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Care Doesn't Scale

stevenscrawls.com

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Re: Care Doesn't Scale

#211

Post by kang »

api wrote: post #37
kang wrote: post #29

> Scale isn’t bad, at least not necessarily. Industrial is perfectly capable of being better than custom. Sometimes the YouTube video is more helpful than the private tutor. This is not true; consider the argument that there is always a loss of quality in scaling. Industrial maybe better than average custom, but is always worse than best customs. Broadcast lecture is almost always worse than a tutor whose discourse i…

I don’t think that holds for everything. Industrial 3nm chips are probably better than whatever you would get if people tried to DIY this. Lots of things get better with scale: materials, precision machinery, process efficiency, power generation. But there’s also plenty of things that don’t work this way. Care is one of the most extreme things that does not.

for eg, asic custom designed for an application is better than a generalised industrial chip

Re: Care Doesn't Scale

#212

Post by drivingmenuts »

bumby wrote: post #157
vanderZwan wrote: post #142

If we're going to talk about how to "scale care" and how not to, then Buurtzorg has to be mentioned[0][1]. It's a Dutch home-care company that was started by nurses who basically got frustrated that managers got in the way of them doing their job. It operates by having a flat organization working with small teams of highly trained nurses, and trusting them to make the right decisions. The result is a low-cost provide…

Your reply seems focused on size, but this line caught my attention: > trusting them to make the right decisions. I'm wondering if trust isn't the real issue. For example, wouldn't a large high-trust organization be able to provide good care? Or is there something intrinsic to scale (e.g. diffusion of responsibility) that makes "high-trust" and "large organization" incompatible?

Most healthcare organizations in the US are profit-oriented, sometimes to the detriment of the patients. That is why we have large, unwieldy organizations surrounding the very few people that actually do hands-on healthcare. There’s also the issue of liability – it can be pretty litigious in the US, and companies are frequently wanting to limit their liability, which means having the paperwork to back up their decisions. Unfortunately, it also means they have to restrict their decision-making to a very small matrix.

Re: Care Doesn't Scale

#213

Post by theamk »

tripper_27 wrote: post #160
dkarl wrote: post #131

Earlier quoted context omitted.

> The food system is different from homecooked meals This is a good point, and everything I've heard from parents says that it's parents, not children, who identify home-cooked meals with care. Children notoriously prefer prepackaged industrially processed food over whole foods prepared with care and love. In order to feel cared for, all children need is to trust that the person caring for them will make sure they ge…

if you'll forgive my prior snark, some people successfully involve the children in the cooking. When this is done, the children seem to prefer the home-cooked because they are part of the cooking and they are part of the feeding/providing to others. Don't underestimate the human desire to provide value to the tribe, it runs deep in the evolutionary make-up.

Pretty sure no amount of participation in cooking can make children start liking food with specific tastes, like eggplants or celery. If they like it - great! I they don't like it, but parents do - well, _that_ kind of home-cooked food will never be liked.

(Unless you process them so much, and add so many spices, that they no longer have any original taste.. but by that point they are at "pre-packaged" level of cooking)

Re: Care Doesn't Scale

#214

Post by lelandfe »

bell-cot wrote: post #140
croes wrote: post #129

Earlier quoted context omitted.

The countless hours of voluntary unpaid work by many people shows don’t act only for their own benefit

True-ish. But try talking to some old folks, about the vastly reduced scale of such volunteer work since (say) the 1950's. That "voluntary unpaid" stuff would include religious organizations, civic groups, housewives, ...

America's in-person group membership plummeted across the decades[0], but I don't know about overall volunteerism. It may just come in different forms. Anecdotally, here in NYC volunteer orgs are stuffed to the gills; spots to clean my local park fill up in days, finding any weekend activity on NY Cares can be hard.

More concrete data are hard to find, AmeriCorps' only started in '02. We can look at volunteer rates across demographics[1] but it's likely true that volunteer hours drop off with age.

[0] see: Bowling Alone (needs a post-COVID update, though)

[1] https://americorps.gov/sites/default/files/document/Voluntee...

Re: Care Doesn't Scale

#215

Post by moolcool »

taylorius wrote: post #197
moolcool wrote: post #150

Earlier quoted context omitted.

I think this is a gross and psychopathic vision of the future. Tell your grandmother that you're going to automate away her need for human connection. What a terrible indignity. I hate my industry.

Psychopathic? I think that's a ridiculous statement. No-one said anything about automating any human connection. I can tell you that my wife is a full time carer for her parents, and though she does it willingly and with love, it exerts a great toll on her, both physically, and mentally. So if we're going to far-too-easily use words like "psychopathic" - I could just as well say that ignoring that cost is psychopathi…

> No-one said anything about automating any human connection

Maybe I was inferring the wrong thing, and if so I apologize, but the context of this comment was invoking LLMs and humanoid robots in a discussion about how "care doesn't scale". Like of course automation and technology should do things to make the lives of the elderly easier, but I would not classify any action done by a machine as "care". My dishwasher is a great convenience, but I would never classify my relationship with it as one of "caring".

> Knowing what her role as a carer has cost her in terms of quality of life, I would never want to subject my children to the same

Of course that's a problem. The answer though, IMO, is creating a society where we value elder care more, and have more programs to provide human support and connection to the elderly. I strongly feel like this isn't something which we can or should automate away.

Re: Care Doesn't Scale

#216

Post by FirmwareBurner »

ImPostingOnHN wrote: post #161
FirmwareBurner wrote: post #99

Earlier quoted context omitted.

Exactly. They come willingly but you can't force them to wipe your old age ass once they're here.

I fear you might have stopped reading halfway through my post. Continue reading after the word "willing": > They come here willing to do those jobs. Someone willing to do a job means you don't need to force them to do it. After all, they aren't slaves.

No, I read what you wrote and I meant what I said. Let me explain again: people are willing to do anything, even jobs they dislike, just to get a visa. That doesn't mean they'll want keep doing that shitty job once they get the visa and can start looking for workarounds. Otherwise there wouldn't be a shortage of staff in those sectors if all workers would stick around for long.

Re: Care Doesn't Scale

#217

Post by skybrian »

vegetablepotpie wrote: post #163
bumby wrote: post #157

Earlier quoted context omitted.

Your reply seems focused on size, but this line caught my attention: > trusting them to make the right decisions. I'm wondering if trust isn't the real issue. For example, wouldn't a large high-trust organization be able to provide good care? Or is there something intrinsic to scale (e.g. diffusion of responsibility) that makes "high-trust" and "large organization" incompatible?

Not OP, but orgs that scale usually rely on metrics. It's metrics that are easier to measure, not the one that measure system performance (i.e. lines of code written per day, points closed per sprint) that get selected. Then management lampoon workers for not meeting those metrics (they need to prove their doing something, and can't lose control), regardless of how the system is performing. So trust erodes.

It might be possible to do a better job at improving and discarding metrics? Shared recently:

Goodhart’s law isn’t as useful as you think https://news.ycombinator.com/item?id=41956587

Though, I’m not sure how well that applies to programming, let alone child care.

Re: Care Doesn't Scale

#218

Post by bumby »

drivingmenuts wrote: post #212
bumby wrote: post #157

Earlier quoted context omitted.

Your reply seems focused on size, but this line caught my attention: > trusting them to make the right decisions. I'm wondering if trust isn't the real issue. For example, wouldn't a large high-trust organization be able to provide good care? Or is there something intrinsic to scale (e.g. diffusion of responsibility) that makes "high-trust" and "large organization" incompatible?

Most healthcare organizations in the US are profit-oriented, sometimes to the detriment of the patients. That is why we have large, unwieldy organizations surrounding the very few people that actually do hands-on healthcare. There’s also the issue of liability – it can be pretty litigious in the US, and companies are frequently wanting to limit their liability, which means having the paperwork to back up their decisi…

>Most healthcare organizations in the US are profit-oriented

According to the American Hospital Association, less that 20% are for-profit [1]. I'm sure all are extremely budget-conscious, but that's not the same as being profit-driven.

It seems to me that the US optimizes for quality to the detriment of cost and, more recently, access.

[1] https://www.aha.org/statistics/fast-facts-us-hospitals

Re: Care Doesn't Scale

#219

Post by erikig »

dflock wrote: post #118

Infrastructure is care at scale, as Deb Cachra would say: http://debcha.org

Her talk on "How infrastructure works" was eye-opening https://www.youtube.com/watch?v=oK6BRwwhgbo

I'm having a hard time translating her points regarding how infrastructure serves and cares for the basic human physical needs (e.g water, clean air etc) and how it can serve social needs like child care or elder care.

Re: Care Doesn't Scale

#220

Post by bumby »

ToucanLoucan wrote: post #171
vegetablepotpie wrote: post #163

Earlier quoted context omitted.

Not OP, but orgs that scale usually rely on metrics. It's metrics that are easier to measure, not the one that measure system performance (i.e. lines of code written per day, points closed per sprint) that get selected. Then management lampoon workers for not meeting those metrics (they need to prove their doing something, and can't lose control), regardless of how the system is performing. So trust erodes.

I honestly think most orgs would leap forward considerably (with some pain) by doing a severe reduction in middle management, basically making them prove why they are actually providing value, and removing them if they aren't. Tons and tons of middle managers do absolutely FUCK ALL in terms of delivering product, meeting goals, and serving customers.

I generally dislike middle-management as much as the next IC, but I think these types of arguments tend to ignore latent or low-probability risks.

You see this all the time in discussions about quality or safety metrics. By definition, if those teams are doing a good job you won't see many quality or safety issues, which leads people to believe they are doing "FUCK ALL" and provide little benefit. Only in hindsight, after a low-probability but high risk event happens, does getting rid of them seem like a bad idea.

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