Looking back, I have virtually no memories from the first half of high school, and many distinct and happy memories from the remaining half. My memories also start almost immediately after I made my first legitimate friend, right around the halfway point. After that, it’s all a rosy haze of hi-jinks and laughter.

    Kinda reminds me of this SMBC comic:

    Sometimes, in the moments when I allow myself to indulge in amateur fakey pretend psychology, I wonder if depressed people are just people who remember all the long stretches of unbearable boredom and unhappiness with clarity. During the one year of my life in which I was depressed, I felt every little moment of nothing crawl by with the excruciating slowness of real time. Minutes actually felt like they were sixty seconds long, if that makes sense. I got weirdly good at keeping track of exactly what time it was without using a watch. I would contemplate just how long the week ahead of me was, and feel hopeless about it.

    Then, when I stopped being depressed, time suddenly seemed to rush back to a tolerable pace. I feel like I could fit the last 3 years of happiness into the 1 year where I was miserable. Now my brain edits out the noise and only hangs on to the important stuff. Maybe part of why some depressed people feel that everything is meaningless is because their brain has somehow lost the mechanism that handles this process; it treats the noise as if it were just as important and worth remembering as the meaningful events, and as a result, life loses a coherent narrative and just looks like a string of nonsense to be endured. All the little individual moments of pleasure and stimulation become harder to spot in the overall picture, because you’re seeing too much of it at once.

    (Alternatively, something something neurotransmitters)

    That’s certainly how being depressed felt for me, anyway. I never got to the point where I contemplated suicide, so I have no idea how that level of depression feels from the inside. Maybe it’s completely different?

    • keranih says:

      Not at all sure how causality goes, but I thought, from my own experiences, that I recall good stuff when I am feeling well, and bad stuff when I am down. It’s not that ruminating on old misery made me feel bad so much as that when I am down I think of old misery. This does, of course, feed on itself, and learning to break the downward spiral is an essential skill.

      Don’t worry, be happy was a song I loathed when it first came out. Like change the radio station/get up and leave the room loathe. (I was in high school/college at the time, and I was miserable for most of it.)

      Then I woke up seven or eight years later, and realized I really liked the damn thing.

      • Matt M says:

        I have a special fondness for that song as one of my drill instructors in basic training for the Navy used to whistle it a lot, most commonly before levying some undeserved physical punishment on the entire division. Ah, memories. It recalls the calm before an inevitable storm of push-ups…

    • xXxanonxXx says:

      I’ve had similar experiences. I used to watch the second hand on the clock above the chalk board and visualize tiny men trying to tug it along faster, standing on the hand and jumping up and down at the 15 second mark, digging in their heels and shoving at the the 30 second mark. In addition to distracting me from the tedium it had the benefit of giving me the absurd sensation I was accelerating time, lessening my sentence by whatever fraction I could.

      Regarding suicide, there’s a David Foster Wallace quote I’ve always liked:

      The so-called ‘psychotically depressed’ person who tries to kill herself doesn’t do so out of quote ‘hopelessness’ or any abstract conviction that life’s assets and debits do not square. And surely not because death seems suddenly appealing. The person in whom Its invisible agony reaches a certain unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise. Make no mistake about people who leap from burning windows. Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the same window just checking out the view; i.e. the fear of falling remains a constant. The variable here is the other terror, the fire’s flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors. It’s not desiring the fall; it’s terror of the flames. And yet nobody down on the sidewalk, looking up and yelling ‘Don’t!’ and ‘Hang on!’, can understand the jump. Not really. You’d have to have personally been trapped and felt flames to really understand a terror way beyond falling.

      I see the blaze as being this vast expanse of time that stretches out in front of me. I have to get up tomorrow and do this again? Then the day after? 25,550 more days! 36,792,000 more hours! 2,207,520,000 more seconds! When I’m bored, that idea is horrifying beyond measure. A straight razor starts to look like a really nice alternative.

      • FacelessCraven says:

        I carry a notebook now. Not the computer kind, the bound-paper kind. drawing is amazing; basically, you will never be bored ever again.

  51. Dave Rolsky says:

    I’m 42 and I still remember high school as one of the most miserable times of my life. I had no friends in my school, I was bored in many of my classes, and depressed for a good chunk of it. College was mostly great, however. Good friends, interesting classes, and living away from home.

  52. Doug S. says:

    My father made a joke: when you get older, you forget the bad stuff that happened and only remember the good stuff. As a result, he has almost no memories of high school. 😉

  53. Doug S. says:

    For me, there were parts of high school that were good, and parts that were pretty damn awful. College actually had more awfulness than high school for me…

  54. Incurian says:

    But it’s brilliant because in the end it’s not just a Catch-22-style romp through hilarious bureaucratic mishaps.

    I’m probably misinterpreting and being overly-defensive because I like Catch-22 A LOT, but when I think “Catch-22” I tend to think about the last third of the book where the implications of all the hilarity are explored and the full extent and cause of Yossarian’s PTSD come out, when we see that Yossarian isn’t crazy and Pianosa isn’t hilarious and he’s been right all along.

    It’s hard enough for a book to be funny, and it’s hard enough for one to be deep, but a book like House of God that can be both at once within the space of a few sentences is an absolute treasure.

    I think that sentence makes for a better comparison with Catch-22. Catch-22 wasn’t about mishaps, it was about the mass insanity that is war, that war would be hilarious if it wasn’t so cruel and deadly serious.

  55. Robert Liguori says:

    I remember, vividly, a conversation I had with a friend. It was in my days as a junior performer at Colonial Williamsburg. I was on the Street Music job, which mean me and a drummer would sit in our horribly hot, uncomfortable costumes, in the Virginia August heat, playing music for the entertainment of the tourists and code-switching between Talking to Tourists and complaining.

    I remember that, after a long, extended, and profanity-filled tirade against the weather, my costume, my shoes, my spittle-filled tin whistle, the directors of the CW Fife and Drum Corps, and similar, I ended with “And you know what the worst thing is? In a few years, I’m going to be an old fuck [that is to say, in college], and if what those fucking alumni [graduates of the Fife and Drum Corps. We were a historically-accurate corps, which mean that we were aged 10-18.] say is true, I’m going to look back on this bullshit as the best years of my life. And when I do that, I’m to have to put my head through a fucking wall.”

    And there is in fact a dent in my wall here, from a moment when I was relating the many light-hearted misadventures I got into in the F&D Corps to friends, and held in my head both the “Aw, that was good times.” and the memory of my tirade.

    And, as with shakeddown, when I actually swung by as an alumni myself, I realized “No, this really is hot and uncomfortable and everyone smells like sweaty unwashed teenager.”, and I finally realized a final piece of the puzzle; people who don’t get nostalgic about the Corps just shrug, move on, and don’t come back to talk about it to younger Corps-members, so there’s a massive bias in how people in the Corps hear about it from alumni.

  56. dawso007 says:

    I have not read the book in decades. I did not analyze it from the perspective of magical realism at the time. I saw it more as just dark humor and not too much more absurd than being sleep deprived, seeing people at their worst (both the medical professionals and the patients), and being constantly anxious about injuring a patient and being stretched to the limit. Years of sleep deprivation creates a different state of consciousness. A quote from Fight Club captures it: “When you have insomnia you are not really asleep and you are not really awake….”

    The landscape has changed dramatically since the book came out. Typical Gomer admissions in my day are gone. Hardly anybody gets admitted (appropriately) for medical detox. If a dying nursing home patient is admitted they are seen by hospice care and managed from that perspective. People are still turfed and unless psychiatrists have the ability to refuse admissions – they will get very complex patients who should not be admitted to psychiatric units.

    I had the perspective of hearing psychiatric patients referred to as Gomers, just based on a psychiatric diagnosis when I was taking care of them on medical-surgical rotations. People who happened to have very treatable cancer diagnoses for example. I observed the most frequent use of the term by physicians with inappropriately intense emotional responses to patients. Physician behavior at the time was as inappropriate and typically at the level of trainees.

    Even then – I didn’t think the term was funny in any way – probably based on those real experiences.

    The other factor was that in the same period of time, I did rotations where the term and all of the drama were never present. On those rotations we saw the same patients. The leadership was different and all of the trainees on those rotations had better role models and in some cases explicit instructions on how to avoid going there.

    • Scott Alexander says:

      Huh. My hospital seems to have a lot of people I would describe as gomers. The usual way I as a psychiatrist run into them is because they hit someone at their nursing home, nursing home declared it a psychiatric issue, and they were admitted for either dementia or delirium depending on which word the ED doc preferred. Then they’re given IV fluids and maybe Haldol, kept for a few days, and sent back to the nursing home.

      We also do what seems to me like a lot of medical detox, but I don’t know if it’s less than it used to be.

  57. shakeddown says:

    Re: The high school thing, I had a similar experience of hating it at the time and looking back on it more fondly. But a few years after graduation, I went back to visit for my brother’s school play. I somehow managed to run into some of the other students and teachers I’d hated when I was there, got into a shouting match, and wound up finding a corner to cry in. And suddenly I remembered what it had been like actually being there.
    So I think this is the solution to the paradox: You blank out the miserable memories, since more intense miserable memories fade on their own, and you don’t like to think about them. But you remember those few times that weren’t miserable.

    • Randy M says:

      I’m going to offer a counter example on both fronts–my time in high school (18-14 years ago) was not terrible, but I don’t remember it fondly. It was boring, occasionally lonesome, and frequently tedious, but I had a couple good friends to joke with, went through a lot of good books, and wasn’t embarrassed horribly all that often.

      Basically it was kind of like having a not great job, only without the added stress of having to do really well or not being able to continue and then needing to look for a slightly worse one.

      edit: Now, my memories teaching high school… shudder

    • Edward Scizorhands says:

      This is also parenthood.

  58. Alsadius says:

    I’m no doctor, but I have a couple thoughts on the highschool thing. One, your memories are a highlight reel – the boring parts fade, the funny stuff lives. After a few retellings of the story about the awful teacher who sent so many students to the office that the office just started telling them to wander the halls or go to the library or whatever, they didn’t care, just don’t worry about your nutty teacher(this actually happened to me), it starts to seem funny. I don’t remember the unending hours of bad English classes, because there’s no highlights there to remember that haven’t faded in the decades since.

    Two, highschool as glory days is true for some, but not really for most folks like us. I didn’t become a fully functional human being until around the time I started university, because before then I was a social incompetent who couldn’t relate to other humans worth a damn. For the popular kids, it’s probably true enough, but for most of the rest it’s more about fond memories of youth in general than school in particular.

    • If the worst thing that happened to you in high school was boredom, you had a fairly good experience. Actually negative stuff, rather than neutral stuff like boredom,stands out too.

      • Autolykos says:

        Yup, school is years of boredom, punctuated by moments of terror…

        • Luke the CIA Stooge says:

          All large hierarchical institutions are pretty much the same (i probably wouldn’t include corporations since they don’t have real, threat of violence power over you like state institutions do, but that might be different in the states where they can take your health coverage by firing you).

          Reading Maus a few years ago i was really shocked by how the horrorfying minutia and sense of powerlessness of people in the Holocaust was really just an extreme of the spectrum that goes from school to summer-camp to the army to prison to supermax to ausswitz. Like to the point that former boy-scouts and criminals had a higher survival rate because they already had the necessary skills.

          My father-in-law currently has throat cancer and it took him TWO MONTHS to get a diagnosis because his doctor wouldn’t take him seriously and even after the diagnosis we’re still getting dicked around by the bureaucracy and wait times (yes the Canadian medical system can be just as bad as the republican fever dreams about socialized medicine).

          Relationships not based on economic exchange all have a really strong habit of devolving into the Stanford prison experiment, i think its because free market exchanges are the only relationships ever devised where the weaker party, the one without the skills, knowledge or position, is the one with the power. In any other system the person in the costumers position would just be easy prey.

          (as to my father in law above, it’s large cell cancer (praise the gods, high survival rate) and its abstructing his airway, which is really good in the canadian medical system because it makes it urgent the the bureaucracy has to respond. So we’re all fealing really relieved (if it it was a faster acting cancer at this point there would be no point in bothering with cemo))

          • fahertym says:

            As a life-long libertarian, that’s a fantastic broad argument for free markets I have no heard before. Mind if I share it?

          • i think its because free market exchanges are the only relationships ever devised where the weaker party, the one without the skills, knowledge or position, is the one with the power.

            So long as they have money. But how do you get money without knowledge skills or power?

          • Luke the CIA Stooge says:

            please do. Glad you appreciated it.

            My flippant answer would be effort (everyone has some little task they’d rather have someone else do), but to be perfectly honest valuable skills and knowledge are shockingly easy to come by, the problem is we have a monoculture which forces people to spend 12+ years in an education which produces no marginal value (4 months in a welding class is worth more on the open market than your entire adolescence spent in the pursuit of “education”), and then railroads them into the same dozen fields that were maybe worthwhile careers in the 50’s but are now blood soaked gladiator tournaments where the winners get to work 80+hrs a week for little above minimum wage once they divide their salary by the hours and the losers become depressed could-of-beens cursing themselves for not competing harder.

            The problem isn’t that their isn’t money to be made its that we’re spending so much and working so hard to not make it. 2 months spent reading up on something no one else is paying attention to is worth more than any ivy league educations at least fifty percent of the time.

    • Murphy says:

      I think it may also come down to the person.

      I have lots of mixed memories of primary school, secondary school and college but I’m under no delusion that highschool was amazing.

      It remains clear in my mind even decades later how unhappy I was in primary school and highschool and how much happier I was in college.

      Perhaps if I related stories to third parties a lot it would distort it more, I can remember spending quite some time talking with a friends little brother about all the things that happened over the years and condensing 6 years of events made it all sound much more fun and eventful and I know how saying things out loud to other people tends to distort memories.

    • moridinamael says:

      I actually wrote my future self a letter at the end of high school to make sure I didn’t forget that it sucked. Thanks to that action, I’m in my thirties and I can still recall the rage.

      The grinding boredom is a big part of it. It truly was torturous. As a highly technical adult with no diagnosed attention issues, I typically say “fuck this” and zone out after about 20 minutes of a meeting or a technical talk. In school we were forced to wake up at biologically-equivalent-to-3-AM and sit and stare at various unengaging stimuli for seven hours with a tight half-hour break for lunch.

      Speaking of the “break”, the dehumanizing regulation of your schedule, and general mentality that the students were prisoners, assumed guilty with no avenue to argue their innocence, was psychologically damaging. Anyone who got on the bad side of a teacher, made a procedural mistake, committed a slip of the tongue at a sensitive time, or even just completed their work too quickly for a teacher’s taste, could be disciplined with outrageous and incontestable prejudice. The stories of this happening to me and my friends are too many to relate. If anything in life is responsible for my raging anti-authoritarianism, it’s just the fact that I went to a public US high school.

      All that is before we even get to the sociological disaster. Schools are designed to be like prisons and scheduled the way prisoners’ lives are scheduled. The friendships you form in school are therefor somewhere between jailhouse alliances and battlefield brotherhoods — not healthy, not particularly based on shared interests so much as mutual suffering. The bullying experienced to varying degrees by almost everyone is just a normal consequence of such a structure.

      I would be willing to chalk up a very large portion of the American “mental illness epidemic” to the fact that we keep our entire adolescent population in massive Stanford Prison Experiment scenario for four years, a system that could barely be worse if it were designed by a team of evil evolutionary psychologists and behaviorists, and then, at the end, kick them out of their homes.

      Fuck the US public school system.

      • Murphy says:

        Luther: High school is a lot like prison: Bad food, high fences; the sex you want, you ain’t gettin’, the sex you gettin’, you don’t want. I’ve seen terrible things.

        Dizzy: Yesterday, an eighty-year-old librarian broke my penis.

        Luther: You win.

      • Murphy says:

        It’s not limited to the US public school system.

        For me it was languages. A lot of things get built on the assumption that if you’re good at one thing you’re good at everything.

        Because I breezed through anything math/science related I ended up stuck in the Higher language classes. 14 years of pulling teeth. The kind of associations most people seem to have with dentistry I have with dead language classes.

        14 years of being forced to babble 1/4 understood drivel and parrot rote-learned poems and pros.

        Utterly worthless to me on every level with no redeeming values but the attempts to simply get through the following day without getting screamed at by a teacher left me in tears on a regular basis. If I’d been allowed to spend the hours wasted of that tripe on something worth something like physics, chemistry, math, genetics…. instead those hours were sacrificed on the alter of a rightfully dead language of no value.

        It was a deep well of suffering inflicted on me for years.

        if I ever go all dark lord any person willing to even suggest that Peig should be mandatory for students under the fucked up pretense of it being “cultural” and “balance” having some kind of intrinsic value will not be allowed the mercy of death.

      • Randy M says:

        You would enjoy reading Gatto. Your bit on the dehumanizing schedules reminded me of portions of his book.

      • silver and ivory says:

        As a current high school student, I can confirm that high school pretty much sucks. It is really really boring. We do have accommodations for “gifted” students, but it took ~half a semester of doing useless packets about a deeply mediocre book before I could be exempted.

        You have to “respect” teachers who assign you meaningless busywork and you also have to do their work. Even if it is useless. Even if you already know everyone on it. Even if it is as far below grade level as you are above.

        They only let you skip grades in math, which is highly inconvenient. I’ve learned nothing new in all of my lit classes since 7th grade, and it wasn’t like we could select different classes- there was only one lit class offered for every year.

        (Of course you can’t just learn about the subject you like. That would be too reasonable. No, you have to be well-rounded. Mysteriously, well-rounded is only applicable when it’s about doing something you don’t like; no one brings it up when one of your teachers is teaching you things you already know.)

        Most kids I’m friends with are sleep deprived almost all the time. They can’t move school schedules back because of bus schedules, because we clearly should base our school start times around when the buses need to leave.

        Emotionally, though, high school is definitely better than middle school, and I seriously appreciate my friends.

        I think that in general high school is better in terms of social dynamics than middle school due to more emotional development, but worse or equivalent in terms of academic busywork.

        • FacelessCraven says:

          I was home-schooled. I read anything I wanted, got in political debates online, learned 3D modelling, and practiced knifemaking for fun. I stayed up late when I wanted and slept in when I wanted.

          I recommend it.

        • Ghatanathoah says:

          I never really found high school to be boring. I think your problem might be that you are expecting intellectual stimulation from the content of the coursework, rather than from the book you brought along to read after you finished all the coursework early.

          When I was in high school I thought being taught stuff I already knew was the absolute best. It meant I could do the homework really, really fast, often before the school day ended. That meant I had more time to read whatever book I had brought from home or checked out from the library. I always carried a paperback novel around with my coursebooks so I could snatch a few moments reading whenever I could.

          I did take some advanced classes out of some misplaced sense of pride, but I tended to enjoy the classes where I already knew everything the best because it meant I got to read a lot as soon as I’d breezed through the coursework.

          I got a fantastic amount of reading done in high school, I read hundreds of books. That’s one reason I enjoyed it.

    • Ozy Frantz says:

      I had very positive feelings about high school at the time, because the incomprehensible malevolent alien intelligences had been replaced with incomprehensible mostly benevolent alien intelligences, and now I was hardly ever harassed and never assaulted.

      As an adult, I am less impressed.

      • Ghatanathoah says:

        I enjoyed high school a lot, but I have since realized that this is because I am some sort of weird freak who actually enjoys doing school work (and getting it done fast so I can read books). I was much better at being a student than I will ever be at holding a job. I was voted “most likely to succeed” because the other kids didn’t realize I liked schoolwork, they assumed I was super-disciplined.

        I suppose a type A personality might be frustrated at the futility of it all, but that was precisely what I loved. All I had to do was finish some simple coursework and people would leave me alone and let me read.

        I was annoyed at the other kids for being so disrespectful towards school, but now that I’ve realized how utterly freakish I am I feel so bad for them. They must have been so bored!

    • Wander says:

      I actually have quite fond memories of highschool, which I’m fairly sure aren’t delusions. That said, I did go to a selective school, which basically meant that 95% of the school was academically minded, that the popular and sporty kids still tended to be the type to write incredible essays, and that general nerd-stuff like video games and anime was pretty much the norm. Like, this was a school where they decided to establish an autistic unit based on the idea that a large number of students were probably somewhere on the spectrum already. It was also single-sex, which meant it was essential drama-less.

  59. hlynkacg says:

    Well Shit…

    So recovering from the initial speechlessness, my first impulse is that I have to read this book / how the fuck have I not already. The second impulse is that for my own sanity it would probably be best not to. I walked away from the medical field for good reasons and it’s probably better to let sleeping dogs lie.

    Magical realism really is the perfect genre for a novel set in an ER, and it makes me wonder why we don’t see it more often. Ditto for Magical Realism and war movies.

    • Scott Alexander says:

      I’m curious: what did you do in medicine and why did you walk away?

      • hlynkacg says:

        I was going to do a second “Edit to add” but then you replied so I might as well just respond in kind.

        The long story short is that I was US Navy SAR for 8 years and then spent a few more years after I got out working the front desk in a major metropolitan ER and acting as a private contractor/consultant for the Red Cross. I’ll refer you to this thread from OT 60.5 if you want more details. Long story short is that by the end I was burnt out and hitting the bottle pretty hard.

        Weirdly enough it was the “benign” normal shit that did it. Chaos? Panic? Disorder? People literally screaming/on fire? I handled that shit with aplomb, GOMERs? No fucking way man, I couldn’t hack it.

        Just give me an honest to god sucking chest wound.

        Give me a moment I’ll be back in a bit.

      • hlynkacg says:

        So I had company over but I’m back now.

    • keranih says:

      I recommend a novelette by SN Dyner – “The July Ward.” (1993 short list for Nebula.) Excellent work in the same theme.

      (Unfortunately, it is one of the hardest works to find – if I couldn’t reliably remember the title, I’d never have found it again. It was most recently reprinted in the Women’s Liberation: A choice of futures. Despite the the title/premise of the anthology, it is a collection of excellent works and I recommend the whole thing as worth the money.)