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Comment author: Vaniver 13 December 2014 12:18:09AM *  2 points [-]

But how can you take issue with our insistence [Edit: more like strong encouragement!] that people use hand sanitizer at a 4-day retreat with 40 people sharing food and close quarters?

So, I have noticed that I am overhygienic relative to the general population (when it comes to health; not necessarily when it comes to appearance), and I think that's standard for LWers. I think this is related to taking numbers and risk seriously; to use dubious leftovers as an example, my father's approach to food poisoning is "eh, you can eat that, it's probably okay" and my approach to food poisoning is "that's only 99.999% likely to be okay, no way is eating that worth 10 micromorts!"

Comment author: Swimmer963 14 December 2014 03:32:51AM 1 point [-]

Interestingly, I think that when I'm not at work, I'm probably less hygienic than the average population–the implicit thought process is kind of like "oh my god, I have washed my hands every 5 minutes for 12 hours straight, I can't stand the thought of washing my hands again until I next have to go to work." I do make some effort at CFAR workshops but it's ughy.

Comment author: Swimmer963 14 December 2014 03:29:08AM 2 points [-]

Wow, reading this is surreal.

Comment author: Swimmer963 09 November 2014 03:03:21PM 18 points [-]

Third time starting the survey, first time finishing it!

Comment author: Lumifer 30 October 2014 09:13:19PM *  2 points [-]

But no automated system can be perfectly reliable

You are using the wrong yardstick. Ain't no thing is perfectly reliable. What matters is whether an automated system will be more reliable than the alternative -- human doctors.

Commercial aviation has a pretty good safety record while relying on autopilots. Are you quite sure that without the autopilot the safety record would be better?

whenever the system spits out, "No diagnosis found".

And why do you think a doctor will do better in this case?

Comment author: Swimmer963 30 October 2014 09:34:46PM 2 points [-]

I was going to say "doctor's don't have the option of not picking the diagnosis", but that's actually not true; they just don't have the option of not picking a treatment. I've had plenty of patients who were "symptom X not yet diagnosed" and the treatment is basically supportive, "don't let them die and try to notice if they get worse, while we figure this out." I suspect that often it never gets figured out; the patient gets better and they go home. (Less so in the ICU, because it's higher stakes and there's more of an attitude of "do ALL the tests!")

Comment author: adamzerner 18 November 2013 07:42:17AM 2 points [-]

I find that the signaling aspect maybe accounts for 20-30% of the phenomenon.

I think that about 20-30% of the time (off the top of my head), my good conversations happen late at night because we stay up late because we're in a good conversation. But more often, we stay up late because we just don't want to go to sleep, and then it is like 3 in the morning, and something about it being 3 in the morning triggers good conversation.

It would be interesting to test what actually about "it being late" triggers the good conversation. For example, you could test to see if it is tiredness, or time of the day, or how many hours it's been since you woke up.

Comment author: Swimmer963 30 October 2014 09:30:56PM 1 point [-]

I think reduced inhibitions that come with tiredness might help here.

Comment author: private_messaging 29 October 2014 04:18:44PM *  2 points [-]

Whereas I'm pretty much always underconfident

That's a bit of self contradictory statement, isn't it? (People can be unassertive but internally very overconfident, by the way).

So you have that patient, and you have your idea on the procedures that should have been done, and there's doctor's, and you in retrospect think you were under-confident that your treatment plan was superior? What if magically you were in the position where you'd actually have to take charge? Where ordering a wrong procedure hurts the patient? It's my understanding that there's a very strong initial bias to order unnecessary procedures, that takes years of experience to overcome.

I suspect it's one of things that look very different from the inside and from the outside... None of those arrogant newbies would have seen themselves in my description (up until they wisen up). Also, your prototype here is the heroic responsibility for saving the human race, taken upon by someone who neither completed formal education in relevant subjects, nor (which would actually be better to see) produced actual working software products of relevance, nor other things of such nature evaluated to be correct in a way that's somewhat immune to rationalization. And a straightforwardly responsible thing to do is to try to do more of rationalization-immune things to practice, because the idea is that screwing up here has very bad consequences.

Other issue is that you are essentially thinking meat, and if the activation of the neurons used for responsibility is outside a specific range, things don't work right, performance is impaired, responsibility too is impaired, etc, whether the activation is too low or too high.

edit: to summarize with an analogy, say, driving a car without having passed a driving test is irresponsible, right? No matter how much you feel that you can drive the bus better than the person who's legally driving it, the responsible thing to do is to pass a driving test first. Now, the heroes, they don't need no stinking tests. They jump into the airplane cockpit and they land it just fine, without once asking if there's a certified pilot on board. In most fiction, heroes are incredibly irresponsible, and the way they take responsibility for things is very irresponsible, but it all works out fine because it's fiction.

Comment author: Swimmer963 29 October 2014 05:41:41PM 7 points [-]

So you have that patient, and you have your idea on the procedures that should have been done, and there's doctor's, and you in retrospect think you were under-confident that your treatment plan was superior?

I'm not sure that the doctor and I disagreed on that much. So we had this patient, who weighed 600 pounds and had all the chronic diseases that come with it, and he was having more and more trouble breathing–he was in heart failure, with water backing up into his lungs, basically. Which we were treating with diuretics, but he was already slowly going into kidney failure, and giving someone big doses of diuretics can push them into complete kidney failure, and also can make you deaf–so the doses we were giving him weren't doing anything, and we couldn't give him more. Normally it would have been an easy decision to intubate him and put him on a ventilator around Day 3, but at 600 pounds, with all that medical history, if we did that he'd end up in the hospital for six months, with a tracheotomy, all that. So the doctor had a good reason for wanting to delay the inevitable as long as possible. We were also both expecting that he would need dialysis sooner or later...but we couldn't put him on dialysis to take water off his lungs and avoid having to intubate him, because he was completely confused and delirious and I had enough trouble getting him to keep his oxygen mask on. Dialysis really requires a patient who stays still. We couldn't give him too many medications to calm him down, because anything with a sedative effect would decrease his respiratory effort, and then he'd end up needed to be intubated.

Basically, it was a problem with so many constraints that there was no good solution. I think that my disagreement with the doctor was over values–specifically, the doctor thought of the scenario where we intubate him and put him on dialysis on Monday as basically equivalent to the scenario where we delay it as long as possible and then end up intubating him on Thursday. Whereas to me, latter, where my patient got to spend four extra days writhing around, confused and in pain and struggling to breathe, was a lot worse. I think nurses are trained to have more empathy and care more about a patient being in pain, and also I was seeing him for twelve hours a day whereas the doctor was seeing him for five minutes. And I was really hoping that there was a course of action no one had thought of that was better...but there wasn't, at least not one I was able to think of. So the guy suffered for five days, ended up intubated, and is probably still in the hospital.

What if magically you were in the position where you'd actually have to take charge? Where ordering a wrong procedure hurts the patient?

I would be terrified all the time of doing the wrong thing. Maybe even more than I already am. I think as a nurse, I basically have causal power a lot of the time anyway–I point a problem out to the doctor, I suggest "do you want to do X", he says, "Yeah, X is a good idea." That's scary, despite the presence of a back-up filter that will let me know if X is a terrible idea. [And doctors also have a lot of back-up filters: the pharmacy will call them to clarify a medication order that they think is a bad idea, and nurses can and will speak their opinion, and have the right to refuse to administer treatment if they think that it's unsafe for the patient.]

Comment author: private_messaging 29 October 2014 07:01:25AM *  5 points [-]

There may be Dunning-Kruger effect though...

I don't know about the medical context but in the software context, the "heroically responsible" developer is the new guy who is waxing poetic about switching to another programming language (for no reason and entirely unaware of all the bindings that would need to be implemented), who wants others to do unit tests in the situation where they're inapplicable or do some sort of agile development where more formal process with tests is necessary, and fails to recognize unit testing already in place, etc.

He puts himself and his need to be the hero of the project's story ahead of the needs of the project, which is irresponsible, he doesn't actually take time to critically evaluate his own proposals before making them (not fun), which is again irresponsible. His need to heroically save the project is more important than the success of the team. People like him are the starters of those 90%+ start-ups that fail, wasting other people's money and time.

But in his own mind he's the only responsible person on the whole team. The tech lead spents his near-deadline weekend going over thousands lines of other people's code and fixing up other people's bugs? Doesn't register to that new guy, it's still just him.

Eventually most people grow out of that mindset. (I'd dare say most people exhibit some of such behaviours for at least a short period of time. )

Comment author: Swimmer963 29 October 2014 07:32:30AM 2 points [-]

This may indeed be a failure mode that new people on teams are prone to, and maybe even something that new people on teams are especially prone to if they've read HPMOR, but I don't think it's the same as the thing I'm talking about–and in particular this doesn't sound like me, as a new nurse who's read HPMOR. I think the analog in nursing would be the new grad who's carrying journal articles around everywhere, overconfident in their fresh-out-of-school knowledge, citing the new Best Practice Guidelines and nagging all the experienced nurses about not following them. Whereas I'm pretty much always underconfident, trying to watch how the experienced nurses do things and learn for them, asking for help lots, and offering my help to everyone all the time. Which is probably annoying sometimes, but not in the same way.

I think that there is a spirit of heroic responsibility that makes people genuinely stronger, which Eliezer is doing his best to describe in HPMOR, and what you described is very much not in the spirit of heroic responsibility.

A discussion of heroic responsibility

36 Swimmer963 29 October 2014 04:22AM

[Originally posted to my personal blog, reposted here with edits.]


You could call it heroic responsibility, maybe,” Harry Potter said. “Not like the usual sort. It means that whatever happens, no matter what, it’s always your fault. Even if you tell Professor McGonagall, she’s not responsible for what happens, you are. Following the school rules isn’t an excuse, someone else being in charge isn’t an excuse, even trying your best isn’t an excuse. There just aren’t any excuses, you’ve got to get the job done no matter what.” Harry’s face tightened. “That’s why I say you’re not thinking responsibly, Hermione. Thinking that your job is done when you tell Professor McGonagall—that isn’t heroine thinking. Like Hannah being beat up is okay then, because it isn’t your fault anymore. Being a heroine means your job isn’t finished until you’ve done whatever it takes to protect the other girls, permanently.” In Harry’s voice was a touch of the steel he had acquired since the day Fawkes had been on his shoulder. “You can’t think as if just following the rules means you’ve done your duty. –HPMOR, chapter 75.

I like this concept. It counters a particular, common, harmful failure mode, and that it’s an amazingly useful thing for a lot of people to hear. I even think it was a useful thing for me to hear a year ago.

But... I’m not sure about this yet, and my thoughts about it are probably confused, but I think that there's a version of Heroic Responsibility that you can get from reading this description, that's maybe even the default outcome of reading this description, that's also a harmful failure mode. 

Something Impossible

A wrong way to think about heroic responsibility

I dealt with a situation at work a while back–May 2014 according to my journal. I had a patient for five consecutive days, and each day his condition was a little bit worse. Every day, I registered with the staff doctor my feeling that the current treatment was Not Working, and that maybe we ought to try something else. There were lots of complicated medical reasons why his decisions were constrained, and why ‘let’s wait and see’ was maybe the best decision, statistically speaking–that in a majority of possible worlds, waiting it out would lead to better outcomes than one of the potential more aggressive treatments, which came with side effects. And he wasn’t actually ignoring me; he would listen patiently to all my concerns. Nevertheless, he wasn’t the one watching the guy writhe around in bed, uncomfortable and delirious, for twelve hours every day, and I felt ignored, and I was pretty frustrated.

On day three or four, I was listening to Ray’s Solstice album on my break, and the song ‘Something Impossible’ came up. 

Bold attempts aren't enough, roads can't be paved with intentions...
You probably don’t even got what it takes,
But you better try anyway, for everyone's sake
And you won’t find the answer until you escape from the
Labyrinth of your conventions.
Its time to just shut up, and do the impossible.
Can’t walk away...
Gotta break off those shackles, and shake off those chains
Gotta make something impossible happen today... 
It hit me like a load of bricks–this whole thing was stupid and rationalists should win. So I spent my entire break talking on Gchat with one of my CFAR friends, trying to see if he could help me come up with a suggestion that the doctor would agree was good. This wasn’t something either of us were trained in, and having something to protect doesn't actually give you superpowers, and the one creative solution I came up with was worse than the status quo for several obvious reasons.

I went home on day four feeling totally drained and having asked to please have a different patient in the morning. I came in to find that the patient had nearly died in the middle of the night. (He was now intubated and sedated, which wasn’t great for him but made my life a hell of a lot easier.) We eventually transferred him to another hospital, and I spent a while feeling like I’d personally failed. 

I’m not sure whether or not this was a no-win scenario even in theory. But I don't think I, personally, could have done anything with greater positive expected value. There's a good reason why a doctor with 10 years of school and 20 years of ICU experience can override a newly graduated nurse's opinion. In most of the possible worlds, the doctor is right and I'm wrong. Pretty much the only thing that I could have done better would have been to care less–and thus be less frustrated and more emotionally available to comfort a guy who was having the worst week of his life. 

In short, I fulfilled my responsibilities to my patient. Nurses have a lot of responsibilities to their patients, well specified in my years of schooling and in various documents published by the College of Nurses of Ontario. But nurses aren’t expected or supposed to take heroic responsibility for these things. 

I think that overall, given a system that runs on humans, that's a good thing.  

The Well-Functioning Gear

I feel like maybe the hospital is an emergent system that has the property of patient-healing, but I’d be surprised if any one part of it does.

Suppose I see an unusual result on my patient. I don’t know what it means, so I mention it to a specialist. The specialist, who doesn’t know anything about the patient beyond what I’ve told him, says to order a technetium scan. He has no idea what a technetium scan is or how it is performed, except that it’s the proper thing to do in this situation. A nurse is called to bring the patient to the scanner, but has no idea why. The scanning technician, who has only a vague idea why the scan is being done, does the scan and spits out a number, which ends up with me. I bring it to the specialist, who gives me a diagnosis and tells me to ask another specialist what the right medicine for that is. I ask the other specialist – who has only the sketchiest idea of the events leading up to the diagnosis – about the correct medicine, and she gives me a name and tells me to ask the pharmacist how to dose it. The pharmacist – who has only the vague outline of an idea who the patient is, what test he got, or what the diagnosis is – doses the medication. Then a nurse, who has no idea about any of this, gives the medication to the patient. Somehow, the system works and the patient improves.

Part of being an intern is adjusting to all of this, losing some of your delusions of heroism, getting used to the fact that you’re not going to be Dr. House, that you are at best going to be a very well-functioning gear in a vast machine that does often tedious but always valuable work. –Scott Alexander

The medical system does a hard thing, and it might not do it well, but it does it. There is too much complexity for any one person to have a grasp on it. There are dozens of mutually incomprehensible specialties. And the fact that [insert generic nurse here] doesn't have the faintest idea how to measure electrolytes in blood, or build an MRI machine, or even what's going on with the patient next door, is a feature, not a bug.

The medical system doesn’t run on exceptional people–it runs on average people, with predictably average levels of skill, slots in working memory, ability to notice things, ability to not be distracted thinking about their kid's problems at school, etc. And it doesn’t run under optimal conditions; it runs under average conditions. Which means working overtime at four am, short staffing, three patients in the ER waiting for ICU beds, etc. 

Sure, there are problems with the machine. The machine is inefficient. The machine doesn’t have all the correct incentives lined up. The machine does need fixing–but I would argue that from within the machine, as one of its parts, taking heroic responsibility for your own sphere of control isn’t the way to go about fixing the system.

As an [insert generic nurse here], my sphere of control is the four walls of my patient's room. Heroic responsibility for my patient would mean...well, optimizing for them. In the most extreme case, it might mean killing the itinerant stranger to obtain a compatible kidney. In the less extreme case, I spend all my time giving my patient great care, instead of helping the nurse in the room over, whose patient is much sicker. And then sometimes my patient will die, and there will be literally nothing I can do about it, their death was causally set in stone twenty-four hours before they came to the hospital. 

I kind of predict that the results of installing heroic responsibility as a virtue, among average humans under average conditions, would be a) everyone stepping on everyone else’s toes, and b) 99% of them quitting a year later.

Recursive Heroic Responsibility

If you're a gear in a machine, and you notice that the machine is broken, your options are a) be a really good gear, or b) take heroic responsibility for your sphere of control, and probably break something...but that's a false dichotomy. Humans are very flexible tools, and there are also infinite other options, including "step out of the machine, figure out who's in charge of this shit, and get it fixed." 

You can't take responsibility for the individual case, but you can for the system-level problem, the long view, the one where people eat badly and don't exercise and at age fifty, morbidly obese with a page-long medical history, they end up as a slow-motion train wreck in an ICU somewhere. Like in poker, you play to win money–positive EV–not to win hands. Someone’s going to be the Minister of Health for Canada, and they’re likely to be in a position where taking heroic responsibility for the Canadian health care system makes things better. And probably the current Minister of Health isn’t being strategic, isn’t taking the level of responsibility that they could, and the concept of heroic responsibility would be the best thing for them to encounter.

So as an [insert generic nurse here], working in a small understaffed ICU, watching the endless slow-motion train wreck roll by...maybe the actual meta-level right thing to do is to leave, and become the freaking Minister of Health, or befriend the current one and introduce them to the concept of being strategic. 

But it's fairly obvious that that isn't the right action for all the nurses in that situation. I'm wary of advice that doesn't generalize. What's difference between the nurse who should leave in order to take meta-level responsibility, and the nurse who should stay because she's needed as a gear?

Heroic responsibility for average humans under average conditions

I can predict at least one thing that people will say in the comments, because I've heard it hundreds of times–that Swimmer963 is a clear example of someone who should leave nursing, take the meta-level responsibility, and do something higher impact for the usual. Because she's smart. Because she's rational. Whatever. 

Fine. This post isn't about me. Whether I like it or not, the concept of heroic responsibility is now a part of my value system, and I probably am going to leave nursing.

But what about the other nurses on my unit, the ones who are competent and motivated and curious and really care? Would familiarity with the concept of heroic responsibility help or hinder them in their work? Honestly, I predict that they would feel alienated, that they would assume I held a low opinion of them (which I don't, and I really don't want them to think that I do), and that they would flinch away and go back to the things that they were doing anyway, the role where they were comfortable–or that, if they did accept it, it would cause them to burn out. So as a consequentialist, I'm not going to tell them. 

And yeah, that bothers me. Because I'm not a special snowflake. Because I want to live in a world where rationality helps everyone. Because I feel like the reason they would react that was isn't because of anything about them as people, or because heroic responsibility is a bad thing, but because I'm not able to communicate to them what I mean. Maybe stupid reasons. Still bothers me. 

Comment author: Swimmer963 27 October 2014 10:22:21AM 0 points [-]

Anecdotally, it doesn't feel like I get overall improved functioning from caffeine, but I can use it to gain control of when my high-alertness and low-alertness periods will happen. This is 100% a must for the kind of shift work schedule I'm doing right now, which definitely was not intended for humans. I usually consume caffeine at work only and minimize it on my days off; ideally this adds up to consuming it on 4/9 days, in practice more because I take overtime. I take longer breaks whenever possible. Caffeine is pretty much what allows me to function during 12 hour night shifts.

I think that maybe if I could completely remove the effects of current caffeine dependence, I might be able to handle 12 hour day shifts (7 am-7 pm) caffeine free, but I'm not sure about that. Caffeine helps smooth out dips and slumps in my circadian rhythms, and I need all of the alertness I can muster to take care of humans on ventilators.

In response to On Caring
Comment author: Swimmer963 07 October 2014 02:00:08PM 8 points [-]

Wow this post is pretty much exactly what I've been thinking about lately.

Saving a person's life feels great.

Yup. Been there. Still finding a way to use that ICU-nursing high as motivation for something more generalized than "omg take all the overtime shifts."

Also, I think that my brain already runs on something like virtue ethics, but that the particular thing I think is virtuous changes based on my beliefs about the world, and this is probably a decent way to do things for reasons other than visceral caring. (I mean, I do viscerally care about being virtuous...)

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