Hospitals have made sure they hire JUST ENOUGH nurses to cover shifts and no more. With covid hitting, this blew out the number of nurses needed resulting in a lot of "I know you've already worked 60 hours, but can you do another 20? we are short!".

Rather than hiring permanent people or upping salary, Hospitals have instead elected to just use travel nurses and an extreme premium so as to avoid any salary increases.

The fix is one that Hospital admins don't want. Pay your nurses more and hire more than the minimum to cover shifts so a nurse being out sick doesn't result in another working a 80 hour week.

So, instead it's been day old pizza with superhero stickers.

I look at academia which is rife with money sloshing around, and see undergraduate classes are taught by grad students who make ~30k a year who are basically the Nurses of the academic world and treated like garbage. The justice system is dysfunctional, courts systems are overwhelmed and understaffed so criminals just enter and exit like a revolving door, and police is basically useless because the best they can do is taxi criminals into the system that automatically spits them out again, while they take the brunt of public criticism for how they are forced to deal with a problem that is mostly beyond their scope.

In all of these cases it seems like the bottom if falling out of these institutions, and the responsibilities have fallen on their respective janitors to deal with it when the solutions need to come from places that have been incentivized to create the mess in the first place.

https://www.jerrypournelle.com/reports/jerryp/iron.html

"In any bureaucratic organization there will be two kinds of people:

First, there will be those who are devoted to the goals of the organization. Examples are dedicated classroom teachers in an educational bureaucracy, many of the engineers and launch technicians and scientists at NASA, even some agricultural scientists and advisors in the former Soviet Union collective farming administration.

Secondly, there will be those dedicated to the organization itself. Examples are many of the administrators in the education system, many professors of education, many teachers union officials, much of the NASA headquarters staff, etc.

The Iron Law states that in every case the second group will gain and keep control of the organization. It will write the rules, and control promotions within the organization."

These are all jobs where people sign up for the job. Whether it’s altruism or genuine passion. They’re willing to compromise and put up with less pay and harder working conditions.

But because they’re willing to compromise, these people are pushed to their limit. With not only low pay and shit conditions, but higher-ups which actively exploit their altruism and passion. “If you don’t work, patients / children are going to suffer!” coming from the same beaurocracy which created the situation where a) they suffer or b) you work extra hours.

They’re being pushed past the limit in fact, which is why there’s now a nursing and teaching shortage despite these actually being popular fields. A lot of people want to work these professions, they just don’t want the jobs.

People that go out of their way to say that their startups have a higher mission make me uneasy. I don't know if they're just trying to convince others that they're running something other than for-profit businesses driven by expected returns on investment for investors, or if they truly believe it themselves. It's either borderline manipulation or delusion, and neither are something I want to hitch myself to.

Oh, no, that reads like I just turned into a Musk fanboy. Surely there's got to be some non-Musk company that I can add to that list?

Biotech startups? Develop a cure for horrible disease X (save lives, give people a few more years with their families, etc–feels good?)–and then get rich selling that cure.

I think Blue Origin's messaging is in principle similar to SpaceX (Bezos wants to save the environment by moving manufacturing to orbit, etc.) It is just that SpaceX rather obviously delivers on that message, and has grown rich delivering; Blue Origin hasn't delivered much yet, and it is hard to grow rich prior to delivery–but maybe, give them a few more years, they'll finally get their act together, and they'll become more SpaceX-like.

https://en.wikipedia.org/wiki/Mass_killings_under_communist_...

It was funny and personable. Still one of the better VPs I remember.

Because how to get filthy rich is by changing (improving) the world.

It's easy on the body, compared to similar paid blue collar jobs, like union construction. And it seems better than office work.

Durning the AIDS crisis a lot of nurses--who could quit did. They quit because many were legitmetly scared.

Hospitals got worried, and told their marketing departments to throw out the word, "We need nurses!". Most smaller hospitals had a hard time keeping qualified egos (The Medical Doctor), and they couldn't be bothered besides doing just the bare minimum.

Let's not forget their are many classifications of nurses (RN, LVN, etc., and porely trained Candy Stripers, or cheap help, hospitals (especially union controlled) use instead of nurses. Some are not porely trained though, but nursing unions don't like competition. I'm not berating unions. Moneynot spent on help seems to go to administrators anyway.)

(I went to school with nursing students. Most were divorced. Most were around mid 30's. This was in the 90's. Now nursing is a good path to middleclass for immigrants.)

That is no longer the case and many now require 4 year bachelor programs to be hired as RN nurses. My wife has her bachelors in nursing and runs an ER and the hiring requirements includes a bachelors degree in nursing and not a 2 year degree.

He nicked it from Robert Michels, who wrote about the Iron Law of Oligarchies in 1911: https://en.wikipedia.org/wiki/Iron_law_of_oligarchy

I was reading some old Analog magazines the other day, and man, Pournelle was one deranged man in his "non-fiction".

It's possible this dichotomy works in theory only. Being generous, it's possible they just disagree about the goals of the organization.

As a result only those who act to increase the power/wealth at the expense of all else, such as the original goals of the organisation, get promoted and hang around. The end result, an organisation that achieves very little, and consumes huge amounts of resources, full of people who really don’t care about the fundamental goals of the organisation.

Note that the strict formulation of this law (ie. "in _every_ case..") is profoundly anti-democratic in that it assumes no democracy can ever exist or function. Of course, I hope your household provides a good counter example (if not, then you should seek outside support).

Anyway, for those of us who still believe in democracy, it has long been recognised that the cost of it is that everyone has to be a adult who takes responsibility for basic things in life like maintaining the social fabric of the institutions you belong to in order to prevent them from being taken over by sociopaths.

So the question is, will we support medical professionals in doing this? In the UK, before COVID, when junior doctors went on strike to try and remedy the situation, the media denounced them as enemies of the people and they were completely crushed by the state (with the help of their own professional organisations like the BMJ). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4902702/

And for that I completely blame the 'right' thinking, honest, hardworking nerd types - even when given the reins to power they will often not take it, because it is uninteresting work, compared the cool gadget/problem they are working on.

Every institution has already been taken over by sociopaths. That's why it's called an "iron law", and not a mere concern.

+ "that is so large so there's a pyramid to climb and a bunch of sociopaths who start climbing".

Smaller orgs can get away, can avoid the iron law.

But a big country is a bit doomed

I certainly doesn’t seem it.

why is this such a common story across pretty much every single industry? There's more people in the country than 10, 20, 30 years ago. More customers, more money. Why do they think they can handle more work with less workers whose salary is less when adjusting for inflation?

During covid Business owners saw that the consumer was willing to take it so they will continue to run on skeleton crews as long as the consumer takes it.

Sure the consumer will complain but they are still using their money to buy from skeleton run places.Partly because most industries nowadays are Oligarch control and what one does the other does as well and the consumer has lost their control of the marketplace.

We are living in a world where the big guys have the majority control of the market place and the market want's skeleton crews.

This is seen across the board in all big business run industries. However with nursing, especially in the ER and the ICU that are now running a skeleton crew the consequence is your health and even your life. Until the big healthcare providers,insurance industry, hospitals, doctors , etc start to get sued over low staffing as the cause of death nothing will change and they know how to document to prevent such a case.

yeah...or stay in business because their prices aren't 10x their competitors.

The anti-capitalism is strong on HN these days...

Depending on the type of job you also get a different "product" depending on how much you pay and you might not be able to measure it. Employees cut corners in the least visible way and do not brag about extra effort if they are paid well enough.

This[0] was a fun read.

>Nursing care services are the most intensely used hospital services by acute hospital inpatients yet are poorly economically measured [...] >Nurses are an anomaly in the current inpatient billing system. Rather than bill for the actual services provided to the patient or the amount of time spent providing nursing care, the cost of nursing is embedded into the line item for room and board, which is the same fixed cost for every patient receiving the same level of care within a particular institution. In other words, all patients cared for on a given unit are billed the same room and board charge regardless of the actual amount of nursing care the patient utilized during that hospitalization.

[0] - http://frogfind.com/read.php?a=https://www.ncbi.nlm.nih.gov/...

It depends on what portion of the cost of production is materials vs capital costs vs labor. You're presuming that labor is a small portion of the cost of production, which is probably true if you're selling them for $10. If it's an extremely low cost item, like plastic washers, labor can still be a significant part of the production costs. It also depends on whether you carry that down the supply chain, since part of your material cost is someone else's labor costs.

> Nursing care services are the most intensely used hospital services by acute hospital inpatients yet are poorly economically measured

This doesn't strike me as utterly insane. Most treatment prices should include the cost to have a nurse deliver it. The tiers of rooms should roughly approximate the amount of nursing care required outside of treatments. It's not perfect, but it might be better on the net than having nurses spend more time on the patient chart to add billing items.

I.e. it might be overall better to not have a specific line item for "rolled patient over to prevent sores" that the nurse has to enter in, and then billing has to argue with insurance about whether a roll was needed or not. It might be cheaper for everyone to figure out the average cost of providing nursing per tier, add a profit margin, and charge everyone that.

I'm not saying it is better, but it seems at least plausible.

I'm consistently surprised by misunderstandings of supply and demand.

There is a labor market. It's relatively free, all things considered. Sometimes companies conspire to keep prices down (see: high tech antitrust lawsuit/settlement) but usually the thing that keeps wages low isn't business owner collusion it's the availability of workers accepting work with a low wage.

Sure, all things being equal business owners would like to pay less for labor. They'd also like to pay less rent, less for insurance, lower taxes, etc. And sometimes they want to pay less than anyone is willing to accept, and sometimes instead of raising wages they rant about it on Twitter or in opinion pieces or whatever.

But that doesn't get them employees!

But if you have a labor shortage and low wages at the same time, that means that workers accepting work with a low wage aren't available, but the employers are keeping wages low anyway. (And in this context, poor working conditions amount to "low wages" because they decrease the value of the job to the employee.)

In capitalism, "labor shortage" means "the employers had better pay their employees more, or else they won't have the employees to compete against other employers who will pay more".

Only a profit-averse business owner would turn away revenue-exceeding-costs work merely because it involves paying workers more -- that business will likely not last super long unless there are special circumstances in play.

>The demand also doesn't neccessarily increase linearly with the population.

for elastic goods, no. But medicine is about as inelastic a product as you can get.

In the academia that contains money sloshing around, the only grad students teaching are the ones who want to.

In the academia that doesn't contain money sloshing around, it's a different story.

But the truth is, no one in academia is making bank from academia directly -- not the grad students, certainly, but also not the adjuncts, or even the professors. You have to look higher up the chain (or, I guess, laterally?) for that. (Yes, there's the caveat that some faculty make good use of their prestigious affiliations or professional connections to increase income from outside of academia.)

Staying when you want to leave indicates there's enough compensation to 'make it worth it' at least versus whatever shitty alternatives you have. Leaving when you want to stay, to me, would be a much bigger indicator that nurses who want to stay in the profession can't because of wage/benefits/conditions issues.

I think the conclusion of this sort of economic thinking is basically: Give your employees just enough money that they can keep they keep their head above the water but not enough to flourish, and just enough pressure/responsibility that they don't have energy to do anything else, but not too much that they have a complete mental breakdown that leaves them with the conclusion that they should leave your industry at any cost.

When you spent a lot of time and money into a specialized and demanding career, I imagine it practically very difficult to actually change your career, even if it's killing you. It's probably even worse if you have familial obligations. You likely do not have time or energy to better your situation after hours, and if you quit, you potentially resign yourself (perhaps) to many years of destitution while you accumulate the necessary knowledge to do something else. I would not be surprised if many people just bear bad conditions because the cost to do anything else worth one's time is simply too high.

https://www.latimes.com/business/story/2022-01-24/wisconsin-...

Yes, you hire them back at travel nurse rates, while you lobby for your state legislators to ban your employees from doing any work if they quit.

https://medium.com/geekculture/the-dead-sea-effect-d71df1372...

I recall hearing about one desert conflict "gratuitous" allocation of several times the prior typical water per day resulted in outsized military performance. I think it may have been the Six Day War. But Silicon Valley is basically the exemplar of that business model as they specifically go with a very high COL area in the world's richest country instead of mass outsourcing. Even assuming that the actor is a heartless and selfish bastard what truly matters first is net profit.

It is the same fallacious false economy seen both among slaveowners and the Soviet Union. That the labor is free or already paid for so don't worry about its efficiency.

They are not like computer programmers who can make an industrial process be 10,000x faster. They cannot magically care 10,000x more, no matter how relaxed and comfortable they are.

Furthermore, as they are pushed closer and closer to failure, the collapse in patient care standards does not result in a collapse in profit. People aren't going to not seek medical treatment, it's a basic human need, sometimes a life or death need.

So we're back to the question: does that mean they should be exploited and milked of all their caring, at the same time the standard of care collapses, because the economic incentives reward that?

And that is fundamentally a moral/humanitarian question in which you have to make an adult moral judgement.

There are a lot of jobs openings available to someone with an RN certificate and some experience. Unemployment in that group is close to zero. They don't all work in direct patient care roles.

But I'll go ahead and explain the joke. There is a long history of the private sector using the spectre of communism (or socialism, or "big government" or "nanny state") as a canard to prevent sensible policies eg. anything that would improve patient care, even if it were at minuscule costs and will use that canard to justify lobbying aggressively to prevent it. And if they cannot obstruct legislative action then they switch to defunding the state bodies which enforce the regulations as an exercise in "cost cutting" because "the state is wasting your hard earned taxes!!" etc.

Hope you have a better rest of your day.

Edit: I mean, once you have set a regulation, and established a body to police it, you have already interfered with the market, so even what you are suggesting could be described as having "done a communism"

Exactly, remove regulations from health care. I'm dead serious. Regulatory burden on nurses and health care workers are insane. It's completely plausible the net effect would be far more people saved than lost, due to greater access to healthcare and lower burdens to achieving outcomes.

For example, hospitals spend a lot of money complying with CMS reporting rules on iatrogenic harm such as bed sores and secondary infections. Should they stop doing that?

You're right, apologies for not being specific.

>Which specific regulations would you propose to remove?

Specifically, all of them.

>Should they stop doing that?

Object to framing of the question. Hints at a false dichotomy. Desirable outcomes can be achieved without precisely following a regulation.

The second point is entirely accurate. It's one of the major factors that makes communism, socialism, untenable in many ways.

What's hilarious / frustrating is how these same people think that humans in a libertarian utopia won't be corrupt, won't want for money and power, and as a result, "Sure, remove all regulation - the market will get more efficient! It certainly won't end up like the railroads in the 19th century, or something out of an Upton Sinclair novel!"

Never the supplier using ill gotten capital from predatory business practices to lobby or perpetrate regulatory capture.

Nope, it's always those pesky regulators sticking their hands out. Never those Captains of Industry! Paragons of Humanity and Unquestionable Beings of Moral Fiber and Impeccably Ethical Manner!

What part of that didn't you understand? Where did I say the captains of industry aren't corrupt. I said "everyone."

The consumer has the power to voluntarily spend or not spend with a particular health care provider for the vast majority of health care decisions. Their providers are beholden to the customer.

The regulator, on the other hand, is not beholden to the customer this way. The regulator, are typically integrated as part of government and thus not only are they unbeholden to the customer but they also are part of the same entity as men with guns who can use violence to achieve their ends. They are nearly always unelected and only in the loosest sense does the customer have any control -- no one seriously votes for their senators / representative based on who they approve of in say the FDA (can 99% of voters even name a single regulator in say the FDA?) -- that vote is dominated by other even more important issues you need your representative for. These regulators are effectively an ultimate source of corruption, backed by guns and only in the most tangential sense accountable to consumers but with wide latitude to control industry in ways that harm the consumer.

Yes everyone is corrupt, including the 'captains of industry' and even the 'consumer' but regulators make things massively worse. Regulators create an amplification effect of corruption.

Many people don't have even a little optionality.

I definitely feel for those paying child support, because 'imputed income' means you must pay at whatever rate the judge thinks you can make the best money at. You can never take a more relaxing lower paying job, because it will result in your imprisonment. Those people really have no future in the US -- their only option to throttle back their income is suicide, leave the country, or wait to go to jail. I blame society for the existence of these debtor's prisons, not nursing employers.

This is basically how it works when you're married, though, at least in my family. Whether I'm unemployed or my work life is booming, the child cost the same for me as when I'm not. During bad times I liquidate my engineering tools / spend from savings / go into debt / sell my vehicle to take care of my kid if needed. On the flip side during the good times the extra money goes into investments and retirement. The amount I need to take care of the kid is fixed, with the amount I spend having virtually nothing to do with the amount I make. My level of personal real spending has changed very little since I got my first near minimum wage job after leaving home at 18; and definitely not linearly with my salary (at best I eat out more now, but that's because I'm busier making money). When the kid came they've always been a relatively fixed cost -- or at least unaffected by our salaries.

My kid would not be effected the slightest, better or worse, for my wage unless I was stuck below ~$12/hr for an extended time, so maybe it would make more sense to take a variable amount up to say $12/hr and then just a fixed price after that.

>doesn't mean that what you can afford is enough to raise the child well

Really depends. Some children grow up in situations where money is scarce but nonetheless have fulfilling childhoods that lead them towards success. It's also worth noting parents who can provide other things in lieu of money -- such as a homestead where they grow their own food and build their own house is perfectly acceptable in a marriage but somehow not acceptable as part of child support enforcement. It doesn't make sense.

>This has the benefit of allowing low earning parents to pay less

Again this is an odd choice. When I am making nothing, I still contribute half to the family costs. When I'm making 6 figures, my half stays the same. Both my wife and I have a deal where we pay half the costs. That way there is no resentment that someone is paying more just because they make more. It happens to be my wife makes significantly more money than me, but we still pay 50/50 costs of child and other bills with the remainder going into our own unshared accounts. It would be extraordinarily selfish and greedy of me for me to demand my wife to pay more simply because she makes more money, yet if we divorced this is precisely what the judge would order in many states. No matter how nasty the divorce I would simply return her share of her savings along with anything over half for spending of the child -- to not do so would make me a vile and greedy person who cowardly uses the violence of the state to unjustly take from others.

In our case the cost of the child is about 6-8% of our current salaries; so as you can see from child support calculators, about half of the money calculated by child support worksheets would be entirely for the lolz of the judge.

>So the compromise is to base the amount paid on the amount the parent makes

Unfortunately this isn't how it works, as above alluded. Once you make a certain amount it becomes your 'imputed income'. Once you set the precedent you can earn a maximum, the judge expects that to be your income you're capable of. You pay based on that higher amount whether you relax back to a lower paying job or not. In this way you're set up into a trap where if you try to get a higher paying job to save up to pay off years of child support, you're stuck in an even more fucked position and meanwhile if your kid is like mine and has a relatively fixed cost then the rest is bled off as backdoor alimony as a reward to your ex-spouse for divorcing you.

Another interpretation is that the economy is a tool for exploiting people. For example, human beings are inherently of the opinion that human decency is good, they want to be functioning members of society, they care about the wellbeing of others, and if they are paid crap and treated like garbage, they will endure that, even to the point of great personal cost, emotional distress, mental illness, alcoholism, and even death. But as long as they don't quit, then everything is fine.

If you want to see an indocator of terrible compensation - check why pretty much noone (at least here) wants to be a nurse.

Profession is rapidly aging because new ppl are not joining. And they are not joining because work is hard and pay is terrible.

The whole Healthcare system if we dont get robots in place fast is going to crumble soon like a house of cards.

https://www.npr.org/sections/health-shots/2021/10/25/1047290...

The work is hard, but the pay is well above many other jobs and there are jobs everywhere.

+ emigration of nurses to Germany

People don't 'switch careers' when they've spent years getting good at it. What they do instead is sit around posting on HackerNews and fucking the dog in all sorts of other ways.

Do you realize the irony of it all? This place gets like 1/10th the traffic on weekends. That's not a coincidence.

There are, of course, onlookers who are unable to even perceive the moral dimensions that normal human beings take for granted. Perhaps they were beamed down from the mothership just yesterday? The prevalence of psychopathy among human beings cannot be as high as it would appear from the average internet message-board, can it?

In healthcare I get the feeling that a lot of workers feel stuck in that there are many patients and people depending on them, and to leave would sort of be like abandoning them while increasing the burden on ex-cowoerkers.

Not necessarily. The "transaction costs" of switching careers are huge. If you want to make comparable money to nursing, you probably need training in something else, which likely requires a period of low or no income, possibly years of schooling or other training, etc.

It's hard to switch careers after 30 -- not always impossible, but certainly hard to revert back to the lifestyle of a 20-something for some time. People may stick it out despite unhappiness.

Doesn't mean compensation is adequate.

At what point in time did America have better jobs? A lot of people may reference the glory days of 70s and 80s manufacturing, but those jobs went from bad to good with the power of unionization. There was no free lunch.

The criminal justice system may be overwhelmed, but its reaction certainly isn't to just let criminals "exit like a revolving door". The US is still incarcerating people at 10x the rate of other wealthy countries.

Nurses being overworked is simply due to there not being enough nurses. It matters little if there's too much bureaucracy somewhere, or if too much money is spent on pharmaceuticals (about twice as expensive as anywhere else) or if doctors make too much money or if the US has a uniquely unhealthy population.

yes but this begs the obvious question of "why?", which either leads to the immediate thoughts of

1. not enough people want to be nurses 2. companies don't want to hire more nurses

I'm assuming #1 is false, so #2 is the go-to conclusion, at least on the high level. I'm sure I'm missing some more nuanced #3/4/5 explanations, but it does seem to ultimately come down to money that isn't being spent (be it maliciously or simply due to not having the budget).

What some people will call government waste - other people will call ethical employee treatment... sure there are a lot of other sources of inefficiency outside of your comment - but complaining about overpaid government bureaucrats is essentially advocating for the same race-to-the-bottom that has stagnated wages in large parts of the labour pool.

https://en.m.wikipedia.org/wiki/Federal_Employees_Retirement...

The teacher retirement systems I know of have rules like (age + years_worked)>=80 ==> full pension benefits.

Retiring after 20y will earn you a smaller monthly and is only possible (under that rule-of-80 above) if you start teaching at age 40. Teachers are much more likely to retire after 25+y (age_start=30, age_retire=55).

(There are complexities and counter-examples that moderate this generally true statement.)

Defund the organisation to point of total chaos and near-collapse. Blame employees for collapse in work quality.

Here are some more generally true statements:

Increase profits and improve efficiency by cutting out maintenance tasks and firing the people who do them. Blame accidents or outages on employees, customers, bystanders.

People die? Company goes bust? Who cares? Even if there are consequences, the executives/officials to blame have already taken the money and moved on to the next thing. You can't prosecute them or get the money back (unless they were stupendously dumb and got directly involved and stayed on 'til the bitter end and centres of power were so affected that prosecutors can't ignore it: see Theranos, Enron, etc.).

Otherwise good points I think, @scaramanga:

>>> cutting out maintenance tasks and firing the people who do them. Blame accidents ... Who cares? ... You can't prosecute them

> It's actually not sure that they are doing work. > (There are complexities and counter-examples that moderate this generally true statement.)

Guess, based on that I cannot really have a counter argument here :)

Hah, sorry. If you don't qualify a general statement, you'll get jumped on by people supplying the qualifier for you. I wish it weren't like that.

Relative size is a good point, certainly. We can look to several huge companies to see frustrating interaction points (hence my qualifier.)

But slack can also be perceived as waste, which can be cut.

And if your budget is cut, you are likely to see that slack as "first thing on the copping block" with the consequence that the queue begins to expand. But most systems have natural buffers which delay catastrophic failure. By that point there have been elections, you have retired, etc. and someone else is left holding the bag.

At that point you can blame the organisation for being "slow", or "inefficient", and then you can cut it's funding further, or destroy it outright or maybe outsource it to the private sector.

Then the private sector can drive profits by asset stripping and cutting safety or vital maintenance work, then when the whole system collapses, you can hold the taxpayer hostage by demanding a bailout of the, presumably vital, service (or you can renationalise it), and the whole cycle starts again.

Welcome to our planet, enjoy your stay, it's likely to be a brief one :)

I'm glad you've enjoyed writing your comments--like your style. :)

Yeah, more efficient nodes can delay that effect, but it seems that in real world system the existence of buffers means that consequences are delayed in ways that have significance (across careers, elections, etc) and those factors tend to dominate.

yw, nice that anyone reads it, without that i'd just be another mad shouty bloke on the internet, maybe i still am :)

What makes you think government is that much worse than the private sector in this regard?

Sure a lot of people coast in the private sector, hiding in the corners of their organizations. But if the business allows too much of that to happen, they go bust. In government, they just go get a tax increase.

You seem to think that people cannot escape the consequences of their actions, and that consequences arrive swiftly and fairly. But I should think a quick look around the world we actually live in will disabuse you of that notion in short order. Especially when it comes to gigantic centres of power with vast reserves of cash and well protected revenue streams.

And if you've worked in any tech company, you've probably already seen that the people who coast do not "hide in corners" they make up an entire class, called "management", especially "middle management", they're front and centre because they have no productive work to do so they can devote the majority of their time to extravagant displays justifying their existence and their elevated positions and compensation.

But eventually the work got done and we kept getting work because Big Companies buy from other Big Companies. You're not going to risk tendering to a 3 man office who gets it done faster, cheaper, better because if it doesn't happen questions will be asked. Unfortunately there are a lot of talented small businesses out there but they just don't get the work due to this.

Of course, eventually yes it's impossible to ignore the value gap. But I've seen companies threaten to leave but keep paying the bills for many years because in a big company, it's not really anyone's problem in particular and it's easier to just keep going along to get along. One example we had was B2C email communications, there are so many cheaper more capable players out there but they just got us to do it because we did other stuff for them.

Come on. They often try to sue each other out of business, get the government to declare competition illegal, "cut off their air supply", "knife their baby", etc.

> because we did other stuff for them

There you go. Not because of the goodness of their hearts.

I've known people in every corporation I've worked for who accomplished nothing and were not managers. I was often given the job of trying to turn whatever they did into something useful. Everybody knew who they were. I remember one person, we'll call "Smith". "Smith" would check in code, and it was always so bad that someone else would have to redo the whole thing. After a while, the term "smith-code" became a generic term for code that was worse than nothing.

How bad can you be that your name becomes a generic term for useless work?

"Smith" eventually got laid off. The team was relieved.

I've known a few Smith's in my time, one thing they all had in common was the protection of a manager who had no interest in the quality of Smith's work, as long as Smith would take his side in any disputes. When the consequences became too great, the manager would suddenly understand the problem and approve the minimum of changes to fix it, while taking credit for the work. Smith would not complain about this slight because he understood the nature of the transaction.

Edit: btw. congrats getting rid of your Smith, these people can be very difficult to dislodge. Presumably your guy did not have the protection of a manager.

Zilog was the maker of the Z80 microprocessor that powered a huge number of games consoles and simple computers in the 80s. Also still around - its parent company was acquired for $750 million.

I had to look up Curtis-Mathis because it wasn't a thing in the UK.

And MicroPro / WordStar International does seem to be legitimately dead: acquired by SoftKey who were acquired by Mattel who have since gotten rid of all the associated brands.

But in any practical sense, they ceased to exist. (I meant Lotus of 1-2-3 fame, not car fame.)

Their scopes are still for sale and still good.

> part of an umbrella corporation

meaning their former glory is gone. When I was starting out Tektronix was a very big deal in computers and electronics. I haven't even heard their name in 20-30 years.

Hah, wasn't it UCLA who recently got excoriated for advertising for grad students to teach undergraduate classes with this stellar line:

"This is an uncompensated position"?

You're delusional. America has more people in jail, serving longer sentences, than _any country in history_.

Here: https://www.cnn.com/2018/06/28/us/mass-incarceration-five-ke...

My mom was a nurse, my aunt was a nurse, my sister is a nurse and my best friend’s mom is a nurse. I really can’t believe anyone continues to be a nurse given the insane working conditions these folks have to put up with. Twelve hour shifts, overflowing with patients, watching newcomers earn more than seasoned veterans… When I compare it to my laid back software engineering job it’s like I’m living in an entirely different universe. The hospital industry is a hugely demoralizing place.

On top of that, they also hire as few orderlies and nursing assistants as possible, so the nurse doesn't even have anyone to offload things to, and ends up having to do more work on more patients.

This has been a problem well before the pandemic.

It's a trope among nurses that they are so busy they don't have time to use the bathroom, let alone eat lunch.

Source: My wife is a nurse, most of her friends are nurses, and she left the profession ~a year before the pandemic because of exactly these issues.

He kept getting vacation requests denied due to lack of staffing, yet if he asked if they were looking to hire, the answer was always No.

He was super lucky and had some early cryptocurrency investments pay off big, so he decided he was done with it retired. He said that he loved helping people as a nurse, but not at the cost of his own physical and mental health, having to work 60-80 hours/week. If he ever gets back into it, he would establish at the interview phase that he works 50 hours/week tops, and that vacation "requests" are not requests, but notices.

Like what did you expect to happen? We're not stupid.

At the place I'm at right now, we have an unlimited policy and I've got 25 days of PTO planned over the course of the year that's all been approved.

But yeah...I do know not every place is that good about it.

At all jobs, vacation time was almost never a problem. Maybe that's more the case now that I'm a freelancer, though. I just announce when I won't be available, and although we do try to plan things so that we never have the entire team gone at the same time (unless the company as a whole plans for that; Christmas breaks are often like that), they always accept my absense. It's really notifications, rather than requests.

But this is Netherland. We've got quite a different work culture than the US does.

As someone who worked in hospitals to help redesign their processes, this one piqued my interest.

For every project I worked on (and I mean literally every one), the team lead wanted to jump to the solution that they just need the ability to hire more people. In the rare instances where they were able to convince hospital admins to do so, it never fixed the problem. Not once.

Why? Because it never addressed the root causes. They needed to take a process-oriented approach. There's a saying that adding more people to a broken process makes things worse. You can hide a lot of quality issues with inventory; if you have a requirements for 100 widgets a day and you have a crap process that only makes 10 quality widgets, you can meet your goal by increasing throughput 10x, but nobody thinks that would be a good approach. It's the same with injecting more staff onto a broken system. If the system causes nurses to spend disproportionate amounts of time on admin work and not on direct patient care, it may be better to look at your admin processes rather than just hire more nurses.

It's natural when people to feel overwhelmed to think the solution is to just hire more people, but it's almost always better to hold off on hiring until the system/process is fixed.

Edit: I'm curious about the downvoting. I think it would help illuminate the conversation if you could explain where your disagreement lies. I'm basing my statements on actually tracking when hiring was increased to the levels desired and metrics did not improve.

The problems are caused by a "just in time" approach to staffing, where you have exactly enough people to cover the shifts at bare minimum. What solution would you suggest other than more people? They are not saying to throw more nurses at patients simultaneously, they are saying to hire more nurses so existing ones aren't bound to spent the entire week stretching themselves across the hospital.

Also, I think you are being downvoted because you are applying software engineering rules to medicine.

>What solution would you suggest other than more people?

It obviously depends on the situation but most of the time it comes down to reducing process waste. That may be automation through software where a nurse was hired specifically to only generate reports 40 hours a week, to re-designing a layout that minimizes travel time for nurses when they are delivering to patients. My experience with the staffing situation is that managers did not know how to staff to meet the needs of their patient loads and just revert to simple heuristics that left them understaffed at some times while being overstaffed at others.

I think talking about micro-optimizations like this misses the forest through the trees.

It's neat and cool. Fun to wring out those last bits of efficiency. But the fact you even need to discuss it shows how hiring adequate amount of bedside staff is the absolute last thing any medical system will do.

> revert to simple heuristics that left them understaffed at some times while being overstaffed at others

Showing that they were better than modern day automated shift planning.

I will submit that if your hospital floor staff is not 50% idle on your average given fully-staffed boring day, you are understaffed. Only extremely exceptional events should cause your staff to be booked 100%. When it happens it should be root cause analyzed and be immediate cause for executive concern.

The trope of card playing nurses should be true, because of all industries there are - you want surge capacity in healthcare. Both physically speaking in terms of warm bodies available, as well as mentally speaking in brains not being stressed to their max the entire shift.

I understand these ideas don't end up with maximal efficiency. I am likely naive as well - but it's pretty clear that hospital systems are being operated in an intentional manner to keep staffing cut to the bone right up until the point the system or people break.

This doesn't just hold true for healthcare, it's endemic in a lot of service industries where the bottom tier employees are expected to live in service of the profession and take up all the slack from above.

However, this seems to be unsatisfying to modern management styles. Apparently if you aren't running the employees into the ground like an Amazon warehouse, you're "leaving something on the table".

It may be different in practice than you are imagining. It's been years so I don't have the exact numbers, but something on the order of 10-20% increased patient throughput in radiology of a major metropolitan hospital that provides for an underserved community. (Keep in mind, it's not just nurses who have to traverse hospitals but patients. Many of them are old or lack mobility, so the changes are compounded.) I don't consider that "micro" but you may have different expectations. As a comparison, I don't think nurses would think a 20% increase in staffing is trivial, but my preference is to measure at the patient level, because that is the outcome I'm most concerned with.

>Showing that they were better than modern day automated shift planning.

Can you explain? I'm not following this statement. I was involved because it wasn't working.

>you want surge capacity in healthcare.

I agree. But like all complicated systems, you rarely get something for nothing. The trope in healthcare is you can choose between quality, cost, and access, but you only get to choose two. Lots of slack in the provider supply side is great for surge capacity, but it generally comes at the expense of cost. That's difficult when many of the same people who complain about the lack of providers also like to point out the cost of healthcare. I would prefer to take system-level view so we aren't essentially just shifting the waste around in the system and instead work to cut it out completely. In this case, excess capacity isn't waste but a desired measure of resilience. But I do think it needs to be measured and managed. My experience has been that nurse managers will just constantly increase the slack in the system rather than address the other issues.

And I absolutely agree there are issues, across many industries, where JIT thought-processes are short-sighted. COVID, and prior to that, Fukashima, has demonstrated this error. There are certain critical systems that we do not want operating at maximum input/output efficiency. If the staffing issues I've referenced were consciously framed in that sort of pragmatic, data-driven argument, I would be the first to stand behind it. But often they were really coming from a "we're-overwhelmed-and-don't-know-what-else-to-do-so-just-hire-more-people" perspective.

Here, better traffic design is necessary. And room alternative, more efficient forms of traffic (public transport, bikes).

I do think nursing (and many similar fields) do need to hire more people, but I also suspect they have to redesign how nurses work. Less overhead, more focus on the core of their work. Streamline the processes, especially the administrative side, and not expect them to fill in for many other kinds of work at the hospital. Get separate specialists for that.

I get the impression that the same is often true for teachers, academics and cops: too much focus on administration, which takes the focus away from the reasons they chose these jobs in the first place. Streamline the administrative process, or have dedicated administrators help them with the boring stuff, so the nurses, teachers and cops can focus on the actual content of their jobs.

If it's because it provides more patient care beyond what a nurse can provide in a good system, it might be a valid point. But if it's because the system is fundamentally broken, I'm skeptical that hiring more people will actually fix anything. From personal experience, it will only create a lag that will require the same need for more hires down the road.

The issue I'm pointing to is that sometimes it's "needed" because of a bad process, like when there is redundant work. Sometimes it's needed because the system needs slack to compensate for disruptions in system dynamics. Sometimes it's "needed" because "that's how we've always done things." Point being, if it's needed, it should be because it contributes directly to better patient outcomes rather than bad processes.

It's hard to adequately staff to that level when the systems/processes are largely unmanaged. By definition, an unmanaged process doesn't know how much nursing gets spent on each element, from patient care to admin work. So it becomes just a guess as to how many you need; when people work in unmanaged processes they tend to feel overwhelmed and the knee-jerk reaction is to hire more people. And often when you add more people to an unmanaged process, the inefficiency can compound, leading you to feel like you need more people to fill the continuing gaps.

Hiring more people can be part of the solution. But you need to understand and manage the process first to get to the right answer.

My position is precisely that "I looked at nursing work in hospital and it was unmanaged." (not in every instance, of course, but certainly in those relevant to this conversation)

I'm a UK doctor working in the field, always looking to optimise processes while keeping quality.

Email is in my profile.

The problem is that they had two consecutive shifts.

The alternative is that the hospital hires enough people so they can schedule them such that everybody has time to go home relax and sleep after they are done with a shift.

Yeah, let's keep not evolving as a species.

Then I open my recruiter inbox and I see like 20 new B2C healthcare startups.

It really feels like the entire economy is designed to prevent problems being solved. Some people in healthcare are making massive amounts of money and the quality of life of everyone that performs the actual work has taken a nosedive when it was already a really crappy situation.

Sans the covid anomaly, immigration has never been higher in Western nations. The issue isn't restrictive migration. It's that we're not treating nurses well. That means fewer people pick this career, and more nurses leave prematurely. Suggesting that we need to import more nurses is only admitting that migrant nurses are willing to work for worse pay and worse working conditions, and I don't think that's fair to anyone.

In case people want an idea of what travel nurses made during COVID...

https://khn.org/news/highly-paid-traveling-nurses-fill-staff...

> In April, she packed her bags for a two-month contract in then-COVID hot spot New Jersey, as part of what she called a “mass exodus” of nurses leaving the suburban Denver hospital to become traveling nurses. Her new pay? About $5,200 a week, and with a contract that required adequate protective gear.

> Months later, the offerings — and the stakes — are even higher for nurses willing to move. In Sioux Falls, South Dakota, nurses can make more than $6,200 a week. A recent posting for a job in Fargo, North Dakota, offered more than $8,000 a week. Some can get as much as $10,000.

But it also isn't an option for everyone. Many don't have the flexibility to switch to travel nursing. For example, you may not be able to get a nearby contract and may not be able to travel (e.g. because you have children). Plus, traveling isn't an option for new nurses without experience, who now have to work in hospitals that are hemorrhaging experienced nurses to traveling AND have worse staffing ratios than ever.

> The $5200/wk rate is more likely 3 or 4 12-hour shifts

3 or 4 12 hour shifts a week is normal for salaried nurses. $5200/wk isn't. It's over double.

> which pay outrageously but often require a full week of 12-hour shifts or something similar with the expectation the nurse will only do one week then recover.

I'm not sure what you're trying to say. Yes, it may be a full week of 12 hour shifts, but it's still a much higher pay. And if you get the next week off, it's a fantastic deal.

For context, pre-pandemic, I knew a nurse who often would do this schedule for her salaried job - she requested it as she liked having a full week off.

What I mentioned elsewhere: Travel nurses have a lot more control over the contracts they take. They can work fewer hours per year and still make significantly more. They may have stretches of long hours in a given contract, but annually they work less.

It's a normal shift schedule, and they pay travel nurses much more than staff nurses to work the same shift schedule. These are typically 3 month contracts, but not always.

> I'm not sure what you're trying to say. Yes, it may be a full week of 12 hour shifts, but it's still a much higher pay. And if you get the next week off, it's a fantastic deal.

I don't disagree, but a lot of people do not want to work (or feel like they can't provide good care for) 12 hours every day for a week.

What happens is they'll accept a few weeks (or 2 months) of long hours, and then take a month off and relax. As you can imagine, if they're getting paid $6000/week, they can easily take a lot of time off and still get paid more annually than their salaried counterparts (while overall working fewer hours per year).

I can agree that executive compensation is exorbitant, but do not agree that "MBA types" (what does that even mean?) have no value add. There's nothing inherent with being in the health care industry that translates directly into administering a (large) business. Why would you think doctors or nurses would be good at that?

I agree that Doctors and Nurses would likely be poor administrators - however the disparity in income is incomprehensible in healthcare.

Anecdotally, I know a travel nurse who works in pediatric ICUs (PICUs). One shift a couple months ago, the overnight staff on her unit was >80% travelers. And this is in peds units that aren't as affected by COVID, because ~1/2 of the patients are cardiac babies with congenital heart issues. The only case I can see for not paying staff more to increase retention is that they can respond to a dip in cases over the summer, but that can't possibly be an 80% decrease in patients. Maybe they're waiting until travel rates come down to offer an increase in pay so their 1.2x salary offer is more enticing in comparison to the travel rates, but the current system is ridiculous financially. I did mention that we've seen first-hand that hospitals can afford to pay nurses $4k/week, though, and I'm sure I'm not the only one who noticed.

This is a two-edged sword. If you hire more than you need, the nurses' hours will be cut during normal situations and they won't make enough money. If hospitals don't cut extra hours and instead keep the staff on the clock, a public scandal will erupt surrounding well-paid medical professionals sitting around doing nothing.

I don't think that's true. Increasing the amount of nurses means simply increasing the amount of care. If you have twice as many nurses, you'll have twice as much care for your patients. No way nurses would be sitting around doing nothing.

As an example, if we assume you are a software engineer and you double your work hours, will you double your code output? Probably not, just like it's not a 1:1 translation of nurse hours to patient care.

Combined with willfully ignoring that basically all floors are intentionally understaffed and have been for years.

We probably agree about the staffing levels to an extent, but I would be curious to hear the staffing estimation methodologies used in your experience.

I'm not sure its the flex in this argument you think it is.

I mean they clearly are still working there, they can always do a bit more to cover right?

My position is not that they were always adequately staffed, but that in my experience increasing staffing did not fix the problems as expected because the problems were rooted in more systemic issues. As I've stated elsewhere staffing may be part of the solution but rarely a panacea. Also, my stance is that fixing the systemic issues will help them do less non-patient-centered work so they can focus more on being a healthcare provider, where they are the most valuable.

[1]https://news.ycombinator.com/newsguidelines.html

They employ on-call, PRN, contract nurses, etc to fill in the gaps which mostly works in non-pandemic situations.

Also if I never have to hear people complain about bloated admin budgets in education and healthcare ever again it’ll be too soon. Those admins aren’t sitting around on their thumbs—they’re dealing with the ridiculous legal and administrative system the insurance companies and government have created. Those people are absolutely critical for the institution to exist.

I looked up my local hospital network, UCHealth (Colorado, there are many UCHealths it would seem), and their EBITDA in 2021 was 16.6%. Mayo Clinic posted 1.2 billion dollars in _operating profit_ in 2021, and also have a gigantic investing arm with several billion dollars under management.

Then we look at networks like Spectrum in Michigan, who posted only a 3.6% margin, or Henry Ford, with a negative operating margin offset by investment income, and it becomes clear that _some_ hospitals barely make their budget while _others_ rake in dollars.

Profit how? Your 2 examples of UCHealth and Mayo Clinic are both non-profits.

Instead, the story as I've heard it seems to be similar to education: massive administrative overhead permitted by fundamentally broken insurance billing.

Sure I may not know healthcare but they really need to fix their shit.

The sad truth is labor in America is incredibly expensive. Healthcare is extremely labor intensive. And everything else is expensive too. We don’t pay the came cost from the source for things like drugs, medical supplies, etc. A thing that cost $100 in another country costs $1000 in the US. That’s from the manufacturer who can control what price they charge. It’s capitalism doing it’s thing. But we also have a ton of middle men. Insurance, brokers, wholesalers, distributors, and on and on. All of who need a margin of profit and maintains some level of administration overhead. So when people here say administrators and too bloated and over paid, it’s really the supply chain that is deep and prices that are uncontrolled.

Even parts of this thread exemplifies how difficult it is to get agreement on what the problem/solution even is. People are complaining that healthcare is too expensive others saying nurses need to be paid more or have hospitals increase staffing. These ideas are in complete opposition.

I’m guessing if you’ve seen that is hyper localized to some place/issue.

The situation is so bad that regulation or standard practices encouraging employers to document compensation figures instead of quasi-mythical salary figures would do a lot of good to reduce confusion in this area.

https://www.beckershospitalreview.com/finance/12-latest-hosp...

If there's a location that isn't profitable to operate a hospital in then the hospital will probably fail. America is the country still clinging to market-driven healthcare services and the market can be a cruel mistress.

And all that doesn't at all erode the fact that nurses are paid pauper's wages at extremely profitable hospitals - some tech companies are going out of business, some probably closed their doors today... that doesn't mean that all engineers are expected to work for 60hrs/week at $15/hr.

https://www.gpb.org/news/2022/04/08/wellstar-closing-er-hosp...

https://www.post-gazette.com/opinion/editorials/2022/04/04/c...

In 2020 the US median salary for an RN was $75K. That was well above the median household income. Hardly pauper's wages.

Most hospitals are not extremely profitable. In fact the majority are run by governments or non-profit organizations.

https://www.kff.org/other/state-indicator/hospitals-by-owner...

Tech companies will pay engineers as little as they can get away with. Expectations have nothing to do with it. Wages are set by the market.

Hearsay from the nurses I know: a large hospital near me has a separate budget line item for full time nurses vs. travel nurses or other "mercenery" roles. This incentive system will never create the best patient care, but I suppose that's not really the goal.

With additional nuance that this kind of thing used to be protected a bit by the additional guard of a pharmacist. The automated dispensary changed those criminally liable people into a checkbox bypass that this nurse (and from the sounds of it, the rest of them by effect of policy) regularly bypassed.

Game developers are likely the people who love video games and so are willing to put up with the worse working conditions in order to work on the games they love.

https://khn.org/news/article/radonda-vaught-fatal-drug-error...

On an individual basis, nurses are overworked because they choose to be and their employers allow for it. The standard work week is 3 12 hour shifts, which is much less than most professionals work. Like a retail or warehouse worker, they are expected to clock out as soon as possible and leave when the shift ends. Those of us with salary jobs knows how difficult that can be in our arrangements and how much "free" work we end up performing. They get paid premiums for everything; night, weekend, etc. And since they're hourly, they typically LIKE the overtime and signup for it as much as possible. They also might work FT at one hospital and pull extra shifts at another hospital on a PRN basis. These things are very common. Just like in a retail environment, people typically LIKE to work holidays so long as it's voluntary because it's 1.5x pay (or more?).

> Rather than hiring permanent people or upping salary, Hospitals have instead elected to just use travel nurses and an extreme premium so as to avoid any salary increases.

This makes no sense. Capacity is the problem, paying more for the same capacity does not solve the problem. Hospitals try very hard to avoid overtime and the travel nurses due to the cost. It's also a very elastic model to balance and a lot of flex (non Full Time) folks are needed to fill the gaps and manage cost somewhat.

> The fix is one that Hospital admins don't want. Pay your nurses more and hire more than the minimum to cover shifts so a nurse being out sick doesn't result in another working a 80 hour week.

That is the current system. The problem is usually time. If someone calls in sick, they do it an hour before their shift starts. They usually can solve for this. Either they call from their roster or a supervisor level person with an active RN license steps into the clinical side that day. Staffing at 2x just in case everyone calls in makes no sense. Staffing at 5x just in case a pandemic hits makes no sense.

Hospitals barely make money as it is, I don't see how this is a sustainable solution. Paying more does not create capacity in this industry.

It's also important to note that "nurse" is a very generic term. For example, ICU nurses is a very distinct type of nurse that has been dealing with COVID first hand (caring for vent patients). They are the ones you hear about making $150-200/hour in COVID times. It is difficult to become an ICU nurse. It hasn't been possible for a surgical nurse to pivot to ICU nurse in these times so the labor pool has been rather fixed, or shrinking due to natural churn and inability to onboard new folks. It would be akin to suggesting why does some [insert super specific domain expertise] developer make $1M/year at FAANG when they could hire a PHP coder for $15/hour on a freelance website. There is no immediate/cheap substitute for the experience and knowledge that the expensive developer has, so they cost more. This is happening in nursing where some are thriving while many actually got furloughed early on in the pandemic.

My personal opinion on the matter, is one only has to look at the demographics of an average nurse. It's become quite "old" and like other industries, the boomer's retiring is causing a labor issue. The handful of nurses that made 5-10 years of salary since Q1.2020 are now ready to retire early as well. I don't blame them.

The problem is – and this may be very bizarre in a society as capitalistic as the US – healthcare should not be beholden to making a profit.

Rehabilitating people is clearly "valuable" to the economy in that without people to participate in the economic system, a debt-based economy collapses; I'd argue that healthcare is much more valuable to capitalism than is reflected on a balance sheet of paper costs/revenues/profits, and yet a system such as ours has absolutely no way in its current form to price that in (sure, in an academic defense you could wave hands that "positive externalities" such as these should be priced in to the model, but it's clear with the racket the medical industry has found itself in that will never happen practically).

The main issue profit-seeking conflicts with is that whole rehabilitating/healing/saving people is an intrinsically good thing to do, and that letting people who have full lives to live die or suffer is an intrinsically bad thing to do.

What's not sustainable is that healthcare has to survive within the confines of a system that is many times in complete opposition to it. Other otherwise-capitalist countries have at least tried to insulate their healthcare industry from market forces, meanwhile the US has just wrapped it in another layer of capitalism with its insurance market.

Capacity is generally limited by staffing, not space or actual beds. When hospitals report how many "beds" they have available, they're generally not talking about the furniture.

Might ship in more nurses, and until they do, the beds that can't be staffed don't count towards capacity.

> 50% occupancy

Having the capacity to staff those beds is not the same as the beds being occupied. Beds are occupied by patients, not nurses.

I happen to work at a healthcare company that reports number of beds and did receive FEMA sourced labor during the pandemic in some of our rural hospitals that were short staffed and literally do not have the physical labor pool to tap into.

I think you’re discussing how you like to interpret the metrics of beds and occupancy but it’s not how it’s actually discussed in the industry.

' October 22, 2020, the FDA approved remdesivir (Veklury) for the treatment of COVID-19 for adults and certain pediatric patients requiring hospitalization '

That stuff is lethal. https://www.fiercebiotech.com/biotech/gilead-mulls-repositio...

https://www.drugdiscoverytrends.com/50-of-2021s-best-selling...

' Veklury (remdesivir) Gilead Sciences $5,565,000,000.00 COVID-19 requiring hospitalization '

And it is administered via IV, so add maybe $1000 for the IV procedure.

It doesn't even work for helping recovery. Literally poison with no medical use anywhere for anything. Another drug company and hospital emergency payday.

LTAC companies, in capitalism, would simply not accept patients if they thought they were too sick to make money on. Accepting parients put them out of business. The government wants hospitals to admit as many patients as they can in a health crisis. So , I feel this was more of a case where they acted quick and broad and didn’t actual think much about whether the drug was valid. If doctors want to prescribe it, it shouldn’t bankrupt the hospital where they work. The clinical value is up to the medical professions to figure out.

They aren't supposed to.

It doesn't match up to the reality of the US's "system"

[0]: https://www.beckershospitalreview.com/rankings-and-ratings/1....

What you need to realize is that nursing salaries in the US are NOT uniform. From what I've seen in past discussions about it is they range anywhere from $20/hr -> $100k/year. The $100k/year are usually achieved only in cities and generally only by travel nurses.

The majority of nurses, that I've seen, are clocking in at 50->60k yearly salary.

Sort of like saying "Oh, that google dev makes $300k a year. How much more do devs in the US need?"

"Sysadmin" seems the most readily comparable title in IT, going from "I push software to Windows PCs" to "I manage supercomputer clusters."

And the answer to that is "how much is Google worth?" If your business relies on the efforts of software engineers to design and build your primary products, they should have the primary equity in the company. So no, even Google developers aren't paid nearly enough...and they're certainly overworked, regardless of how much they make.

The average tenure at Google is 4 years. This means that most current Google's have joined when the company was already at sky high valuation. They made incremental improvements to the product line. But arguing that they should own the majority of the shares is just ridiculous. Think about it: if google had made no new development in the last 4 years, how much would it still be worth ? The answer is: not as much as today, but probably quite a lot.

Current employees thus deserve a part of the pie, as they are the one tending for it. But when they joined the pie was already very nice, and they had 0 impact on that. Not with their work nor their investment, so they can't claim that part for themselves.

While $100K/year is not the norm throughout the country, it is normal in my city (non-SV). Travel nurses made a lot more during COVID.

From my conversations, pay is not the reason they are considering leaving. Working conditions are.

Something something freemarket no longer applies when it comes to paying peons?

It never did.

They will bear a lot of that, because these people care for their patients and leaving a job because of bad circumstances also means leaving their patients behind with those bad circumstances.

Which is not something that comes easy to everybody who makes "helping others" such a big part of their work motivation.

People get into it because they love it, and then have their love exploited for profit by businesses masquerading as social charities.

Some hospitals and clinics do great philanthropic work. There are also a lot that don't, but have the same cross over their door.

To be honest, I am amazed that Canada has a healthcare system left.

Decades of mismanagement and underinvestment aside, almost any Canadian healthcare worker can cross the border and instantly see a substantial pay bump and increase in QoL.

I do imagine within the next 20 years, Canadian healthcare is going to look vastly different. Like something from an emerging market, where sure there is universal healthcare, but you generally avoid it if you have the means.

Already happened. It's impossible to get a primary care physician in the Maritime provinces and in BC.

For example, I have to pay $9000 a year BEFORE my insurance starts covering healthcare costs. (at $5000 my insurance starts paying out and I owe 10% of the bill). My insurance does not cover medicine costs at all.

Besides they need their health workers too.

This seems perfectly consistent with econ101. Prices for something is high, so we need more supply.

5. Pay cuts - Most of the critical doctor specialties (ER, ICU, primary) that were the backbone of the pandemic got "raises" that were less than inflation (hers was 1.5%) while profitable elective specialties got big raises. The root cause is the billing system where elective surgeries bill pay out more than critical roles. Still, it's extremely demoralizing to be called a "pandemic hero" and have your pay get cut.

6. Criminal and Financial Liablity - Healthcare is delivered by a team yet the financial and criminal penalties for mistakes are assessed at the individual level. Recently a nurse was given a criminal sentence for a drug mistake which many believe was systematic failure (bad UI / IT systems, bad hospital practices, AND negligence on the nurse). Imagine getting sued or jail time as an engineer for dropping a production database. The few malpractice cases my partner has been involved in, it was very clear that the issues were systematic and perpetuated by hospital practices. However, if they had gone to trial, an arbitrary worked would d have been sued and the hospital wouldn't change its crappy practices. Institutions have effectively dodged liability in many cases.

7. Chronic understaffing and burnout - most ICUs have been understaffed throughout the pandemic. From an economics POV it seems crazy that their is a labor shortage but salaries are effectively dropping.

The majority of the blame here lies with the thousands of politicians, bureaucrats, and administrators who haven't reformed the system in *sixty years*. Not the people who were doing their best with much less information than their successors have had.

There are a lot of first actions that need to be reexamined in the 21st century.

With the inflation numbers this year I have no idea what we are going to do, since we are already 6-7% in the hole from the 2021 cuts and now inflation is 8-9% ( assuming the economic numbers are correct... )

there's bound to be at least a third option and the fact that you ignored it is part of the problem.

Im not sure where you are getting the ‘you ignored it’ comment, when the new rates were announced we adjusted pay according to the decrease in rates.

Insurance is a scam on patients and providers.

So...this is also the biggest reason (besides lack of pay or basic human dignity) that restaurants and retailers are having a lot more trouble finding employees. Rude (and sometimes violent) customers were already an issue, but they've become absolute animals lately. It's increasingly bad for your own health, mentally and physically, to have any public-facing job. In the last few years, we've let go any pretense of expecting people to be civil and reasonable, and adult children are rewarded for their behavior instead of being trespassed.

Teachers are also quitting in droves (and in the middle of the school year, in some cases) for the same reason. Children are awful and the parents are worse. You risk sickness and violence, and are constantly harassed by parents. Then there's the whole attack on the curricula and book banning...

The FAA reported 1099 incidents with unruly passengers last year, up from a normal 100-300 in prior years. Because some sorts of people simply won't do what they're told...and disobeying flight crew instructions is generally a federal crime.

Everyone's increasingly overworked and underpaid, and they have to deal with degenerates like that daily. Of course they want out.

We're having a societal implosion.

It's toxic but it's the direction the world is moving to as long as the people in power keep choking their underlings and taking away every piece of joy they ever had.

You're right that there are definitely opportunities for improvement here. As a Product person that has worked in EMR/Healthcare IT systems, I can tell you the biggest challenge is most of the decisions are driven by legally-required compliance. In many cases, you literally cannot make it better because the brokenness is /by design/ to comply with the law.

Nearly across the board, especially in the US, our legal and regulatory climate has not kept up with technology and often actively works to the detriment of technical innovation and improving our systems.

Systems that nobody has ever asked us to use. Entire APIs with full access to key data, that nobody uses.

Keep in mind, the boomers are retiring and there aren't enough Gen X to replace them. Here's the graph of job postings for my specialty (takes a bit of finagling for it to render, esp. mobile, but suffice to say the system is going bonkers): https://www.pathologyoutlines.com/jobs?jbl=1

Shared system resources (e.g., registers, main memory, secondary storage) are released back to the system, protected from disclosure to other systems/applications/users, and users cannot intentionally or unintentionally access information remnants.

Doctors and hospitals are not necessarily aligned groups (either with each other or with nurses) on the issues, and private insurers, state governments (as market participants themselves, via operating public insurers such as Medicaid agencies), and other players are also very powerful lobbies.

It's like asking why most software devs don't go to bat for technical support people.

I think this is looking at the problem wrong. The problem is that implementing positive change in these systems is impossible for reasons far outside the control of any product designer or developer currently on the team.

This software is old, has byzantine requirements, probably cut costs all over the place, and conceived in a board room without the benefit of an adequate development lifecycle or stakeholders advocating for the users.

It probably takes 3 months to move a button around, and instead of moving that button executives are having them push a feature that earns a few more million, or a feature that the customers want more then a UX improvement.

I've worked here before... Half our customers are complaining about feature X that doesn't work right/ is inconvenient. Exec: we don't care they are already paying us on a 3 year contract. Hack this new feature into the program that a potential new customer wants.

Horrible places to work they are. Thats why I avoid using any long term contracts like the plague. The second I see call for pricing I close the window.

A developer working on something is different from a product designer. For product designer I don't mean a UI/UX developer. I mean someone empowered to design the thing. This is often a leader or product manager.

Product design isn't something taught well in most schools. It's often out of sight and mind. An engineer who was good at building hardware or writing code didn't learn the skills needed for product design through that. Product design requires looking at the whole system differently.

> It probably takes 3 months to move a button around, and instead of moving that button executives are having them push a feature that earns a few more million, or a feature that the customers want more then a UX improvement.

A better UX would reduce the amount of time nurses spend using these systems. That productivity could be used to do more other work (like taking on more patients). I don't like this argument but it's easy to make in terms of cost effectiveness.

I don't think the cost effective conversations are happening. I expect there isn't that level of depth to these. It's hard to do when a purchasing organization (like a hospital) only have a few options and they are all bad.

This is an opportunity. To build software that is both compliant and has a good UX. There's an opportunity to disrupt all the crap software here.

The thing that everyone is overlooking here is that EMR software is not designed with patient outcomes as the top priority. Every single EMR software I've seen in the field has been designed with BILLING as the top priority -- everything is organized around making sure that you can bill for the maximum number of services.

I don't think this can possibly change without regulation. The incentives are all wrong at every other layer.

Better documentation means more revenue. If your doctors and nurses are not filling in the forms because the interface isn't user friendly, you're losing money.

This is not actually the way the system works, as currently designed, and so correspondingly this is not how EMR systems are designed. The documentation that matters is capturing the procedure codes and inventory codes for billing -- and EMR systems and the associated hospital workflows and security mechanisms are designed around making sure that those billing codes must be entered in order to do anything else.

> There are 2 types of billing, even for hospitalized patients. FFS and DRG based payments. Fee For Service does depend on capturing those billing codes correctly. But DRG based payments depend solely on documentation and the billing codes are irrelevant. FFS is 2/3s of US health care spend currently ($2.6T) while DRG is $1.3T.

> I don't think the cost effective conversations are happening.

I think it would take years to overhaul these products and the conversations on that and how the price would roll down hill to the healthcare organizations have happened, and been summarily shut down.

I also think startups have tried to sell software via this value prop but have not managed anything close to feature parity or sales-org-maturity as the dominant enterprise players.

> This is an opportunity.

I think various startups and other organizations are trying but there is a reason enterprise-style organizations exist and dominant their various verticals.

Its not only about a good product, its about navigating painfully expensive sales cycles of multi-year or even near-decade, political wheeling and dealing at the municipal, state, and federal levels, dealing with compliance and legal liabilities etc.

> This is an opportunity.

Is it though? Hospitals still run. Yeah its expensive as hell, nurses are quitting, but I don't see the horsemen of the apocalypse quite yet. Healthcare outcomes are ok-ish. Young people are still entering the medical field as a viable profession.

I don't think the companies developing the software care, because they're getting paid either way.

Look at the RaDonda Vaught case or the Michelle Heughins case; terrifying to be looking at jail time for a med error.

Many nurses are watching these cases more closely and deciding that since staffing isn't getting any better and they won't be protected, it's not worth the risk.

She pulled the wrong med, and then injected it and walked out of the room rather than observing for effects. Also the med she pulled had warnings on all sides of the bottle and on the top saying very clearly that it's fatal to administer without ventilation. This went beyond a mistake to negligence.

“In response to a story like this one, there are two kinds of nurses,” Garner said. “You have the nurses who assume they would never make a mistake like that, and usually it’s because they don’t realize they could. And the second kind are the ones who know this could happen, any day, no matter how careful they are. This could be me. I could be RaDonda.”

https://khn.org/news/article/radonda-vaught-nurse-error-medi...

HN readers can look at this case filing:

https://www.documentcloud.org/documents/6785652-RaDonda-Vaug...

> Also the med she pulled had warnings on all sides of the bottle and on the top saying very clearly that it's fatal to administer without ventilation.

The linked PDF includes images of medicine in question. There's a single warning on top that reads "WARNING: PARALYZING AGENT" and a red cap. I don't see any warnings on the side. The vial appears to be tiny, smaller than my thumb.

But yes, she made a series of mistakes, listed on the last two pages of the PDF.

I am not a nurse, but I can easily imagine how someone could make the errors she did in an overworked and high-stress environment. It's a cascading series of errors that starts with overriding the medicine cabinet when she can't find the medicine she's looking for. But according to her defense, overriding the cabinet had become almost standard operating procedure at Vanderbilt at that timeframe. Once she starts down this path, she's operating on automatic and almost blind to what she's doing.

I agree she was negligent. I don't think she should go to prison for it. In the bigger picture, this is causing more nurses to quit, likely leading to more medical errors and deaths, not fewer.

There are so, so many differences between the two meds, I don't see how confusing them would be possible short of gross negligence (for context, I am a paramedic, and often administer medications (including both of the meds involved here) in a high stress environment).

Vecuronium (the paralyzing drug) is a powder in the vial and you need to first inject saline it into the vial, shake it up, and then draw out the "reconstituted" med. This is very unusual (there are only a handful of medications in common use that require this, and Midazolam, the intended med, is _definitely_ not one of them). The reconstitution process means she would have had to look at the top of the vial several times, and warning on the tops of vials are, again, very uncommon. Also uncommon is the red cap on the vial.

I have made errors before while caring for patients, and I will likely make them again. I am very aware of the fact that we all can make mistakes, but the number of mistakes that needed to be made here far exceeds the standard of what is reasonable, and is well into the territory of "gross negligence", in my opinion.

But let me allow for a second that this is a case of gross negligence, despite the fact that CMS investigated Vanderbilt and found many other issues in the workplace:

https://www.documentcloud.org/documents/6535181-Vanderbilt-C...

It's not clear to me how criminalizing her mistake helps prevent future medical errors. Do you think criminally prosecuting her was the right decision?

I think the question of "should we put this person in prison for these actions" is equivalent to any other criminal act (which isn't a clear cut answer either, in my opinion).

but we literally have a law for "negligent homicide"?

Her employer, by not creating a culture of safety, set her up for failure.

I just don't see how in the long term this prosecution reduces medical errors and generally disagree with criminalizing mistakes; even ones such as this.

I'm not arguing that hospitals aren't currently a shitshow, I'm aware I've worked in them. That doesn't excuse this nurse's complete lack of respect for the risks she took.

We cannot prosecute our way out of medical errors, and what you claim is at odds with the opinions of medical professionals.

https://www.nytimes.com/2022/04/15/opinion/radonda-vaught-me...

https://pubmed.ncbi.nlm.nih.gov/25077248/

We do sometimes punish pilots criminaly. For example one easy way to go to prison is trying to fly a plane under the influence of alcohol. (Here is an example [1])

We do not punish criminaly pilots for other kind of mistakes. For example you are unlikely to go to prison if you miscalculate the required fuel for a flight.

I don’t know the details about the nurse. Was it more like the first or more like the second?

1: https://www.bbc.co.uk/news/world-us-canada-39485928.amp

I'm not sure what world you live in, but I'd like to live in the one where criminal negligence resulting in avoidable death is prosecuted.

edit: minor grammar fix

The hospital has far too many incentives to play fast and loose and then leave the nurses in the lurch with a system stacked against them. The hospital has far too many incentives to skimp on training and safety. etc.

Should this nurse also have her license looked into? Yeah, it looks like it. And is it up to the hospital to fire her or not? Yes.

However, barring actual proof of premeditation, all charges and fines should land on the hospital--not the nurse.

With staff shortages nurses dont have the time for that.

Hire 2x more nurses - so there is 2x more time for each patient.

No, very different from every other med in the drawer. The red cap on the vial is very unusual (reserved for very dangerous meds like this), and the bold printed warning on the top (that you have to look at at least twice while while preparing to administer this medication) is also something used very rarely.

Edit: I should say that doesn’t mean I think it makes any sense the hospital isn’t liable and jail time for the nurse seems odd

Welcome to being an engineer, if that's what you want to call yourself. The engineer who approves a bridge design can be held liable if it collapses due to a design fault.

Another aspect is that certain HIPAA allowances for data usage require a lawyer's expertise, not an engineer's. For example, can a health insurer use patient data to train a model w/o first obtaining patient consent? If the model will be used for "healthcare operations" (i.e., adjudicating claims), you might argue that the answer is yes. If the same model will be used for suggesting treatment options to doctors, you might argue that the answer is no. If you answer wrongly, you are hit with a statutory fine.

It's like having a fine for painting the bridge the wrong color because there is a law that bridges must be green, but you used lime. Not because you're worried about the bridge collapsing, but because the law says so.

Generally, civil engineers don't need to worry about fines or jail as long as things stay up.

Basically, contracts can control the liability in most cases, but HIPPA prevents that by explicitly defining liability under the statute.

Here's some info on the engineer portion.

https://www.nspe.org/resources/professional-liability/liabil...

*HIPAA

* Vaught stated her department was not understaffed, nor was she tired. The incident also occurred in 2017, so pre-pandemic

* Vaught went to dispense Versed (generic name midazolam) by the brand name, instead of the generic name as they're trained to do. This led to her selecting vercuronium bromide instead

* Vaught stated she had dispensed midazolam several times before, which would have had to have been by the generic name

* Vaught ignored several warnings from the dispensing machine stating the patient was not prescribed vercuronium bromide

* Vaught ignored the red cap on the vial dispensed that stated it was a paralytic agent

* Vaught ignored that vercuronium bromide needed to be reconstituted with sterile water (unlike midazolam, which comes as a liquid). She stated she thought it was odd that she didn't have to reconstitute it before when dispensing the correct medicine

* Vaught did not scan in the medication before or after giving it to the patient, which would have likely prompted another warning about it not being prescribed

* Vaught could not recall exactly how much she gave to the patient

* Vaught immediately left the room after injection, and did not wait to observe the patient for any side-effects

All of this information is available in the DA discovery documents (https://www.documentcloud.org/documents/6785652-RaDonda-Vaug...) and the CMS report (https://www.documentcloud.org/documents/5346023-CMS-Report.h...).

The opinions on the case I've observed have been nurses who aren't aware of this and saying she should not have been convicted, and the nurses who are aware who think the conviction is fair ...ish. The latter is at least unanimous she should have her license revoked.

Most agree that Vanderbilt should be held responsible for negligence as well. My wife's hospital for instance does not stock _any_ paralytics within machines, to prevent it being accidentally dispensed without involving the pharmacy. There's also evidence that Vanderbilt tried to cover the incident up.

I've made a point of stressing to any RN I've talked about it with the importance of having a lawyer with you when talking with investigators. Vaught straight up incriminated herself multiple times during her initial interview.

[1]https://www.npr.org/sections/health-shots/2022/03/24/1088397...

And of course, a lot of nurses are in the job for the human connection, and will consequently be burned out at an increasing rate.

To some degree this might actually be good long term, because it will be that much harder for hospitals to manipulate nurses into working around the limitations of the system to provide real care, which allows the administration to turn a blind eye to their own flaws. There's going to be a surge of malicious compliance that ends up shining a bright spotlight on just how abusive and dysfunctional hospital systems really are.

And patients will ultimately be the ones who suffer.

The nurse in that case was prosecuted for criminal reckless homicide (not malpractice, which is civil negligence.) The characterization of the hospitals direct responsibility is negligence not arising to criminal (gross) negligence (as the principal of respondeat superior doesn't apply in criminal law, the employees recklessness would not be imputed to the employer the way it would in a civil case.)

As for civil liability if the hospital, that was settled out of court with the victims family, the hospital did not get off scot free.

This... isn't a new thing that deserves the “now” label like it is a change. Criminal wrongdoing by employees (including in healthcare) very often does not rise to a level of criminality for the employer, and that's been true for a long time.

>This... isn't a new thing that deserves the “now” label like it is a change. Criminal wrongdoing by employees (including in healthcare) very often does not rise to a level of criminality for the employer, and that's been true for a long time.

Of course criminal charges for a patient death cannot be administered on an entity like an entire hospital, I didn't mean to insinuate that. But those who share responsibility for her actions: the administrators, doctors, morticians, everyone involved in designing the processes which led to this disaster and being involved in covering it up (i.e. the "hospital"), all seem at least partially liable if we are looking at this mistake through a criminal lens. Would you agree?

Some studies say that medical error is the third leading cause of death in the US [1] - yet how often do we see "criminal reckless homicide" brought against nurses? There was an incredibly disingenuous serious of mistakes that had to happen for this nurse to mess up so badly, don't get me wrong. But when nurses are working 50-70 hours a week doing 14 hour shifts under extremely high pressure from management, these insane strings of mistakes are simply going to be an occurrence, and we shouldn't be using our tax dollars to pay for shitty lawyers to go after them for these mistakes. It's a waste of everybody's time, energy, and money, is detrimental to patients, and is a contributor to the fact that 90% of nurses are considering leaving the profession.

[1]https://news.yale.edu/2020/01/28/estimates-preventable-hospi...

https://www.npr.org/sections/health-shots/2022/03/25/1088902...

Strange to see that HN, which is generally suspicious of copaganda, falls for very transparent nursepaganda.

Absolutely. To each according to their authority.

RaDonda Vaught made a mistake, and admitted it, repeatedly, in multiple interviews.

But that mistake was only partly because of her free will. Vanderbilt University Medical Center incentivized her to make that choice, for their own profit, and with control over her employment.

RaDonda Vaught goes to prison.

VUMC pays a fine and nobody goes to prison.

I think HN takes a dim view of a company holding someone's contract in their hands, saying "Do something illegal or I tear this up," and then blaming the employee when everything explodes.

They're playing chicken with patients' lives, and passing off the charges to their employees when they lose.

When you have millions of drugs being issued, there will be some legitimate mistakes happening -- some will even cause death. If you want people to actual work in healthcare, they shouldn't be fearing for their lives for being less than perfect.

From what I've seen there's been a lot of reporting on her case, and how Vandy rightfully deserves a lot of pain, and a lot on how a subset of nurses feel she's been railroaded, but I've not seen what you claim and would like to know where I missed it.

I'll also re note that pharmacists have carried this burden for over a hundred years, and their removal from the process is part of how this chain of mistakes happened to begin with.

From the article:

"pursued penalties and criminal charges only against the nurse and not the hospital itself...Vanderbilt received no punishment for the fatal drug error...appears to support defense arguments that Vaught's fatal error was made possible by systemic failures at Vanderbilt."

That certainly seems to lay claim that there are more issues than the single nurse. Holding others accountable doesn't negate her culpability but it would prevent her from becoming a scapegoat.

From the article:

> Janie Harvey Garner, the founder of Show Me Your Stethoscope, a nursing group on Facebook with more than 600,000 members, worries the conviction will have a chilling effect on nurses disclosing their own errors or near errors, which could have a detrimental effect on the quality of patient care.

> "Health care just changed forever," she said after the verdict. "You can no longer trust people to tell the truth because they will be incriminating themselves."

That's the exact opposite of how the NTSB operates. It satisfies the infantile urge to blame and shame a supposed evildoer, to the great detriment of everybody in the long run.

Bingo! I have a friend in the UK who organizes "post-mortem" (no pun intended) workshops and process training for hospital staff, precisely to do the NTSB-like thing after medical procedure errors occur. Rather than trying to point fingers and identify scapegoats, the central question is: "what went wrong here, and how do we reduce the chances of that happening again?"

Of course, occasionally the answer might be "We hired the wrong person, and we should fire them", but that seems to be only very rarely true.

> The objectives of a well-run M&M conference are to identify adverse outcomes associated with medical error, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications. Conferences are non-punitive and focus on the goal of improved patient care.

0: https://en.wikipedia.org/wiki/Morbidity_and_mortality_confer...

When failures happen, it's usually the organization rather than the individual that's key to changing.

Do you believe that people who vote for "tough on crime" prosecutors are seeking harsh punishment of mistakes?

Or do they want criminals acting in malice to have the book thrown at them so other people aren't needless victims?

Only a small subset of prosecutors elected in the most liberal districts are rewarded by their constituencies for exercising prosecutorial discretion. I say that without making any judgment as to whether they're using that discretion well — I'm just observing that very few prosecutors work that way.

Well, I think your position is probably one of ignorance. Plenty of people I talk to are for tough prosecution on things like violent crime and against tough prosecution for simple drug possession.

> Only a small subset of prosecutors elected in the most liberal districts are rewarded by their constituencies for exercising prosecutorial discretion. I say that without making any judgment as to whether they're using that discretion well — I'm just observing that very few prosecutors work that way.

Yes, that does seem to be a trend. Prosecutorial discretion is actually important, but it doesn't mean you let crime run rampant, either.

I don't live in a jurisdiction that elect prosecutors, but is this actually a thing? Do candidates/incumbents run campaign ads on their conviction rate? Are voters researching/talking about the conviction rate of the candidates like it's a pissing contest?

https://theintercept.com/2019/02/07/kamala-harris-san-franci...

> If the conviction rate had been measured by actual cases pursued, rather than all cases referred by police, Hallinan said, his office would have had a conviction rate that was relatively similar to Los Angeles and other major cities.

> And Hallinan was getting results. Overall, crime rates were plummeting. Violent crime had gone down close to 60 percent in San Francisco since Hallinan took office.

> Still, the low conviction rate resulted in headline after headline about San Francisco’s permissive attitude toward crime, a media environment harnessed by the Harris campaign.

This was driven purely by the state prosecutor.

We don't allow plaintiffs to sue without standing. Why do we allow DAs to prosecute without a victim?

The state has a justification to pursue crime, but it seems like that should be limited when there's (no victim) or (victim who disagrees with prosecution).

In reality, the justice system is imperfect, inequal access to defense, imperfect identification of killers, etc.

All murder is bad.

But I'd certainly say murdering a good person is worse than murdering a bad one. And if a family, who on average has more incentive to think well of the victim than anyone, doesn't... should that be ignored?

And furthermore, perversely-incentivized blindness. Get a high conviction rate, by throwing the book at people charged with "PR bad" crimes, regardless of the individual, and as long as they aren't politically connected and potentially useful in your future political career.

Compared to that motivation of your average DA / USA, "How surviving family feels" doesn't seem worse.

Not sure that that is a good idea, justice is about more than just those immediately affected by a crime

If you are responsible for the death of another person due to your own negligence then you should be prosecuted for a crime and be removed from any scenario where you are able to repeat that mistake.

Furthermore, the nurse is in a profession where people die all the time due to reasons beyond the nurse's control, and surviving relatives are not always rational in who they blame. So nurses will be falsely accused much more often than police.

This was found to be by recklessness, which is beyond negligence but short of malice.

> We use the word "accident", but it's never really an accident.

Acts due to negligence, and even recklessness, really are accidents.

> Furthermore, the nurse is in a profession where people die all the time due to reasons beyond the nurse's control, and surviving relatives are not always rational in who they blame.

Surviving relatives don't make prosecutorial decisions, nor are they triers of fact in criminal cases.

> So nurses will be falsely accused much more often than police.

That...doesn't follow from what you’ve described, even taking everything preceding it as true.

I'm not sure this is true, specifically because the difference between a nonviolent traffic stop and a lethal (to the officer) traffic stop can be a split second.

If my keyboard had a 0.01% chance of lethally shocking me... I'm pretty sure that would alter my typing behavior.

The biggest cause for police death are traffic accidents.

Negligence means "failure to take proper care in doing something", which is often just called an accident.

That is exactly what the nurse did, she failed to take proper care and someone died. The nice thing about the law is that what the relatives feel should not matter at all, that's why we are supposed to have impartial prosecutors that review the facts and determine if charges are warranted.

Bottom line, no matter the profession if you fail to take proper care and someone dies as a result, you should be prosecuted and prevented from getting the opportunity to do it again.

This is not true, because you're equivocating on the word "proper". An accident is failure to take proper care, where proper care means "care that follows the rules". Negligence is failure to take proper care, where "proper" means "can reasonably be expected". They are not the same thing.

There's no way to get a certification with online learning or with any kind of in person time schedule compatible with my job... ok... maybe I can get time off? I have to re-get all sorts of immunizations I already have and re-do medical checks that I already had to get for my green card, like a year ago... ok... that's a lot more time off. Oh, they drug check me! well... I guess even I would work on healthcare more for vocational reasons I'm not doing it while I'm in California. It's just too much of a hassle and with the staff shortages I feel I'm just being taken advantage off.

In Nevada it's only take the course, pass the exam and you can already go on an ambulance, so are most other states.

> This one is big for product designers. Often we listen to the people who pay for it and miss out on the people who actually have to use it.

This resonates with me strongly for two reasons. First my mother is a retired RN, and the electronic record keeping was her biggest frustration. It is hilarious to me how much my mother hates computers, while I make a living in software.

Second, I'm now working for a startup, Smarter Dx (we're hiring: https://angel.co/company/smarterdx/jobs ) that works with these records and tries to make better use of them. To the extent that we're successful, incentives are created for the hospital to improve them, conceivably including improving the UX that nurses see. I don't mean to underestimate the difficulty of the problem, but I think it's possible to at least push in the right direction.

20 minutes later (while my mom was well on her way into work) the phone rang again- it was a false alarm, she didn't need to come in anymore. Naturally, it was my (not so happy) dad who answered.

By the time she got in, they didn't have anything for her, so sent her back home.

At the time, there wasn't quite such a crunch in nursing, so the pay part wasn't accurate yet, but everything else you listed (substitute COVID for %50+ of patients) was already true 30 years ago.

This is just abusing the nurse to save a buck.

You couldn't be more right about that. Last week a nurse had to use a computer in my wife's hospital room to log that she'd given her a painkiller. The IT staff had failed to configure the hospital computers to disable windows updates or restrict them to off-hours and the nurse was forced to stand there for ten solid minutes while Update churned, the pc restarted, and Update churned some more.

I'd add to #1 that travel (temp) nurses are making 4x+ more than staff nurses, I've heard as high as $13-17k per week in high-demand areas. This exacerbates the problem, as staff nurses hear this, and if they can, they leave. Travel nurses can be great, but they won't know the facility and workflows and people as well as staff nurses: staff nurses now pick up more slack, all while getting paid 1/10th what their new colleagues are. This is more than most doctors.

For #3, this problem is made worse by additional compliance burden. Nurses need to document more and more, click more and more, read more and more… with less and less time. And on systems that are unpleasant to use. Among other issues, this leads to problems like these[0], which drive more and more nurses away.

I'm working with a badass team on solving some parts of these problems, particularly relating to technology and workflows. If you're interested (across basically any role, but product designers, engineers, product managers are top of mind right now), let me know (email in bio)!

[0]: https://www.cbsnews.com/news/radonda-vaught-nurse-guilty-dea...

I can speak to this a bit. After interviewing lots of hospital workers, I can tell you that the hospital quality people love EHRs because the reporting functions actually work. Previously, it was not possible to measure how well the hospital was doing and convince the doctors to improve practices - think washing hands before doing examinations.

EHRs are shitty because (1) the big players are entrenched - they are already implemented and the cost / disruption to switch to a new EHR is extremely high, and (2) the market isn’t big enough to justify the level of investment it will take to break through - Apple made more money from one product (AirPods) last year than all the EHR vendors combined.

At this point my hope is that mobile devices and meta-EHRs are able to crack this.

Part of EHR's problems are definitely that the market is only one single country, the United States.

The nurses aides would argue that they do the majority of the frontline work while getting paid a fraction of what the nurses make, and get even less credit.

I think non-performance-based pay is something endemic to many female-dominated professions. My wife used to work in childcare, and it did her head in that she was paid less than complete idiots who'd been working there longer than she had.

- There is a ladder of nursing credentials, and the shortage effects them differently. Hiring for roles like CNA and LPN/LVN has exploded because of the shortage of RNs and above. CNAs get trained in 4-12 weeks to do the heavy lifting of care; RNs get ~3 year degrees to perform much more complicated tasks.

- Burnout, and the nursing shortage, are in a positive feedback loop/downward spiral. That is, the more nurses burn out, the more they cause other nurses to burn out. Short-staffed facilities have a very hard time pulling back to normal staffing, because nobody wants to join a skeleton crew. (I know of long-term care facilities where the scheduling nurses (the bosses) are working the graveyard shift because they can't fill it.)

- Many nurses work rigid schedules on 12-14 shifts, and a lot of medical errors happen at the end of those shifts. *

- The hot US job market (Great resignation, great reshuffle) is hitting nursing especially hard; it is very sensitive to external shocks. There are paths to easier work and higher pay.

- Many healthcare facilities and systems don't give nurses flexibility or the possibility of advancement. (One family member will need to quit her current job and come back in a year or two to her current employer if she wants to move up a pay grade -- which is like some tech companies -- but slower moving and lower paying.)

- Many facilities are run entirely on foreign staff (the H2-B visa allows that). And many nurses are imported from the Philippines.

* https://clipboardhealth.com

* https://www.nursing.upenn.edu/nhhc/workforce-issues/where-di...

* https://www.nytimes.com/video/opinion/100000008158650/covid-...

(plug: if you're interested in this problem, we're hiring: https://culture.clipboardhealth.com)

I'm curious what the consequences of this are, how does this impact the profession in the US?

(2) is a really perverse statistical phenomenon, and it's unfortunate that nurses are bearing the brunt of our civic and public information failures. It must be particularly soul-draining to heal someone who resents the single thing that would have protected them the most from needing hospitalization in the first place.

Pedantic, but: I think it's the responsibility of the people that pay for it to talk to the people who use it, and buy the best software.

I have a hard time believing that you can sit a bunch of nurses in a room to talk about the software, and that they'd design and/or elaborate on an awesome UX. Is there an example of that ever working? People have funny ideas about what they want. Homer Simpson's car design is a meme for a reason.

Maybe, but nurses have also used "because covid" as an excuse to engage in some pretty awful behavior. Fathers have only very recently been allowed in the room during ultrasounds, for instance. NICUs only recently started allowing both parents to visit at the same time.

It sounds like the issues nurses face are global and do not significantly change across different systems (the system in my country is completely different from USA)

It probably comes down to the fact that this is a human problem and to solve it we must radically change the expectations around care and primarily being taken care of.

There's no technological deus ex machina or amount of training that can change the situation without shifting the POV.

IMO people working in HC are subject to a lot of stress and must be protected at the cost of making it a bit unpleasant for the patients to be cured.

It's such a fundamental foundation of our lives that the system should be calibrated to create the best possible working environment for those who are working instead of moving it toward a customer reviewd activity that focuses on their satisfaction.

I know it can sound unpopular, but receiving the best medical care possible is not a right, it's a goal that more often than not it's almost impossible to achieve, so let's improve the working conditions so that the workers can give their best without questioning too much all the sacrifices that the job requires.

What I've seen in the past 30 years is a gradual shift towards becoming some sort of wellness centers for disease: patients that complain about other patients, patients that complain about their accomodations, patients that complain about therapies, most of all patients relatives that want to have a say on everything that's going on up to the point that doctors simply do what asked to not waste too much time with them.

And to add insult to injury, all the legalities that made taking a decision virtually impossible without risking too much.

Of course there are situations were malpractice causes more damages than the illness itself and those must be reprimanded, we can't afford to disrupt trust in medicine in any way, but the results should be taken into higher consideration than the opinions.

ER, intensive care and other kinds of "hardcore" department should also be judged differently, just like it happens to military personnel who are not subject to regular justice while on duty.

If you know ANYTHING about finance, that should send shivers up your back and also make you realize why this happening with nursing.

Private Equity is where you go to get money if:

• Your business is floundering and no one will loan to you

• Your industry is in the ebbing phase and not growing

• You are ignorant or naive about getting money for business

• You haven't done your due diligence

• Your company is in play for a hostile take-over

Having Private Equity getting involved is always a major Red Flag if not Black Flag.

In general, Private Equity knows nothing about your business norms or markets - they don't care. They are a one-size-fits-all investor and that primarily means "Cut Costs on Everything".

It's very akin to having a lawyer become your CEO (e.g. Sears/Kmart) - it's a omen of VERY BAD things being imminent.

A case in point: the COVID bounties from Medicare for testing, admissions, treatment AND DEATH BY COVID are exactly something that Private Equity would love maximally, dream up and probably try to enact with lobbyists.

This was exactly my experience when I worked for a medical software startup. Our (very unfinished) software got deployed in a hospital with no training, no orientation, no nothing, and it was such a disaster that it was a patient safety issue. Mind you, the engineering team had no say in any of this, not that we were even given the chance, and we weren't even aware that the deployment was for real. We were under the impression that the deployment was for testing purposes, because we were aware that the software was unfinished.

It was a breathtakingly poor decision purely on the part of managers (and, frankly, sales) on both sides of that deal and it was doctors and patients who suffered because of it. An absolute nightmare all around and I'm glad to no longer be there.

This!! I had a friend who retired early because she was literally being worked to death. A big part of that is the hours she spent after hours trying to deal with the new IT system.

Anyway, it's nice to make software like that :-)

>This one is big for product designers. Often we listen to the people who pay for it and miss out on the people who actually have to use it.

Thats an interesting comment because I know the main developer for one of the most popular hospital systems used throughout Europe and its popular because its good.

Saying that, I also know there are medical consultants at a world famous hospital who dont really know how to program but because of their position have got their software in use when it perhaps shouldnt be.

I know alot of US programmers doing various medical systems for local hospitals and health care regions with various standards of programming skills.

Like you I also know of people in various roles, from world famous multi millionaire consultants to nurses on the front line. Every team & dept is different. Sometimes its a managerial problem at the top of the health trust, other times its just the team and low level management.

Saying that there is a culture of taking a sicky probably because they see consultants putting private work before NHS work and they see the wages some of these consultants get paid and Google Scholar, PubMed, DrugBank etc keeps highlighting the inadequacies of the teaching, ie they dont keep up to date, some areas appear to be decades behind the science other areas are within a few years of the latest research.

Too much reliance on drug companies when superior non patentable solutions already exist.

Interesting thread because this is my current $dayjob! I work for an organization that is both a tech company, and a medical services provider, so we can optimize away the boundary between vendor and customer as far as the software is concerned. My particular area of interest is in providing system programmability that can be exploited by tech-capable clinicians to provide both better patient outcomes and more pleasant provider experience. Basically don't try to have software developers understand every last detail of the practice of medicine. Instead provide a programable platform that's usable by a subset of clinicians.

Ultimately, it is not the radiologists or technologists who make this decision. From a purely technical point of view, modern systems hardly differ from each other, at least as far as diagnosis is concerned. The fact that a better UX means new users need less training and the time between scan and diagnosis is reduced are hardly taken into account when making a purchase decision.

Every time the computers went down at a friends ER, the waiting room emptied out as the staff were able to use paper forms and just get their jobs done, instead of being forced through thousands of menu clicks and choices that made no sense.

EVERY SINGLE TIME -- Epic or as I call it... the Epic Failure. I always give my condolences to staff forced to use it.

No idea where you live but in German hospitals I've never been given the food by anyone but a nurse. There are literally zero people/professions besides doctors, nurses, and cleaning staff near patient rooms.

I worked at a large emr company and the developers had access to nurses and were required to support go lives a few times a year to support nurses on the floor.

This is a very common issue with enterprise systems, since incentives aren't aligned. Users of such systems aren't the ones choosing them.

I wonder if you are talking about Eclipse software which seems to be universally frustrating for doctors and nurses across many countries.

Is it mainly lack of information (and exhaustion) that prevents these more experienced nurses from negotiating for what they're worth?

My mom worked in food service for several years at a hospital and took the food into the rooms. Is this not the norm?

For profit healthcare is an abomination and a blight on the very soul of this country. If I believed in religion I would say God will judge us very harshly for allowing this system to stay in place for so long.

Working in Healthcare IT I can only concur on this point.

For me there's multiple reasons behind this issue :

1. Regulations. First and foremost, IT is here to help/force users in complying to those regulations. So it's the first thing that dictates how you'll develop the piece of software. Those regulations are mostly written by people that aren't Healthcare professionals nor IT professionals. They are regulations people. So they can't produce something that makes sense for Healthcare people and is even harder to _solve_ for IT people. And those regulations are updated quite frequently, most often creating breaking changes. So if you want to keep up (and you have to if you don't want people ending in jail) you must work fast, meaning skipping important steps to produce something user oriented.

2. There isn't much money. At least on my side of the Atlantic. This is not necessarily a huge problem because contrary to people at FAANG-like companies, here most people are focused on helping people to help other people, not on their paycheck. But there's so much middle-men taking their cut that in the end, you only worked understaffed with unrealistic schedules. Meaning the only way to deliver something is to take big shortcuts. And again, leaving UX/UI on the side of the road to reach the main goal : being compliant with regulations. And when I say there isn't much money, it's partially true. When it's about buying a nice startup, there is heaps of cash. Because you need to keep the market as closed as possible. But when it's time to actually invest in making better software, the wallet is empty.

3. There's a weird mindset where in most cases, end-users are simply not considered. At my previous jobs, I always asked to sit with actual users of the software to see how they work and what their actual requirements are. Since I joined Healthcare IT, on the ~20 projects I worked on, there's only one case where I was authorized to do so. On all the other cases, the "IT Project Manager" (whatever this is) just said that they knew exactly what the users needed, even though they never actually worked with them. And on the project I was allowed to work correctly, instead of the original proposal that was agreed on, based on my observations, I came up with a solution that was much simpler for the users, easier to build for the IT team, so delivered faster and at a lower cost. So the customer was happy and decided to sign a contract for another piece of software at the company. Everyone happy in the end. But it's an exception. In the other domains I worked on, it seems obvious to everyone that gathering intel from the actual users was mandatory to produce something valuable. Here, management think they know better. They don't.

And honestly I don't see how it can improve since those three points keep getting worse and worse every half-year.

Mean customers, and rude coworkers? I sympathize, but this is a reality in a lot of industries. I have no reason to believe that healthcare here is worse than average.

Healthcare workers are not slaves they can quit after all.

And in my experience it is not even about the money most of the time but more the work pressure and conditions.

The example stories they have shared are the type of thing I can't relate to and I've worked in software, general engineering, food service, construction, and tech support (I answered calls for 3 years).

She's been punched in the face by a patient, she's had coworkers who sabotage each other due to personal vendettas, she's had bosses go on racist tirades in meetings, and on and on and on. As I remind my wife whenever she has a particularly awful day, there's a reason why the classic NP-hard CS problem is literally named the Nurse Scheduling Problem[1]. And yes, she's considering a career change.

[1] https://en.wikipedia.org/wiki/Nurse_scheduling_problem

Grouping these people as conspiratorial is unfair and seems politically motivated. While you definitely have some overlap with conspiratorial people, people have a right to be skeptical of medical care, which is often incorrect and potentially life threatening. Being able to explain things concisely and with evidence is a core skill for a nurse, much like being able to explain to someone why their technical decisions are setting them up for failure is a core skill for a software architect.

But from talking to nurses, this isn't the drive for negative workplace satisfaction. Patients who are hospitalized are less likely to be mentally stable: many pathways to hospitalization come from extremely poor decision making, and many of these people are repeatedly hospitalized. Combine this with the fact that it's a very physical job, primarily handled by women, and you have a multi-faceted problem that's not as easy to solve as just giving people right-think.

Personally I think the pathway to fixing this is appropriately valuing nursing care, what is often a highly-skilled profession with large physical, legal, and downstream risk, and compensating people appropriately. While nursing is a disproportionately paid job relative to educational requirements, current compensation really doesn't accurately account for just how demanding a job it is.

The amount of nurses you see who become addicted to painkillers, benzos, etc., is truly sad. Much like teaching, it's an area where I feel that society is inaccurately evaluating what the overall impact could be if the role functioned well.

All jobs suck donkey dick, but jobs directly dealing with sick and dying people are on a different level.

There's a culture problem there.

Mistreatment by doctors and management isn't excused by that, but I think it can be seen (partially) through that lens.

I think a computer guided system would help. My experience in lower grades, high school, college and grad school is that there is a consistent lack of showing students the concept of self-study, this is exemplified with the famous self studiers AKA autodidacts, like Newton as a prime example. This skill is a very important one to develop early in children. Sort of give a person a fish a day - or teach him how to fish. Online teaching at all levels up to and perhaps including grad school is well suited to complex programs that show a student a module of this or that. This can be history or mechanics. After the module is presented, the student is queried on the facts of the lesson and then asked what he can deduce from the lesson. Say the 300 against the Persians - why did the Persians fail? The student should then deduce that because the front of battle was only 30 people wide that it was a battle of 30 against 30, and better training, armor, skill and weapons that meant the Persian masses were useless - it was an attritive war of 30:30 until one side lost enough men that it became 30:29, 30:28....30:1 = war over. Some students have greater intelligence and will analyze this aspect correctly. Those that do not are sent to the first fork..... and on to the full analysis. In this case, the Greek better arms/skills may well have endured until the entire 300,000 Persians were killed, via re-supply from various Greek city-states - in this case, the Persians did an end run and were able to change the combat ratio to the point where the Greeks were overwhelmed.

Going to the general case:- The auto-didactic skill of the student needs to be developed one-on-one via the skillful design of the course material, with forks and subforks and re-entrant forks into the stream as each student masters an item and proceeds. At every point there should be a fork for every fail point - you can have as many forks as needed to imbue understanding. Modern computer systems are quite capable of this degree of complex interaction - but it requires a good amount of work with both masters in topics(many of them to variegate the forks) and up to now I have seen few produced. Large amounts of $$ and time have been spent on thousands of parallel minimalist approaches - it needs a central command/fund structure. /rant...