If I could change one thing about healthcare, it would be how we handle end of life care. Sadly, hospitals are full of 80-90+ year old people who cannot walk or talk for years, advanced dementia plus many other serious comorbidities, with severe malnutrition and recurrent aspiration pneumonia, with large non-healing sacral ulcers, who shit and piss themselves, and the family continues to insist we "do everything" to help this person. It is by far the most demoralizing part of working in healthcare, in my opinion, and an astronomical amount of expenditure and effort goes into torturing these people - at the direct order of the family - only to prolong suffering a few more months.
I suspect this happens in the UK too, although doctors (in my very limited experience of this) do tell families the truth about what they can do.
I think there is a cultural problem about facing up to death, because people do not talk about it. It is a taboo subject to many, and people use euphemisms a lot (which is always a sign of a topic people do not want to talk about).
We need much better end of life care. Hospices seem to do a great job (no experience from the patient and family end, but I knew someone who used to work in one) but there are not enough of them.
> I think there is a cultural problem about facing up to death
It definitely is culture problem, just look on average police chase in USA followed by a news helicopter. The moment when suspect crashes, news camera will start wildly zooming off and panning away. Why is that? You don't want to see the end of chase, where a guy is getting crushed by momentum of his car, while he could stop and get arrested anytime during the chase? Show the consequences of his actions and tell that if he would not try to run, he would likely be still alive. Arrested, maybe little bit beaten by the cops, but alive.
Until you have to make that decision it’s easy to judge. Even if you think you are doing the right thing for someone that can’t speak for themselves, the guilt can stick with you.
I read a comment on here a while back that highlighted EoL care as the main way The Machine has to sap resources between generations, and it makes a lot more sense when looked at through that lens. I don't see it going away any time soon since its a guaranteed process for every person that moves wealth away from the lower/middle classes into the industry at a grand scale.
How much of that is The Machine, and how much of that is kids & grandkids not wanting grandma to pass away?
For what it's worth, when my grandma was in the hospital with congestive heart failure, the surgeon was very clear with her and with us that "do nothing, and die" was very much an option, and a choice that she and she alone could make.
Often the family dynamic is that the next-of-kin who have the power to make end-of-life decisions hesitate to cut off care even when they know it is pointless or cruel because they're afraid of being criticized by other family members later. Sometimes this extends to vicious backbiting and cutting off contact. I've seen these issues break extended families apart. It takes a strong and confident person to take responsibility in this situation, and then accept the consequences.
That's true. Grandma initially wanted to get no treatment, and boy did we hear about it - the rest of her family convinced her to go ahead and undergo treatment.
I think this was the correct choice, but I have no idea.
On the one hand, she's feeling much better now, and I'm glad she's around, because I like spending time with her.
On the other hand, the recovery was pretty rough, though thankfully she doesn't really remember the truly bad parts. And she's 90 years old, and has repeatedly stated that she doesn't particularly want to go on living.
On the gripping hand, the doctor's description of letting yourself die of congestive heart failure sounded rather unpleasant, and hopefully instead of undergoing that, she'll pass away in her sleep.
On the hands that I'm running out of, maybe an even worse fate awaits.
At least in the US, in general we talk to the family about code status "Do you want your loved one to receive CPR if their heart stops?". We can make them DNR/DNI. Then next discussion would be hospice. They would have a hospital bed sent to their home, be discharged with a weekly nurse visit and doctor available by phone/text, and get minimal medications focused on minimizing suffering.
>Sadly, hospitals are full of 80-90+ year old people who cannot ... and the family continues to insist we "do everything" to help this person.
so what? It is on their dime, not yours. If i'm a 90 years old and wanna drag my existence out it is my choice as long as i'm paying for it, directly or through insurance (and Medicare is an insurance too btw)
It is easy to suggest to terminate lives earlier when it isn't your life. History is full of such attempts.
One should be glad that such a large sector of economy - healthcare - has a great stable demand and a great labor market. Overwork - teach more nurses and doctors. The issue is completely self-inflicted as the labor supply is artificially constrained:
"In 2023, U.S. nursing schools turned away 65,766 qualified applicants from baccalaureate and graduate programs, according to the American Association of Colleges of Nursing (AACN)"
In my experience it is rarely the patient making this choice. Much more often the children, who are often making a big show of how much more they love mom or dad compared to the other sibs.
And the patient made that choice by establishing that family dynamics and by not having specific instructions even while seeing over decades the family dynamics they created themselves. I'd say that is an explicit clear choice. And anyway it isn't outsider's business to tell a family how to care for their own.
Medicare is not insurance. The word "insurance" has a specific meaning, and the traditional Medicare fee-for-service program doesn't meet that definition. (There are a variety of other payers or health plans in the US healthcare system which fill a similar role to insurance but are not actually insurance.)
ok, call it a contract between an individual and society - the individual pays taxes today and when retired gets his/her medical needs taken care about by the society. Looks like an insurance contract to me, btw.
Anyway, like with any contract, whatever the individual is due under that contract is his dime, not the taxpayers'.
It doesn't matter what you're due under a contract if the counterparty is insolvent. Medicare beneficiaries are going to have to accept reduced benefits and higher fees. This is unavoidable due to demographic changes.
the society reneging on its contract today means that the current taxpayers will lose the trust in the society and in particular will be significantly discouraged from paying taxes, etc. as they would lose belief in the society keeping its side of the bargain in the future.
Yes can confirm this is real. I know both German and Dutch nurses who say that the workload is incredibly high. One older nurse also said the pressure today is much higher than years ago.
I am not surprised. Healthcare costs have been rising faster than inflation for several years. It's a difficult sell to increase budgets, so we have to resort to these "invisible" cost cutting measures to try and stay afloat.
Over here in Canada healthcare spending has been rising faster than general inflation more or less continuously since the 1960s. Seems to be generally true of many wealthy countries. More tech and therapies. And an ageing population. And probably other factors.
Another factor is Baumol's cost disease. While some aspects of healthcare have been automated, much of it still comes down to individual clinicians performing procedures on patients.
That does not explain everything. While you could make a reasonable case that doctors are overpaid in the US, the same budgetary crisis is happening all over Europe where salaries are much lower.
The crisis in France is clearly not on the same level that is in Quebec. It's not the only factor, but a serious one. As a continuation of it we have a heavily caped number of doctors what can be 'minted' every year. Same caps exist in the USA states.
Perhaps in the US, but nobody is getting paid that in most public European systems. A quick google suggests that the absolute highest pay band for a doctor in the UK is ~£142k (~$190k USD). And there won't be many making that.
Yeah hospital accounting is weird. I had family in the ER and one of their crappy meals was like $60, for basically just rice and canned vegetables on a tray. A single bandaid cost like $25 or something outrageous like that. This was pre-covid too. I'm sure that same meal is getting close to $100 by now.
Not sure why we would walk into the sea because work doesn't need doing anymore. If you are worried about needing work to put food on the table, I think our best solution is to start with a small UBI that we try to increase as automation increases.
The way I see it, you have three choices, the government, corporations, or billionaires. It's an oversimplification of power in this world today, but those are your choices. Which one of those do you pick to clothe and feed and house you, after the singularity happens?
Another potential alternative is healthy capitalism, where a large number healthcare providers are in competition with each other to provide the best service at the lowest cost. In this model a hospital, for example, would be forbidden to buy another hospital down the road, in the same way a doctor’s office would be forbidden to buy a second doctor’s office, because both cases reduce competition.
No, it would be a mixed economy, where private individuals and businesses provide most of the goods and services, and the government plays a significant role in regulating the market.
Monopolized markets are almost always evidence of regulatory failure.
"Healthy capitalism" isn’t an option distinct from government intervention. Healthy capitalism it is government-regulated capitalism. Any system where competition is protected depends on active, ongoing government enforcement of the rules. Without that, markets naturally tend toward monopoly or oligopoly.
Advocating for "healthy capitalism," is advocating for a system where government sets boundaries and steps in to preserve competition. That places it firmly within the spectrum of government-regulated options, not outside or apart from them.
It's tempting to imagine ideal or the worst versions of each option and then claim, "what I want is none of these." Instead, we should look at whether our preferred scenario is actually possible within the real-world range of choices. In this case, "healthy capitalism" is only possible when government is both the referee and the enforcer, so it's a version of the government option, not a separate path.
Government. 100%. It has issues certainly as every organization created by humans does, but corporations already run almost everything and that's why most everything is on fire. And billionaires are just the dumbasses in charge of the aforementioned corporations.
It's the baby boom. If level of care stays the same then at some point one third of the labour force is projected to have to work in healthcare, it's not possible.
To anyone here open minded enough to give it a shot, I encourage you to read The Real Anthony Fauci, or at least the first chapter. To people who feel resistance: what is the worst that can happen? If you after reading disagree then your brain will soon forget about it anyway so nothing is lost.
You seem to have the causality backwards. Prior to the 1960s, the healthcare system couldn't really do much. Most of the drugs, devices, and procedures were relatively cheap. After that the capabilities increased tremendously as did costs, and then government had to get involved to control costs and ensure patient access. (Although many of those government interventions ultimately had the opposite effect.)
Why did Lasik machines decrease in cost, while increasing in efficacy?
Drugs were far cheaper before the 1962 FDA Amendments, after that was a massive increase in costs. See "Regulation of Pharmaceutical Innovation" by Sam Peltzman.
Before 1962, drugs were already regulated to be safe. 1962 brought about the requirement for effective, which enormously increased drug prices. It's all in the book I referenced.
The reference says what happens with the greatly increased cost to develop a new drug, is the number of new drugs developed dropped dramatically. But the percentage that turned out to be effective stayed the same.
So, yes, we are worse off because of that, because we wind up with far fewer effective drugs.
A proper solution is for the patient, a legal consenting adult, to sign a piece of paper that says he understands that the FDA has not verified the drug to be effective.
Nurses in Spain make 2500-3000 euro a month, in a country where the most common salary is 1250 euro. Are they overworked? Well then they can take a pay cut so we can hire more of them.
Eurostat average full time salary 2022 for Spain is €31k. 2021 average nurse salary €38k.
While mean is not median the stats seem to show much less of a difference than your figures. For comparison in the US median full time wage is $66k while median nurses wages is $86k.
Nursing is a skilled occupation requiring a bachelors degree. Seems good they get paid around average wages for graduates.
Averages as well as you say are useless. You know this, so I don’t know why you bring averages up. I specifically mentioned the most common salary, not the average or the mean, which are completely skewed.
You should also research the salaries of other people who also have a “bachelor’s degree” as you call it. That is, if they get employment and don’t have to emigrate.
Same for doctors, we constrain the number of new doctors trained every year to keep their salaries high. Just like constraining the housing supply to keep housing prices high, greed has corrupted these systems from getting better and now we’re just asking people to die instead.
Which country are you talking about, and who is "we"? In the USA, Congress constrains the number of new doctors trained every year not to keep salaries high but rather to limit Medicare expenses. If Medicare beneficiaries can't get an appointment due to a doctor shortage then no claim will be submitted to CMS. Most of the funding for residency programs comes from Medicare, and every year there are medical students who graduate with the MD but are unable to practice medicine because they don't get matched to a residency program.
At one point the AMA did lobby Congress to limit the number of doctors but they reversed their position on that issue long ago.
At least here in Norway, the doctor associations fights hard against any talk about reducing the ridiculously long shifts that nets the doctors large paychecks.
They'd much rather have 1-2 doctors do the work of 3-4, so they can cash in.
Though there is a change of guard happening. Younger people, including doctors, value work-life balance much more and are less inclined to work long hours for more cash.
"Nurses should be at the very top of our social hierarchy but we live in a world where it’s just the opposite," she says. "This film is a love letter to the profession."
I moved furniture for 3 years in the early 2000s to support my shareware business. Something like 500 moves, sometimes 9+ hours per day, occasionally 6 days per week. It made me who I am today, but also broke me in countless ways.
I witnessed single mothers giving us $20 tips each (around $40 today) while wealthy people didn't even offer us water. I saw the best and worst of the human condition, sexist pay policies, how workers are exploited by not being provided a schedule for the next few days so they have to call in each morning, how truck fuel costs more than workers' pay, how Right to Work states allow businesses to throw employees away on a whim, how tax brackets at the bottom create the impression that any additional pay gets skimmed by the man, among a great many other injustices, and how all of those conspire to keep the working class down so that a handful of individuals can become fabulously wealthy.
With every improvement in tech, I see the gulf widening. We can talk about how poor people now have cell phones and flatscreen TVs, while conveniently ignoring how people with a net worth over $10 million who couldn't spend that money in a lifetime are now buying politicians to shred the social safety net, among other dubious endeavors.
I say with complete confidence that the arrival of AGI will bring about ultimate wealth inequality. I foresee a world where 10 billion people work performatively to survive long after robots can do the work better, while less than 1 million people live like gods, free even of senescence. Assuming that we stay on this timeline and don't shift to a more equitable one.
I went into computers in the late 1980s to eventually build an android like Data. I didn't know that Turing test-passing AI would arrive 20 years early, or that I would spend the first quarter of the 21st century hustling to make rent due to unfortunate geopolitical realities driven by unmitigated greed and regulatory capture.
Now I'm not so sure that I even want to stay in tech anymore. It has been anything but kind to me. Every time I level up, so does the world, and expectations upon me just grow for the same pay. My people-pleasing has cost me my health on a number of fronts. I know that someday, I'll have to choose computers or my life.
After all of that, one might think that I'm all doom and gloom. But I'm not. I've come to treasure my time at the warehouse as a teaching tool after a great deal of shadow work. I admire my foreman for being the provider that I can only hope to be someday. I look in awe upon the borderline homeless vets, deadbeat dads and ex-cons who showed me what it is to give without expectation of reward. I see them in all of us, even the people I disagree with, and that gives me hope that maybe we can come together and avoid the iceberg that's about to sink this ship.
I'm reminded of this scene from Jaws which always stuck with me:
I see a world divided into two camps: one that does much for little, and one that does little for much.
It makes me wonder where we all sit in relation to this. What kind of impact we could have on the future, and how that might help everyone to self-actualize.
I don't pretend to have the answers. Some of my best years happened when things were at their worst, and vice versa.
But I do know that everything is upside-down right now, and always has been, since the dawn of civilization. I feel that tech won't really be tech until it addresses and undoes that injustice.
That's why I write this malarky when I should be working. For all the other working people who don't have time to say what needs to be said.
Although I am younger than you, I feel somewhat similar. The never ending treadmill of technology seemingly makes things worse rather than better. I’m working in robotics, and I think is this actually the right thing to be doing? - but if I dont, then I wont eat and afford my future.
Really feels like society is burning the candle at both ends.
Try to avoid a grizzly end of life. Go to the gym, and if/when you get some form of cancer or some other degenerative disease, think about how ending things well is important.
The person with the yacht, obviously. They have the money to fund making many more movies and marketing pushes about how awesome they are for reducing waste and controlling labor costs.
Every time I've been in the hospital
- unfortunately too many times -it's the nurses I see and who do the work,
with the occasional lab tech visiting to do a test or draw blood.
The doctors show up once a day,
doing their rounds.
Don't get me wrong,
I've had some wonderful doctors,
hospital patient visits are only part of the work doctors do.
I remember the good nurses,
the patient nurses who understood why I'd be grouchy,
even angry at times,
and would sit down and talk to me.
I remember the young new nurses,
sometimes struggling with an IV placement but persevering to get the skill they know they need.
Most importantly I remember how every time I'd wake from general anesthesia,
the first face I saw was a nurse letting me know where I was and what's happening.
I have thought that we should make entering the medical professions much easier. In order to become a nurse, you usually need a 4 year degree. This has two issues:
1. This is way to much time in the classroom. Much of that coursework simply isn't necessary.
2. You have people that would be good nurses piking other programs because they can't get passing marks in classes that are irrelevant to day to day nursing.
Binding what are essentially professional programs to the academy is a mistake. Don't get me wrong, I love the academy. But we need nurses.
At least in the US, nursing does not require a 4 year degree. You can become an RN with an associates degree. A 2 year nursing degree has one of the highest returns on investment of any training program (especially if you go to community college). Ivy Tech CC in Indiana and WGU both have nursing programs with great returns. Keep in mind, nursing is not an easy path and has a super high burnout rate. It's a tough and demanding job.
Other professions with a great return on training are HVAC, electrician, plumber, robotics/logic systems (CAM, conveyors, etc.). These are especially high paying if you focus on commercial and industrial.
A lot of people are surprised to learn the the average wage for both plumbers and electricians is ~30 bucks an hour, then that’s in exchange for body breaking work. A small subset earn more, but it’s not the norm.
Industrial electrician around here start at 30 - 35 for 2 years as a trainee then go to 40. That's top 10% income for low cost of living area. It's not unusual to hit 100k with no school debt at a young age.
Industrial automation technician I have worked with makes north of 300k but he is traveling all over the world to do it.
Union electricians and plumbers make good money, and the non-union shops that do commercial work have to pay close to union wages plus some fringes to get enough manpower. I pay $100/hr for a union journeyworker electrician in a metro area of ~3 million, $106
for a foreman, and $112 for a general foreman. Both of those include fringes, the split is about 55/45 or so. The contracts are for three-year terms with raises every year.
Residential construction is a whole different ballgame that I’m unfamiliar with, but I’d imagine that’s where the average gets dragged down.
So are you hoping to be treated by nurses who are worse academically than the ones we have now?
Or are you hoping that "others" will be treated by them while increased supply depresses wages for the good ones that you think will treat you?
Also being a nurse is a very hard job, most people wouldn't last a year as an ER nurse in the US.
Huh? There have been multiple levels of nursing for many decades, probably longer than you've been alive. At the lowest level a CNA or LPN doesn't even need an Associate's Degree.
In the 1980s 55% of registered nurses were working with diploma. It is down to 6% today. Bachelors or greater was 27% and is now over 70% today.
As your link points out, many states are continually raising the bar and many have already moved to a BSN minimum.
I'm probably dating myself, but there was a time when people started working occupational nursing programs while in high school and were licensed a few years later.
We make them take classes like organic chemistry where they have to memorize the reaction of various metal catalysts. Calculus. Physics. These are all two semester classes that are considered hard in undergrad. And yet the nurse will never ever use what they learn in these classes outside them. They aren’t the ones synthesizing the drugs.
CNAs (Certified Nursing Assistants) have low up-front training costs, but don't make a lot of money: an average of $19/hr [1]. So at least some of the less skilled work is being done with economic efficiency.
In the US, it's not worth going into because you have to put in hundreds of hours of clinicals which are unpaid, yet just as useful to the employer as a job. Unpaid internships are illegal, yet these are legal and mandatory.
Cuts down on health costs but also increases life span, so you have the issue with the number of elderly citizens vs number of working citizens who can provide care. That needs to be tackled too somehow.
That definitely increases outcomes and QALY but it only is cost neutral or saves costs if you also more tightly ration low-cost-effectiveness care down the road that ends up usually being near end-of-life, which is where A LOT of current spending is.
This is rational on a broad social level but is very difficult of a change to implement.
I think most of the increase in healthcare costs is coming from elderly people (because people are living longer). So while otherwise a good thing, I'm not sure that will help this particular problem.
This is good to do for its own sake, but on a large scale it does not decrease health care costs: it makes people live longer, but they will still ultimately need the kind of end-of-life care where the majority of health care costs come from. Those costs don't go down for healthier people, and it might even increase health care spending on net if it takes people longer to die.
I know it’s easy to say but you do hear stories of families going to extraordinary lengths for an elderly loved one to give them a couple months of low quality of life. Is it the family trying to feel better or hoping for a miracle, or the patient themselves; I’m sure it’s both, but I can’t help but think if we were more comfortable with death, these really costly situations would go away and suffering would actually be reduced. I know it’s easy say and it sounds like I’m advocating for death, and in a way I am, but we all have to go. If your quality of life is so terrible… I’m also a hypocrite because I think that when it will be my turn or my parents’ and I have to decide, I’ll tell them to do everything possible within their directives.
My answer is more sympathy across the board. People are going to make mistakes. People are going to have a hard time. Both lead to more mistakes. Neither are reasons to give up.
On the money angle, I'm on board with the abundance crowd that I internalize as "be willing to spend money." Especially since most value is generated, and not necessarily discovered.
The narrative is wrong - the wages are low while the working times are exhausting. Half of each trainee's leave each year, while the nurses that can actually endure this shit are going into pension in the next 10 years. And the money is spent on SAP systems who further take time from the already overworked nurses, because they now have to spent a ton of time entering data into a computer with no benefits.
Its not people getting sicker, its mismanagement. Source: Two nurses in family
Yeah, also over here in Finland the amount of money our public sector spends on stuff like Microsoft licenses is insane. Then there's lots of other craziness, like buying a very expensive and totally unsuitable American healthcare management system from Epic, and then spending lots of money on license fees and customizing it for local purposes (the end result also sucks, and is universally hated by healthcare staff).
I'm not sure whether it's a result incompetence, corruption or both, but massive amount of money is wasted on IT solutions that could be implemented more cheaply in-house, or at least by European companies.
The main problem with Healthcare when it comes to costs is that it is to a certain extent labour intensive, is it not? This makes it difficult to reduce costs as wages rise over time.
Make that a discussion with the local politics. In theory at least, everybody will need healthcare in their lives and more so when aging. And we need a plan for that, not to act surprised (the way some leaders act surprised with gas dependency, or with immigration, or with...). Everything can have solutions, if it's not swept under the rug.
There is nothing more irrelevant than addressing large scale social issues in local politics. Besides not once in my life have I seen politics improve anything, politics seems to attract the dumbest and most self righteous types of people, who care about nothing but their self image. My time on earth is limited and much too precious to spent it in the company of politicians or just people invested in politics. No Thanks!
Absolutely. Especially the old think that they deserve unlimited funding, even when they have failed totally at creating the conditions which would make that funding possible and now their costs are spread over an ever declining population of young people.
Modern society is based on a pyramid scheme and the cancer of infinite growth. We will burn this planet to the ground to ensure that certain classes of people never lose.
If I could change one thing about healthcare, it would be how we handle end of life care. Sadly, hospitals are full of 80-90+ year old people who cannot walk or talk for years, advanced dementia plus many other serious comorbidities, with severe malnutrition and recurrent aspiration pneumonia, with large non-healing sacral ulcers, who shit and piss themselves, and the family continues to insist we "do everything" to help this person. It is by far the most demoralizing part of working in healthcare, in my opinion, and an astronomical amount of expenditure and effort goes into torturing these people - at the direct order of the family - only to prolong suffering a few more months.
I suspect this happens in the UK too, although doctors (in my very limited experience of this) do tell families the truth about what they can do.
I think there is a cultural problem about facing up to death, because people do not talk about it. It is a taboo subject to many, and people use euphemisms a lot (which is always a sign of a topic people do not want to talk about).
We need much better end of life care. Hospices seem to do a great job (no experience from the patient and family end, but I knew someone who used to work in one) but there are not enough of them.
> I think there is a cultural problem about facing up to death
It definitely is culture problem, just look on average police chase in USA followed by a news helicopter. The moment when suspect crashes, news camera will start wildly zooming off and panning away. Why is that? You don't want to see the end of chase, where a guy is getting crushed by momentum of his car, while he could stop and get arrested anytime during the chase? Show the consequences of his actions and tell that if he would not try to run, he would likely be still alive. Arrested, maybe little bit beaten by the cops, but alive.
Until you have to make that decision it’s easy to judge. Even if you think you are doing the right thing for someone that can’t speak for themselves, the guilt can stick with you.
I read a comment on here a while back that highlighted EoL care as the main way The Machine has to sap resources between generations, and it makes a lot more sense when looked at through that lens. I don't see it going away any time soon since its a guaranteed process for every person that moves wealth away from the lower/middle classes into the industry at a grand scale.
How much of that is The Machine, and how much of that is kids & grandkids not wanting grandma to pass away?
For what it's worth, when my grandma was in the hospital with congestive heart failure, the surgeon was very clear with her and with us that "do nothing, and die" was very much an option, and a choice that she and she alone could make.
Often the family dynamic is that the next-of-kin who have the power to make end-of-life decisions hesitate to cut off care even when they know it is pointless or cruel because they're afraid of being criticized by other family members later. Sometimes this extends to vicious backbiting and cutting off contact. I've seen these issues break extended families apart. It takes a strong and confident person to take responsibility in this situation, and then accept the consequences.
That's true. Grandma initially wanted to get no treatment, and boy did we hear about it - the rest of her family convinced her to go ahead and undergo treatment.
I think this was the correct choice, but I have no idea.
On the one hand, she's feeling much better now, and I'm glad she's around, because I like spending time with her.
On the other hand, the recovery was pretty rough, though thankfully she doesn't really remember the truly bad parts. And she's 90 years old, and has repeatedly stated that she doesn't particularly want to go on living.
On the gripping hand, the doctor's description of letting yourself die of congestive heart failure sounded rather unpleasant, and hopefully instead of undergoing that, she'll pass away in her sleep.
On the hands that I'm running out of, maybe an even worse fate awaits.
Can't see the future. :/
In most places is it even possible to give these people mercy and opt them out of life if they and/or the family wanted to?
At least in the US, in general we talk to the family about code status "Do you want your loved one to receive CPR if their heart stops?". We can make them DNR/DNI. Then next discussion would be hospice. They would have a hospital bed sent to their home, be discharged with a weekly nurse visit and doctor available by phone/text, and get minimal medications focused on minimizing suffering.
DNR: Do Not Resuscitate DNI: Do No Intubate
>Sadly, hospitals are full of 80-90+ year old people who cannot ... and the family continues to insist we "do everything" to help this person.
so what? It is on their dime, not yours. If i'm a 90 years old and wanna drag my existence out it is my choice as long as i'm paying for it, directly or through insurance (and Medicare is an insurance too btw)
It is easy to suggest to terminate lives earlier when it isn't your life. History is full of such attempts.
One should be glad that such a large sector of economy - healthcare - has a great stable demand and a great labor market. Overwork - teach more nurses and doctors. The issue is completely self-inflicted as the labor supply is artificially constrained:
"In 2023, U.S. nursing schools turned away 65,766 qualified applicants from baccalaureate and graduate programs, according to the American Association of Colleges of Nursing (AACN)"
In my experience it is rarely the patient making this choice. Much more often the children, who are often making a big show of how much more they love mom or dad compared to the other sibs.
And the patient made that choice by establishing that family dynamics and by not having specific instructions even while seeing over decades the family dynamics they created themselves. I'd say that is an explicit clear choice. And anyway it isn't outsider's business to tell a family how to care for their own.
Medicare is not insurance. The word "insurance" has a specific meaning, and the traditional Medicare fee-for-service program doesn't meet that definition. (There are a variety of other payers or health plans in the US healthcare system which fill a similar role to insurance but are not actually insurance.)
ok, call it a contract between an individual and society - the individual pays taxes today and when retired gets his/her medical needs taken care about by the society. Looks like an insurance contract to me, btw.
Anyway, like with any contract, whatever the individual is due under that contract is his dime, not the taxpayers'.
It doesn't matter what you're due under a contract if the counterparty is insolvent. Medicare beneficiaries are going to have to accept reduced benefits and higher fees. This is unavoidable due to demographic changes.
the society reneging on its contract today means that the current taxpayers will lose the trust in the society and in particular will be significantly discouraged from paying taxes, etc. as they would lose belief in the society keeping its side of the bargain in the future.
It doesn't matter whether taxpayers are discouraged. Medicare taxes are automatically deducted by employers for most workers.
> so what? It is on their dime, not yours.
Actually in Europe it is on a dime of a taxpayer so also his.
No, they paid into it their whole life. So, it is their dime not the current taxpayer’s. The taxpayer is paying for their own future.
That's not how state pensions or state healthcare works.
Yes can confirm this is real. I know both German and Dutch nurses who say that the workload is incredibly high. One older nurse also said the pressure today is much higher than years ago.
I am not surprised. Healthcare costs have been rising faster than inflation for several years. It's a difficult sell to increase budgets, so we have to resort to these "invisible" cost cutting measures to try and stay afloat.
> rising faster than inflation for several years
Over here in Canada healthcare spending has been rising faster than general inflation more or less continuously since the 1960s. Seems to be generally true of many wealthy countries. More tech and therapies. And an ageing population. And probably other factors.
https://commons.m.wikimedia.org/wiki/File:Health_care_cost_r...
Another factor is Baumol's cost disease. While some aspects of healthcare have been automated, much of it still comes down to individual clinicians performing procedures on patients.
https://a16z.com/solving-baumols-cost-disease-in-healthcare/
Salaries probably pay factor as well? Check the sunshine list, plenty of radiologists making 600k/year. That's literally 10x of the median salary.
That does not explain everything. While you could make a reasonable case that doctors are overpaid in the US, the same budgetary crisis is happening all over Europe where salaries are much lower.
The crisis in France is clearly not on the same level that is in Quebec. It's not the only factor, but a serious one. As a continuation of it we have a heavily caped number of doctors what can be 'minted' every year. Same caps exist in the USA states.
Perhaps in the US, but nobody is getting paid that in most public European systems. A quick google suggests that the absolute highest pay band for a doctor in the UK is ~£142k (~$190k USD). And there won't be many making that.
See: https://www.worktheworld.co.uk/blog/highest-paying-medical-j...
Sure but at least radiologists do something. What do hospital administrators do? Like a university a hospital has bureaucracy that grows.
Yeah hospital accounting is weird. I had family in the ER and one of their crappy meals was like $60, for basically just rice and canned vegetables on a tray. A single bandaid cost like $25 or something outrageous like that. This was pre-covid too. I'm sure that same meal is getting close to $100 by now.
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This will continue to happen as long as automation in health care is slower than in other sectors. It's due to Baumol's Cost Disease: https://en.m.wikipedia.org/wiki/Baumol_effect
The same is true for other sectors that struggle with automation like education.
Which part of a nurses shifts would you automate?
So after every industry is fully automated and everyone has lost all their jobs, do we all just hold hands and walk into the sea together or...?
Not sure why we would walk into the sea because work doesn't need doing anymore. If you are worried about needing work to put food on the table, I think our best solution is to start with a small UBI that we try to increase as automation increases.
The way I see it, you have three choices, the government, corporations, or billionaires. It's an oversimplification of power in this world today, but those are your choices. Which one of those do you pick to clothe and feed and house you, after the singularity happens?
Another potential alternative is healthy capitalism, where a large number healthcare providers are in competition with each other to provide the best service at the lowest cost. In this model a hospital, for example, would be forbidden to buy another hospital down the road, in the same way a doctor’s office would be forbidden to buy a second doctor’s office, because both cases reduce competition.
That would be government. Markets don't regulate themselves and monopoly is the natural equilibrium state of capitalism.
No, it would be a mixed economy, where private individuals and businesses provide most of the goods and services, and the government plays a significant role in regulating the market.
Monopolized markets are almost always evidence of regulatory failure.
"Healthy capitalism" isn’t an option distinct from government intervention. Healthy capitalism it is government-regulated capitalism. Any system where competition is protected depends on active, ongoing government enforcement of the rules. Without that, markets naturally tend toward monopoly or oligopoly.
Advocating for "healthy capitalism," is advocating for a system where government sets boundaries and steps in to preserve competition. That places it firmly within the spectrum of government-regulated options, not outside or apart from them.
It's tempting to imagine ideal or the worst versions of each option and then claim, "what I want is none of these." Instead, we should look at whether our preferred scenario is actually possible within the real-world range of choices. In this case, "healthy capitalism" is only possible when government is both the referee and the enforcer, so it's a version of the government option, not a separate path.
Those are all the same choice
Government. 100%. It has issues certainly as every organization created by humans does, but corporations already run almost everything and that's why most everything is on fire. And billionaires are just the dumbasses in charge of the aforementioned corporations.
It's not just costs.
It is patient (and relatives) expectations.
It is knowing that any perceived issue could result in litigation.
It is that management may well have never 'worked the floor' so have no insight in to what happens.
There may well just not be the time to do all the tasks that someone else had decided needed to be done.
It's the baby boom. If level of care stays the same then at some point one third of the labour force is projected to have to work in healthcare, it's not possible.
It IS possible,
just unlikely the industry will be able to command more interest than the sugar-mill → grave pathway that's been established.
In CA, USA. We got a 20% hike in healthcare prices for the renewal we just got this month. 20% is insane.
To anyone here open minded enough to give it a shot, I encourage you to read The Real Anthony Fauci, or at least the first chapter. To people who feel resistance: what is the worst that can happen? If you after reading disagree then your brain will soon forget about it anyway so nothing is lost.
Healthcare costs have risen faster than inflation since the 1960s, when the government got involved with providing "free" healthcare.
Before then, costs tracked inflation.
Health care costs that are not provided "free" by the government have fallen, such as lasik eye surgery.
You seem to have the causality backwards. Prior to the 1960s, the healthcare system couldn't really do much. Most of the drugs, devices, and procedures were relatively cheap. After that the capabilities increased tremendously as did costs, and then government had to get involved to control costs and ensure patient access. (Although many of those government interventions ultimately had the opposite effect.)
Why did Lasik machines decrease in cost, while increasing in efficacy?
Drugs were far cheaper before the 1962 FDA Amendments, after that was a massive increase in costs. See "Regulation of Pharmaceutical Innovation" by Sam Peltzman.
https://www.amazon.com/Regulation-Pharmaceutical-Innovation-...
See also:
How American Health Care Killed My Father https://www.theatlantic.com/magazine/archive/2009/09/how-ame...
Drugs were cheaper back then because they were less safe and effective, and because the easy stuff had mostly already been found.
Before 1962, drugs were already regulated to be safe. 1962 brought about the requirement for effective, which enormously increased drug prices. It's all in the book I referenced.
Yes, what's your point? We could have lots of cheap drugs if we don't care whether they actually work.
The reference says what happens with the greatly increased cost to develop a new drug, is the number of new drugs developed dropped dramatically. But the percentage that turned out to be effective stayed the same.
So, yes, we are worse off because of that, because we wind up with far fewer effective drugs.
A proper solution is for the patient, a legal consenting adult, to sign a piece of paper that says he understands that the FDA has not verified the drug to be effective.
Nurses in Spain make 2500-3000 euro a month, in a country where the most common salary is 1250 euro. Are they overworked? Well then they can take a pay cut so we can hire more of them.
Eurostat average full time salary 2022 for Spain is €31k. 2021 average nurse salary €38k.
While mean is not median the stats seem to show much less of a difference than your figures. For comparison in the US median full time wage is $66k while median nurses wages is $86k.
Nursing is a skilled occupation requiring a bachelors degree. Seems good they get paid around average wages for graduates.
https://ec.europa.eu/eurostat/databrowser/view/nama_10_fte__...
https://www.euronews.com/next/2023/12/14/nurses-salaries-acr...
Averages as well as you say are useless. You know this, so I don’t know why you bring averages up. I specifically mentioned the most common salary, not the average or the mean, which are completely skewed.
You should also research the salaries of other people who also have a “bachelor’s degree” as you call it. That is, if they get employment and don’t have to emigrate.
Same for doctors, we constrain the number of new doctors trained every year to keep their salaries high. Just like constraining the housing supply to keep housing prices high, greed has corrupted these systems from getting better and now we’re just asking people to die instead.
Which country are you talking about, and who is "we"? In the USA, Congress constrains the number of new doctors trained every year not to keep salaries high but rather to limit Medicare expenses. If Medicare beneficiaries can't get an appointment due to a doctor shortage then no claim will be submitted to CMS. Most of the funding for residency programs comes from Medicare, and every year there are medical students who graduate with the MD but are unable to practice medicine because they don't get matched to a residency program.
At one point the AMA did lobby Congress to limit the number of doctors but they reversed their position on that issue long ago.
https://savegme.org/
At least here in Norway, the doctor associations fights hard against any talk about reducing the ridiculously long shifts that nets the doctors large paychecks.
They'd much rather have 1-2 doctors do the work of 3-4, so they can cash in.
Though there is a change of guard happening. Younger people, including doctors, value work-life balance much more and are less inclined to work long hours for more cash.
How many hours do they work, compared to the people making €1250/month?
Fewer, for sure.
Not to mention they work for the state so they are guaranteed to have lots of free days by law and their work hours are always respected.
"Nurses should be at the very top of our social hierarchy but we live in a world where it’s just the opposite," she says. "This film is a love letter to the profession."
I moved furniture for 3 years in the early 2000s to support my shareware business. Something like 500 moves, sometimes 9+ hours per day, occasionally 6 days per week. It made me who I am today, but also broke me in countless ways.
I witnessed single mothers giving us $20 tips each (around $40 today) while wealthy people didn't even offer us water. I saw the best and worst of the human condition, sexist pay policies, how workers are exploited by not being provided a schedule for the next few days so they have to call in each morning, how truck fuel costs more than workers' pay, how Right to Work states allow businesses to throw employees away on a whim, how tax brackets at the bottom create the impression that any additional pay gets skimmed by the man, among a great many other injustices, and how all of those conspire to keep the working class down so that a handful of individuals can become fabulously wealthy.
With every improvement in tech, I see the gulf widening. We can talk about how poor people now have cell phones and flatscreen TVs, while conveniently ignoring how people with a net worth over $10 million who couldn't spend that money in a lifetime are now buying politicians to shred the social safety net, among other dubious endeavors.
I say with complete confidence that the arrival of AGI will bring about ultimate wealth inequality. I foresee a world where 10 billion people work performatively to survive long after robots can do the work better, while less than 1 million people live like gods, free even of senescence. Assuming that we stay on this timeline and don't shift to a more equitable one.
I went into computers in the late 1980s to eventually build an android like Data. I didn't know that Turing test-passing AI would arrive 20 years early, or that I would spend the first quarter of the 21st century hustling to make rent due to unfortunate geopolitical realities driven by unmitigated greed and regulatory capture.
Now I'm not so sure that I even want to stay in tech anymore. It has been anything but kind to me. Every time I level up, so does the world, and expectations upon me just grow for the same pay. My people-pleasing has cost me my health on a number of fronts. I know that someday, I'll have to choose computers or my life.
After all of that, one might think that I'm all doom and gloom. But I'm not. I've come to treasure my time at the warehouse as a teaching tool after a great deal of shadow work. I admire my foreman for being the provider that I can only hope to be someday. I look in awe upon the borderline homeless vets, deadbeat dads and ex-cons who showed me what it is to give without expectation of reward. I see them in all of us, even the people I disagree with, and that gives me hope that maybe we can come together and avoid the iceberg that's about to sink this ship.
I'm reminded of this scene from Jaws which always stuck with me:
https://www.youtube.com/watch?v=-xQQIqAiTYA
And I just watched Mountainhead, here's the trailer:
https://www.youtube.com/watch?v=27cN2_k0JF0
I see a world divided into two camps: one that does much for little, and one that does little for much.
It makes me wonder where we all sit in relation to this. What kind of impact we could have on the future, and how that might help everyone to self-actualize.
I don't pretend to have the answers. Some of my best years happened when things were at their worst, and vice versa.
But I do know that everything is upside-down right now, and always has been, since the dawn of civilization. I feel that tech won't really be tech until it addresses and undoes that injustice.
That's why I write this malarky when I should be working. For all the other working people who don't have time to say what needs to be said.
Although I am younger than you, I feel somewhat similar. The never ending treadmill of technology seemingly makes things worse rather than better. I’m working in robotics, and I think is this actually the right thing to be doing? - but if I dont, then I wont eat and afford my future.
Really feels like society is burning the candle at both ends.
Try to avoid a grizzly end of life. Go to the gym, and if/when you get some form of cancer or some other degenerative disease, think about how ending things well is important.
Yes, but someone got a yacht for reducing waste and controlling labor costs, so who’s to say what’s right.
The person with the yacht, obviously. They have the money to fund making many more movies and marketing pushes about how awesome they are for reducing waste and controlling labor costs.
Every time I've been in the hospital - unfortunately too many times -it's the nurses I see and who do the work, with the occasional lab tech visiting to do a test or draw blood.
The doctors show up once a day, doing their rounds. Don't get me wrong, I've had some wonderful doctors, hospital patient visits are only part of the work doctors do.
I remember the good nurses, the patient nurses who understood why I'd be grouchy, even angry at times, and would sit down and talk to me. I remember the young new nurses, sometimes struggling with an IV placement but persevering to get the skill they know they need.
Most importantly I remember how every time I'd wake from general anesthesia, the first face I saw was a nurse letting me know where I was and what's happening.
Wasn't this Nurse Jackie?
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Much of the west is getting older and getting sicker. How unsurprising.
What even is the solution? Expand the already massive healthcare sector further? Where does the money for that come from?
I have thought that we should make entering the medical professions much easier. In order to become a nurse, you usually need a 4 year degree. This has two issues:
1. This is way to much time in the classroom. Much of that coursework simply isn't necessary.
2. You have people that would be good nurses piking other programs because they can't get passing marks in classes that are irrelevant to day to day nursing.
Binding what are essentially professional programs to the academy is a mistake. Don't get me wrong, I love the academy. But we need nurses.
In the US, we have two tiers of nurse below the 4 year degree and one tier above, and we still have a major nursing shortage.
You can get training to be a certified nursing assistant in just a few weeks here.
At least in the US, nursing does not require a 4 year degree. You can become an RN with an associates degree. A 2 year nursing degree has one of the highest returns on investment of any training program (especially if you go to community college). Ivy Tech CC in Indiana and WGU both have nursing programs with great returns. Keep in mind, nursing is not an easy path and has a super high burnout rate. It's a tough and demanding job.
Other professions with a great return on training are HVAC, electrician, plumber, robotics/logic systems (CAM, conveyors, etc.). These are especially high paying if you focus on commercial and industrial.
A lot of people are surprised to learn the the average wage for both plumbers and electricians is ~30 bucks an hour, then that’s in exchange for body breaking work. A small subset earn more, but it’s not the norm.
Industrial electrician around here start at 30 - 35 for 2 years as a trainee then go to 40. That's top 10% income for low cost of living area. It's not unusual to hit 100k with no school debt at a young age.
Industrial automation technician I have worked with makes north of 300k but he is traveling all over the world to do it.
Union electricians and plumbers make good money, and the non-union shops that do commercial work have to pay close to union wages plus some fringes to get enough manpower. I pay $100/hr for a union journeyworker electrician in a metro area of ~3 million, $106 for a foreman, and $112 for a general foreman. Both of those include fringes, the split is about 55/45 or so. The contracts are for three-year terms with raises every year.
Residential construction is a whole different ballgame that I’m unfamiliar with, but I’d imagine that’s where the average gets dragged down.
So are you hoping to be treated by nurses who are worse academically than the ones we have now? Or are you hoping that "others" will be treated by them while increased supply depresses wages for the good ones that you think will treat you? Also being a nurse is a very hard job, most people wouldn't last a year as an ER nurse in the US.
how much worse were nurses when it was a 2 years occupational program or associates degree?
Huh? There have been multiple levels of nursing for many decades, probably longer than you've been alive. At the lowest level a CNA or LPN doesn't even need an Associate's Degree.
https://www.usa.edu/blog/levels-of-nursing-explained/
Have you looked at proportions over time?
In the 1980s 55% of registered nurses were working with diploma. It is down to 6% today. Bachelors or greater was 27% and is now over 70% today.
As your link points out, many states are continually raising the bar and many have already moved to a BSN minimum.
I'm probably dating myself, but there was a time when people started working occupational nursing programs while in high school and were licensed a few years later.
https://nap.nationalacademies.org/read/12956/chapter/9#186
We make them take classes like organic chemistry where they have to memorize the reaction of various metal catalysts. Calculus. Physics. These are all two semester classes that are considered hard in undergrad. And yet the nurse will never ever use what they learn in these classes outside them. They aren’t the ones synthesizing the drugs.
That's misinformation. Most BSN programs don't include those course requirements.
https://www.sjsu.edu/nursing/programs/bsn.php
That doesn't help if we don't have money to hire qualified nurses.
If nurses had lower up-front costs for their own training, I could imagine that allowing lower wages without them being worse off financially.
If we hand-wave away a lot of other market dynamics, I'm guessing.
CNAs (Certified Nursing Assistants) have low up-front training costs, but don't make a lot of money: an average of $19/hr [1]. So at least some of the less skilled work is being done with economic efficiency.
[1] https://nursa.com/salary/cna
Larger supply leads to lower prices, if demand stays flat.
you usually need a 4 year degree
In the US, it's not worth going into because you have to put in hundreds of hours of clinicals which are unpaid, yet just as useful to the employer as a job. Unpaid internships are illegal, yet these are legal and mandatory.
Solution: preventive health care, promoting a healthy lifestyle from an early age, and healthy eating
Cuts down on health costs but also increases life span, so you have the issue with the number of elderly citizens vs number of working citizens who can provide care. That needs to be tackled too somehow.
That definitely increases outcomes and QALY but it only is cost neutral or saves costs if you also more tightly ration low-cost-effectiveness care down the road that ends up usually being near end-of-life, which is where A LOT of current spending is.
This is rational on a broad social level but is very difficult of a change to implement.
I think most of the increase in healthcare costs is coming from elderly people (because people are living longer). So while otherwise a good thing, I'm not sure that will help this particular problem.
This is good to do for its own sake, but on a large scale it does not decrease health care costs: it makes people live longer, but they will still ultimately need the kind of end-of-life care where the majority of health care costs come from. Those costs don't go down for healthier people, and it might even increase health care spending on net if it takes people longer to die.
I know it’s easy to say but you do hear stories of families going to extraordinary lengths for an elderly loved one to give them a couple months of low quality of life. Is it the family trying to feel better or hoping for a miracle, or the patient themselves; I’m sure it’s both, but I can’t help but think if we were more comfortable with death, these really costly situations would go away and suffering would actually be reduced. I know it’s easy say and it sounds like I’m advocating for death, and in a way I am, but we all have to go. If your quality of life is so terrible… I’m also a hypocrite because I think that when it will be my turn or my parents’ and I have to decide, I’ll tell them to do everything possible within their directives.
The last thing you think of when your loved one is on the edge is if you can save money for the system
too late for most of the burden
Obesity is currently only getting worse and many of these sicknesses are already irreversible in people. This also does not do anything about ageing
Luckily obesity is getting more and more solveable tbh
I imagine that means people will face whatever the next problem is (heart disease, or dementia or etc...)
but hopefully at a later age?
Yeah, although some of them are comorbid with obesity so they shouldn't get too much worse?
But cancer treatments probably get more common if you're living longer and your heart doesn't get you, etc
good luck -- https://www.npr.org/2025/07/27/nx-s1-5481828/rfk-jr-uspstf-a...
My answer is more sympathy across the board. People are going to make mistakes. People are going to have a hard time. Both lead to more mistakes. Neither are reasons to give up.
On the money angle, I'm on board with the abundance crowd that I internalize as "be willing to spend money." Especially since most value is generated, and not necessarily discovered.
What's the solution to the symptoms of low interest rates, low fertility rates and declining productivity?
Low interest rates are trivially solvable. Declining productivity seems entirely made up.
Send everyone older than 30 to Carousel.
The narrative is wrong - the wages are low while the working times are exhausting. Half of each trainee's leave each year, while the nurses that can actually endure this shit are going into pension in the next 10 years. And the money is spent on SAP systems who further take time from the already overworked nurses, because they now have to spent a ton of time entering data into a computer with no benefits.
Its not people getting sicker, its mismanagement. Source: Two nurses in family
Yeah, also over here in Finland the amount of money our public sector spends on stuff like Microsoft licenses is insane. Then there's lots of other craziness, like buying a very expensive and totally unsuitable American healthcare management system from Epic, and then spending lots of money on license fees and customizing it for local purposes (the end result also sucks, and is universally hated by healthcare staff).
I'm not sure whether it's a result incompetence, corruption or both, but massive amount of money is wasted on IT solutions that could be implemented more cheaply in-house, or at least by European companies.
Yes, I remember a post on the daily WTF ten years ago, about a terrible programming language called MUMPS. Real programming horror story.
That's Epic. That's the thing our highly paid acquisition experts demanded our health care systems buy. They are MUMPS.
The main problem with Healthcare when it comes to costs is that it is to a certain extent labour intensive, is it not? This makes it difficult to reduce costs as wages rise over time.
one answer is raising retirement ages.
Make that a discussion with the local politics. In theory at least, everybody will need healthcare in their lives and more so when aging. And we need a plan for that, not to act surprised (the way some leaders act surprised with gas dependency, or with immigration, or with...). Everything can have solutions, if it's not swept under the rug.
>Make that a discussion with the local politics.
There is nothing more irrelevant than addressing large scale social issues in local politics. Besides not once in my life have I seen politics improve anything, politics seems to attract the dumbest and most self righteous types of people, who care about nothing but their self image. My time on earth is limited and much too precious to spent it in the company of politicians or just people invested in politics. No Thanks!
Correct me please if I'm wrong but do you maybe mean with that "let's do nothing and just die"? That I cannot accept, so what else?
Firstly, the success rate of politics appears to be precisely zero.
Secondly, if I have the choice between politics and death, death is the easy winner.
We have the money. Wealth is everywhere but as a society it's neither evenly distributed nor compassionately allocated. But that is human nature.
Absolutely. Especially the old think that they deserve unlimited funding, even when they have failed totally at creating the conditions which would make that funding possible and now their costs are spread over an ever declining population of young people.
Modern society is based on a pyramid scheme and the cancer of infinite growth. We will burn this planet to the ground to ensure that certain classes of people never lose.