Post-apocalyptic life in American health care

TL;DR:

  • Much of my time for the past year has been spent navigating the medical maze on behalf of my mother, who has dementia.
  • I observe that American health care organizations can no longer operate systematically, so participants are forced to act in the communal mode, as if in the pre-modern world.
  • Health care is one leading edge of a general breakdown in systematicity—while, at the same time, employing sophisticated systematic technologies.
  • Communal-mode interpersonal skills may become increasingly important to life success—not less, as techies hope.
  • For complex health care problems, I recommend hiring a consultant to provide administrative (not medical!) guidance.

Epistemic status: impressionistic blogging during a dazed lull between an oncologist and an MRI. No attempt to validate with statistical data or knowledgeable sources.

No system

My mother’s mild dementia began accelerating rapidly a year ago. I’ve been picking up pieces of her life as she drops them. That has grown from a part-time job to a full-time job. In the past month, as she’s developed unrelated serious medical issues, it’s become a way-more-than-full-time job.

The most time-consuming aspect has been coordinating the dozens of different institutions involved in her care. I had read that the biggest failing of the American health care system is its fragmentation; I’ve now spent hundreds of hours observing that first-hand.

There is, in fact, no system. There are systems, but mostly they don’t talk to each other. I have to do that.

It’s been fascinating watching people working in hospitals and medical offices trying and failing to communicate with each other. I’ll tell one story, and then explain a pattern. This is the most dramatic instance I’ve encountered so far, but is typical in form.

The short version is that at least seven experts spent roughly ten full-time days trying to find out a basic fact about my mother’s insurance, and finally failed. Meanwhile, many thousands of dollars were wasted on unnecessary hospitalization.

This is a stark example of medical cost disease, but the post is not about that. It’s about how institutions fail to talk to each other—and what that implies about our future.

(If the story gets boring, you can skip ahead to my interpretation of the pattern.)

My mother went into the hospital a month ago with severe pain in her hip. (It’s still undiagnosed.) After two days, she was medically ready for discharge from the hospital: whatever the pain was, it wasn’t one they could help with. Instead, she should be sent to a “skilled nursing facility” (SNF) where she’d get “physical therapy,” i.e. leg exercises.

For a SNF to agree to take her, they had to get confirmation from an insurance company that insurance would cover her stay. She has two kinds of health insurance, Medicare plus coverage through a private insurer (Anthem). Which would cover her? Or both, or neither?

SNFs have admissions officers, whose full-time job is to answer this question. Two different SNFs started working on the problem. I talked with the admissions people every day. Both claimed to be working on it more-or-less full-time. The hospital wanted to free up my mother’s bed, so their insurance person was also working on it.

Days passed. The hospital doctor on rounds said “Well, this is typical, especially with Anthem. It’s costing them several thousand dollars a day to keep her here, versus a few hundred dollars a day in a SNF, but it might take a week for them to figure out which local SNF they cover. Don’t worry, they’ll sort it out eventually.”

Meanwhile, I learned that Anthem and Medicare were confused about their relationship. (As far as I can tell, this was a coincidence and not the underlying problem, although I’m still not sure.) Medicare believed that my mother (who retired in 1997) is employed and therefore ineligible. Her Anthem coverage is through her former employer.

I talked with her ex-employer’s benefits person (whose full-time job is understanding insurance, pretty much). She looked into it and said she couldn’t understand what was going on. She called the company’s outside insurance consultant. He couldn’t understand what was going on. He called people he knew at Medicare and Anthem. He said that they couldn’t understand it either, but that multiple people in both organizations were working on straightening it out.

A week later, I called Medicare to verify that it worked. The surprisingly competent customer service person looked up my mother’s info and said: “This is really weird… I don’t know what’s going on… there was a record that said Anthem is primary. And then on November 16th, there’s a note that said it’s deleted, and Medicare is primary. But then there’s an update on the 18th that says Anthem is primary. But obviously since your mother is 84 she’s not employed, so Medicare should be primary… I’ll delete the record again…”

After three days of trying, one of the SNFs gave up. I talked to the admissions dude there. I’ll call him Paul. He was smart and friendly, and he was willing to explain:

My full-time job for ten years has been understanding how to get insurance to pay us, and I have no idea how the system works. Even if I somehow learned how it works, it changes completely every year, and I would have to start over. But at most of the insurance companies I know people who can sometimes make things happen, so I call them up, and then they try to figure out how it works. But Anthem… I spent hours and hours on hold, and in phone trees, getting transferred from one department to another, and eventually back to where I started. The most clueful-sounding person I could find sent me to a web site that just says ‘This program is not implemented yet.’ Does ‘program’ mean software, or does it mean some project they haven’t got going?

Hospitals are bad places that make you ill; you don’t want to spend any more time there than you have to. On day six, I said “if she doesn’t go to a SNF today, I’m taking her home—the risk of her dying there seems less now than the risk of her dying here.” That got results: the other SNF agreed to take her “on spec.” Their admissions person was reasonably confident that either Anthem or Medicare would pay, even though neither was willing to say either yes or no ahead of time.

The SNF called me to tell me they needed my mother’s records from the hospital. Well, what do you want me to do about that? We need you to call the hospital and ask them to fax us the records. “Fax”? Why not send clay tablets in wicker baskets on the back of a donkey?

No interface

To ship a package by FedEx, you don’t need to call someone who knows someone who knows someone. You go to a web site, put in some numbers, it gives you back some numbers, you put them on the envelope, drop it in a box, and it appears at a farmhouse on an island in Lapland the next day.

If Amazon sends you the wrong type of cable adapter, you don’t have to call them up and try to act pathetic and virtuous in order to convince someone that you need and deserve a refund because your poor mother is so ill. You go to a web site and push a button.

FedEx and Amazon have systematic interfaces. They are transparent on the outside, and black boxes on the inside. You don’t have to know anything about how they operate in order to use them.

Health care organizations are—at best—the opposite. They may run on systems internally, but the interface is opaque. There’s no defined way to get them to do something.

This is not their fault.

No fault

I was trying to get my mother into a SNF—but all I could do was talk to Paul, who couldn’t say yes or no. It wasn’t his fault. He was trying to talk to people at Anthem, who couldn’t say yes or no. Was that their fault?

Just speculating, I imagine they are supposed to apply 1600 pages of rules for what’s covered in what situation. And the rules are vague and conflicting and change constantly, and who can read 1600 pages of rules anyway? So eventually someone has to make up a yes-or-no answer on the basis of what seems more-or-less reasonable. Whoever it is could get blamed if someone higher up later decides that was “wrong” based on their interpretation of the rules, so it’s better to pass the buck.

Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to reconcile federal, state, and local legislation, plus the rules of three federal regulatory agencies, nine state agencies, and fifteen local agencies. All those are vague and conflicting and constantly changing, but Anthem’s rule-writing department does their best. They call the agencies to try to find out what the regulations are supposed to mean, and they spend hours on hold, are transferred from one official to another and back, and eventually get directed to a .gov web site that says “program not implemented yet.” Then they make something up, and hope that when the government sues Anthem, they don’t get blamed for it personally.

I imagine people working in legislative offices and regulatory agencies find themselves in a similar position.

In this maze, even competent people with good intentions cannot act systematically. Their work depends on coordinating with other institutions that have no systematic interface.

Traditional life in the ruins of systematicity

It’s like one those post-apocalyptic science fiction novels whose characters hunt wild boars with spears in the ruins of a modern city. Surrounded by machines no one understands any longer, they have reverted to primitive technology.

Except it’s in reverse. Hospitals can still operate modern material technologies (like an MRI) just fine. It’s social technologies that have broken down and reverted to a medieval level.

Systematic social relationships involve formally-defined roles and responsibilities. That is, “professionalism.” But across medical organizations, there are none. Who do you call at Anthem to find out if they’ll cover an out-of-state SNF stay? No one knows.

What do you do when systematicity breaks down? You revert to what I’ve described as the “communal mode” or “choiceless mode.” That is, “pre-modern,” or “traditional” ways of being.

Working in a medical office is like living in a pre-modern town. It’s all about knowing someone who knows someone who knows someone who can get something done. Several times, I’ve taken my mother to a doctor who said something like: “She needs lymphedema treatment, and the only lymphedema clinic around here is booked months in advance, but I know someone there, and I think I can get her in next week.” Or, “The pathology report on this biopsy is only one sentence, and it’s unsigned. The hospital that faxed it to me doesn’t know who did it. I need details, so I called all the pathologists I know, and none of them admit to writing it, so we are going to need to do a new biopsy.”

But at the same time, each clinic does have an electronic patient records management system, which does work some of the time. And there are professional relationships with defined roles that operate effectively within the building.

I suspect increasing “patchiness” of systems may be typical of our post-systematic atomized era. Understanding the medical case may help predict the texture of cultural and social life as atomization proceeds.

A central research topic in ethnomethodology is the relationship between formal rationality (such as an insurance company’s 1600 pages of unworkable rules) and “mere reasonableness,” which is what people mostly use to get a job done. The disjunction between electronic patient records and calling around town to try to find out who wrote a biopsy report that arrived by fax seems sufficiently extreme that it may produce a qualitatively new way of being.

I would like to ask:

  • How does health care continue to function at all?
  • Can it continue to function at all?
  • How do people within the ex-system navigate a world that mashes up high-tech infrastructure that only sometimes works with pre-modern social relationships across organizations?
  • How do they understand this contrast? How do they cope personally?1
  • What can we do about it?

Maybe an ethnomethodological understanding of how health care organizations operate in practice could make the systems work incrementally better. Maybe an enlightened COO could incorporate the view that the systems and reality are only vaguely related. But… it may be impossible to improve individual organizations.

No local fix

It’s obvious how to fix health care. Just make everything run systematically, like FedEx or Amazon. There are no technical or business obstacles to this. Anyone who understands IT and/or business can see how to do it.2

Back-of-envelope calculations say a working health care system would deliver dramatically better quality at 10-20% of the current cost.

Health care is notionally a profit-driven free market. This looks like an easy opportunity to make trillions of dollars by making the world better for everyone. Why doesn’t someone do that?

It appears that 73% of the labor cost of a health care organization is spent on trying to communicate with other health care organizations that have no defined interface.3 Patrick Collison has suggested calling this pattern “Leibenstein’s Inefficiency Disease,” by analogy to Baumol’s Cost Disease. An organization can’t improve the 73% by much on its own; that inefficiency is forced on it by the environment it operates in.

Instead, organizations in sectors afflicted with inefficiency disease try to push their own administrative work outside. Both out into other organizations, and—more visibly—they force it onto you, the customer. It’s your job to fill out forms they could have done more efficiently themselves. When they screw up, you have to try to fix it. This negative externality could be called “paperwork pollution,” by analogy with negative externalities of smokestack industries.

Standardizing an interface between health care providers and insurance companies would be a huge win. No matter how badly designed, it would be better than the current mess, and save several percent of US GDP. That would need cooperation from most of the major players in the industry. Other industries manage that routinely: machine screws and futures contracts come in standard sizes, without which manufacturing and finance would be as inefficient as health care. The need for a standard insurer/provider interface is obvious. Since it’s lacking, I imagine some powerful group extracts enormous rents from the inefficiency. I know nothing about that, so I won’t speculate.

You will need village life skills

Perhaps American health care is a bellwether model for the future of other aspects of life in the post-systemic world? A pattern that occurs in many other sectors: as systems fail, people fall back on innate communal logic. Politics and the media are obvious current examples.

The hope of the tech industry is that “software is eating the world,” as Marc Andreessen put it in 2011. That is, we’re FedEx-izing every aspect of the economy: making it radically more efficient and reliable, using well-designed IT-supported systematic business processes.

In that world, systematic-mode skills (especially programming and finance) will be ever more valuable. Hooray! We will create a utopia for all, in which (for once) those of us with high-functioning autism get properly rewarded.

In 2017, software is conspicuously not eating the cost-disease economic sectors: health care, education, housing, government. They are being eaten—by communal mode tribalism.

In 2017, tribalists are threatening to eat the tech industry.

There’s a possible future in which all systems fall to tribalism. Then everyone dies, because tribal signaling does not deliver electric power. In another possible future, we create a meta-systematic society that addresses the inherent defects of both tribalism and systematicity. (I discussed both these possibilities tangentially in “A bridge to meta-rationality vs. civilizational collapse.” I hope to write more soon.)

In the short run, more likely, current trends will continue. Additional aspects of life will increasingly revert to the communal mode, but some critical systems will fend off the barbarians and limp along well enough to keep us alive.

In that world, people skills will be ever more valuable. Surviving and thriving in 2037 may depend mainly on who you can charm, who you know, and whether they owe you favors.

Techies take note.

You might consider working in a medical office, to get some practice.

Hire a consultant

Some more-serious, practical advice:

If you find yourself in a situation like mine, hire an independent health care administration consultant. Their job is to know administrative people inside organizations who can get stuff done. They also know what can be gotten done, which is unknowable to the public. They can also deal with inscrutable paperwork and organizational screw-ups.

Hiring someone became imperative for me when coordinating my mother’s care got to be a way-more-than-full-time job. (In retrospect, I wish I had done that months earlier.)

It could also be worthwhile in less critical cases, if no one in the family can take enough time off from work, or in which you’d simply rather pay someone else to clean up after a hospital’s paperwork pollution.

This role has developed only recently, as systems have broken down. There’s not yet a standardized term; “health care advocate” is one among several.

Mine specializes in gerontology and dementia. Others specialize in other disease areas; or in other aspects of the administrative nightmare, such as sorting out bogus hospital bills, which frequently include fraudulent additions.

They are not inexpensive (mine charges $150/hour), so not an option for everyone.

There are good and not-so-good advocates. I spoke with several before hiring one. Some were clearly clueless; the one I hired last month has seemed consistently competent.

Since they recommend particular providers, there is an inherent principal-agent problem. Ask if they get any compensation from services they recommend. Take their recommendations with a grain of salt in any case.

  • 1. I imagine for many it’s awful. “Communal” sounds “nice,” but most are in medicine because they want to help others, and they can’t get their jobs done when the system breaks down.
  • 2. Step 1: Throw away the ubiquitous fax machines. Sink or swim. Hire donkeys if necessary.
  • 3. The number 73% is my dazed estimate based on informal observation and analysis conducted in doctors’ examination rooms.

Comments

Healthcare

Marshall's picture

From Eliezer’s new book:

“For our central example, we’ll be using the United States medical system, which is, so far as I know, the most broken system that still works ever recorded in human history. If you were reading about something in 19th-century France which was as broken as US healthcare, you wouldn’t expect to find that it went on working when overloaded with a sufficiently vast amount of money. You would expect it to just not work at all.”

I can empathize

Ian's picture

Sounds similar, but even worse, than my grandmother’s situation about 10 years ago. Blessedly, she did not have to deal with cancer on top of dementia. But she was transferred to an SNF without any notification to family members, or management of her residence! It is both fascinating and depressing that a new class of professionals has arisen, simply to be one’s “agent” within the system.

I'm sorry to hear

James's picture

My family recently went through a similar sort of situation. It’s really tough and I’m sorry to hear that you have to deal with this. Best wishes to your mother, you, and the rest of your family.

Medical systems

Caleb's picture

I’m sorry to hear of your mother’s situation and your difficulties. I wish you both well. While I realize the post was epistemological and ontological commentary rather than political, and knowing that in the US healthcare is a political football, I say the following in the hope that it can be seen as something other than a political comment. There is a context to these systems that you describe. There are assumptions embedded in both the description and the speculation. Some of the assumptions are ‘political’ in nature. Maybe I agree with them, maybe not. But let me make the following empirical point - we know that despite spending massively more both in absolute terms and on a per capita basis, the US healthcare outcomes rank well down the pack, so why use the US as the paradigm of what is possible or likely for the future? That’s a narrow perspective at best, and it’s the kind of narrowness that becomes self-fulfilling. Anyhoo, I used to live in Japan. No lack of medical technology or capabilities there. Significantly better outcomes. Much less work expected of patients, and much less stressful to deal with than the US system. And the really big difference is that the Japanese don’t think of their medical system as a “trillion dollar free market” or whatever. They think of it as a social good and design structures, processes and incentives accordingly. You see where I’m headed, obviously; the reason that a return to primitive modes of engagement is a subject of this post might have something to do with limitations in the set of assumptions embedded within both the system and the way the writer thinks.

A more conservative estimate

Adrian Wilkins's picture

A more conservative estimate of the costs of admin is around 27% ; this is the percentage of staff employed in the American healthcare system solely for billing administration [1].

The UK NHS by comparison is simpler - noted for it’s efficiency yet still primitive in terms of technology (fax!), plenty of room to improve - and manages to provide universal healthcare to the UK for less than half the cost per head of the US. You actually pay around 30% more per head in taxes spent on healthcare than we do. The fact that the majority of you get no healthcare at all for that should be causing riots all up and down every state.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4283267/

Healthcare

James X. Kennedy, MS, LMSW's picture

Your so-apt comment that healthcare offices are like a pre-modern town had me and kept me. I am still in health care administration (nonprofit, upstate NY) and was previously (in the 1980s) and SNF administrator. Thank you and I am sharing this post widely.

Jim, Geneva NY

Here's your consulting business

R C's picture

“Maybe an ethnomethodological understanding of how health care organizations operate in practice could make the systems work incrementally better.”

Very hard work, to be sure, but deeply insightful.

System is broken forever and we keep breaking it more

Deepa Shiva's picture

I had been advocating for Integrated Health Care Platform - even tried building one in India, a country with less regulations and more private hospitals. I have worked in United States with Kaiser Pharmacy division and Blue Shield of California. Lot of people have right intentions to fix the system, but no where to begin. With the on-going changes in the political system makes it more difficult.

With the electronic medical records, EPIC (http://www.epic.com) is almost the monopoly and between their systems they can exchange records (Stanford and Kaiser did this for me), but when it came to Sutter Health they couldn’t, so all my records had to be faxed from Stanford to Sutter (this is because of change of my Insurance). Beginning with two major players as like you proposed Insurance and Hospitals, we do have systems (for ex: http://www.trizetto.com/PayerSolutions/CoreAdministration/Facets/), but not exposed to patients. The biggest challenge apart from fragmentation of the data and information, I notice is lack of transparency to patients.

The UCLA health network has

Anonymous's picture

The UCLA health network has bought up so many private practices in and around LA that it carries at least some of the benefits of an integrated system. However, it also seems to cause a 300% price increase. It’s all somewhat reminiscent of the Mythical Man Month, but at least the doctors all have access to the same body of records …

I know MMM is an old book with antiquated prescriptions, but the problems of communication overhead remain very prescient. It seems to me that once systems scale beyond practical boundaries of communicating they decay into a chaotic background noise that seems to naturally invoke tribalist stylings

Health Care Reform: Dynamics Without Change

Sound familiar? It was written in 1972. The core of the problem is trust and incentives. When you contact Fedex to ship that envelope to an island in Lapland, you KNOW where you want it to go and you know what you want to send. FedEx would not look so great if you had to show up at Fedex and the worker there got to recommend (or demand) where the envelope would go and what was in it.

We can’t know as much as the doctors and nurses. So we have to trust them. You could trust the counter worker at FedEx. But would you still trust that worker if her income depended on where she told you to send your package? (Fee for service). Nor could you trust them if she got a bonus for only sending your package across the street? (Managed care). And if the envelope or packing supply companies could pay her on the side, it would get even crazier. (Drug companies and medical device companies.)

The instant these financial incentives spring up you get (if you’re lucky) the 1,600 pages of regulations necessary to keep them in check.

Costs

tooearly's picture

You wrote:”Back-of-envelope calculations say a working health care system would deliver dramatically better quality at 10-20% of the current cost.”
Surely you don’t mean we really could save 80-90% of current cots?

80-90% off!

Yes, that’s my best guess. I do the analysis by considering a particular medical service, finding out roughly how much a person providing it gets paid per year, and dividing by how long it takes to do to get the direct labor cost; finding out the cost of the equipment used and amortizing it; and adding in an estimate of the overhead (cost of the building and a reasonable level of administrative work). I’m reasonably skilled at this sort of analysis as a consequence of having run small businesses.

Estimates may vary, but everyone seems to agree that heath care is way more expensive than what you’d expect based on this sort of analysis. No one seems to know why; or, put a different way, where the money all goes. Everyone who has studied the problem agrees that it’s highly mysterious. It’s clear that administrative costs are needlessly much higher in health care than elsewhere, but that’s probably not the only source of the discrepancy.

A healthcare provider's perspective

Foster Ryan LAc's picture

Welcome to my life. Everything about the system is insane. The payment system incentivizes questionable behavior- but if you don’t do these things you will go bankrupt. The insurance companies do anything to reduce payments which then means providers have to become ‘creative’ as a counter measure to the inevitable dramatic payment reductions. Organizations have appeared between providers and the insurance companies to help the insurance companies save money and they cause the provider to be paid 1/2 of the money they need to be paid to survive, and that organization no doubt pockets a ton of money. The amount of record keeping required is exhausting, so it’s not just the administrators that spend time on paperwork- a huge amount of time is spent by the practitioners themselves on paperwork. Small offices are paid less than large organizations for the same procedures, and there’s nothing that can be done- small offices don’t have any leverage. Workloads are too high, in order to save money, so it’s a wonder that anybody gets any of their communications to somebody else. Major amounts of energy goes into protecting against lawsuits. High tech medicine for acute conditions gets all the resources and attention, and virtually nothing gets done for prevention because there’s no money in it, no incentives. By the time people get out of school they are so much debt that profit becomes a big focus. The entire industry is built to maximize profit and minimize risk exposure. It’s a wonder than any medicine gets done at all. The incentives of the industry are the drivers. Also, there is no easy answer for what is an inherently limitless cost, keeping people healthy- when there is a limit to what is possible with a given amount of money, but not to people’s needs. Healthcare is a public good and it doesn’t do well as a private business, but I don’t think anybody trusts a politicized system to do a good job, and medical businesses assume that they will get the short end of the stick if any changes are made. Also, the people in the business are people oriented, and not techies. It’s not that kind of a field, and doesn’t in general attract those kind of people- it’s a caring oriented business, not a tech business, and it’s hard to switch between those modes of thought- but I have to do it constantly anyway, and it’s not easy.

a few extra thoughts since I can't edit my previous post

Foster Ryan LAc's picture

I agree with your analysis. It feels to me that each node in the system is battling for its life against every other node, so cooperation is etremely suspect. Every medical office is in competition with the other offices for patients so aren’t necessarily interested in working with them, unless a reliable referral relationship could be worked out- but even that is still suspect. Practitioners are in fear of enslavement by larger medical organziations- for good reason. Every medical organization is in fear of enslavement to the insurance companies, so any cooperation is extremely suspect and frowned upon, because the payors mostly just want to ream the providers and make more profit by reducing costs. Patients can be difficult and some very litigious so providers are wary of giving the patients too much because when you give them an inch they are almost guaranteed to demand a mile. Payors are terrified of being enslaved to government demands so the relationship is very adversarial. Everybody assumes that any government involvement will be corrupted and controlled by big money so nobody really wants the government involved, becausee the government is enslaved to big money and does not have people’s interests at heart. Then the regulations become impossible to understand so we try not to pay attention to them because I have no time to read them anyway. We are all forced into trying to do what we think’s best and hope that that will work out. I only trust personal relatioships with other medical professionals, attorneys, and payor employees because this is the only way to not give screwed in countless ways. I am very reluctant to work with somebody I don’t personally know to some extent because it always turns out bad if I violate that rule. Village life principles are the only reliable ones in this field. The attorneys I work with operate this way, and everybody wants to minimze the information accessible to others because it only exposes you to risk and to losing patients, business, or payment. The only medical practitioners in my field I will openly communicate with are ones outside my market, across the country, and even then I’m wary because the information can make it back to my area and hurt my business. We all assume that an integrated system will only hurt us because it will lower the barrriers to the big players taking control and screwing the little players, and we will not be able to do anything about it, so it’s better to have roadblocks everywhere for defense.

Emotional intelligence training

Rufus's picture

Perhaps emotional intelligence training will be useful for preparing technical people for post-apocalyptic America. Among other things, it helps people pick up on social cues and the emotional states of the people around them.
More importantly, however, it appears to be capable of getting people to a Kegan’s stage 4 level of self-regulation without them needing social support.Perhaps it can help prevent some of what you’re predicting.
(The version of emotional intelligence training I am familiar with is the one in the book Emotional Intelligence 2.0)

Donations?

zaphod4prez's picture

David, how do we pay you?? I cant seem to find a patreon or donation link on any of your sites, but I want to support your work (because I love it!) Do you have a way for your readers to support your blogs?

Donations

zaphod4prez, thank you so much! I really appreciate your generosity.

I don’t have a Patreon (or anything similar) set up. It’s a good idea, and I’ve added it to my to-do list!

Mentioning the work to other people who might be interested is probably the most valuable way to help, for now.

what happened to deitic representations

Robert Demb's picture

Hello, I’m doing some research and I’m trying to connect the dots from Dreyfus’s critique(what machines still can’t do), “representations,” connectionists (all the way up through the current dnn, cnn - ilk stuff), to the present, and would like to get your perspective on what, if anything remains of your work (and agre’s ) in the “continuum” (in Dreyfus’s view) of AI. I did buy your book some 25 years ago, and managed around that time to obtain Agre’s “Dynamic Structure of Everyday Life,” but have not been able to pick up any current threads on where your stuff has gone. I know this is over simplified, but I am hoping you can provide a brief perspective of how, if at all, your stuff has evolved and/or is being used.

If this “comment” is out of context and/or inappropriate for this “venue” I apologize, but it was the only way I could find to communicate with you directly without getting wrapped around the axle of social media.

Thank you for your time. Robert

Whatever happened to...

Hi Robert, sure, glad to answer questions.

There’s partial answers here and here.

Short version, neither Phil nor I wanted to pursue the matter. Although a lot of technical progress still seemed possible, we couldn’t see how to build a general AI, which is what we’d wanted to do. And we both also kind of lost interest in the project of building a general AI anyway, and went off to do other things. (Phil into communication theory and me in to pharmaceutical drug discovery.)

Some other people continued work along the lines we’d set out, for a few years. But right around then there began an AI Winter (i.e. funding dried up), so there weren’t the resources to pursue what seemed like a somewhat non-mainstream approach. And also, neither Phil nor I was there to spearhead the effort and promote the ideas. So after a few years, our work mostly got forgotten.

Dreyfus did write a follow-up piece about our work in 2007.

When you talk about a “continuum,” is that the one between “really stupid like a bug” and “really smart like Einstein or something”? (Which Dreyfus mentions in that paper.) Or some other one?

Coasian hell

Thank you, that’s a really nice explanation! And it does seem like the right analysis.

The paradigm cases of “mysterious cost disease” in the US also include housing, education, and government. It tends to be implicitly assumed that the same explanations should apply to them and to health care, but they don’t seem to be examples of “Coasian hell,” so probably different stories are needed in each case.

(Transportation infrastructure is another, less catastrophic US cost disease case. That one does seem likely due to the same general causes as the UK rail system.)

US Healthcare

Good blog, many good comments - I particularly liked the one about the Japanese system, and the one introducing Coase-ian Hell. For my sins, I´m a (reluctant) economist.

To add my own two bits. The blog concentrates on communication between institutions, which is fine. it also mentions in passing, but does not emphasise, defective communication between purely medical teams even within US institutions, e.g. hospitals. If that is not tackled it will become an increasingly serious problem, because more and more older people have multiple conditions, as: neurological, urological, cardiac, pulmonary, orthopedic … If medical teams do not communicate effectively, the consequences will be (a) worse treatment and (b) as a knock-on effect, assuming the patient survives, unnecessarily increased long-term costs.

My experience, as a relatively elderly person myself, with the NHS in the UK does not extend much to communication within hospitals. But its various ´out-patient´services and personnel do seem to communicate and cooperate effectively and efficiently on diagnosis, tests, treatment, and follow-up. The manifold institutional writhings and tricks which you report from the US are not necessary because the system is unitary and has effectively only paymaster, HM Govt-

Living people have experienced system breakdown

Amy's picture

I have not lived through this myself, but the description reminds me of light reading about Soviet tolkachi (“pushers”) and Cuban sociolismo (buddy-ism, but only one letter off from “socialism”). It seems a universal (or at least pan-Europeanoid) response to system breakdown.

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