7 ms·

This looks like the same phenomenon as the crisis in staffing nurses that was discussed here the other day. Careerist, indifferent management giving the people

This looks like the same phenomenon as the crisis in staffing nurses that was discussed here the other day. Careerist, indifferent management giving the people on the front line inadequate resources and then blaming them when things start to look shabby, or when someone dies. Scapegoating the people who were in the wrong place at the wrong time, who are tired, inadequately trained, and inured to a climate of normalized deviance. Many organizations don't suffer from these problems to nearly such an extent. I've worked in reasonably functional organizations, and ones that are disfunctional in different ways. Why does this malady strike the U.S. Navy and healthcare so severely? Am I viewing this from too great a distance? Are these actually separate forms of institutional dysfunction?

ethbr0 5y ago
> Why does this malady strike the U.S. Navy and healthcare so severely? Both industries substantially outsourced functionality in the 90s in an attempt to cut costs. Consequently, they are now less empowered (vs historical levels) to effect change in their own processes in a timely manner. Large organizations need to pay more attention to ossification of processes as a serious future risk, that needs to be balanced against immediate savings.
killjoywashere 5y ago
As a Navy physician who has dealt with COVID and fatigue, I think the chronic low pay contributes to a lack of people which leads to overwork, exhaustion, a sort of "this is my lot in life" acceptance of mild to moderate depression. And you get to the point you just look away for your own sanity. Healthcare workers get paid less as you get closer to the coasts. And military gets only very modest pay adjustments for housing costs. A colonel in Kansas may live like a king, but a captain in San Diego can't afford a house. Edit: I also agree with the posts about outsourcing leading to ossification and rigid stratification. You want rigid stratification? Try military medicine.
- ethbr0 5y ago
  Great point! At the end of the day, we're talking about people. Highly trained people in Navy, medicine, and Navy medicine cases. And people have limits, because they need lives and aren't robots. Morale and aligning work to allow for happiness in life is a requirement for people bringing their best to work. If you ask people to toughen up and suffer through the suck to get the job done... there'd better be an eventual light at the end of that tunnel. Otherwise, it's just a death march. PS: Thank you for your service, and especially through COVID.
- jwithington 5y ago
  The Navy pays officers very generously across all fields, EXCEPT medicine and JAG. URL JOs will take a pay cut for the first several years (at least) after leaving for the civilian sector. I never, ever heard a URL peer get out because of financial reasons. FWIW, BAH (pay for housing that is tax-free) is $4000 for an O-6 in Point Loma v. $2777 in Offut, NE. Seems to be aggressive adjustment, no? Enlisted pay might be another story… EDIT: I know one guy who griped about pay once…kind of in passing. Went on to be a YC founder haha.
  - xattt 5y ago
    For Medical and JAG, are VA benefits (ie paid long-term care) worth the loss in income over the longer term?
    - lotsofpulp 5y ago
      You will never know. That is the great thing about “benefits”, the recipient has no control or knowledge. The employer, or politicians, 5, 10, 20 years from now can cut funding and reduce access from MDs to NP/PA, or only cover certain meds, or require excessive prior authorizations to dissuade using the healthcare.
      - yhoneycomb 5y ago
        Exactly this. The VA already is hiring as many midlevels (NP/PA) as possible so that they don't have to hire MDs. You wouldn't believe how low the bar is to become an NP. PAs receive substantially better training, but at the end of the day they are still midlevels. Worse still, many NP programs are now giving out "doctorates" of nursing practice so that NPs can introduce themselves to the patient as "Dr." Smith. In short, the VA is willing to gamble with your life if it means saving a few bucks. It's pretty harrowing.
        nradov 5y ago
        Is there any evidence that care by midlevels produces worse outcomes for routine cases?
- deleted 5y ago
  [deleted]
- metaphor 5y ago
  > A colonel in Kansas may live like a king, but a captain in San Diego can't afford a house. Assuming both sought living accomodations outside of free base housing, I was curious what those figures actually looked like[1]: - O-6 colonel stationed at, e.g. Fort Riley, KS 66442, would draw up to an additional $1500 without dependents, $1911 with. - O-6 captain stationed at, e.g. NAS North Island, CA 92135, would draw up to an additional $3342 without dependents, $4026 with. It's worth mentioning for those unfamiliar that, just like BAS (i.e. food allowance), this BAH (i.e. housing allowance) is completely tax-exempt. The game that active service members play here is to secure a home mortgage (often through VA home loan), then apply BAH directly towards monthly mortgage payments throughout service all the way to retirement. It's not hard to imagine other tax advantaged games to be played here. Applying BAH to rent a house off base is a naive fool's errand. In terms of annual cost of living adjustments to base pay, uniformed service received +2.7% increase this year; in contrast, +2.2% for federal GS civilians. The year before that, it was +3% v. +1%. These adjustments have historically favored uniformed service over the federal civilians that work beside them. Sure, they're lowball relative to inflation, but that ought to be squared against military tax-exempt BAS/BAH and hugely subsidized commissary entitlements. Exceptionally common amongst Navy personnel, married sailors typically draw an additional $250/mo family separation allowance[2] when out at sea for more than 30 continuous days. This will obviously have a greater financial impact amongst the enlisted ranks than officers. Depending on rank and job, there's a litany of allowances, bonuses and incentives (beyond the scope of this remark) that are often ignored when the conversation of military service compensation is brought up...nevermind that no one ever talks about the opportunity to retire with guaranteed pension + benefits for life as young as 38. As an outsider, I'm inclined to agree that military health professions do seem to pay a substantial indirect opportunity cost despite the unique bonuses they're entitled to[3]. I do wonder what individual circumstances led you to choose a Navy commission over everything else? [1] https://www.defensetravel.dod.mil/site/bahCalc.cfm https://www.defensetravel.dod.mil/site/bahCalc.cfm [2] https://www.dfas.mil/militarymembers/payentitlements/fsa/ https://www.dfas.mil/militarymembers/payentitlements/fsa/ [3] https://www.dfas.mil/militarymembers/payentitlements/Pay-Tables/ https://www.dfas.mil/militarymembers/payentitlements/Pay-Tab...
  - sgarland 5y ago
orzig 5y ago
I know much more about healthcare than the Navy, but it’s notable that they both have rigid stratification between roles. I could imagine that hampering operational feedback loops in normal times, and strategic feedback loops given the labor supply/demand situation in these extraordinary times.
- chromatin 5y ago
  At least in healthcare, I doubt this is a major causative factor (presuming when you say roles you mean physicians and nurses) -- the physicians are extremely supportive of the nurses, and their demands for more pay and better conditions in all the healthcare settings I've worked. The real problem is the unaccountable bureaucratic management, which are neither physicians nor nurses, and the numbers of which continue to expand (sucking up financial resources) while physicians and nurses workload increases and pay continues to decrease in real terms.
  - geogra4 5y ago
    I tend to agree with the parent post about the extreme rigidness though causing issues. My wife is an Occupational Therapist and in some states she can supervise showering and some states only nurses can. Some states she can initiate cases and some states she can't. There are too many micro-specialties and not enough crossover. Imagine if once you were a frontend dev you would have to go back to school for 2 years full time to be legally allowed to do ui design of a button even though there is a lot of crossover and knowledge sharing between roles. This definitely causes shortages and issues when the demand naturally rises and falls for various Healthcare disciplines. I'm not saying formal education isn't important but there could be a much more fluid crossover between various allied health disciplines than their is currently. Maybe more transition programs or seeing individual billing codes for Medicare attached to education modules
  - maxerickson 5y ago
    It's driven (or at least exacerbated) by the physician shortage. If it weren't profitable to have large numbers of staff per doctor, there wouldn't be large numbers of staff per doctor.
stefan_ 5y ago
Then we already know the next steps: ships will be rust-free, but nothing that isn't immediately obvious will work.
jonhohle 5y ago
It’s almost as if heavily regulated and entrenched organizations with limited competition develop complacency.
WalterBright 5y ago
> Why does this malady strike the U.S. Navy and healthcare so severely? Totally government run in the case of the military, and healthcare is the most heavily regulated industry (by far) in the US. Heavy bureaucratic regulations make an organization unable to adapt to local and/or changing circumstances. I read in the book "The Pity of War" by Ferguson that the reason the death rates of the German army in WW1 were so much lower than that of the British is the British generals would craft detailed orders on how the soldiers were to achieve objectives. The German generals would instead just give the officers the objectives. The officers were free to adapt to local circumstances. A similar idea is a story I heard where a class of new lieutenants were asked how would they go about raising a flagpole. The lieutenants all wrote down detailed instructions and procedures. The instructor said you're all wrong. The correct answer is "sergeant, get that flagpole up!".
- hollerith 5y ago
  >the reason the death rates of the German army in WW1 were so much lower than that of the British If the advice you just gave is so good, why couldn't you (or the book's author) have found an example in which the side following the advice actually won the war?
  - WalterBright 5y ago
    If you're interest in exploring this further, I recommend the book "Strategy" by Hart for a dance through the history of warfare and what works and doesn't. As for WW1, Germany did defeat Russia. It took America's entry into the war to defeat Germany. But you want an example. Take WW2. When Hitler allowed his generals to run things, things went well for the German army. When Hitler decided he knew better, he micromanaged the Wehrmacht into defeat and ruin. The Luftwaffe's problems were greatly impeded by Goering making a hash of things, despite his officers pleading with him. Goering would dictate tactics that negated the advantages of the Me-109s in the Battle of Britain. Goering also infamously ordered a literal decimation of his pilots for cowardice, an order that was quietly ignored. In the naval war, the U-Boot commanders knew that Enigma had been broken and tactics had to change, but Admiral Doenitz knew better and sent them to their doom. Some histories assert that the Germans were clueless about Enigma, but the U-Boot commanders knew the truth.

ethbr0 5y ago

> Why does this malady strike the U.S. Navy and healthcare so severely? Both industries substantially outsourced functionality in the 90s in an attempt to cut costs. Consequently, they are now less empowered (vs historical levels) to effect change in their own processes in a timely manner. Large organizations need to pay more attention to ossification of processes as a serious future risk, that needs to be balanced against immediate savings.

killjoywashere 5y ago

As a Navy physician who has dealt with COVID and fatigue, I think the chronic low pay contributes to a lack of people which leads to overwork, exhaustion, a sort of "this is my lot in life" acceptance of mild to moderate depression. And you get to the point you just look away for your own sanity. Healthcare workers get paid less as you get closer to the coasts. And military gets only very modest pay adjustments for housing costs. A colonel in Kansas may live like a king, but a captain in San Diego can't afford a house. Edit: I also agree with the posts about outsourcing leading to ossification and rigid stratification. You want rigid stratification? Try military medicine.

ethbr0 5y ago
Great point! At the end of the day, we're talking about people. Highly trained people in Navy, medicine, and Navy medicine cases. And people have limits, because they need lives and aren't robots. Morale and aligning work to allow for happiness in life is a requirement for people bringing their best to work. If you ask people to toughen up and suffer through the suck to get the job done... there'd better be an eventual light at the end of that tunnel. Otherwise, it's just a death march. PS: Thank you for your service, and especially through COVID.
jwithington 5y ago
The Navy pays officers very generously across all fields, EXCEPT medicine and JAG. URL JOs will take a pay cut for the first several years (at least) after leaving for the civilian sector. I never, ever heard a URL peer get out because of financial reasons. FWIW, BAH (pay for housing that is tax-free) is $4000 for an O-6 in Point Loma v. $2777 in Offut, NE. Seems to be aggressive adjustment, no? Enlisted pay might be another story… EDIT: I know one guy who griped about pay once…kind of in passing. Went on to be a YC founder haha.
- xattt 5y ago
  For Medical and JAG, are VA benefits (ie paid long-term care) worth the loss in income over the longer term?
  - lotsofpulp 5y ago
    You will never know. That is the great thing about “benefits”, the recipient has no control or knowledge. The employer, or politicians, 5, 10, 20 years from now can cut funding and reduce access from MDs to NP/PA, or only cover certain meds, or require excessive prior authorizations to dissuade using the healthcare.
    - yhoneycomb 5y ago
      Exactly this. The VA already is hiring as many midlevels (NP/PA) as possible so that they don't have to hire MDs. You wouldn't believe how low the bar is to become an NP. PAs receive substantially better training, but at the end of the day they are still midlevels. Worse still, many NP programs are now giving out "doctorates" of nursing practice so that NPs can introduce themselves to the patient as "Dr." Smith. In short, the VA is willing to gamble with your life if it means saving a few bucks. It's pretty harrowing.
      - nradov 5y ago
        Is there any evidence that care by midlevels produces worse outcomes for routine cases?
deleted 5y ago
[deleted]
metaphor 5y ago
> A colonel in Kansas may live like a king, but a captain in San Diego can't afford a house. Assuming both sought living accomodations outside of free base housing, I was curious what those figures actually looked like[1]: - O-6 colonel stationed at, e.g. Fort Riley, KS 66442, would draw up to an additional $1500 without dependents, $1911 with. - O-6 captain stationed at, e.g. NAS North Island, CA 92135, would draw up to an additional $3342 without dependents, $4026 with. It's worth mentioning for those unfamiliar that, just like BAS (i.e. food allowance), this BAH (i.e. housing allowance) is completely tax-exempt. The game that active service members play here is to secure a home mortgage (often through VA home loan), then apply BAH directly towards monthly mortgage payments throughout service all the way to retirement. It's not hard to imagine other tax advantaged games to be played here. Applying BAH to rent a house off base is a naive fool's errand. In terms of annual cost of living adjustments to base pay, uniformed service received +2.7% increase this year; in contrast, +2.2% for federal GS civilians. The year before that, it was +3% v. +1%. These adjustments have historically favored uniformed service over the federal civilians that work beside them. Sure, they're lowball relative to inflation, but that ought to be squared against military tax-exempt BAS/BAH and hugely subsidized commissary entitlements. Exceptionally common amongst Navy personnel, married sailors typically draw an additional $250/mo family separation allowance[2] when out at sea for more than 30 continuous days. This will obviously have a greater financial impact amongst the enlisted ranks than officers. Depending on rank and job, there's a litany of allowances, bonuses and incentives (beyond the scope of this remark) that are often ignored when the conversation of military service compensation is brought up...nevermind that no one ever talks about the opportunity to retire with guaranteed pension + benefits for life as young as 38. As an outsider, I'm inclined to agree that military health professions do seem to pay a substantial indirect opportunity cost despite the unique bonuses they're entitled to[3]. I do wonder what individual circumstances led you to choose a Navy commission over everything else? [1] https://www.defensetravel.dod.mil/site/bahCalc.cfm https://www.defensetravel.dod.mil/site/bahCalc.cfm [2] https://www.dfas.mil/militarymembers/payentitlements/fsa/ https://www.dfas.mil/militarymembers/payentitlements/fsa/ [3] https://www.dfas.mil/militarymembers/payentitlements/Pay-Tables/ https://www.dfas.mil/militarymembers/payentitlements/Pay-Tab...
- sgarland 5y ago

orzig 5y ago

I know much more about healthcare than the Navy, but it’s notable that they both have rigid stratification between roles. I could imagine that hampering operational feedback loops in normal times, and strategic feedback loops given the labor supply/demand situation in these extraordinary times.

chromatin 5y ago
At least in healthcare, I doubt this is a major causative factor (presuming when you say roles you mean physicians and nurses) -- the physicians are extremely supportive of the nurses, and their demands for more pay and better conditions in all the healthcare settings I've worked. The real problem is the unaccountable bureaucratic management, which are neither physicians nor nurses, and the numbers of which continue to expand (sucking up financial resources) while physicians and nurses workload increases and pay continues to decrease in real terms.
- geogra4 5y ago
  I tend to agree with the parent post about the extreme rigidness though causing issues. My wife is an Occupational Therapist and in some states she can supervise showering and some states only nurses can. Some states she can initiate cases and some states she can't. There are too many micro-specialties and not enough crossover. Imagine if once you were a frontend dev you would have to go back to school for 2 years full time to be legally allowed to do ui design of a button even though there is a lot of crossover and knowledge sharing between roles. This definitely causes shortages and issues when the demand naturally rises and falls for various Healthcare disciplines. I'm not saying formal education isn't important but there could be a much more fluid crossover between various allied health disciplines than their is currently. Maybe more transition programs or seeing individual billing codes for Medicare attached to education modules
- maxerickson 5y ago
  It's driven (or at least exacerbated) by the physician shortage. If it weren't profitable to have large numbers of staff per doctor, there wouldn't be large numbers of staff per doctor.

stefan_ 5y ago

Then we already know the next steps: ships will be rust-free, but nothing that isn't immediately obvious will work.

jonhohle 5y ago

It’s almost as if heavily regulated and entrenched organizations with limited competition develop complacency.

WalterBright 5y ago

> Why does this malady strike the U.S. Navy and healthcare so severely? Totally government run in the case of the military, and healthcare is the most heavily regulated industry (by far) in the US. Heavy bureaucratic regulations make an organization unable to adapt to local and/or changing circumstances. I read in the book "The Pity of War" by Ferguson that the reason the death rates of the German army in WW1 were so much lower than that of the British is the British generals would craft detailed orders on how the soldiers were to achieve objectives. The German generals would instead just give the officers the objectives. The officers were free to adapt to local circumstances. A similar idea is a story I heard where a class of new lieutenants were asked how would they go about raising a flagpole. The lieutenants all wrote down detailed instructions and procedures. The instructor said you're all wrong. The correct answer is "sergeant, get that flagpole up!".

hollerith 5y ago
>the reason the death rates of the German army in WW1 were so much lower than that of the British If the advice you just gave is so good, why couldn't you (or the book's author) have found an example in which the side following the advice actually won the war?
- WalterBright 5y ago
  If you're interest in exploring this further, I recommend the book "Strategy" by Hart for a dance through the history of warfare and what works and doesn't. As for WW1, Germany did defeat Russia. It took America's entry into the war to defeat Germany. But you want an example. Take WW2. When Hitler allowed his generals to run things, things went well for the German army. When Hitler decided he knew better, he micromanaged the Wehrmacht into defeat and ruin. The Luftwaffe's problems were greatly impeded by Goering making a hash of things, despite his officers pleading with him. Goering would dictate tactics that negated the advantages of the Me-109s in the Battle of Britain. Goering also infamously ordered a literal decimation of his pilots for cowardice, an order that was quietly ignored. In the naval war, the U-Boot commanders knew that Enigma had been broken and tactics had to change, but Admiral Doenitz knew better and sent them to their doom. Some histories assert that the Germans were clueless about Enigma, but the U-Boot commanders knew the truth.