Alorael at Large

No One Cares About Crazy People by Ron Powers. It's of professional interest. It's sad and moving and actually quite good at walking the fine line of what we know (little), what we don't know (quite a lot), and what we don't know for certain but have compelling hypotheses about (substantial). —Alorael, who has When Breath Becomes Air sitting on his nightstand and taunting him. It's been there for almost a year. He's not sure 2018 is looking too good for it either.

Before assuming that, I'll ask the fraught question: do you have a next step? A job lined up, either in or out of academia, or a career in mind? —Alorael, who offers a virtual firm handshake and hearty greeting of "Doctor!"

I was also with Edgwyn, but then on closer inspection I found the first one looking like a short wavy blade in front and a longer one behind, perfectly aligned with the view perspective so at a glance it looks like a single blade. Now I can't unsee it as a weird double sword and prefer the second one. —Alorael, who actually thinks he likes the wavy blade more then the spiraling one. But only one wave or his brain hurts.

I'm not really an expert in either work-hour rules or the research about the subject, so take what I say with a little bit of skepticism. Better hand-off systems can be and have been designed. Getting hospitals to implement them is an uphill battle (medicine is a conservative institution generally, with some good reason, but making positive changes can be slow going), but it's happening. Still, it's pretty clear that hand-offs come at a cost. Even with the clearest summaries and instructions, overnight coverage doesn't know patients as well as the primary team unless it happens to be the primary doctor. But having the same doctor on-duty and knowing the patient well 24-7 doesn't work. It's all finding the optimal balance, and it's not obvious. Planes and flights are more interchangeable than medical care. You can have one pilot go off duty, another come on, and it goes smoothly. The same could be true for a patient, probably; it's less true for dozens or hundreds of patients at a time. Medical errors for these studies are often things caught before there is any potential harm. Things like ordering the wrong medication and nurses or pharmacists catching and correcting the problem, or something important being left undone and only caught with later review. Malpractice requires both actual harm and some kind of deviation from standard of care; not doing the right thing, or doing the wrong thing, can be noticed later and counted as medical error even if nothing bad actually came of it. You can also have bad outcomes with no error. Some of that comes with the job of taking care of sick people, some of whom will have bad outcomes because of the nature of illness. Some is because of mistakes; figuring out where things when wrong, like when the wrong thing was done or a critical sign or symptom was missed, is a big part of medicine (legally, with assigning culpability in malpractice, but also for root cause analysis to try to avoid having the same bad things happen again if it's avoidable). —Alorael, who is in favor of everyone having access to healthcare. There are a number of ways to accomplish that; single-payer is one, but not the only one. There are reasons to pick among the options, and he's not expert enough to have a professional opinion. Simply not providing coverage for people is a reasonable free-market choice, but he views it as morally untenable; the current system also doesn't let doctors or hospitals leave people to die even if they want to, so it's not even like there's a true free market now. It's just a really expensive system that will provide care without repayment only in extremis, which is the most miserable and expensive way to go about it.

History, from when I asked that very question. A rich family can help one be able to afford education, but it's on the student to perform the work. That's up to intelligence and, as the reputation of grad school has it, endurance. —Alorael, who doesn't know what to make of the comma.

The research is actually a pretty mixed bag. Being awake for too long increases medical errors, but so does handing off patients to someone else. Work hour restrictions haven't clearly led to better results. To be fair, they also haven't reliably led to residents actually working fewer hours, and have created the idea of "night float" which research does consistently show is even worse. —Alorael, who thinks there is immediate and catastrophic consequences to sleep deprivation in pilots and drivers that doctors don't quite have. But another big difference is that if you don't let pilots fly or truckers drive, then the planes and trucks just don't go. Less work is done. That doesn't work for doctors; you can't have a doctor be off duty without another doctor going on duty, because there's no way to put people being sick on hold for a mandatory rest. Crises can't be predicted or delayed the way a transit route can.

Salary and quality of life aren't quite the same. On the economic side the money is fine, mostly. From a free market perspective, highly qualified applicants vastly outnumber spots in medical schools; clearly pay could be lower and there would still be doctors. There are distorted incentives on speciality, but on the whole the money's good and job security is nice. But physician rates of burnout, depression, and suicide are much higher than the general population. Particularly with the much-touted doctor shortage, this seems like a problem to me. I'd certainly take a significant pay cut in exchange for getting out of nights and weekends! (Many of my colleagues in fact work additional nights and weekends. Partly for loans, and partly because of the somewhat perverse way moonlighting pays far, far better than our regular salary. It also feels very different when you opt in than when you are forced into it as a quasi-legal requirement.) —Alorael, who has heard that the situation is even worse in the UK, in part because there aren't the levels of protection for trainees that the US has, and possibly also because the monolithic NHS has such overwhelming ability to simply dictate what doctors must do and how they must work. Being limited to 80 hours per week and 28 hours in a row is better than the horror stories of the past, but can still be crushing.

All Spiderweb art is contracted. People are paid to provide art, but they're not employees. —Alorael, who thinks Exile I was the only exception. He's pretty sure some of the graphics were crude creations of Jeff Vogel himself. It was a simpler time.

In the US there has been a move to limit resident (junior doctor) working hours in a variety of ways, and intern (first-year doctor) hours even more. There's been pushback. The restriction on interns working more than 16 hours has been repealed, and they're now allowed 24 hours, plus a few extra to hand off work, like other residents. The tradeoff is always that each time someone ends a shift patients have to be signed out or handed off to whoever is still in the hospital. Handoffs are a known risk. But as risky as being awake for days? There's research, it's fairly consistent, and it tends to be expressed one of two ways: 1. The outcomes of patients cared for by doctors with limited work hours are no better, and therefore hours should not be limited; this reduces the number of handoffs. 2. The outcomes of patients cared for by doctors with limited work hours are no worse, and therefore hours should be limited; this reduces errors due to exhaustion. There is also work on making the handoff/signout process more efficient and effective, and there's evidence suggesting that doing it systematically really does improve patient outcomes. But notice also that lost in this is the idea of giving doctors' quality of life any priority. That's not under discussion. —Alorael, who can still work at the end of a 24 hour shift even if he hasn't gotten to sleep much (or at all). He can't sustain concentration to, say, read complicated medical literature (without falling asleep). He also doesn't store new long-term memories very well, so it's a terrible time to meet a new patient he'll be continuing to care for. But he can do a decent job of a workup and coming up with a plan of treatment that he can hand off. Is it an ideal system? No. But it's demonstrably non-inferior to other systems, and there's no clearly good way to provide 24 hour coverage.

Congratulations! —Alorael, who thinks the original wording is important. A defense before your committee is good. An offense before the committee is not so good.

The medical profession doesn't think they're a good idea. Well, some probably do; there's still a culture of character-building cum hazing. But someone has to be working overnight. Having done both a bunch of consecutive night shifts and isolate 24+ hour shifts, they're both terrible. But at least the latter is briefly terrible. —Alorael, who says this knowing he's due for a 24+ hour workday tomorrow. Somewhat perversely, the busier the afternoon and evening, the later he has to stay in the morning. There's a strong incentive to be obtusely useless and dump all possible work on the day team.

That's true for all the Spiderweb games. It's a one-man operation with a little help from one woman. —Alorael, who supposes there's been mention of Linda Strout having possibly helped with game scutwork as well as with the business end. She was an employee for a while, mostly but maybe not entirely on the office/sales side of things.

Insufficient sample size! I am not a morning person. I'm in the starting late camp, with one caveat. Sometimes I work overnight, and if that's the case I'd much rather get to go home an hour early in the morning than show up an hour late. (Actually, it used to be that work would start at 6:00 PM and end at roughly 9:00 AM. Now it's usually 8:00 AM to sometime between 9:00 AM and 12:00 PM the next day. And I'm not all that sure whether I'd rather start that long day at 9:00 or end it a little earlier.) —Alorael, who brings this up after a discussion at work with passionate defenses on both sides. The one thing everyone could agree on is that work days starting at 1:00 AM were terrible. Fortunately they're a thing of the past.

What it says in the title. Let's suppose you get an unexpected change in schedule, and an hour is shaved off your regular work/school day. But which one would you rather not have, if you get the choice? The first hour of the morning or the last hour of the day? —Alorael, who realizes this may be different if you find out a month in advance or just hours before. He didn't break up the questions. In fact, for himself he knows it depends on the exact day and schedule of the day. But it's still one question; answer as best you can.

Or b10011100010000, as Drakefyre would once have had it via Lilith. —Alorael, who brings you this post with an extra helping of memories from way back in those 10k posts.

Welcome to Spiderweb! Leave your sanity at the door, as the traditional greeting goes. —Alorael, who supposes that goes for both of you. Anyone else who hasn't already left sanity in the standard repositories, too.

Well done! You made it this far nary a Canned moment! —Alorael, who is pleased to see that you have successfully utilized the post with such frequency and vigor.

Thank you! —Alorael, who has fond memories of that bunch. Also a lot of ooks, eeks, and glurks. The sound effects, like the graphics, had a great deal of rough charm.

Exile 1 had a different premade party than Exile 2, 3, and Blades of Exile. It had to; Thissa and Frrrr obviously couldn't be there. But all of them were a little different. —Alorael, who suspects he added Michael from the later iteration. John, Ariel, and Samantha were definitely the first three.

I don't think any of us know the answer to that, but it seems unlikely that he gets a bigger cut from somewhere other than his own website. —Alorael, whose memory of the ancient Exile premade party is now foggy. John, Ariel, Samantha. A Michael, perhaps? And two others, now forgotten.

This is definitely true for Avernum, and definitely not true for Avadon, where classes have entirely different abilities. I think you confused the names and posted this in the wrong place. I'm going to move the thread. —Alorael, who will continue Ess's line of reasoning by saying that the original Avernum games, of which Avernum: Escape from the Pit and Crystal Souls are remakes, also had classes as ways to pre-assign points but without significance after character creation. In those games, though, some classes got more skill points total than custom characters built from scratch. Since those points were often assigned in much less than optimal ways, most min-maxers would still use custom characters, possibly with a handful of exceptions.

That's a question that only Jeff can answer. But to speculate, because he doesn't want to enable grinding to surmount all challenges. —Alorael, who considers it relatively unlikely that too many levels have been used up in earlier games and rationing forced the cap.

Sure. Except not for the most recent holiday, because it was Yom Kippur, famously devoid of eating or drinking anything. So I guess I could say I religiously don't drink wine, but I probably wouldn't have anyway. —Alorael, who encourages a return to regularly scheduled discussion of what everyone consumes, not just him. There's a whole world of nomming and guzzling to discuss!

I have actually no idea what you mean. —Alorael, who does not drink... wine. Much. Certainly not regularly with dinner.

Lots and lots of lentils. —Alorael, who makes them by the giant vat and then goes through them steadily for a week. He was off the stuff for a while, but easy, tasty, and filling is a hard combination to give up.