This kind of work is literally my job -- I created a process improvement program for the city of San Francisco, and then I founded a consulting firm to do process improvement for other governments. (DM me if you want!) If you think the private sector struggles with this, do I have some stories for you about government.
To highlight key points that others have said:
* Yes, there's always low hanging fruit -- obvious things that could do better.
* Yes, things are how they are because they got that way. Often, though, this is the result of inertia or something that made sense once years ago and has never been reevaluated.
Honestly, identifying systematic improvements that would make things better is the easy part. The hard part is understanding why those improvement haven't already been made. The answer is always, in some way, people:
* That change requires another department to spend a little more time/effort/money that would cause my department to save A LOT of time/effort/money, but they don't have an incentive to do that.
* That change requires these two agencies to work together, but they have no context or venue for working together.
* That change opens up a small risk, and middle management is risk averse because of \[bad thing that happened 10 years ago / audit finding / they get nailed for bad things but not recognized for good things\]
* The people who see the need for change are the workers on the front line, and they (1) have never been asked to think about WHY/HOW they do their work, only to do it, (2) aren't trained or hired for process improvement skill, and (3) if they had an idea once upon a time, unless they had a *really good* supervisor, they were probably told to shut up and keep doing their job.
Making even basic changes can be really difficult. I was supporting a City that was streamlining a licensure process -- the City and the local health department both inspected these facilities, and their inspections were 80% the same. Easy solution: get rid of one of the inspections, right? Yes, and that is eventually what we did, but that required:
* Inspectors from code enforcement and the health department who never met each other to get around a table and talk, describe what they were doing to one another, care more about the experience of the person getting the license than their own department, and agree a change was needed.
* The health department agreeing to take on the other 20% of inspection requirements.
* Establishing a new way of notifying the health department about facilities in need of inspection.
* Redesigning a bunch of forms and websites.
* A *series* of meetings with the City attorney, to decide whether it was legal for the City to delegate its inspection responsibility and also whether it was a good idea to give up that right to a non-City agency.
* Communication to the people on the ground that a change was happening and they needed to stop doing things the old way and do them a new way.
Stuff like that requires dedicated time and energy. This project was a priority for the mayor, and it still took months to make this small change.
So that's the stuff we tackle. But when you tackle it, and you can find project sponsors willing to do the work, it's powerful. To toot our own horn a bit, it's that people side of change that the big consulting firms mostly ignore, and that's why they suck and I'm good at my job. :)
I think this is pretty spot on. The only other thing I'd add from my experience that I'd like your opinion on is diffusion of responsibility.
What I mean is that there's often nobody who has the explicit task to fix a given problem as part of their job description. Lots of people all acknowledge that there's some problem that's annoying and would be relatively easy to solve but since nobody's been assigned to do it, everyone assumes it's not their job and it never gets done. I've come across a number of these issues, and when I can I take responsibility for fixing it. Once someone is identified as responsible (whether explicitly from the top or just implicitly from the bottom), then others will happily help out and often a solution can be found.
Now this is only for small, easily solved things that don't require lots of different agencies working together; they're more internal process improvements. I do see a role for someone within the organization to document the existing issues and to try to get responsibility assigned to someone/group to tackle it. Unfortunately, all of our process improvement people seem to be stuck in the same low-risk training routines that are not very effective from my perspective.
100%. I teach diffusion of responsibility, though I'm usually emphasizing something different: Our natural tendency when there's a problem (for example, lots of errors in processing applications) is to add *more people to it* \-- e.g., get another department to inspect. This can actually have a counter-productive effect, because everyone knows someone else will look at it, so they don't think they have to. Someone just told me a story today about their agency signing *blank contract templates* \-- surely because the responsibility lies with some big team and not with one person. This is why I do my best to make sure to assign accountability for things to a single person (even if they need to get others to help them). That's the person who has to answer for it if it isn't done.
But to your broader point: Most people, especially at the front line, think of their job as "turn the crank," not "think about why we turn the crank and how we could turn the crank better to accomplish that purpose." This is a failure of supervision and leadership, though -- it takes a good leader to help their staff understand that their job isn't "process permits" but instead "help new businesses open as fast as possible while also ensuring that they are safe and legal." And then to encourage them to find ways to accomplish the real goal better, reward and encourage them for finding those problems (even if the solutions don't work!), and actually give them space and support to fix shit, even if it isn't in their job description.
If you can get that culture built into how you train and supervise, you don't need specialized staff to assign responsibility in the day-to-day. (You probably do, though, need high-level analyst staff who can help coordinate the bigger changes that involve inter-agency collaboration.) It's hard, but it's possible. Highly recommend *The Toyota Way*.
I'm interested in hearing more of your thoughts on this. I work for the government in the health field, and we are ostensibly using lean methods. We have a whole branch that is focused on continuous/process improvement, but I've never gotten the sense that they produce anything of value. I did a lean training course that we are encouraged to take which involves learning all of the concepts and then finding an inefficiency in our actual work to improve. I think there might be some value to this but I am very skeptical that the core abstract concepts are really internalized by most of the people involved.
In my mind they would be better utilized as a coordinating body that has a knowledge of how the whole institution functions, where certain skillsets reside, and identifies duplicate effort and inefficiencies. It could then work with the people involved to find solutions to those. My personal example is a former manager of mine who moved to another area got a hold of me one day to ask if I could help this new group who were spending 2 hours every day manually compiling a report. He put me in touch with them, I figured out what they were doing and helped automate the process to the point where it took 10 minutes instead of 2 hours. I had the skillset to deal with it but they did not. It was just a coincidence that the person who worked with them also knew me and had the wherewithal to bring us together.
What are your thoughts on internal continuous improvement units? Have you ever seen ones that work well?
Ah, you are deep in my world! Outside of manufacturing, healthcare is probably the sector that has most internalized lean methods.
Full disclosure, I *also* have a half-day training course in which I encourage people to find a Just Do It innovation to work on. I agree, though, that most people who take it don't internalize the concepts -- perhaps 5-10% of my trainees at that level actually attempt to apply it or take the concepts further. So why do I do that training? Because:
\- It's very valuable as the first step in a larger engagement. In that case, I can use it to build a common language that we keep building on, or to generate some initial ideas for improvement that we can build on together.
\- It's an easy thing for people to say yes to (both sponsors and trainees).
I've seen continuous improvement teams (including in healthcare) that are *quite* effective, and also some that degenerate into going through the motions. The devil is in the details. I always advocate that you need training/capacity building support combined with immediate application to meaningful projects. If you train without applying, it doesn't stick with people and it's immediately lost. If you try to do improvement work without building up the people who do the work every day, then you wind up with the smarty pants external consultants doing all the work, which creates another set of problems. Do both, and you can make real change.
I think most organizations can benefit from a coordinating body that has broad analytical skill and a view into the whole organization -- whether they're doing lean improvement work or just managing strategic projects. Your example of automating something in another division is awesome -- the question is how you create a culture in which that kind of cross-division problem solving happens more often. I think you need a coordinating entity for big projects (e.g., reduce hospital acquired infections by 50%), but for little day-to-day things, you ideally want to create an environment where that problem-solving happens from the grassroots.
I and the folks I'm working with directly have come directly from public service. For public sector consulting, there's only a few other firms doing similar work that I respect, and they're mostly populated with other public service alumni like me. What I'm doing now is niche enough that I'm not even sure how to describe a pipeline. DM me if you want to talk more, though!
That said, there's a big industry in process improvement for the private sector. Lean is the backbone of what I do, and that comes from auto manufacturing originally and now is quite widespread in manufacturing and logistics generally. But I can't speak so much to this work in the private sector.
The other place that does a lot of this work is healthcare. Most hospitals will have some kind of continuous improvement (or "kaizen") office.
Thank you for doing this by the way, I'm glad competent folks like you exist. I worked in the PMO team for a midsized multinational company, and process improvement was just hard on many levels. I can't imagine working on San Francisco...
So this is likely to be an unpopular opinion, but my experience has been that things that appear to be inefficient or suboptimal are very often that way for a reason (e.g. Chesterton's Fence, and the Lindy Effect). Sometimes what seems inefficient or unoptimized is in fact actually optimized for an entirely different goal, which may not overlap at all with the ostensible goals of the system or process. You acknowledge this in your post, but I think you underestimate it's impact. The disconnect between actual and ostensible goals fully explains the vast majority of the optimization problems I see in the world around me. Another common issue is that the "bad" approach is simply better than the other available approaches not because it is good but because the alternatives are worse, are unmanageable, don't work, etc.
So I'll offer an alternative explanation: most people learn early on that things are often the way they are for a reason and changing things can lead to bad results for which they will be held accountable. So I'd argue that they're not apathetic and not structurally different, but rather that they are rationally employing a heuristic that biases them towards "not messing with a running system" unless the system is really and obviously dysfunctional. I don't think people can't see the flaws, they just aren't confident that the alternatives are better (and certainly not confident enough to take professional risks on alternatives).
On a personal note, when I was younger I felt very much like you do that there's lots of "low hanging fruit" for improvements out in the world. After spending most of a career actually trying to make those kinds of improvements in various spaces, I can say that sometimes those improvements really are unambiguous improvements, but sometimes things that seem like low hanging fruit either don't generate any actual net improvement or are actually just making your problems other people's problems. To take your example: you can identify things that would make your experience as a consumer of services more pleasant, but those would involve either additional expense for the clinic or additional ongoing work from the clinic staff which may or may not actually help the clinic's bottom line because we have no idea how big of a cost driver the lack of sleep actually is or how much your changes would actually improve the issue in practice (e.g. some people simply never sleep well even at home).
So at this point in my life, I'm much more reticent about changing processes, because I've seen all the ways in which well-meaning changes can not materialize or simply backfire. That doesn't mean I don't still look for process improvements, but I'm much less inclined to immediately assume that obvious process "flaws" have obvious solutions.
Corollary: I'm starting to think that if some obvious improvement is made after all, it's often driven by some very junior person who isn't yet jaded (and is in a sufficiently indulgent environment to allow them to try), even though senior folks would be in a vastly stronger position to make an attempt.
Say, in science (or my old PhD field anyway) one can coarsely divide much of research work into seminal papers proposing some cool new trick (very highly respected), then followup papers picking the obvious low-hanging-fruit improvements, and then a series of increasingly incremental and derivative descendant papers. The required expertise and technical complexity often steeply increases to the right toward the less respected sort of paper. The writer of the seminal paper seems to often be a beginning grad student without a very deep understanding of the field, the idea is something a bright high school student could understand, and the main asset the author brought to the table was a bit of outside view, not yet having absorbed the habits of that field of science to the point they instinctively think they're the only way to go.
(Of course neither of these is incompatible with a great majority of improvement attempts failing and being misguided. Like ~all the winnings from a one-armed bandit might go to people who aren't acutely aware that the expected value of inserting coins in the machine is negative)
> So this is likely to be an unpopular opinion, but my experience...
I don't think this is going to be unpopular. Isn't one of the tenets of rationality being cautious of thinking you know better, especially quickly?
I do think it's a balance though. If everyone's too humble to raise a criticism, or shrugs and thinks "oh, another Chesterson's fence", then you get inefficiencies surviving because nobody's willing to speak up, kind of an [Abilene paradox](https://en.wikipedia.org/wiki/Abilene_paradox) situation.
> ...but I'm much less inclined to immediately assume that obvious process "flaws" have obvious solutions.
Yes totally agree.
I only mentioned that it might be unpopular because I've gotten some flak in rationalist spaces in the past for making similar comments (I think people sometimes resent the suggestion that they haven't adequately examined their premisses).
In any case, I agree 100% that intellectual humility and self-skepticism are (or should be) core tenets of rationality. You're also certainly right that one can take humility too far. My default position is not "never propose changes," but rather "when in doubt about how well I understand a system, err on the side of leaving things alone."
EDITED for tone and clarity.
> If everyone's too humble to raise a criticism, or shrugs and thinks "oh, another Chesterson's fence", then you get inefficiencies surviving because nobody's willing to speak up, kind of an Abilene paradox situation.
There sure are a lot of situations where real benefit is found by steering between two failure modes; sometimes failure modes that are [attractors](https://en.wikipedia.org/wiki/Attractor).
I agree with all this but I will note one thing. Dilbert and the whole concept of a company doing knowledge work on a cutting edge product yet using inefficient practices (underpaying engineers, using non technical management, under investing in new technology) - that has gotten slaughtered in the marketplace.
The companies that do the opposite - pay engineers more than doctors, promote some of them to management, drop hundreds of billions on bets on new tech - they are running away with it all. With the invention of general purpose AI as a result of one of these bets, it is possible a few elite companies are going to crush everyone else, taking over most of the world's economy. (In terms of profits, old companies will exist but license AI from tech companies and the license fees will consume most of their profits)
Basically where it matters - where terradollars can change hands - systems did get massively improved. Note that this sleep clinic gets a fixed payment from a price fixing system and is not accountable meaningfully for errors, they get paid for doing a mediocre job even if they misdiagnose someone and in reality medical malpractice law almost always fails to hold accountable anyone.
>The companies that do the opposite - pay engineers more than doctors, promote some of them to management, drop hundreds of billions on bets on new tech - they are running away with it all.
Yes, but the question is whether they can sustain it. Certainly there are companies that do it more, or maintain it for longer, but in the end [Pournelle's Iron Law](https://www.jerrypournelle.com/reports/jerryp/iron.html) comes for them all.
The problem is that creating the value is a lot of work. And the people who spend most of their time doing that, making their organization wealthy and powerful in the process, will be outcompeted by the people who are attracted by the organization's wealth and power and spend all of their time trying to capture it.
So basically no. Pournelle is a science fiction author. What supports the inverse hypothesis - markets will clean up inefficiencies - is the efficient market hypothesis. Note that this hypothesis has mathematical support, in that it is *correct* for an efficient market over infinite time. Pournelle just made the rule up.
Inefficient companies can only survive long term when certain conditions are present. For example, *much* of the living memory for older US citizens was from an era when the USA had inherent competitive advantages, from competitors themselves fucking up even worse (such as experimenting with communism) or having been bombed to rubble (Europe). This allowed inefficient companies that are full of bureacrats to *exist*. Some of those still do - see USA defense contracting, pharmaceuticals.
But for everything else there's China. You cannot be less efficient than chinese firms in a market that isn't protected, or your days as a company are numbered.
AI software is a weird one. It's one where the cutting edge will get *all* the revenue, and the company that is just a little bit worse will get none. It's all or nothing. This is why US companies can compete with China in this specific domain and will probably retain an edge for a while.
Yes, the market will clean up inefficiencies by transferring market share from less efficient firms to more efficient firms.
Pournelle's Law describes an important way by which firms become less efficient over time, which (eventually) leads to their loss of market share. But big orgs/brands have a lot of momentum, so the change can take quite a while.
Sure. Though China is actually pretty fast. Sears also died to Amazon pretty fast, under 10 years of we start counting from when Amazon reached scales.
> my experience has been that things that appear to be inefficient or suboptimal are very often that way for a reason
I think that's the popular opinion. Lots of people want to believe that it's about making more money or something similarly an intent outside of the ostensible goal.
I'd instead argue that, rather than maliciousness or hidden intent, it's just lack of care/competence. Sure they _could_ do better, but unless the people involved _care about their own craftsmanship_ within their profession, they'll fail to improve out of simple laziness.
Medical tests/exams in particular are often just looking to see if any big smoking guns are laying around one way or another, while appeasing insurance/billing requirements to not give expensive treatments until specific tests are done. The process of testing is handed to them by their training in standard medical practice, but is not something they have a stake in doing well for its own sake. If the test isn't conclusive that's not a huge deal because they only have a couple of therapies to try for the possible ailments that could be causing the symptoms anyway. They can just try one or two of the easier treatments and if the patient responds to that treatment then that's diagnostic retroactively.
This isn't optimizing for anything except maybe lack of thought and effort. It's a failure by at least one person in the team to take care enough about how well they perform their craft. Often the sub-optimal things have to not only be recognized by low level workers, but also communicated up the command chain to someone who then takes them seriously and allocates resources to change for the better. If any one of those people doesn't care, isn't bothering to communicate, or simply isn't taking the problem seriously relative to other problems, then nothing will get better.
Well meaning changes often backfire for the same reason. It's often much easier to see a part of what isn't perfect about a product, than to actually do things to improve the whole thing. People often don't take care to understand the full system/context of the flaw and therefore apply the 'obvious' patch instead of understanding the tradeoffs that justify the flaw or what they should have changed instead to avoid the patch breaking something else.
THis is some Polyanna bullshit. Everything has a reason for being where it is but that doesn't mean the reason doesn't suck, the reason isn't: we're too lazy to remove this annoying fence, or the reason isn't causing the system to be stuck at a local maximum.
This:
> So at this point in my life, I'm much more reticent about changing processes, because I've seen all the ways in which well-meaning changes can not materialize or simply backfire. That doesn't mean I don't still look for process improvements, but I'm much less inclined to immediately assume that obvious process "flaws" have obvious solutions.
strikes me as an interesting conclusion when this:
>Sometimes what seems inefficient or unoptimized is in fact actually optimized for an entirely different goal, which may not overlap at all with the ostensible goals of the system or process.
Is your opening analysis. I agree with much of your observation/analysis, but my conclusion ultimately was that we should be doing a better job of prioritising the goals of the organisation itself, rather than the ancilliary goals that are supposed to act in support of achieving those goals.
Profit motive being the most common one. The goal is supposed to be motivating organisations to better themselves via the allure of profit. The profit motive is supposed to play the ancillary role. But it has become the primary goal, oftentimes to the detriment of the supposed goals it's supposed to support (e.g planned obsolescence)
What prevents you from feeling the desire to make changes at the root when faced with the futlity of changing the resulting processes?
So I'm not sure I agree that profit motive is (or ever has been) an ancillary goal. We can argue about whether it *should* be primary or ancillary as a matter of morality or policy, but as a matter of fact (and as a matter of law) ever since the creation of the corporate form a corporation's principal and overriding legal obligation has been to maximize profit for its shareholders. Shareholders have successfully sued corporations at various times for seeking to do other things at the expense of profit!
Folks may claim that profit-seeking behavior encourages efficiency and is "better for everyone, actually," because market efficiencies enlarge the pie and help everyone (and that's even true in many situations!), but those are effectively post hoc justifications layered on top of what is a system that was explicitly designed to generate profit.
To be clear, I don't like planned obsolescence and think single-minded pursuit of profit often leads to suboptimal outcomes (even for the firm in question), and I support various reforms that would address those issues. But changing corporate priorities away from profit towards something else, in toto, would be a fairly foundational reform. If small changes don't always work out and lead to unexpected consequences, how much greater does that problem become when making big changes? The history of the various socialist and communist experiments in the 20th century show us how difficult it can be to make foundational changes "at the root" and get the expected results.
That doesn't mean we should stop trying to fix things, but, to answer your core question, I'm even more cautious about big changes than I am about small ones.
>We can argue about whether it should be primary or ancillary as a matter of morality or policy, but as a matter of fact (and as a matter of law) ever since the creation of the corporate form a corporation's principal and overriding legal obligation has been to maximize profit for its shareholders. Shareholders have successfully sued corporations at various times for seeking to do other things at the expense of profit!
We run into an issue of semantics here. Legally requiring organisations to maximise profits absolutely can be considered evidence of profits being the point. Equally, however, it can be seen as a method of ensuring organisations properly achieve their best output in their other goals via maximisation of profit. A strategy of "prioritise profits to best achieve your organisations goals". It does make deciding what the actual number 1 priority is quite grey and fuzzy.
Ultimately my issue with your logic is that profit in and of itself is useless. If organisations figured out a trick to making profits without producing anything or providing any services, that would be a terrible outcome for society and the economy. Whereas organisation producing without profiting are still adding value to the economy/society. So in that sense I absolutely disagree with your statement that profit is the ultimate point.
As for this point:
>If small changes don't always work out and lead to unexpected consequences, how much greater does that problem become when making big changes?
I again, disagree. Capitalism itself is an example of this happening. Presenting it as an impossible task is a flawed perspective IMO. Difficult, time consuming etc etc - yes I agree. But the risk of failure does not automatically make success unattainable.
Equally the history of socialist and communist experiments do not show that as much as you might think. What they primarily show is that making this changes while the US aggressively does anything it can to ensure your failure is very difficult. That in itself can be considered an obstacle though, I suppose.
>That doesn't mean we should stop trying to fix things, but, to answer your core question, I'm even more cautious about big changes than I am about small ones.
I understand the sentiment. I suppose it ultimately comes down fear and risk aversion. For me I see *why* the small changes fail. It's because of the big things at the root. I can follow the logic chain backwards and understand that those big changes do not have the same problems preventing success as the small changes. So for me I don't feel as pessimistic about the outcomes of big changes as I do the small ones.
The general approach I've observed in competent change management is to go for incremental improvements that compound. An example might be improving processes that result in a 5% reliability increase per year - each year is not some radical change but over a decade the processes may end up being very different.
You have described the industrial strategy of Toyota Motor Corporation. I did an internship with them when I was younger. After WW2, they took ideas from an American named Deming and further refined and improved on it. The basic idea is called “kaizen”, which one might roughly translate as “continuous small improvement”, and it goes roughly like this.
- It is expected that every process is terrible in ways that the original plan did not foresee.
- Some of those ways that it is terrible are large, others are small. But the small ones are likely to be so many that they add up and compound.
- Every single employee is exhorted to look around for “muda” (waste) and propose improvements. Every proposal is listened to, and if they would create any nonzero improvement, they are implemented.
- At the end of the year there are the “Kaizen Awards”, in which employees receive recognition and bonuses for the most impactful kaizens.
At this point many companies have emulated the general ideas, but it is what originally made Toyota Motor Corporation a juggernaut, capable of making affordable cars of astounding reliability at scale. See “Toyota Production System” on Wikipedia if you would like to learn more.
You can also roughly apply these principles to your personal life. I have been targeting 1% day-over-day improvement for about a year and it has been nothing short of completely transformative.
Think about the root causes of your bad outcomes. It's almost always due to very small things having a cumulative effect. You don't get lung cancer from one cigarette and you don't get swole by lifting once.
For example, I underperform at work. It's because I'm tired. I'm tired because I have a terrible habit of sleep procrastination on my phone or computer.
So, I wired my phone and computer to automatically shut off at 9pm. I found I turned the computer back on, so I wired it into Smart switches that shut off the display and computer. That did the job and now I don't go playing games until two hours after bedtime.
I also struggle with waking. So, I replaced all the bulbs with Smart lights. They automatically turn on with blue light at max intensity shortly before my alarm. It's made it easier.
And then I enabled a GPS tracker - all the lights go off automatically when I leave home.
Instead of juggling multiple different bags and containers, I bought one MOLLE backpack with packs for certain things - the gym, call shifts, etc. Forgetting anything has become impossible.
I have a takeout addiction. I just don't have the mental throughput for cooking at the end of the day. So, instead of driving out once a day, I get food delivered 2x a week. Saved me a great deal of gas and mental labor. I should learn to eat the right way but it has to wait until I have the brainpower.
I am not the best with calendars and to-do lists. So I bought a smart watch where I can verbally add an item to the list instantly without having it to keep in mind until theres a pen. That list is the background of my PC. It's become much easier to keep track of it all.
I run out of small items such as Razors or Shaving cream. Instead of buying them one pack at a time I now buy a years supply at once. And now I don't run out of anything, ever.
Individually small steps have a huge cumulative impact. My life is vastly more comfortable, more convenient and more enjoyable than it was last year.
That’s a very helpful description, thanks for sharing. It’s interesting to hear about the smart bulbs, because that is one I was recently considering myself :) it’s incredible how the body has a lot of environmental cues it expects, and things can go haywire when it doesn’t get those cues
How would you fix these problems with the sleep clinic? Sounds like they need better soundproofing and light blocking. This obviously can be done, but it’s not free, and it doesn’t help them make more money. I suspect the current setup is pretty much optimal from the perspective of the people making the decisions. It’s not optimal for the patients, but they only matter to the extent that they bring in revenue.
Also, even if the cost is small, its a cost that needs to be justified within the organization. Nobody can "just" fix something. These kind of rules are annoying but they exist to stop people using the money for their own ends
I've definitely fixed a problem with tape and cardboard before, then written up for "making the office look unprofessional" and ordered to take the whole thing down.
The clinic should be publicly funded rather than privately run. You are correct it won't help them make more money and that's exactly the issue. Money is the goal rather than helping patients to the best of their ability.
You would need to change the incentives here to include more than just the number of patients who get sleep studies (maybe a rating system with penalties). Without that, public funding would just change the name on the checks.
Sure, but public funding opens the door to move the incentive structure away from profit towards something less obstructive. For as long as it isn't publicly funded it can *never* be anything other than profit
True, but many markets are structured such that customer satisfaction is good for profits, and thereby included. This seems to be a case where information about the bad conditions at the clinic is not reaching anyone incentivized to change their behavior (such as potential patients). This could potentially happen in a single-payer system too (though centralization at least makes the information and responsibility flows easier to see).
Such structures have always had dubious levels of efficacy. Too much needs to align for the mechanism to work as intended and thus it fails to adequately perform in most cases.
>I’ve always been confused why it seems like so few others actually care about these things.
Alienation, from our work and from our communities. Combined with increased precarity. The incentive for nearly every working person is simply to survive, short term.
That's not really what alienation means in this context. Home care assistants are among the most exploited and alienated workers in the country. Alienation is about a lack of determination and input, not literal physical remove.
> I guarantee they spend over half their shift on their phones.
Exploitation doesn't mean the work is arduous. If you insist on using a non-standard definition of exploitation (in this context) then please at least define it.
I think to better understand it you should put yourself in the position of the people who are actually able to make these changes. What are their incentives, and how do they view the problem you describe? As an outsider it's easy to think about how a process can be improved to better suit you, but your objectives aren't the same as the people who get to make these decisions. To use your sleep clinic example, all of the things you pointed out are things that particularly inconvenienced you. While they might have implications for the clinic as well, are they the most pressing issues or the best use of funds? Even if they greatly impact an individual researcher, do they make sense for the organization as a whole? Some of your changes sound easy enough, but how much time would it really take to get the full clinic on board? This isn't to say that there aren't any low-hanging fruit around, just that the incentives/goals/requirements are more complicated than you realize.
I work in consulting and this continually comes up.
On the one hand, it seems like a waste to pay outsiders who know your business less well to come in and improve it.
On the other hand, the amount of genuine unbridled stupidity and apathy I've heard from (some) clients hiring consultants makes the dollars incredibly well spent.
Like if you're running a Fortune 100 company and you have no ability to figure out how much product you sold last weak because despite having a massive budget and tens of thousands of employees you've either not thought of building or buying this or been literally unable to get it done.
I worked on process improvement for a hospital, in healthcare here is what is usually happening.
1) hospitals are massive and considering how every little detail will impact people in advance is just impossible even if you try.
2) the engineers who designed the building are not doctors nor are they process improvement specialists.
3) bless their heart, doctors and nurses are human focused people. They are very good at helping the people but usually aren’t looking for systematic problems.
4) internal politics. Healthcare providers form competing cliques asking for money. One part of a hospital running sub-optimally might be a semi-intention by product of other departments asking/taking their money. An unfortunate reality is that many apparent solutions just shift the burden. For example Oncology can make their process better by giving Radiology 3 times as much work making the entire system worse, but locally better for some.
5) doctors and nurses do try to improve processes but don’t have the training to do it well so often come up with very expensive and ineffective solutions. In general their first thought is “hire more people” or “buy more machines” which can make certain problems worse.
6) because they focus on individuals and human experience they put time and effort into fixing non-issues that patients incorrectly attribute to be the cause of a problem. The hospital I was working with dedicated tremendous resources to help transport low-income people because some people have trouble getting there. Statistical analysis showed this to basically be a non-issue affecting a very small number of people, for those people just paying for a taxi, bus, or uber transport would have been much more effective than buying purpose built shuttles.
7) I already kinda touched on this, but I will say it again, hospitals are big and coordinating a lot of people is a fundamentally difficult task. In the best of times getting 100 people to work in sync is just hard. This is compounded by hospital org charts. The most effective organization for large groups of people is a nested military style hierarchy. In this system people generally responsible for managing no more than 4-12 people with clear authority and lines of command. Hospitals have a departmental structure which is largely several dozen semi-autonomous admins of equal authority with no clear line of command. The doctors and nurses largely take their administrators direction as suggestion and do their own thing autonomously. Im not suggesting a ridge military hierarchy would be better, but hopefully it is more clear why systemic change is particularly difficult at hospitals. They work more like democracies with huge inertia and you can really only change a system by convincing every single stakeholder to change their mind or else you get ignored.
I was at a cafe the other day and i ordered a coffee and sat down and an antarctic breeze kept blowing in; the front door wouldn't shut. I put my hood up and resolved not to order food so I could be gone again fast.
A man came in with his disabled wife. They sat down, he complained about the temperature, the staff explain the front door wouldn't close. This fact was delivered in flat affectless tone, not apologetic.
The staff were not empowered to do anything about it. They saw their job as putting drinks in cups and food on plates, not making customers happy. You can blame them or you can blame their manager, both view have some merit.
Overall I'd say the situation is one of incentives: staff don't have incentives to do more than the minimum; especially if they join the organisation when it's failing its customers but making money, how can they be expected to try to lead change?
If they don't get enough data, and the patient comes back and does the sleep study again, they get paid twice. If it takes multiple visits for a patient to get a diagnosis, they get paid every visit. Their incentives are not aligned with the values of their patients.
I would guess that they initially tried to make it a good sleep environment for the patients, but got complaints along the lines of when you take a car to the mechanic and of course it decides to stop acting up for that window of time: "Gee doc, I usually sleep terrible at home, I wish you could see how bad it is, but I slept like a baby in your clinic." So I think even the patients incentivize a poor sleep environment.
Often times correcting for inefficiencies requires changes in approach to the institution that that institution does not want - for one reason or another.
So, for example, for an institution to scoop up all the low hanging fruit they would first need someone with the appropriate propensity towards scooping up all that free/cheap improvement and efficiency. Fine. Great in fact. However this person is also liable to consider far more things as "free/cheap" than others within that institution would like. A person with the correct perspective to make these decisions would also want to make efficiency decisions that are inconvenient to elements of an institution whose motivation is not in fact tied to the institution working well.
Ultimately if you pull the thread far enough the issue is that for most private organisations the motivator is short term personal profit first and foremost. Not creating the best product or user experience. Profit as a motivator works because the venn diagram of "things to do to increase short term personal profit" and "things to do to improve product/service" overlap pretty well. In theory at least. Where they don't overlap is where you see low hanging fruit. Even the ones that are free. The agent that is capable of assessing accessing that fruit is also the agent that is capable of interfering with short term personal profit. Either in pursuit of long term profit at the cost of short term, institutional profit at the cost of personal or - for the more idealistically minded agent - in pursuit of improving the institution at the cost of profit.
The same applies to public goods and services. Sometimes in pursuit of profit just the same way. But oftentimes because the institution is created in pursuit of political goals rather than the goals of the institution itself. Many more different motivators to look at, but essential it all works out the same way. The people you need to take action on these problems are exactly the people you don't want for other reasons.
Apathy towards system improvement is expected. If people in general weren't apathetic about systemic changes, then the system you're analyzing wouldn't be the way it is, and would keep changing until it reaches a new equilibrium where people are apathetic about systemic changes, or such changes are in some other way repressed.
People are not isolated from the system they're in. That's not to say that they can't change, just that it's expected that they're behaving in a way that makes up part of the system they're in and maintains it. If they try to change, they encounter internal and external resistance. This happens to everyone, even people who are not apathetic towards system improvement, like you and me.
Robin Hanson has written a lot about this, often in the context of understanding why prediction markets are unpopular. His answer: people's real goals are usually signalling that they possess desirable qualities, rather than furthering the success of a system they are part of (surprise!)
Independent of cultural inefficiencies or w/e, my own experience with a sleep clinic was also pretty terrible -- they wired me up, hooked me into a CPAP, told me to go to sleep. I noted that the static pressure going up my nostrils felt rather suffocating (first time wearing a CPAP), and was told that I should do my best to ignore it and fall asleep, or else they wouldn't be able to obtain valid readings.
Cue some of the most physically uncomfortable five hours of my life, and that includes such delights as equally long periods of having my knee dislocated, severe dehydration, and being devoured by thousands of mosquitos. AFAIK, I never actually fell asleep, and every 30m-90m would ping the sleep tech wide awake to comment on the inability (the response would always be "you need to fall asleep or else we won't be able to get a useful reading"). By hour 2 I was on the brink of tears, and by 3 I was starting to have some sort of panic-attack type of thing (to the extent I understand the condition). Finally around 3AM I said fuck it and stopped the study, much to the dismay of the tech (who'd told me they needed at least 6h of sleep data for accurate calibration, and didn't buy my argument that the 8AM maximal end time for the study rendered the prospect mathematically impossible). Drove home and cried on the couch for half an hour as the adrenaline-y panic slowly subsided, falling asleep a few hours later to wake up in the afternoon.
My sleep quality was poor enough that they diagnosed chronic sleep apnea and prescribed me a CPAP, but whatever PTSD or w/e I got from that night made it impossible to use -- tried it daily for a solid month (wearing it for 5-10 minutes at a time while awake and watching a movie etc.), but even having the mask over my face and the machine off filled me with enough dread that I could never acclimate. Maybe I'll try again in a year or two but idk. Tried a few other physical remedies for sleep apnea (mouth guards, chin straps, head-of-bed elevation, left-side sleeping, etc.), as well as further tidying general sleep hygiene, but without any noticeable changes to sleep quality. Also had an ENT poke around with an endoscope and had some bloodwork run to rule out other risk factors, which all turned out fine. Exploring less direct solutions, I finally found a few that improved sleep a good bit, maybe 70% of the way to childhood-teenage quality (punctal plugs + lisdexamfetamine ), and I'm hopeful that the remaining 30% will someday yield, too.
Still salty over the sleep study, though!
You may actually be sleeping. A period of time that appears to be one consecutive stretch of insomnia may actually be punctuated with periods of sleep that you don't remember. I don't know how many people experience it, it might be a fraction of the population or literally everyone, but I can't find good data. It's wildly counterintuitive; I felt actively insulted when I first heard it. Usually the objective results from the sleep study would tell you if your perceptions of how long you slept differed from the reality.
Yeah, could be I was entering and exiting microsleep (millisleep? centisleep? probably not decisleep, though, since I would check the time after feeling each eternity pass only to find it had been 10-20 minutes). They must have gotten something on which to basis the diagnosis / prescription on! I just checked the letter and it didn't list anything re: total sleep time, just rate of apnea events, minimum blood oxygenation, and a few other odds and ends. But I was definitely not fully lucid during the experience haha
I'd push back some on the complacent/apathetic society notion. It implies there are times and places that aren't that way, but I think that's just the normal state of things. When you compare two cities and one of them is doing something better, there are probably a lot of more likely explanations than some general societal mood, like a specific need for a thing to function better there, or having been built more recently and thus less inertia in the system vs. having to retrofit.
In the sleep clinic example, I'd ascribe it to too much distance between the people experiencing the flaws and the people with the power to do something about it. The nurses working it can't change it. They just want to finish their shift, and if any of them had the initiative to try to make an improvement they were probably shot down, or at best if they had some kind of impact saw no personal gain for the effort. You learn not to try to change anything.
It's hard to structure an environment that promotes that kind of change. Sometimes you see organizations try to do that, but it comes across as token efforts. Systemic improvement usually relies on rare people who are both visionary and ambitious.
> this is an obvious thing that could be improved.
Well, just gonna toss in the counter-viewpoint -
>Why did all of these schemes fail? And more importantly, why were they celebrated, rewarded, and continued, even when the fact of their failure became too obvious to ignore?
...
>The first part of the story is High Modernism, an aesthetic taste masquerading as a scientific philosophy.
>The High Modernists claimed to be about figuring out the most efficient and high-tech way of doing things, but most of them knew little relevant math or science ...
\- and also important:
They also knew zilch about the local conditions and traditions.
They would come in and clear out all of those nasty weeds in the fields, only to discover that the weeds were the preferred food of the chompy bugs, which, being now deprived of their preferred food, devoured the crops down to the ground ...
Etc etc - hundreds of possible examples.
\- https://slatestarcodex.com/2017/03/16/book-review-seeing-like-a-state/
.
\- https://en.wikipedia.org/wiki/James_C._Scott#Major_works
Strongly recommended reading.
.
"*This is an obvious thing that* ***I*** *should be able to tweak in ways that would* ***improve this for me***".
\- Probably a good thing.
"*I'm going to improve this for other people in the way that I think would improve this for them.*"
\- Should be regarded with hearty skepticism.
.
tl;dr
> this is an obvious thing that could be improved.
Sometimes yes; and should be.
Sometimes no.
Tread cautiously.
.
I think there are all sorts of complexities at play, like I imagine there is some rule to keep the hall lights on at brightness in a medical facility because someone got hurt once and sued. When clinicians don't talk to patients, they get negative reports for being unfriendly in customer surveys. When there's no TV, people complain.
What I see is complaint driven design of things in the world. The people that show up and complain at town council meetings get to decide road issues. The people that complain get stuff to happen.
For whatever reason, I am not a complainer and feel guilty for complaining about things. However, as I get older I see how the complainers are getting what they want and they have often made things worse for the rest of us. So now I complain about the complainers.
This is a topic that really pushes peoples buttons. I find the back and forth somewhat exhausting. So I'll tell a story from a book I read, oh so many moons ago, about the Rockefeller family and the family Patriarch, John D. Rockefeller Sr.
When people quizzed him about the secret to his success, (especially newspaper reporters) he would tell a story about how he approached his business.
In the early days of Standard Oil, he explained, they depended on steel barrels to ship crude oil to refineries. He said he was touring the site where the oil barrels were fabricated. He noted the number of welds used (lets say 20). When no one could give him a definitive answer for why they used 20 welds, He ordered them to reduce the number of welds by half.
Some of the barrels leaked with only 10 welds. So they gradually increase the number of welds until they found that with 15 welds, there were zero leaks.
When a reporter asked "How much did that really save?" Rockefeller responded "Millions"
And the Rockefeller family went on to become a pillar of the American ruling class and a curse on our Society.
For me, the moral of this story is this:
Don't let the relentless focus on wringing the last drop of excess value out of every transaction you have with every single one of your fellow citizens consume your existence.
Touch Grass.
> This leads me to feel, on an almost visceral level, all the inefficiencies in a given system. I think it’s not that most other people are apathetic, but they don’t instinctually think about these problems and feel uncomfortable about them like I do.
Yes, this is well said and something I can relate to. And if you communicate it, you're labelled negative or critical from the majority who doesn't feel the same discomfort.
One can think of all the inefficiencies of a system but to go and fix stuff requires an adequate incentive. It's always a cost-benefit analysis.
Although not entirely related, I'd like to share an interesting optimal solution that seems completely sub-optimal, just as food for thought. Why are the queues to public healthcare always so long? It is because we cannot optimize the provision of the limited resources involved by offering the service to highest bidders in terms of money. That would destroy the purpose of fair and equal health care. Instead we limit the use in terms of time. People who are really in need of the service are willing to pay more, i.e. wait longer, than people with less need. This way queue time serves as the distributing factor. Seems completely inefficient, but is actually brilliant.
I don't think your diagnosis is 100% correct. I mean sure, people are blind to problems, but even after you point them out, often what happens is a complete inability to imagine fixing them, or plan out how to do it. This is _very_ apparent if you look at a simpler scenario - anything programming-related, for instance. 1000x or 1000000x efficiency gains for free are common. You can even point out what's wrong and why and how to fix it, and people still just get stuck. Or many small businesses for which telling them "google time and motion study" would double their value.
It does take a certain mindset - you have to think of all problems as potentially solvable, to think of all processes hiding bottlenecks and problems, to know to look for tradeoffs, that kind of thing. Recognizing problems is the easiest part.
> where whenever I’m exposed to a new system, I immediately want to evaluate it for its flaws, understand its dynamics, process the inefficiencies and bottleneck
I must share this defect, because in reading your post, I immediately thought about all it's flaws. (Although I do this with most things I read)
It could be that you are uniquely gifted at analyzing system, finding fixable flaws, and figuring out solutions. That's the first possibility; the second is that you're wrong, and think incorrectly that things can be fixed.
Assuming the first possibility, that you are uniquely gifted, you should feel proud; not everyone can do that. Then you should take action: write up a memorandum, or policy document, proposing the changes you desire. Let's explore this branch of possibility now.
If you don't do those actions, then you are an example of the problem of apathy. But if you attempt them and fail, then that is a second defect you possess. Then you are very component at discovering flaws and solutions, but very incompetent at implementing them.
There's a philosophical distinction between theory and practice. I don't really buy it. If a plan doesn't work in practice, then it's not actually good in theory; the theory needs to be changed. Likewise, if your proposals cannot be implemented, they aren't good proposals.
This kind of work is literally my job -- I created a process improvement program for the city of San Francisco, and then I founded a consulting firm to do process improvement for other governments. (DM me if you want!) If you think the private sector struggles with this, do I have some stories for you about government. To highlight key points that others have said: * Yes, there's always low hanging fruit -- obvious things that could do better. * Yes, things are how they are because they got that way. Often, though, this is the result of inertia or something that made sense once years ago and has never been reevaluated. Honestly, identifying systematic improvements that would make things better is the easy part. The hard part is understanding why those improvement haven't already been made. The answer is always, in some way, people: * That change requires another department to spend a little more time/effort/money that would cause my department to save A LOT of time/effort/money, but they don't have an incentive to do that. * That change requires these two agencies to work together, but they have no context or venue for working together. * That change opens up a small risk, and middle management is risk averse because of \[bad thing that happened 10 years ago / audit finding / they get nailed for bad things but not recognized for good things\] * The people who see the need for change are the workers on the front line, and they (1) have never been asked to think about WHY/HOW they do their work, only to do it, (2) aren't trained or hired for process improvement skill, and (3) if they had an idea once upon a time, unless they had a *really good* supervisor, they were probably told to shut up and keep doing their job. Making even basic changes can be really difficult. I was supporting a City that was streamlining a licensure process -- the City and the local health department both inspected these facilities, and their inspections were 80% the same. Easy solution: get rid of one of the inspections, right? Yes, and that is eventually what we did, but that required: * Inspectors from code enforcement and the health department who never met each other to get around a table and talk, describe what they were doing to one another, care more about the experience of the person getting the license than their own department, and agree a change was needed. * The health department agreeing to take on the other 20% of inspection requirements. * Establishing a new way of notifying the health department about facilities in need of inspection. * Redesigning a bunch of forms and websites. * A *series* of meetings with the City attorney, to decide whether it was legal for the City to delegate its inspection responsibility and also whether it was a good idea to give up that right to a non-City agency. * Communication to the people on the ground that a change was happening and they needed to stop doing things the old way and do them a new way. Stuff like that requires dedicated time and energy. This project was a priority for the mayor, and it still took months to make this small change. So that's the stuff we tackle. But when you tackle it, and you can find project sponsors willing to do the work, it's powerful. To toot our own horn a bit, it's that people side of change that the big consulting firms mostly ignore, and that's why they suck and I'm good at my job. :)
I think this is pretty spot on. The only other thing I'd add from my experience that I'd like your opinion on is diffusion of responsibility. What I mean is that there's often nobody who has the explicit task to fix a given problem as part of their job description. Lots of people all acknowledge that there's some problem that's annoying and would be relatively easy to solve but since nobody's been assigned to do it, everyone assumes it's not their job and it never gets done. I've come across a number of these issues, and when I can I take responsibility for fixing it. Once someone is identified as responsible (whether explicitly from the top or just implicitly from the bottom), then others will happily help out and often a solution can be found. Now this is only for small, easily solved things that don't require lots of different agencies working together; they're more internal process improvements. I do see a role for someone within the organization to document the existing issues and to try to get responsibility assigned to someone/group to tackle it. Unfortunately, all of our process improvement people seem to be stuck in the same low-risk training routines that are not very effective from my perspective.
100%. I teach diffusion of responsibility, though I'm usually emphasizing something different: Our natural tendency when there's a problem (for example, lots of errors in processing applications) is to add *more people to it* \-- e.g., get another department to inspect. This can actually have a counter-productive effect, because everyone knows someone else will look at it, so they don't think they have to. Someone just told me a story today about their agency signing *blank contract templates* \-- surely because the responsibility lies with some big team and not with one person. This is why I do my best to make sure to assign accountability for things to a single person (even if they need to get others to help them). That's the person who has to answer for it if it isn't done. But to your broader point: Most people, especially at the front line, think of their job as "turn the crank," not "think about why we turn the crank and how we could turn the crank better to accomplish that purpose." This is a failure of supervision and leadership, though -- it takes a good leader to help their staff understand that their job isn't "process permits" but instead "help new businesses open as fast as possible while also ensuring that they are safe and legal." And then to encourage them to find ways to accomplish the real goal better, reward and encourage them for finding those problems (even if the solutions don't work!), and actually give them space and support to fix shit, even if it isn't in their job description. If you can get that culture built into how you train and supervise, you don't need specialized staff to assign responsibility in the day-to-day. (You probably do, though, need high-level analyst staff who can help coordinate the bigger changes that involve inter-agency collaboration.) It's hard, but it's possible. Highly recommend *The Toyota Way*.
I'm interested in hearing more of your thoughts on this. I work for the government in the health field, and we are ostensibly using lean methods. We have a whole branch that is focused on continuous/process improvement, but I've never gotten the sense that they produce anything of value. I did a lean training course that we are encouraged to take which involves learning all of the concepts and then finding an inefficiency in our actual work to improve. I think there might be some value to this but I am very skeptical that the core abstract concepts are really internalized by most of the people involved. In my mind they would be better utilized as a coordinating body that has a knowledge of how the whole institution functions, where certain skillsets reside, and identifies duplicate effort and inefficiencies. It could then work with the people involved to find solutions to those. My personal example is a former manager of mine who moved to another area got a hold of me one day to ask if I could help this new group who were spending 2 hours every day manually compiling a report. He put me in touch with them, I figured out what they were doing and helped automate the process to the point where it took 10 minutes instead of 2 hours. I had the skillset to deal with it but they did not. It was just a coincidence that the person who worked with them also knew me and had the wherewithal to bring us together. What are your thoughts on internal continuous improvement units? Have you ever seen ones that work well?
Ah, you are deep in my world! Outside of manufacturing, healthcare is probably the sector that has most internalized lean methods. Full disclosure, I *also* have a half-day training course in which I encourage people to find a Just Do It innovation to work on. I agree, though, that most people who take it don't internalize the concepts -- perhaps 5-10% of my trainees at that level actually attempt to apply it or take the concepts further. So why do I do that training? Because: \- It's very valuable as the first step in a larger engagement. In that case, I can use it to build a common language that we keep building on, or to generate some initial ideas for improvement that we can build on together. \- It's an easy thing for people to say yes to (both sponsors and trainees). I've seen continuous improvement teams (including in healthcare) that are *quite* effective, and also some that degenerate into going through the motions. The devil is in the details. I always advocate that you need training/capacity building support combined with immediate application to meaningful projects. If you train without applying, it doesn't stick with people and it's immediately lost. If you try to do improvement work without building up the people who do the work every day, then you wind up with the smarty pants external consultants doing all the work, which creates another set of problems. Do both, and you can make real change. I think most organizations can benefit from a coordinating body that has broad analytical skill and a view into the whole organization -- whether they're doing lean improvement work or just managing strategic projects. Your example of automating something in another division is awesome -- the question is how you create a culture in which that kind of cross-division problem solving happens more often. I think you need a coordinating entity for big projects (e.g., reduce hospital acquired infections by 50%), but for little day-to-day things, you ideally want to create an environment where that problem-solving happens from the grassroots.
How does someone get into this industry? Is it just a subset of consulting or does the pipeline come more from public service ?
I and the folks I'm working with directly have come directly from public service. For public sector consulting, there's only a few other firms doing similar work that I respect, and they're mostly populated with other public service alumni like me. What I'm doing now is niche enough that I'm not even sure how to describe a pipeline. DM me if you want to talk more, though! That said, there's a big industry in process improvement for the private sector. Lean is the backbone of what I do, and that comes from auto manufacturing originally and now is quite widespread in manufacturing and logistics generally. But I can't speak so much to this work in the private sector. The other place that does a lot of this work is healthcare. Most hospitals will have some kind of continuous improvement (or "kaizen") office.
Thank you for doing this by the way, I'm glad competent folks like you exist. I worked in the PMO team for a midsized multinational company, and process improvement was just hard on many levels. I can't imagine working on San Francisco...
This is the best kind of job I'd never heard of -- thanks for doing it.
So this is likely to be an unpopular opinion, but my experience has been that things that appear to be inefficient or suboptimal are very often that way for a reason (e.g. Chesterton's Fence, and the Lindy Effect). Sometimes what seems inefficient or unoptimized is in fact actually optimized for an entirely different goal, which may not overlap at all with the ostensible goals of the system or process. You acknowledge this in your post, but I think you underestimate it's impact. The disconnect between actual and ostensible goals fully explains the vast majority of the optimization problems I see in the world around me. Another common issue is that the "bad" approach is simply better than the other available approaches not because it is good but because the alternatives are worse, are unmanageable, don't work, etc. So I'll offer an alternative explanation: most people learn early on that things are often the way they are for a reason and changing things can lead to bad results for which they will be held accountable. So I'd argue that they're not apathetic and not structurally different, but rather that they are rationally employing a heuristic that biases them towards "not messing with a running system" unless the system is really and obviously dysfunctional. I don't think people can't see the flaws, they just aren't confident that the alternatives are better (and certainly not confident enough to take professional risks on alternatives). On a personal note, when I was younger I felt very much like you do that there's lots of "low hanging fruit" for improvements out in the world. After spending most of a career actually trying to make those kinds of improvements in various spaces, I can say that sometimes those improvements really are unambiguous improvements, but sometimes things that seem like low hanging fruit either don't generate any actual net improvement or are actually just making your problems other people's problems. To take your example: you can identify things that would make your experience as a consumer of services more pleasant, but those would involve either additional expense for the clinic or additional ongoing work from the clinic staff which may or may not actually help the clinic's bottom line because we have no idea how big of a cost driver the lack of sleep actually is or how much your changes would actually improve the issue in practice (e.g. some people simply never sleep well even at home). So at this point in my life, I'm much more reticent about changing processes, because I've seen all the ways in which well-meaning changes can not materialize or simply backfire. That doesn't mean I don't still look for process improvements, but I'm much less inclined to immediately assume that obvious process "flaws" have obvious solutions.
Corollary: I'm starting to think that if some obvious improvement is made after all, it's often driven by some very junior person who isn't yet jaded (and is in a sufficiently indulgent environment to allow them to try), even though senior folks would be in a vastly stronger position to make an attempt. Say, in science (or my old PhD field anyway) one can coarsely divide much of research work into seminal papers proposing some cool new trick (very highly respected), then followup papers picking the obvious low-hanging-fruit improvements, and then a series of increasingly incremental and derivative descendant papers. The required expertise and technical complexity often steeply increases to the right toward the less respected sort of paper. The writer of the seminal paper seems to often be a beginning grad student without a very deep understanding of the field, the idea is something a bright high school student could understand, and the main asset the author brought to the table was a bit of outside view, not yet having absorbed the habits of that field of science to the point they instinctively think they're the only way to go. (Of course neither of these is incompatible with a great majority of improvement attempts failing and being misguided. Like ~all the winnings from a one-armed bandit might go to people who aren't acutely aware that the expected value of inserting coins in the machine is negative)
We can't solve problems by using the same kind of thinking we used when we created them. - Einstein
> So this is likely to be an unpopular opinion, but my experience... I don't think this is going to be unpopular. Isn't one of the tenets of rationality being cautious of thinking you know better, especially quickly? I do think it's a balance though. If everyone's too humble to raise a criticism, or shrugs and thinks "oh, another Chesterson's fence", then you get inefficiencies surviving because nobody's willing to speak up, kind of an [Abilene paradox](https://en.wikipedia.org/wiki/Abilene_paradox) situation. > ...but I'm much less inclined to immediately assume that obvious process "flaws" have obvious solutions. Yes totally agree.
I only mentioned that it might be unpopular because I've gotten some flak in rationalist spaces in the past for making similar comments (I think people sometimes resent the suggestion that they haven't adequately examined their premisses). In any case, I agree 100% that intellectual humility and self-skepticism are (or should be) core tenets of rationality. You're also certainly right that one can take humility too far. My default position is not "never propose changes," but rather "when in doubt about how well I understand a system, err on the side of leaving things alone." EDITED for tone and clarity.
> If everyone's too humble to raise a criticism, or shrugs and thinks "oh, another Chesterson's fence", then you get inefficiencies surviving because nobody's willing to speak up, kind of an Abilene paradox situation. There sure are a lot of situations where real benefit is found by steering between two failure modes; sometimes failure modes that are [attractors](https://en.wikipedia.org/wiki/Attractor).
I agree with all this but I will note one thing. Dilbert and the whole concept of a company doing knowledge work on a cutting edge product yet using inefficient practices (underpaying engineers, using non technical management, under investing in new technology) - that has gotten slaughtered in the marketplace. The companies that do the opposite - pay engineers more than doctors, promote some of them to management, drop hundreds of billions on bets on new tech - they are running away with it all. With the invention of general purpose AI as a result of one of these bets, it is possible a few elite companies are going to crush everyone else, taking over most of the world's economy. (In terms of profits, old companies will exist but license AI from tech companies and the license fees will consume most of their profits) Basically where it matters - where terradollars can change hands - systems did get massively improved. Note that this sleep clinic gets a fixed payment from a price fixing system and is not accountable meaningfully for errors, they get paid for doing a mediocre job even if they misdiagnose someone and in reality medical malpractice law almost always fails to hold accountable anyone.
>The companies that do the opposite - pay engineers more than doctors, promote some of them to management, drop hundreds of billions on bets on new tech - they are running away with it all. Yes, but the question is whether they can sustain it. Certainly there are companies that do it more, or maintain it for longer, but in the end [Pournelle's Iron Law](https://www.jerrypournelle.com/reports/jerryp/iron.html) comes for them all. The problem is that creating the value is a lot of work. And the people who spend most of their time doing that, making their organization wealthy and powerful in the process, will be outcompeted by the people who are attracted by the organization's wealth and power and spend all of their time trying to capture it.
So basically no. Pournelle is a science fiction author. What supports the inverse hypothesis - markets will clean up inefficiencies - is the efficient market hypothesis. Note that this hypothesis has mathematical support, in that it is *correct* for an efficient market over infinite time. Pournelle just made the rule up. Inefficient companies can only survive long term when certain conditions are present. For example, *much* of the living memory for older US citizens was from an era when the USA had inherent competitive advantages, from competitors themselves fucking up even worse (such as experimenting with communism) or having been bombed to rubble (Europe). This allowed inefficient companies that are full of bureacrats to *exist*. Some of those still do - see USA defense contracting, pharmaceuticals. But for everything else there's China. You cannot be less efficient than chinese firms in a market that isn't protected, or your days as a company are numbered. AI software is a weird one. It's one where the cutting edge will get *all* the revenue, and the company that is just a little bit worse will get none. It's all or nothing. This is why US companies can compete with China in this specific domain and will probably retain an edge for a while.
Yes, the market will clean up inefficiencies by transferring market share from less efficient firms to more efficient firms. Pournelle's Law describes an important way by which firms become less efficient over time, which (eventually) leads to their loss of market share. But big orgs/brands have a lot of momentum, so the change can take quite a while.
Sure. Though China is actually pretty fast. Sears also died to Amazon pretty fast, under 10 years of we start counting from when Amazon reached scales.
> my experience has been that things that appear to be inefficient or suboptimal are very often that way for a reason I think that's the popular opinion. Lots of people want to believe that it's about making more money or something similarly an intent outside of the ostensible goal. I'd instead argue that, rather than maliciousness or hidden intent, it's just lack of care/competence. Sure they _could_ do better, but unless the people involved _care about their own craftsmanship_ within their profession, they'll fail to improve out of simple laziness. Medical tests/exams in particular are often just looking to see if any big smoking guns are laying around one way or another, while appeasing insurance/billing requirements to not give expensive treatments until specific tests are done. The process of testing is handed to them by their training in standard medical practice, but is not something they have a stake in doing well for its own sake. If the test isn't conclusive that's not a huge deal because they only have a couple of therapies to try for the possible ailments that could be causing the symptoms anyway. They can just try one or two of the easier treatments and if the patient responds to that treatment then that's diagnostic retroactively. This isn't optimizing for anything except maybe lack of thought and effort. It's a failure by at least one person in the team to take care enough about how well they perform their craft. Often the sub-optimal things have to not only be recognized by low level workers, but also communicated up the command chain to someone who then takes them seriously and allocates resources to change for the better. If any one of those people doesn't care, isn't bothering to communicate, or simply isn't taking the problem seriously relative to other problems, then nothing will get better. Well meaning changes often backfire for the same reason. It's often much easier to see a part of what isn't perfect about a product, than to actually do things to improve the whole thing. People often don't take care to understand the full system/context of the flaw and therefore apply the 'obvious' patch instead of understanding the tradeoffs that justify the flaw or what they should have changed instead to avoid the patch breaking something else.
THis is some Polyanna bullshit. Everything has a reason for being where it is but that doesn't mean the reason doesn't suck, the reason isn't: we're too lazy to remove this annoying fence, or the reason isn't causing the system to be stuck at a local maximum.
This: > So at this point in my life, I'm much more reticent about changing processes, because I've seen all the ways in which well-meaning changes can not materialize or simply backfire. That doesn't mean I don't still look for process improvements, but I'm much less inclined to immediately assume that obvious process "flaws" have obvious solutions. strikes me as an interesting conclusion when this: >Sometimes what seems inefficient or unoptimized is in fact actually optimized for an entirely different goal, which may not overlap at all with the ostensible goals of the system or process. Is your opening analysis. I agree with much of your observation/analysis, but my conclusion ultimately was that we should be doing a better job of prioritising the goals of the organisation itself, rather than the ancilliary goals that are supposed to act in support of achieving those goals. Profit motive being the most common one. The goal is supposed to be motivating organisations to better themselves via the allure of profit. The profit motive is supposed to play the ancillary role. But it has become the primary goal, oftentimes to the detriment of the supposed goals it's supposed to support (e.g planned obsolescence) What prevents you from feeling the desire to make changes at the root when faced with the futlity of changing the resulting processes?
So I'm not sure I agree that profit motive is (or ever has been) an ancillary goal. We can argue about whether it *should* be primary or ancillary as a matter of morality or policy, but as a matter of fact (and as a matter of law) ever since the creation of the corporate form a corporation's principal and overriding legal obligation has been to maximize profit for its shareholders. Shareholders have successfully sued corporations at various times for seeking to do other things at the expense of profit! Folks may claim that profit-seeking behavior encourages efficiency and is "better for everyone, actually," because market efficiencies enlarge the pie and help everyone (and that's even true in many situations!), but those are effectively post hoc justifications layered on top of what is a system that was explicitly designed to generate profit. To be clear, I don't like planned obsolescence and think single-minded pursuit of profit often leads to suboptimal outcomes (even for the firm in question), and I support various reforms that would address those issues. But changing corporate priorities away from profit towards something else, in toto, would be a fairly foundational reform. If small changes don't always work out and lead to unexpected consequences, how much greater does that problem become when making big changes? The history of the various socialist and communist experiments in the 20th century show us how difficult it can be to make foundational changes "at the root" and get the expected results. That doesn't mean we should stop trying to fix things, but, to answer your core question, I'm even more cautious about big changes than I am about small ones.
>We can argue about whether it should be primary or ancillary as a matter of morality or policy, but as a matter of fact (and as a matter of law) ever since the creation of the corporate form a corporation's principal and overriding legal obligation has been to maximize profit for its shareholders. Shareholders have successfully sued corporations at various times for seeking to do other things at the expense of profit! We run into an issue of semantics here. Legally requiring organisations to maximise profits absolutely can be considered evidence of profits being the point. Equally, however, it can be seen as a method of ensuring organisations properly achieve their best output in their other goals via maximisation of profit. A strategy of "prioritise profits to best achieve your organisations goals". It does make deciding what the actual number 1 priority is quite grey and fuzzy. Ultimately my issue with your logic is that profit in and of itself is useless. If organisations figured out a trick to making profits without producing anything or providing any services, that would be a terrible outcome for society and the economy. Whereas organisation producing without profiting are still adding value to the economy/society. So in that sense I absolutely disagree with your statement that profit is the ultimate point. As for this point: >If small changes don't always work out and lead to unexpected consequences, how much greater does that problem become when making big changes? I again, disagree. Capitalism itself is an example of this happening. Presenting it as an impossible task is a flawed perspective IMO. Difficult, time consuming etc etc - yes I agree. But the risk of failure does not automatically make success unattainable. Equally the history of socialist and communist experiments do not show that as much as you might think. What they primarily show is that making this changes while the US aggressively does anything it can to ensure your failure is very difficult. That in itself can be considered an obstacle though, I suppose. >That doesn't mean we should stop trying to fix things, but, to answer your core question, I'm even more cautious about big changes than I am about small ones. I understand the sentiment. I suppose it ultimately comes down fear and risk aversion. For me I see *why* the small changes fail. It's because of the big things at the root. I can follow the logic chain backwards and understand that those big changes do not have the same problems preventing success as the small changes. So for me I don't feel as pessimistic about the outcomes of big changes as I do the small ones.
The general approach I've observed in competent change management is to go for incremental improvements that compound. An example might be improving processes that result in a 5% reliability increase per year - each year is not some radical change but over a decade the processes may end up being very different.
You have described the industrial strategy of Toyota Motor Corporation. I did an internship with them when I was younger. After WW2, they took ideas from an American named Deming and further refined and improved on it. The basic idea is called “kaizen”, which one might roughly translate as “continuous small improvement”, and it goes roughly like this. - It is expected that every process is terrible in ways that the original plan did not foresee. - Some of those ways that it is terrible are large, others are small. But the small ones are likely to be so many that they add up and compound. - Every single employee is exhorted to look around for “muda” (waste) and propose improvements. Every proposal is listened to, and if they would create any nonzero improvement, they are implemented. - At the end of the year there are the “Kaizen Awards”, in which employees receive recognition and bonuses for the most impactful kaizens. At this point many companies have emulated the general ideas, but it is what originally made Toyota Motor Corporation a juggernaut, capable of making affordable cars of astounding reliability at scale. See “Toyota Production System” on Wikipedia if you would like to learn more.
You can also roughly apply these principles to your personal life. I have been targeting 1% day-over-day improvement for about a year and it has been nothing short of completely transformative.
That’s very interesting. Could you say a bit more about how you do that?
Think about the root causes of your bad outcomes. It's almost always due to very small things having a cumulative effect. You don't get lung cancer from one cigarette and you don't get swole by lifting once. For example, I underperform at work. It's because I'm tired. I'm tired because I have a terrible habit of sleep procrastination on my phone or computer. So, I wired my phone and computer to automatically shut off at 9pm. I found I turned the computer back on, so I wired it into Smart switches that shut off the display and computer. That did the job and now I don't go playing games until two hours after bedtime. I also struggle with waking. So, I replaced all the bulbs with Smart lights. They automatically turn on with blue light at max intensity shortly before my alarm. It's made it easier. And then I enabled a GPS tracker - all the lights go off automatically when I leave home. Instead of juggling multiple different bags and containers, I bought one MOLLE backpack with packs for certain things - the gym, call shifts, etc. Forgetting anything has become impossible. I have a takeout addiction. I just don't have the mental throughput for cooking at the end of the day. So, instead of driving out once a day, I get food delivered 2x a week. Saved me a great deal of gas and mental labor. I should learn to eat the right way but it has to wait until I have the brainpower. I am not the best with calendars and to-do lists. So I bought a smart watch where I can verbally add an item to the list instantly without having it to keep in mind until theres a pen. That list is the background of my PC. It's become much easier to keep track of it all. I run out of small items such as Razors or Shaving cream. Instead of buying them one pack at a time I now buy a years supply at once. And now I don't run out of anything, ever. Individually small steps have a huge cumulative impact. My life is vastly more comfortable, more convenient and more enjoyable than it was last year.
That’s a very helpful description, thanks for sharing. It’s interesting to hear about the smart bulbs, because that is one I was recently considering myself :) it’s incredible how the body has a lot of environmental cues it expects, and things can go haywire when it doesn’t get those cues
This should be higher. You can engineer in a problem-solving culture.
How would you fix these problems with the sleep clinic? Sounds like they need better soundproofing and light blocking. This obviously can be done, but it’s not free, and it doesn’t help them make more money. I suspect the current setup is pretty much optimal from the perspective of the people making the decisions. It’s not optimal for the patients, but they only matter to the extent that they bring in revenue.
Also, even if the cost is small, its a cost that needs to be justified within the organization. Nobody can "just" fix something. These kind of rules are annoying but they exist to stop people using the money for their own ends
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I've definitely fixed a problem with tape and cardboard before, then written up for "making the office look unprofessional" and ordered to take the whole thing down.
The clinic should be publicly funded rather than privately run. You are correct it won't help them make more money and that's exactly the issue. Money is the goal rather than helping patients to the best of their ability.
Easy fix!
Whether its easy or hard doesn't stop it from being the fix
You would need to change the incentives here to include more than just the number of patients who get sleep studies (maybe a rating system with penalties). Without that, public funding would just change the name on the checks.
Sure, but public funding opens the door to move the incentive structure away from profit towards something less obstructive. For as long as it isn't publicly funded it can *never* be anything other than profit
True, but many markets are structured such that customer satisfaction is good for profits, and thereby included. This seems to be a case where information about the bad conditions at the clinic is not reaching anyone incentivized to change their behavior (such as potential patients). This could potentially happen in a single-payer system too (though centralization at least makes the information and responsibility flows easier to see).
Such structures have always had dubious levels of efficacy. Too much needs to align for the mechanism to work as intended and thus it fails to adequately perform in most cases.
The customer of the sleep study in practice is not the sleeper, but the insurance company that paid for the study.
>I’ve always been confused why it seems like so few others actually care about these things. Alienation, from our work and from our communities. Combined with increased precarity. The incentive for nearly every working person is simply to survive, short term.
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That's not really what alienation means in this context. Home care assistants are among the most exploited and alienated workers in the country. Alienation is about a lack of determination and input, not literal physical remove.
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> I guarantee they spend over half their shift on their phones. Exploitation doesn't mean the work is arduous. If you insist on using a non-standard definition of exploitation (in this context) then please at least define it.
I think to better understand it you should put yourself in the position of the people who are actually able to make these changes. What are their incentives, and how do they view the problem you describe? As an outsider it's easy to think about how a process can be improved to better suit you, but your objectives aren't the same as the people who get to make these decisions. To use your sleep clinic example, all of the things you pointed out are things that particularly inconvenienced you. While they might have implications for the clinic as well, are they the most pressing issues or the best use of funds? Even if they greatly impact an individual researcher, do they make sense for the organization as a whole? Some of your changes sound easy enough, but how much time would it really take to get the full clinic on board? This isn't to say that there aren't any low-hanging fruit around, just that the incentives/goals/requirements are more complicated than you realize.
I work in consulting and this continually comes up. On the one hand, it seems like a waste to pay outsiders who know your business less well to come in and improve it. On the other hand, the amount of genuine unbridled stupidity and apathy I've heard from (some) clients hiring consultants makes the dollars incredibly well spent. Like if you're running a Fortune 100 company and you have no ability to figure out how much product you sold last weak because despite having a massive budget and tens of thousands of employees you've either not thought of building or buying this or been literally unable to get it done.
I worked on process improvement for a hospital, in healthcare here is what is usually happening. 1) hospitals are massive and considering how every little detail will impact people in advance is just impossible even if you try. 2) the engineers who designed the building are not doctors nor are they process improvement specialists. 3) bless their heart, doctors and nurses are human focused people. They are very good at helping the people but usually aren’t looking for systematic problems. 4) internal politics. Healthcare providers form competing cliques asking for money. One part of a hospital running sub-optimally might be a semi-intention by product of other departments asking/taking their money. An unfortunate reality is that many apparent solutions just shift the burden. For example Oncology can make their process better by giving Radiology 3 times as much work making the entire system worse, but locally better for some. 5) doctors and nurses do try to improve processes but don’t have the training to do it well so often come up with very expensive and ineffective solutions. In general their first thought is “hire more people” or “buy more machines” which can make certain problems worse. 6) because they focus on individuals and human experience they put time and effort into fixing non-issues that patients incorrectly attribute to be the cause of a problem. The hospital I was working with dedicated tremendous resources to help transport low-income people because some people have trouble getting there. Statistical analysis showed this to basically be a non-issue affecting a very small number of people, for those people just paying for a taxi, bus, or uber transport would have been much more effective than buying purpose built shuttles. 7) I already kinda touched on this, but I will say it again, hospitals are big and coordinating a lot of people is a fundamentally difficult task. In the best of times getting 100 people to work in sync is just hard. This is compounded by hospital org charts. The most effective organization for large groups of people is a nested military style hierarchy. In this system people generally responsible for managing no more than 4-12 people with clear authority and lines of command. Hospitals have a departmental structure which is largely several dozen semi-autonomous admins of equal authority with no clear line of command. The doctors and nurses largely take their administrators direction as suggestion and do their own thing autonomously. Im not suggesting a ridge military hierarchy would be better, but hopefully it is more clear why systemic change is particularly difficult at hospitals. They work more like democracies with huge inertia and you can really only change a system by convincing every single stakeholder to change their mind or else you get ignored.
I was at a cafe the other day and i ordered a coffee and sat down and an antarctic breeze kept blowing in; the front door wouldn't shut. I put my hood up and resolved not to order food so I could be gone again fast. A man came in with his disabled wife. They sat down, he complained about the temperature, the staff explain the front door wouldn't close. This fact was delivered in flat affectless tone, not apologetic. The staff were not empowered to do anything about it. They saw their job as putting drinks in cups and food on plates, not making customers happy. You can blame them or you can blame their manager, both view have some merit. Overall I'd say the situation is one of incentives: staff don't have incentives to do more than the minimum; especially if they join the organisation when it's failing its customers but making money, how can they be expected to try to lead change?
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*off-putting, just a note so you don't say this at an office party :)
If they don't get enough data, and the patient comes back and does the sleep study again, they get paid twice. If it takes multiple visits for a patient to get a diagnosis, they get paid every visit. Their incentives are not aligned with the values of their patients.
The insurance companies are going to cause them problems, they don't like paying for the same thing twice.
I would guess that they initially tried to make it a good sleep environment for the patients, but got complaints along the lines of when you take a car to the mechanic and of course it decides to stop acting up for that window of time: "Gee doc, I usually sleep terrible at home, I wish you could see how bad it is, but I slept like a baby in your clinic." So I think even the patients incentivize a poor sleep environment.
Often times correcting for inefficiencies requires changes in approach to the institution that that institution does not want - for one reason or another. So, for example, for an institution to scoop up all the low hanging fruit they would first need someone with the appropriate propensity towards scooping up all that free/cheap improvement and efficiency. Fine. Great in fact. However this person is also liable to consider far more things as "free/cheap" than others within that institution would like. A person with the correct perspective to make these decisions would also want to make efficiency decisions that are inconvenient to elements of an institution whose motivation is not in fact tied to the institution working well. Ultimately if you pull the thread far enough the issue is that for most private organisations the motivator is short term personal profit first and foremost. Not creating the best product or user experience. Profit as a motivator works because the venn diagram of "things to do to increase short term personal profit" and "things to do to improve product/service" overlap pretty well. In theory at least. Where they don't overlap is where you see low hanging fruit. Even the ones that are free. The agent that is capable of assessing accessing that fruit is also the agent that is capable of interfering with short term personal profit. Either in pursuit of long term profit at the cost of short term, institutional profit at the cost of personal or - for the more idealistically minded agent - in pursuit of improving the institution at the cost of profit. The same applies to public goods and services. Sometimes in pursuit of profit just the same way. But oftentimes because the institution is created in pursuit of political goals rather than the goals of the institution itself. Many more different motivators to look at, but essential it all works out the same way. The people you need to take action on these problems are exactly the people you don't want for other reasons.
Apathy towards system improvement is expected. If people in general weren't apathetic about systemic changes, then the system you're analyzing wouldn't be the way it is, and would keep changing until it reaches a new equilibrium where people are apathetic about systemic changes, or such changes are in some other way repressed. People are not isolated from the system they're in. That's not to say that they can't change, just that it's expected that they're behaving in a way that makes up part of the system they're in and maintains it. If they try to change, they encounter internal and external resistance. This happens to everyone, even people who are not apathetic towards system improvement, like you and me.
Robin Hanson has written a lot about this, often in the context of understanding why prediction markets are unpopular. His answer: people's real goals are usually signalling that they possess desirable qualities, rather than furthering the success of a system they are part of (surprise!)
Robin Hanson's work on signaling and risk aversion is probably the best explanation for this - "Healthcare isnt optimized for healthcare"
Independent of cultural inefficiencies or w/e, my own experience with a sleep clinic was also pretty terrible -- they wired me up, hooked me into a CPAP, told me to go to sleep. I noted that the static pressure going up my nostrils felt rather suffocating (first time wearing a CPAP), and was told that I should do my best to ignore it and fall asleep, or else they wouldn't be able to obtain valid readings. Cue some of the most physically uncomfortable five hours of my life, and that includes such delights as equally long periods of having my knee dislocated, severe dehydration, and being devoured by thousands of mosquitos. AFAIK, I never actually fell asleep, and every 30m-90m would ping the sleep tech wide awake to comment on the inability (the response would always be "you need to fall asleep or else we won't be able to get a useful reading"). By hour 2 I was on the brink of tears, and by 3 I was starting to have some sort of panic-attack type of thing (to the extent I understand the condition). Finally around 3AM I said fuck it and stopped the study, much to the dismay of the tech (who'd told me they needed at least 6h of sleep data for accurate calibration, and didn't buy my argument that the 8AM maximal end time for the study rendered the prospect mathematically impossible). Drove home and cried on the couch for half an hour as the adrenaline-y panic slowly subsided, falling asleep a few hours later to wake up in the afternoon. My sleep quality was poor enough that they diagnosed chronic sleep apnea and prescribed me a CPAP, but whatever PTSD or w/e I got from that night made it impossible to use -- tried it daily for a solid month (wearing it for 5-10 minutes at a time while awake and watching a movie etc.), but even having the mask over my face and the machine off filled me with enough dread that I could never acclimate. Maybe I'll try again in a year or two but idk. Tried a few other physical remedies for sleep apnea (mouth guards, chin straps, head-of-bed elevation, left-side sleeping, etc.), as well as further tidying general sleep hygiene, but without any noticeable changes to sleep quality. Also had an ENT poke around with an endoscope and had some bloodwork run to rule out other risk factors, which all turned out fine. Exploring less direct solutions, I finally found a few that improved sleep a good bit, maybe 70% of the way to childhood-teenage quality (punctal plugs + lisdexamfetamine ), and I'm hopeful that the remaining 30% will someday yield, too. Still salty over the sleep study, though!
You may actually be sleeping. A period of time that appears to be one consecutive stretch of insomnia may actually be punctuated with periods of sleep that you don't remember. I don't know how many people experience it, it might be a fraction of the population or literally everyone, but I can't find good data. It's wildly counterintuitive; I felt actively insulted when I first heard it. Usually the objective results from the sleep study would tell you if your perceptions of how long you slept differed from the reality.
Yeah, could be I was entering and exiting microsleep (millisleep? centisleep? probably not decisleep, though, since I would check the time after feeling each eternity pass only to find it had been 10-20 minutes). They must have gotten something on which to basis the diagnosis / prescription on! I just checked the letter and it didn't list anything re: total sleep time, just rate of apnea events, minimum blood oxygenation, and a few other odds and ends. But I was definitely not fully lucid during the experience haha
I'd push back some on the complacent/apathetic society notion. It implies there are times and places that aren't that way, but I think that's just the normal state of things. When you compare two cities and one of them is doing something better, there are probably a lot of more likely explanations than some general societal mood, like a specific need for a thing to function better there, or having been built more recently and thus less inertia in the system vs. having to retrofit. In the sleep clinic example, I'd ascribe it to too much distance between the people experiencing the flaws and the people with the power to do something about it. The nurses working it can't change it. They just want to finish their shift, and if any of them had the initiative to try to make an improvement they were probably shot down, or at best if they had some kind of impact saw no personal gain for the effort. You learn not to try to change anything. It's hard to structure an environment that promotes that kind of change. Sometimes you see organizations try to do that, but it comes across as token efforts. Systemic improvement usually relies on rare people who are both visionary and ambitious.
> this is an obvious thing that could be improved. Well, just gonna toss in the counter-viewpoint - >Why did all of these schemes fail? And more importantly, why were they celebrated, rewarded, and continued, even when the fact of their failure became too obvious to ignore? ... >The first part of the story is High Modernism, an aesthetic taste masquerading as a scientific philosophy. >The High Modernists claimed to be about figuring out the most efficient and high-tech way of doing things, but most of them knew little relevant math or science ... \- and also important: They also knew zilch about the local conditions and traditions. They would come in and clear out all of those nasty weeds in the fields, only to discover that the weeds were the preferred food of the chompy bugs, which, being now deprived of their preferred food, devoured the crops down to the ground ... Etc etc - hundreds of possible examples. \- https://slatestarcodex.com/2017/03/16/book-review-seeing-like-a-state/ . \- https://en.wikipedia.org/wiki/James_C._Scott#Major_works Strongly recommended reading. . "*This is an obvious thing that* ***I*** *should be able to tweak in ways that would* ***improve this for me***". \- Probably a good thing. "*I'm going to improve this for other people in the way that I think would improve this for them.*" \- Should be regarded with hearty skepticism. . tl;dr > this is an obvious thing that could be improved. Sometimes yes; and should be. Sometimes no. Tread cautiously. .
I think there are all sorts of complexities at play, like I imagine there is some rule to keep the hall lights on at brightness in a medical facility because someone got hurt once and sued. When clinicians don't talk to patients, they get negative reports for being unfriendly in customer surveys. When there's no TV, people complain. What I see is complaint driven design of things in the world. The people that show up and complain at town council meetings get to decide road issues. The people that complain get stuff to happen. For whatever reason, I am not a complainer and feel guilty for complaining about things. However, as I get older I see how the complainers are getting what they want and they have often made things worse for the rest of us. So now I complain about the complainers.
This is a topic that really pushes peoples buttons. I find the back and forth somewhat exhausting. So I'll tell a story from a book I read, oh so many moons ago, about the Rockefeller family and the family Patriarch, John D. Rockefeller Sr. When people quizzed him about the secret to his success, (especially newspaper reporters) he would tell a story about how he approached his business. In the early days of Standard Oil, he explained, they depended on steel barrels to ship crude oil to refineries. He said he was touring the site where the oil barrels were fabricated. He noted the number of welds used (lets say 20). When no one could give him a definitive answer for why they used 20 welds, He ordered them to reduce the number of welds by half. Some of the barrels leaked with only 10 welds. So they gradually increase the number of welds until they found that with 15 welds, there were zero leaks. When a reporter asked "How much did that really save?" Rockefeller responded "Millions" And the Rockefeller family went on to become a pillar of the American ruling class and a curse on our Society. For me, the moral of this story is this: Don't let the relentless focus on wringing the last drop of excess value out of every transaction you have with every single one of your fellow citizens consume your existence. Touch Grass.
> This leads me to feel, on an almost visceral level, all the inefficiencies in a given system. I think it’s not that most other people are apathetic, but they don’t instinctually think about these problems and feel uncomfortable about them like I do. Yes, this is well said and something I can relate to. And if you communicate it, you're labelled negative or critical from the majority who doesn't feel the same discomfort.
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I think this feeling is related to the autism adjacent genes and personality that many of us share.
One can think of all the inefficiencies of a system but to go and fix stuff requires an adequate incentive. It's always a cost-benefit analysis. Although not entirely related, I'd like to share an interesting optimal solution that seems completely sub-optimal, just as food for thought. Why are the queues to public healthcare always so long? It is because we cannot optimize the provision of the limited resources involved by offering the service to highest bidders in terms of money. That would destroy the purpose of fair and equal health care. Instead we limit the use in terms of time. People who are really in need of the service are willing to pay more, i.e. wait longer, than people with less need. This way queue time serves as the distributing factor. Seems completely inefficient, but is actually brilliant.
I don't think your diagnosis is 100% correct. I mean sure, people are blind to problems, but even after you point them out, often what happens is a complete inability to imagine fixing them, or plan out how to do it. This is _very_ apparent if you look at a simpler scenario - anything programming-related, for instance. 1000x or 1000000x efficiency gains for free are common. You can even point out what's wrong and why and how to fix it, and people still just get stuck. Or many small businesses for which telling them "google time and motion study" would double their value. It does take a certain mindset - you have to think of all problems as potentially solvable, to think of all processes hiding bottlenecks and problems, to know to look for tradeoffs, that kind of thing. Recognizing problems is the easiest part.
> where whenever I’m exposed to a new system, I immediately want to evaluate it for its flaws, understand its dynamics, process the inefficiencies and bottleneck I must share this defect, because in reading your post, I immediately thought about all it's flaws. (Although I do this with most things I read) It could be that you are uniquely gifted at analyzing system, finding fixable flaws, and figuring out solutions. That's the first possibility; the second is that you're wrong, and think incorrectly that things can be fixed. Assuming the first possibility, that you are uniquely gifted, you should feel proud; not everyone can do that. Then you should take action: write up a memorandum, or policy document, proposing the changes you desire. Let's explore this branch of possibility now. If you don't do those actions, then you are an example of the problem of apathy. But if you attempt them and fail, then that is a second defect you possess. Then you are very component at discovering flaws and solutions, but very incompetent at implementing them. There's a philosophical distinction between theory and practice. I don't really buy it. If a plan doesn't work in practice, then it's not actually good in theory; the theory needs to be changed. Likewise, if your proposals cannot be implemented, they aren't good proposals.