cracksinthemeta

@rhojnn1 @BoringBiz_ that's fine! how much does a senior VP make then? coming from someone who had no idea

@cracksinthemeta @BoringBiz_ lol lots of clowns commenting on how supposedly standard 2mm is at that point…can guarantee you with near certainty that in early 30s PE/HF that is not “standard” even at a well known PE firm

Recently grabbed coffee with a senior VP at a very well-known private equity firm Well above $2M in net worth. Not enough to fully retire but can walk away for a better work life balance if he wants to Just had a kid few months ago and now struggling to decide between continuing this career path or shifting to something that would let him spend more time with family I asked him what is keeping him at the current firm, beyond just money His answer was simple: "Insecurity. I might look back in 10 years and feel bad knowing that my friends are buying their second vacation homes while I walked away to chase an easier life. Whatever job or title I have next would not earn me the same respect" That is when it really hit me A lot of people stay in high-performing careers, not even because they need the money, but rather because they are used to a certain level of status and respect from people around them This only gets worse as you move higher up the ladder and start spending time around people at the same level in terms of career or wealth I asked him if he was okay if I posted this on my X and sought advice on what my followers would do. He agreed. So I am genuinely curious: what would you do if you were in his situation?

@CyborgPeds "Im not calling you out specifically". I'm not accusing you of this specifically, but plenty of doctors have said the same, but also talk about saving lives as a fulfilling goal, which feels off to me.

@cracksinthemeta When did I say that

Correct. The doctors would fire all their sick patients.

I also don't want to make the statement that I think value based care is strictly better. My main curiosity is that I think the current system seems to fail a lot of individuals, and I'm wondering what is a better system. It doesn't have to be conventional VBC, but I'm curious what your take is for system where people are treated in a timely manner while minimizing perverse incentives

I think you're correct that the above is a potential mechanism, but I don't necessarily follow that this makes value based care worse than the status quo right now, unless you have more sources to back up why it's directionally worse. For example, you describe that value-based care has issues because it'll create services that a hospital must legally provide to poorer individuals that needs subsidies to stay afloat. But this is already the case with ER visits! And hospitals are already quite expensive because ER visits exist! So it becomes a weighing mechanism to me on which is worse or better, and my own naive intuition is that emphasizing preventative care is cheaper than an ER bill. To be clear, I could be wrong, but I feel like the present information I have doesn't sway me to say that the current system is doing well.

@Xeon4f145d96s1 I'd have to see an example of how a given conversation plays out, because there are multiple situations where I'd agree with the patient or doctor, depending on the specific words.

ah, you're correct, but I was more so saying that if we can accurately predict cohort level outcomes, and therefore accurately reward doctors based on directional improvement in healthcare vs. baseline, we can get a situation where doctors aren't incentivized to drop sick patients in a value based care model you're right that it's a political problem. I'm moreso asking if we can implement something closer to value-based care, but also avoiding the potential failure modes like "doctors self-selecting their cohorts to game the system"

@cracksinthemeta @CyborgPeds Value-based care is not a computational problem. It's a political problem. Assigning value is not the job of a statistician. It's already feasible to some degree as something called "bundled price" is based on indication.

@seanluomdphd @CyborgPeds Ah that's a good point! Do you think it's a limitation that will eventually be broken once the technology develops, and therefore make a value-based care model more feasible, or do you think this is a true physical limitation?

Because it's modeling a stochastic process, because in real life, cohorts *change in time*. Also, remember cohort and outcome are linked. For example, a poorly performing methadone clinic would gradually have more adherent patients. So cohort outcomes relate to input of the clinic as well. My next grant is aiming to use deep reinforcement learning to model this, though that's not the primary aim. outcome prediction per se is the primary aim.

oh yeah, that's fair. in order to claim you have improved the health relatively, you need to accurately establish what the "default case", which could be infeasible or unfair based on geography or whatever. Can i ask why it's computationally non-trivial for methadone clinics? My current instinct is that we have a lot of actuarial data on what the "default case" is sliced on multiple levels, but open to being wrong here.

@cracksinthemeta @CyborgPeds If you don't randomly assign, you'd need to be able to accurately predict at least the cohort-level outcomes. This is currently not feasible without substantial bias. We are trying to do this with methadone clinics, for example. This is computationally non-trivial.

A doctor smart enough to seriously entertain thought experiments! Aristotle would be proud! Do you think there's a way to make this achievable without random assignment? For example, perhaps relative health improvements could also be rewarded, similar to the HCC model in medicare, but applied to doctor rewards.

Yeah, the way this would work is if they *randomly assign* you patients by transporting them to you. It's interesting to think about this conceptually in "value-based care". It could be done, eg, if you are doing pure telemed. And in fact is done now in telemed. The problem is, provide groups now must do actuarial work in the case where they are randomly assigned a bad cohort in a particular year, and there's a re-insurance market on that premise. I was just told this by a colleague. Fascinating, kind of, lol. It's the financialization of medicine. Providers choose cohorts already implicitly by practicing in a certain geography, payer mix, that sort of thing. This wouldn't be a problem except that in high shortage (such as Canada, referenced here), this sort of implicit selection massively amplifies the shortage for people who are loud.

That makes sense! But it's not like FFS doesn't have failure states either. FFS incentivizes doctors to do operations that, while minorly helpful, may not be worth it for the patient relative to the cost. Main point being is that it's fine to call out a legitimate potential flaw in the system, but it's not like people aren't unhappy with the current status quo.

@cracksinthemeta @DrDiGiorgio It does point out the problem with value based care - doctors are incentivized to keep patients that are relatively healthy and compliant, and drop patients that are not. I'm now retired but I was incentivized to drop my cantankerous patients.

Let’s incentivize doctors to only treat healthy patients and wonder why the sick can’t find care.

@Arbitrary_user @dredinvestments @MiserlyTightwad @rbarbosa91 That sounds consistent with my experience too!

I will weigh in here. I am an MD who did hard-core NIH-funded basic science research for 10 years, before I flamed out. The average science PhD is smarter than the average MD and contribute a lot. But I worked with some PhD's who were maddeningly dense. And the very smartest doctors are extremely bright and often have both an MD and PhD.

It turns out that when people that were at the top of the class, and were required to endure extreme self-sacrifice for 15+ years, and start their first real job at age 35, that they do in fact want to be able to live in the nice neighborhood along with the corporate types.

No, I'm saying that if you just took an objective look at the real world, you'll see that the people at the top are not the ones who optimized on good grades. Believing something that isn't true, slaving away based on that false belief, and then getting mad that it turns out false should be an easy mistake to avoid. I don't expect doctors to make peanuts, nor do i expect them to do everything out of the kindness of their hearts, but a lot of this butthurt could have been avoided if they just took an objective view of what a shit-show the healthcare system and acted on what is actually true, instead of what "should" be true.

@cracksinthemeta @elschwet @lemonade3677 @rbarbosa91 It's really not. For starters, the 'grades' are specific competencies in an advanced field. And describing it that way implies that you expect people to grind themselves to a paste for 15 years out of nothing but altruism to you, which is a much more childish and entitled take.

@dredinvestments @MiserlyTightwad @Arbitrary_user @rbarbosa91 "but they never needed in past" have you been driving for 7 hours or are you really this bad at basic english

@cracksinthemeta @MiserlyTightwad @Arbitrary_user @rbarbosa91 UK study 😂. Keep that shit over there. Plus IQ in itself does not define if a person can be a doctor. Lot of smart people could not make it past med school cause there was so much information to process. So hard work was needed but they never needed in past.

@dredinvestments @MiserlyTightwad @Arbitrary_user @rbarbosa91 Doctors will routinely say that: 1. the job doesn't pay enough 2. burnout is common 3. you feel routinely underappreciated 4. the work itself is hell If all the above is true...isn't the smart thing to do is not apply to med school in the first place?

@cracksinthemeta @MiserlyTightwad @Arbitrary_user @rbarbosa91 Sounds like you got rejected from med school. I meet losers like you. 😂 I got to go. Don’t have time for your low life. Have to save lives. Maybe your mother’s.

@dredinvestments @MiserlyTightwad @Arbitrary_user @rbarbosa91 You guys aren't even top 3 gwern.net/doc/iq/ses/202… and by long tails, you guys aren't even top 5

@cracksinthemeta @MiserlyTightwad @Arbitrary_user @rbarbosa91 lol. I am driving so I am trying here. If you take 5 secs u can see insulin, penicillin so many other discoveries were found by docs. Keep living in your world remember when you walk into a hospital that’s our world. We smarter it’s proven.

ah yes, classic case of doctors thinking they're geniuses above everyone else, but not even able to do the bare basics, like string together a grammatically correct sentence. Even when all the important breakthroughs in the world are discovered by non-MD researchers, you still think doctors are better at academia, which is kind of hilarious.

@cracksinthemeta @MiserlyTightwad @Arbitrary_user @rbarbosa91 Yes I worked with full time phds dumbass on break through research at Yale. 😂 I did it for years. Lot of phds became phds because they could not be MD. Like my uncle

@dredinvestments @MiserlyTightwad @Arbitrary_user @rbarbosa91 *you're dumb Are you saying that a doc doing research is as academically valid as a full-time academic researcher doing research?

@cracksinthemeta @MiserlyTightwad @Arbitrary_user @rbarbosa91 lol. Your dumb. You do realize every doc has to do research. I did research for years at Yale for free before I became a doc. 😂 plus nothing is better than actually saving patients lives and their families thanking you.