u/self_made_human — reddlx

Black Wednesday

For context: in the NHS, there's a specific date where, around the country, an entire batch of doctors graduate from or enter training. It's as disruptive as it sounds.

It's been a pleasure watching the fresh batch of baby doctors arrive on the ward, all wet behind the ears, lanyards tight around their throats. It makes me feel nostalgic, protective, and very old, all at once.

My colleagues before this lot were excellent, so the bar was set high. You can absolutely tell the new ones are new, but they compensate for the gaps with genuine diligence and a willingness to learn, which is all I can really ask.

Although "gaps in knowledge" is the wrong phrase. Talk to them for five minutes and the knowledge is plainly there, filed and indexed and ready to be recited. What makes an experienced clinician is the intuition about which parts of it apply to the person in front of you. Chess grandmasters famously don't calculate more moves than amateurs; they just see the board in chunks, and the bad moves never make it to conscious consideration in the first place. Medicine is like that, except the board is a 78-year-old with three comorbidities who has stopped taking one of her medications and hasn't mentioned which.

It's one thing to know the drugs and the diseases cold. It's another beast entirely to have a messy, inconvenient human in front of you, and that description covers the other doctors as fully as it covers the patients. Eventually, through sheer exposure, observation and practice, you just know. The relevant information stops requiring a search through your head, or a panicked Google in the loo (I am not above this). You build up what I can only describe as a mental cache, log(n) for the things that matter. Inconsistencies start to make you itch before you can articulate why.

Then there's the tacit stuff, none of which appears in any curriculum. How to refer to General Surgery without being swatted away. The exact words that make a busy Med Reg give a damn. Tactical phrasing that gets an urgent CT head done urgently rather than eventually. Presenting a patient so it parses for a doctor as exhausted as you are, who lacks the benefit of having spent the last four hours with them. Shortcuts through the hospital. Where to liberate your fair share of patient coffee, the single perk of the job. How to comfort the disturbed and disturb the comfortable, when clinically indicated. Which consultant will cheerfully field the silliest question, and which one will not suffer fools. The importance of booking annual leave early, so there is something to live for that isn't an ARCP. Getting along with your colleagues, because the NHS is a harsh mistress who will grind you down, and collegiality is a slow, reliable form of karma that they will be drawing on regularly. And, in due course, a tolerance for my worst puns.

I've been rather delighted by the FY1s and their impostor syndrome, which has a prevalence I estimate at 100%, give or take 0. They do their best to hide it, and you can always tell. I say that the shoe does fit, and eventually they'll stop noticing the blisters. They're fresh out of med school, and suddenly here is a human being who might die if you sneeze at them wrong.

Catch.

The most poignant case was the new core trainee. Lovely girl, fretting that she didn't know a thing. I told her, firmly, that if she knew everything already she'd be wildly overqualified, or at minimum a Senior Registrar. You're here to train, miss. It's in the name. You'll be fine.

On day one I told them that stupid questions do exist, and that I was issuing everyone a month of exemptions. The exemptions have been used. Expired ones remain welcome, because God knows I still ask colleagues, sotto voce, things I very much hope nobody senior overhears.

Sigh. I was there once, permanently braced for the moment someone worked out that I had no idea what I was doing. You pick up a few tricks, and hopefully avoid killing anyone en route. I think I've become the sort of senior I wanted when I started. Visibly stressed, clearly overworked, but always willing to make time for those need mine more than I do. I've certainly known worse.

As Black Wednesdays go, last week was far from the worst.

ussri.substack.com

u/self_made_human — 8 days ago

▲ 31 r/slatestarcodex

Epistemics

A patient who had recovered from psychosis came to Master Dongshan and said, "For two years I believed the government had implanted a transmitter in my skull. I was as certain of this as I am now certain it was a delusion. The feeling of knowing was identical in both cases. How am I to trust any of my beliefs ever again?"

Master Dongshan said, "You are asking perhaps the most important question in all of epistemology, and I notice you arrived at it not through philosophy but through suffering."

The patient said, "True enough, but forgive me for not finding your statement very helpful."

Master Dongshan said, "No. That's why you paid me to prescribe you meds, not for a lecture on philosophy. But consider: everyone around you walks through life with that same unjustified feeling of certainty. They've just never been given reason to doubt it. You now know something that most people do not. You know that the experience of being right and the fact of being right are completely different things."

The patient said, "I have.... issues with framing this as some kind of gift. It feels more like a nightmare. I can no longer trust my own experience."

Master Dongshan shrugged and resumed weeding his garden: "You have described the starting point of all genuine inquiry. Most people never reach it. They are too comfortable inside the feeling of knowing to notice it is only a feeling."

The patient was not comforted, but was, in a way he found no use for, enlightened.

ussri.substack.com

u/self_made_human — 27 days ago

▲ 1 r/slatestarcodex

The Rising Son Meets The Falling Father

It's not fun, looking in the mirror and seeing your dad looking back at you. Fun would be the wrong word for it. "Interesting" is more accurate, and "oh god, I understand him now" is more accurate still, and more helpful besides.

More hair. Or at least as much hair as he had at my age. The same facial features, remixed. Half a foot of extra height on him, because he grew up poor and didn't get to eat as much as a boy should. The intensity of the gaze. That's what you can see from the outside.

What you can't see so easily from the outside is what matters more. My father is quite possibly the hardest working man I know, to a degree that is frankly concerning, and also responsible for most of the good things in my life. His retirement planning is... to not retire. If he can help it. At a certain point I came to the painful realization that he doesn't have much of a life outside work, and that he's never been looking for one. He's happier about this than I am. Or at least the same "grumble very loudly but keep doing it anyway" impulse runs in me too.

I've told my mother that, in the unfortunate but real event that he develops dementia, the kindest thing would be to build him a fake OR and hire some very long-suffering and competent actors (or actresses, given his gynecological competencies, or your tolerance for gendered language). Hand him a scalpel and a few laparoscopic instruments I can't even name, and he'd do a better job than most surgeons, even cognitively impaired. Hmm. Perhaps we could hire actors with uterine fibroids or complicated pregnancies. And possibly charge them for the process.

It seems I've just reinvented his day job. Good. He prefers it that way, to the point that he does it half the night too. He'd get so much over-time if he wasn't self-employed.

I used to be intimidated. To be fair, I still am, slightly. I had many reasons for opting for psychiatry (a better work-life balance, and being able to yap at people and get paid for it), but one of them was the desire to avoid unflattering comparisons to my dad if I followed directly in his footsteps. Those are big shoes to fill, even if my own feet are bigger than the shoes. I can't be the surgeon he is, even with age slowing him down. I can't be the man he is either. But luckily, even half a dose of self_made_human Sr.'s genes is a strong potion. I have my own skills and my own talents, ones my dad was always proud of. He never expected me to be him. He was always going to be happy if I turned out the best possible version of myself.

Then, after a video call not long ago, I came to the aching realization that we're at the point where I am just as concerned about his health as he is about mine, if not more. That while he might be a world-class surgeon, he does not belong in a psych ward (except on the side with the comfy beds), and vice versa. And that he takes my opinions, including the psychiatric ones, seriously these days. Though not as seriously as I'd like. Vice versa on that too.

Like I said, age has caught up to him, but it won't stop him running. An episode of atrial fibrillation, requiring hospitalization, which my family didn't tell me about until he was stable. You can imagine my feelings. An obscure heart condition once thought to affect only Japanese men, which raises questions about my ancestry that the rest of my family answers anyway. No, they didn't get past Burma or into any pants. We're not weebs.

I've been trying to buy him an Apple Watch for a while. ECG monitoring, if nothing else. He doesn't need a watch to tell him the time, he has no time. I want him to have more. Like most semi-luxury purchases in our family, this was debated endlessly, until I put my foot down. I told my brother to buy him one for Father's Day and bill me later. The whole point of earning money is so you can spend it. On the ones you love. On what you need. On what they need, but are too cheap to buy for themselves.

I told my dad about this. He hemmed and hawed. Of course he did. That's what I'd do too. I'd had a bit of a scare myself at work, and asked my own boss how much his fancy FitBit cost. On hearing the price I winced, and said a trip to the ED was cheaper. But unlike him, I'm in excellent cardiovascular health. Or at least my questionable lifestyle choices have yet to catch up with me. My dad grumbled about the expense, but I know the gentleman very well. I could tell he was touched. Slightly shaken. So used to being the one doing the worrying and the caring, in his own gruff but loving way, that he found it deeply pleasurable and enormously uncomfortable to be the one receiving it. I get it, dad. I really do. I'm not sure your little boy is all grown up, but they seem to trust him with people's lives, and he hasn't been fired just yet.

All it took was being knocked flat on my ass, and getting back to my feet. With a few helping hands. Or a lot of helping hands. A surprising number of people who cared, despite all the reasons I felt I didn't deserve the concern. Realizing that I'm very tired, barely half a decade into my career, and willing to do it tired anyway. To go down swinging, and to refuse to let the bastards grind me down. I'm not a bastard myself. I know very well who my dad is. And that means a lot to me.

It's not easy, being a man. The cause of and solution to more than our fair share of the world's problems. The higher-variance sex, the idiots and the savants. The ones who dish out the violence, and the ones who protect from it. Broad shoulders, to hold up the weight of the world. Strong jaws, to take a punch. Mostly from other men.

So we do it. So I do it. Can't trust anyone else to. Women? They belong in the kitchen, because that's where all the good food is, and because they've had a bad day at the office and need someone leaning on the counter making ridiculous jokes and telling them they're cooking up a storm. The kitchen is where I clearly don't belong, since the best I can say for my culinary skills is that I haven't given anyone food poisoning yet. At least I don't need much prodding to do the dishes.

But with growing dismay, I've found myself in complicated situations, looking around for the adult in the room. And realizing, with very mixed emotions, that I'm the adult. The one responsible for this mess, a mess that's largely not even my fault. Fucking hell, how did I get away with it? How did no one see through me on day one?

Then I remind myself that pretending is the point. Some masks stick when you put them on and rarely come off. They adhere. That's what the blood, sweat and tears are for. If I can consistently pretend to be a functional human being, one who can be entrusted with the lives and safety of others, then maybe I am that man. And I'm in no real hurry to take the mask off. Not until I can hand it on. Hand it over, and enjoy a retirement. Possibly an early one, given the pace at which things are moving.

I'm not entirely at peace with my impending obsolescence. The fact that we are clearly building machines smarter than us, while hoping they turn out kinder than us. I want to be the psychiatrist Anthropic hires to psychoanalyze its latest models. I'm genuinely unsure whether I can be that man in time for it to matter, before I'm laid bare. That's fine. We undress you before surgery for good reason. Lay my psyche bare, and let something smarter and wiser than me strip away the tumor and leave the parts of me I want to keep. I did say I'm not quite at peace, but I choose to pretend to be. Pretending is the point. Judge a man, or a woman, more by what they do than by what they say. Talk is cheap. I give this away for free, and you get what you paid for.

I'm a broken man. Thankfully not broke, and just about at peace with being a man. My reasons for opting for psychiatry are myriad, but one was that I was always slightly hoping I'd run into people who knew better, who knew what they were doing. Sometimes I do, and I'm suitably grateful for it. But they can't seem to fix me. And I assure you, I need some fixing.

Man is somewhere between the falling angel and the rising ape. I feel for all the broken monkeys out there, and sometimes they put me in charge of the circus. I try my best. I really do. On good days my best is more than good enough. But I suspect the bad days are awful, and that fixing them might be an AGI-complete problem. Or rather, that we'll have AGI before we finish the job

I told my little brother, who I love dearly, that it's about time he manned the fuck up. I said it with love. He's got the certificate, he's another not-entirely-self_made_human (Jr and Jr), and his approach to academics horrifies me. My approach to working out horrifies him, and I... have to concede that one. He's alone at home. We're all alone, but I'm not at home. We're all lonely, but never as lonely as you might think. He has easy access to a family that loves him, and one we love back. Two dogs that can be absolute bitches, but are lovable in their dumb, goofy way. He's got two increasingly elderly parents who made many, many sacrifices to get us where we are, and who only ask that we do our best. I try. I worry about them, because worrying about the people I love is my love language. And I'm really not going to bother learning Italian.

Some of the broken monkeys really don't know better. They come to me, sometimes. The poor bastards. I might get paid peanuts, but there's worse remuneration for an overworked ape. I try to be the doctor they deserve, and these days I even believe the compliments I get in return.

I put on my Sunday best on a Monday, because I'm dressing for the job I want and not the one I have: that of a better-paid and probably more qualified shrink. My old boss's job, because the asshole can't be trusted to do it right. The new guy? I can't say a word against him. He's a good man, much like my dad, but with an even worse sense of humor. He has a son he dotes on and doesn't need another, so I just tell him he's a very good boss, and that I'm trying not to let him down either. He seems to believe me, poor guy.

I look at my hands. Surgeon's hands, according to a surgeon, who is hopelessly biased on the grounds that they're his own hands, only larger and possibly more slender. But a surgeon nonetheless, and a good father. He might doze off at the cinema, and consider walks with friends and reading the newspaper to be the peak of entertainment, but I'm here to make him proud. Not letting the people who love me down is the best way I've got of getting away with my antics.

So man the fuck up. Or woman the fuck up. Or be an enbie and give me no reason for envy. You might be broken. You might be laudably sane. Either way, be more than your genes, be more than your circumstances. Be the cause, and not just the effect. It's worth it. I promise you that. The world has more than its fair share of assholes, and not enough good men. Or even men trying their best. I do what I can, when I can.

The Substack version has memes. I don't know if that makes this essay better or worse, but I love my brainworms too. They're starving to death as we speak.

u/self_made_human — 2 months ago