This, as always, is an excellent digestion of both the good and bad of the category in which
bureaucracy sits. SteveS expressed some admiration for the diversity with which "we"
experimented with responses to COVID19, even if they were not designed experiments. What you
propose at the end is a kind of systematic collection of experiments - or at least observational
studies - to span the space of medical-service ecologies. It feels a bit like artificial life to me
"medical-service as it could be".
But I can't help but wonder if it's a bit like a phenotypic trait of an organism. Perhaps
the character of medical-service isn't a standalone "pleiotropic" trait. The
character may be part and parcel of the society (and individuals) under consideration. If
so, we can think of complexes like medical-service (or military or car-centric cities or
whatever) as either endemic or invasive/introduced. Our desire for
homogeny/recognizability (like staying in a Hilton even if you're in some far-flung
place) may be part of the problem.
I like the idea of things like bureaucracy filling the interstitial space like glial
cells, organically grown to address multiscale "coordination problems". I guess
most complaints come from myopic perspectives on those systems. But there might be a
kernel of truth in those complaints where the interstitial coordination outlives its
purpose ... bureaucracy for its own sake, justification of death/dismemberment sentences
for corporations, including things like PE firms, hospitals, etc.
On 4/17/25 2:33 PM, Santafe wrote:
Totally agree.
In one of the long-time collaborative groups I have attended, the two main
cohorts are agriculture-related (practice, research, policy) and the
corresponding medical-related. Everything you point to here is core to their
complaints.
Where are the drivers, and is it appropriate to try to reduce to a modest
number of main actors (or would that just be the human desire for
comprehensibility making a projection)? I am willing to suppose there are two
drivers. The most-visibly-different recent one is private equity. My reading
says this is the major driver behind the extinction of hospitals in low-density
areas, driving medical-service deserts. (I have deliberately not used the word
“care”, which to me is part of the manipulative jargon, even though sometimes
it applies.) I guess the insurance companies aren’t exactly private equity,
but if I look at business practices like those of which UHC was (presumably
still is) one of the worse offenders, and the way their lobbying severely
limited what Obama and Pelosi could do to trim around the edges of
health-service improvement in the US, the business model isn’t far at all from
the one driven by private equity. But PE, specifically, looks to me like a
symptom of when near-singularity levels of wealth-concentration become possible
from the network-way in which the current capitalist economies are set up.
Money concentrated from one area (crypto-mining companies and their VCs?)
suddenly gets to purchase hospitals, veterinary clinics, residential buildings,
and god-knows what else, and carve them all up and sell them off, or pimp out
the doctors until service degrades enough to close them. If money accumulation
beyond operating expenses were less easy, requiring that the quality of “risk”
it supports be improved, and if regulation against predatory practices added a
little dimensionality to the pure-money valuations of things, we could probably
cut that problem down considerably.
My understanding, too, has been that the Scandinavians have managed to hold
this off longer than most of the West, but that they are by no means secure.
One of my long-term group is a Danish cardiologist, and he complains and
worries that what starts in the US doesn’t stay in the US, and Europe gets
dragged in similar directions, with Scandinavia getting drafted in eventually
even if less-so. So they somehow haven’t managed to hold off the forces of
institutional Darwinism that seem to homogenize every domain.
But the one that really stumps me is the one for which I have held off blaming
universities and funding agencies as well, which is what you term bureaucracy.
From my days with Shubik, I stopped regarding bureaucracy as an inherently
negative term (which is the normal social usage), and tried to understand in
how far it is driven into existence by coordination problems that people
collectively commit themselves to, whether wittingly or piecemeal through local
things they accept or even want. One of our friends (as I have mentioned
before) tried to start a 401C3 organization for people to do scientific
research out of the house, but have legal access to agency funding etc. They
survived for about 10 years, but eventually collapsed under the workload of the
accounting and legal, which they hadn’t committed to hiring (and charging for)
a significant paid and trained staff to handle. A lot of that regulatory and
reporting load was adopted “with good intentions (?)”, either to forestall
cheating, or at least to give legal cover against getting sued or
congressional-witch-trialed out of existence for. I don’t like the result, but
had I been the decision maker piece by piece, I don’t have good (and plausible)
ideas for what I would have proposed in its place as a defensive measure. I
think that overhead creeps, and would have significantly impaired medicine and
research in any publicly-accountable sector, even without the problems created
by singular wealth concentration.
Now would be a great time to see high-quality professional comparative analysis
of alternative models, how they work and to what extent that depends on other
aspects of their circumstances. I have been very very impressed with medical
services in Japan, as a quite complex institution that is not publicly run, per
se (so not “socialized” in the strict sense), but is a quite tight coordination
at all levels from the national government down to the training and staffing of
local functions like accountants and techs. Very clearly, these are all
ordinary human beings, of a range of talents and sharpnesses etc., and yet the
system they are in gets _so_ much more benefit from their efforts than in the
US, as to be shocking.
Eric
On Apr 17, 2025, at 22:50, glen <[email protected]> wrote:
I guess we could make the same argument with physicians: "act like a physician, not
a business".
https://linkprotect.cudasvc.com/url?a=https%3a%2f%2fwww.statnews.com%2f2025%2f04%2f15%2fai-scribes-artificial-intelligence-medicine-note-writing-physician-patient-relationship%2f&c=E,1,3gRfDNHkk13o310iM0_6Fs5EyrSEX6kI2z4AlJI9DhLGsUitet_kuxYKHltOpfoQxMpF6PKKY-Ww3t0zxto0GYV5WGgaQRiDu6UngCRtSekff1A,&typo=1
I guess I'd prefer "act like a witch, not a doctor". My GP back in Oregon was a
great example of a *general* practitioner. Granted, I had insurance. But he rarely
recommended specialists. He'd cut pieces off me right there in his office, tolerated my
rants against acupuncture pamphlets, etc. But! He was originally trained in India. I only
have a couple of experiences. But it wouldn't surprise me if Global South doctors act
more like physicians than US trained doctors, in general. Actually, I've seen studies
that show the average visit with a physician in Scandinavia is ~1 hour, whereas the
average in the US is more like ~15 min. So, maybe it's not the Global South, but the rest
of the world versus the US?
And it's not quite fair to blame the humans. The hospital and clinic systems, coerced
by insurance/payers, captures them in their ion traps. Even the less-than-greedy ones
are subliminally encouraged to escape into a specialty. If we think university
accreditation is resource hungry, take a look at the firey hoops hospitals jump
through:
https://linkprotect.cudasvc.com/url?a=https%3a%2f%2fpmc.ncbi.nlm.nih.gov%2farticles%2fPMC8011742%2f&c=E,1,taSSkOtyvDln2I-WXAWBr6OoE-KAaYP9hqnPUWgSPrVxYCmCZgASDhQUvZLRQ1BZK4Pk7Y0VBEsIvc5aVl7K6Hxe-P876x4UQeLO9bCXLr9F0qmhAEw4wg,,&typo=1
Stupid bureaucracy.
On 4/15/25 1:11 PM, Santafe wrote:
Turns out Masha Gessen wrote a kind of nice piece in the NYT a few days ago,
which came to me on a different list.
14gessen-videoSixteenByNineJumbo1600-v2.jpg
Opinion | This Is How Universities Can Escape Trump’s Trap, if They Dare
<https://www.nytimes.com/2025/04/14/opinion/trump-higher-education.html>
nytimes.com
<https://www.nytimes.com/2025/04/14/opinion/trump-higher-education.html>
<https://www.nytimes.com/2025/04/14/opinion/trump-higher-education.html>
To the extent that it has been done, it’s proper to say it is a strategy. I
think the resulting education will end up being rather more restrictive than
what I had hoped for from a full educational program, and probably focused
heavily on civics. Math could be possible, in the sense that that can be
taught “behind the hedges”. Medical research, not so much. But, one does what
one can do.
It’s an interesting question what is the proper balance of criticism and
understanding to give the businessmen who run universities, and who have
Darwin-wise managed to eliminate almost any other model from the ecosystem.
It’s not total criticism, in the sense that there is sheer mechanics that they
do contribute to solving, without which the broad set of functions I want don’t
get done. But the sense that they don’t take seriously what it means to live
under a fascist regime where dissidence is the _only_ alternative to
collaboration — there is no more neutrality — does seem to be a deserved
criticism of their responses so far.
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