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This looks like the same phenomenon as the crisis in staffing nurses that was discussed here the other day. Careerist, indifferent management giving the people on the front line inadequate resources and then blaming them when things start to look shabby, or when someone dies. Scapegoating the people who were in the wrong place at the wrong time, who are tired, inadequately trained, and inured to a climate of normalized deviance. Many organizations don't suffer from these problems to nearly such an extent. I've worked in reasonably functional organizations, and ones that are disfunctional in different ways. Why does this malady strike the U.S. Navy and healthcare so severely? Am I viewing this from too great a distance? Are these actually separate forms of institutional dysfunction?

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As a Navy physician who has dealt with COVID and fatigue, I think the chronic low pay contributes to a lack of people which leads to overwork, exhaustion, a sort of "this is my lot in life" acceptance of mild to moderate depression. And you get to the point you just look away for your own sanity. Healthcare workers get paid less as you get closer to the coasts. And military gets only very modest pay adjustments for housing costs. A colonel in Kansas may live like a king, but a captain in San Diego can't afford a house.

Edit: I also agree with the posts about outsourcing leading to ossification and rigid stratification. You want rigid stratification? Try military medicine.

Great point! At the end of the day, we're talking about people. Highly trained people in Navy, medicine, and Navy medicine cases.

And people have limits, because they need lives and aren't robots.

Morale and aligning work to allow for happiness in life is a requirement for people bringing their best to work. If you ask people to toughen up and suffer through the suck to get the job done... there'd better be an eventual light at the end of that tunnel. Otherwise, it's just a death march.

PS: Thank you for your service, and especially through COVID.

The Navy pays officers very generously across all fields, EXCEPT medicine and JAG. URL JOs will take a pay cut for the first several years (at least) after leaving for the civilian sector. I never, ever heard a URL peer get out because of financial reasons.

FWIW, BAH (pay for housing that is tax-free) is $4000 for an O-6 in Point Loma v. $2777 in Offut, NE. Seems to be aggressive adjustment, no?

Enlisted pay might be another story…

EDIT: I know one guy who griped about pay once…kind of in passing. Went on to be a YC founder haha.

For Medical and JAG, are VA benefits (ie paid long-term care) worth the loss in income over the longer term?

You will never know. That is the great thing about “benefits”, the recipient has no control or knowledge.

The employer, or politicians, 5, 10, 20 years from now can cut funding and reduce access from MDs to NP/PA, or only cover certain meds, or require excessive prior authorizations to dissuade using the healthcare.

Exactly this. The VA already is hiring as many midlevels (NP/PA) as possible so that they don't have to hire MDs. You wouldn't believe how low the bar is to become an NP. PAs receive substantially better training, but at the end of the day they are still midlevels.

Worse still, many NP programs are now giving out "doctorates" of nursing practice so that NPs can introduce themselves to the patient as "Dr." Smith.

In short, the VA is willing to gamble with your life if it means saving a few bucks. It's pretty harrowing.

Is there any evidence that care by midlevels produces worse outcomes for routine cases?

Plenty. Here is perhaps the most recent: https://www.ama-assn.org/practice-management/scope-practice/...

But of course, nobody cares. The rich will get MDs and the poor will get midlevels.

You can't just look at enlisted pay broadly. You have to look at the troops that earn BAH and those who don't. Both are underpaid, but those who don't get BAH are inundated in very poor base services and are usually on the clock 24/7: https://veteran.com/2022-military-pay-charts/

Another point that I haven't seen brought up here is that usually the people who paint ships are school washouts. They couldn't get through school and have no classification, so this is what they do. I wasn't in the Navy but this is always what I heard.

Good point RE: sailors in barracks, who don’t receive BAH.

I was a submariner, so I’m not certain who ends up chipping paint on surface ships. Submarines don’t get the people who washed out of schools.

>JAG

>URL JOs

>BAH

if only i knew what any of those words mean. Why haven't people learned to describe their abbreviation unless they already pre-established that the audience will definitely know them?

Quick googling reveals JAG = Judge Advocate General aka a military lawyer

If you have seen JAG or NCIS (tv shows), you probably know some of these and with NCIS being a top (broadcast) show for a few years, it is quite likely a lot of (dare I say older) people have heard of these

I was Navy for 5 years and a navy contractor for 10 and I’ve never seen URL in my life. (Besides, you know, the web meaning)

Only ~30% of people on HN are from the US and I'd assume that the number of non-US people who watched NCIS in the original language are comparatively low.

> Only ~30% of people on HN are from the US

Does anyone have time to cite a source for this? I was thinking this number was a lot higher.

Sure! There are no definitive numbers, but we have a few data points:

Dang mentions quite often that HN has a very international readership, for example: https://news.ycombinator.com/item?id=23363430 and https://news.ycombinator.com/item?id=23438403 and https://news.ycombinator.com/item?id=27052434

An old poll with 32% US (probably the number I remembered): https://news.ycombinator.com/item?id=13819771

There's also a recent poll w/ 47% (2346 of 4891), although this might be timing related: https://news.ycombinator.com/item?id=30210378

> An old poll with 32% US

> There's also a recent poll w/ 47%

Clearly you need one more poll to decide this, as per XKCD 927.

People dont own TVs anymore?

URL: https://en.wikipedia.org/wiki/Unrestricted_Line_Officer basically any officer that isn't a specialist. Doctors and lawyers have artificially high ranks compared to non specialists, but you wouldn't expect them to command a ship.

> but you wouldn't expect them to command a ship.

I know what you mean, but I don't think it would merely be unexpected if one did somehow. I'm pretty sure it isn't possible because, being specialists, they can't also be a line officer. It seems like logic stops them, but then leads me to wonder about the vague possibility of a horribly unfortunate event leaving only specialists on-board... what then? Would logic stop them from sailing, or inexperience and lack of expertise?

Because I’m replying to someone who would know what those acronyms are.

The ELI5 is that the Navy pays officers who do the core ship/flying activities quite well. Compared to their civilian peers, Navy lawyers, doctors, and cyber people don’t get paid well.

The posted article is about rust on ships. A ships management team is paid well. Low pay is unlikely to be the cause of dissatisfaction.

To be clear, “paid well” is not “paid well” as measured by FAANG tech salaries. A submarine officer with 8 years of experience is making something equivalent to $200Ks if I am to believe the calculators that adjust for tax advantages of military pay, discounted value of future retirement cash flows, etc.

"Because I’m replying to someone who would know what those acronyms are."

That only flies in an email or on a specialized forum.

It's curious that you are smart enough to come up with an arguement yet apparently at the same time innocently simple enough not to know why it's invalid.

>That only flies in an email or on a specialized forum.

Counterpoint: It doesn't.

They made a reply to a military member on a thread about military equipment. Googling a few acronyms + "military" would surely lead one to the answer.

It would indeed. But why push the burden onto all the non-specialist readers, who after all come here to both learn and to take part, rather than expand the initialisms the first time they're introduced in a thread?

I'm reminded of an acronym at work: CIM. They come in two variants, CIM-A and CIM-B. I'd been there a year before I finally decided I needed to ask a more senior colleague what they stood for, and he didn't know either. The intention was obvious from the context of their use (although whether -A or -B was more serious wasn't) but most of the people in the weekly meetings discussing Critical Incident Management didn't actually know that was what they were discussing. Nowadays we have a culture that better encourages definition of terms upon first use, and it's less common that someone needs to ask "stupid" questions.

lol I feel like this debate plays out at least weekly in a HN thread about a subculture, specialty, etc.

I was a SWO before going into medicine. My first divo tour was in the engineering dept and my second was in weapons. Did well in both. I'm not sure I agree with you about the SWOs or pilots getting paid well relative to their civilian peers.

Maybe it’s ultimately a subjective thing. If one feels underpaid, they are underpaid. Then it’s a matter if there’s an employer that agrees, and it just takes one.

I’d just note that the service academies crowd the rankings for highest paid graduates at early/mid career https://www.payscale.com/college-salary-report/bachelors#ful...

Anecdotally, I had a reservist friend with a Harvard MBA who realized he could pull down more money as an activated reservist in Bahrain than his role at BlackRock.

Your mileage may vary…

JAG was a TV show for like 10 years. Judge Advocate General. Lawyers.

BAH has a description in parens immediately following, but could be better.

Why do people on technical message board with lots of jargon refuses to do even a modicum of research? If I didn't drop a description of a monad after I said it here would you also be mad? How about Term Sheets. I see Alpha used all the time and I have to look it up.

Since this doesn’t seem to be answered down thread- URL refers to Unrestricted Line officers, for example officers in the aviation, surface or submarine warfare communities etc. Restricted line officers can be found in the medical, supply, or intelligence communities etc. A third type of officer, and one of my personal favorite abbreviations, is the Direct Input Limited Duty Officer. DILDOs are required to have prior enlisted experience, but not required to have a bachelors degree. Restricted line officers and DILDOs could be given command of a training unit, or medical facility, but would not be given command of a ship or squadron.

It's part of the indoctrination of military culture/mindset. The heavy use of acronyms especially in a public context like this serves to signal in group/out group status.

$4000 is a (maybe nice?) 2 bedroom apartment in Point Loma at current rates

> A colonel in Kansas may live like a king, but a captain in San Diego can't afford a house.

Assuming both sought living accomodations outside of free base housing, I was curious what those figures actually looked like[1]:

- O-6 colonel stationed at, e.g. Fort Riley, KS 66442, would draw up to an additional $1500 without dependents, $1911 with.

- O-6 captain stationed at, e.g. NAS North Island, CA 92135, would draw up to an additional $3342 without dependents, $4026 with.

It's worth mentioning for those unfamiliar that, just like BAS (i.e. food allowance), this BAH (i.e. housing allowance) is completely tax-exempt.

The game that active service members play here is to secure a home mortgage (often through VA home loan), then apply BAH directly towards monthly mortgage payments throughout service all the way to retirement. It's not hard to imagine other tax advantaged games to be played here. Applying BAH to rent a house off base is a naive fool's errand.

In terms of annual cost of living adjustments to base pay, uniformed service received +2.7% increase this year; in contrast, +2.2% for federal GS civilians. The year before that, it was +3% v. +1%. These adjustments have historically favored uniformed service over the federal civilians that work beside them. Sure, they're lowball relative to inflation, but that ought to be squared against military tax-exempt BAS/BAH and hugely subsidized commissary entitlements.

Exceptionally common amongst Navy personnel, married sailors typically draw an additional $250/mo family separation allowance[2] when out at sea for more than 30 continuous days. This will obviously have a greater financial impact amongst the enlisted ranks than officers. Depending on rank and job, there's a litany of allowances, bonuses and incentives (beyond the scope of this remark) that are often ignored when the conversation of military service compensation is brought up...nevermind that no one ever talks about the opportunity to retire with guaranteed pension + benefits for life as young as 38.

As an outsider, I'm inclined to agree that military health professions do seem to pay a substantial indirect opportunity cost despite the unique bonuses they're entitled to[3].

I do wonder what individual circumstances led you to choose a Navy commission over everything else?

[1] https://www.defensetravel.dod.mil/site/bahCalc.cfm

[2] https://www.dfas.mil/militarymembers/payentitlements/fsa/

[3] https://www.dfas.mil/militarymembers/payentitlements/Pay-Tab...

There's plenty of reason to not buy. What if something catastrophic happens while you're gone for six months? What if you struggle to close on your house in time to move? How sure are you that the market will appreciate enough in the ~3 years at a given station to make back the realtor fees?

> Why does this malady strike the U.S. Navy and healthcare so severely?

Both industries substantially outsourced functionality in the 90s in an attempt to cut costs.

Consequently, they are now less empowered (vs historical levels) to effect change in their own processes in a timely manner.

Large organizations need to pay more attention to ossification of processes as a serious future risk, that needs to be balanced against immediate savings.

I know much more about healthcare than the Navy, but it’s notable that they both have rigid stratification between roles. I could imagine that hampering operational feedback loops in normal times, and strategic feedback loops given the labor supply/demand situation in these extraordinary times.

At least in healthcare, I doubt this is a major causative factor (presuming when you say roles you mean physicians and nurses) -- the physicians are extremely supportive of the nurses, and their demands for more pay and better conditions in all the healthcare settings I've worked.

The real problem is the unaccountable bureaucratic management, which are neither physicians nor nurses, and the numbers of which continue to expand (sucking up financial resources) while physicians and nurses workload increases and pay continues to decrease in real terms.

I tend to agree with the parent post about the extreme rigidness though causing issues. My wife is an Occupational Therapist and in some states she can supervise showering and some states only nurses can. Some states she can initiate cases and some states she can't.

There are too many micro-specialties and not enough crossover. Imagine if once you were a frontend dev you would have to go back to school for 2 years full time to be legally allowed to do ui design of a button even though there is a lot of crossover and knowledge sharing between roles.

This definitely causes shortages and issues when the demand naturally rises and falls for various Healthcare disciplines.

I'm not saying formal education isn't important but there could be a much more fluid crossover between various allied health disciplines than their is currently.

Maybe more transition programs or seeing individual billing codes for Medicare attached to education modules

It's driven (or at least exacerbated) by the physician shortage.

If it weren't profitable to have large numbers of staff per doctor, there wouldn't be large numbers of staff per doctor.

Even if we had more licensed physicians we would still have a large number of staff per doctor. A radiologist might be able to administer contrast to a patient, check their vital signs, transport them to the MRI machine, and run the scan but that's not a good use of a radiologist's time. Better to have nurses, orderlies, and technicians do all that so the radiologist can focus on reading the images.

Yes, it's obvious that some level of support staff are a good idea.

Now make an argument that the current arrangement is more optimal than the one we might end up with if there were more doctors.

That part is obvious. Regardless of the number of physicians, they will always be the most expensive resources. Thus any procedure which can safely and legally be performed by less expensive resources, should be.

That is scarcity thinking.

Yes resources will always be scarce and we need to manage accordingly. That is reality.

> in these extraordinary times.

What in the world is that supposed to mean? I've been hearing that for years now, and I have not the foggiest idea of what we're even talking about.

Nothing is different. What is extraordinary?

Edit to add: If these times are extraordinary, then that is a valid excuse for rust and a lot of other problems.

That's been used to refer to the changes caused by Covid over the last couple years. It's added mostly up to mild inconvenience for me, but it definitely has had serious impact on the Healthcare sector and is being blamed for the undermanned crews in the Navy.

In the UK at least, there's much less stratification than there once was I think.

For example Advanced Nurse Practitioner status grants nurses almost all prescribing rights you'd get as a doctor. They're allowed scheduled drugs (ie stuff that's commonly abused) because a bunch of those are effective painkillers and a key reason to have Advanced Practitioner is that "This patient is in agony, and I know the only thing a doctor would do is give them these stronger drugs, but I'm not allowed to do that on my own" is a stupid situation to put an experienced nurse in, so let's just authorise them to do it.

I believe there are Advanced Practitioner variants for several other healthcare roles including midwife and pharmacist; in some cases you just get limited prescription rights (so you can only give people some specific prescription drugs from a list) but in other cases like Advanced Nurse Practitioner it's the whole thing, if your knowledge and experience tells you that off-label use of a heart medicine is the right way to solve your patient's acute hiccups you can do that just like a doctor could.

To qualify for advanced practice these professionals are doing much of the same work student Doctors do - but just focused to their specific discipline. Lots of Chemistry, learning how to read research literature, and so on. They get a post-graduate degree of some sort, I don't remember the exact title.

> Why does this malady strike the U.S. Navy and healthcare so severely?

Totally government run in the case of the military, and healthcare is the most heavily regulated industry (by far) in the US. Heavy bureaucratic regulations make an organization unable to adapt to local and/or changing circumstances.

I read in the book "The Pity of War" by Ferguson that the reason the death rates of the German army in WW1 were so much lower than that of the British is the British generals would craft detailed orders on how the soldiers were to achieve objectives. The German generals would instead just give the officers the objectives. The officers were free to adapt to local circumstances.

A similar idea is a story I heard where a class of new lieutenants were asked how would they go about raising a flagpole. The lieutenants all wrote down detailed instructions and procedures. The instructor said you're all wrong. The correct answer is "sergeant, get that flagpole up!".

>the reason the death rates of the German army in WW1 were so much lower than that of the British

If the advice you just gave is so good, why couldn't you (or the book's author) have found an example in which the side following the advice actually won the war?

If you're interest in exploring this further, I recommend the book "Strategy" by Hart for a dance through the history of warfare and what works and doesn't.

As for WW1, Germany did defeat Russia. It took America's entry into the war to defeat Germany.

But you want an example. Take WW2. When Hitler allowed his generals to run things, things went well for the German army. When Hitler decided he knew better, he micromanaged the Wehrmacht into defeat and ruin. The Luftwaffe's problems were greatly impeded by Goering making a hash of things, despite his officers pleading with him. Goering would dictate tactics that negated the advantages of the Me-109s in the Battle of Britain. Goering also infamously ordered a literal decimation of his pilots for cowardice, an order that was quietly ignored.

In the naval war, the U-Boot commanders knew that Enigma had been broken and tactics had to change, but Admiral Doenitz knew better and sent them to their doom. Some histories assert that the Germans were clueless about Enigma, but the U-Boot commanders knew the truth.

That's incorrect. In World War 1 both sides had extremely rigid operational plans. The German operational plan even included specific times down to the hour, for when specific bridges and road junctions should be captured.

Indeed, what saved the Entente in World War 1 was the fact that Belgium, which had been expected to roll over and allow the German army unmolested free passage, actually called up its military and fought. That ruined the German timetables, allowing France to complete its mobilization and brought the British into the war preventing a quick German victory on the Western Front.

Towards the end of the war, yes, Germany was beginning to move towards what we would consider a "commander's intent"-based system. Erwin Rommel's text, Infantry Attacks, captures this transition. However, it's inaccurate to say that the German military was any less rigid than the British.

It is also inaccurate to say that the death rates of the German army were any less than they were for the British. Perhaps in 1914 and 1915, as well-trained German regulars were facing off against the "Pals Brigades", the Germans inflicted more casualties than they received. But by the end of the war, as the German economy was crumbling and the prospect of US involvement made the German generals desperate, they resorted to mass infantry charges with relatively untrained soldiers, and took extremely heavy casualties as a result.

If anything, your description of the German army is more accurate for the Wehrmacht in World War 2 than it is for the Kaiser's army.

Ferguson, the author, backs it up with statistics.

"As Table 32 shows, the greatest of all the paradoxes of the First World War is that, despite being disastrously disadvantaged in economic terms, the Central Powers were far more successful in inflicting death on their enemies. According to the best available totals for wartime military deaths, some 5.4 million men fighting for the Entente powers and their allies lost their lives, the overwhelming majority of them killed by the enemy. The equivalent total for the Central Powers is just over 4 million. The Central Powers' superiority in killing was thus of the order of 35 per cent. The official British statistics published shortly after the war give an even higher margin of 50 per cent, as do the figures in a number of modern textbooks.52 In other words, the Central Powers were at least a third better at mass slaughter." pg 294

"The trouble was - and here the excuses must stop - that the entire culture of the British regular army militated against effective improvisation. The command structure was based on obedience to superiors and suspicion of subordinates; men could still advance according to their connections; and commanders could still be 'unstuck' by personal quarrels.83 This could have serious repercussions: when Haig questioned Rawlinson's original Somme plan, the latter felt unable to stand his ground, with the result that Haig was able to insist on the suicidal breakthrough objective. As Rawlinson said, 'It is a gamble to go for an unlimited offensive but D. H. wants it and I am prepared to undertake anything within reason [sic].'84 An Army Commander did not presume to correct the Commander-in-Chief, even when tens of thousands of men's lives were at stake.85 Similar inhibitions existed at every level. Orders were issued at the top and fed down the line; there was little traffic in the other direction. As a result, officers, NCOs and men grew accustomed to 'waiting for orders'. In battle, as J. M. Bourne has remarked, 'when German shelling interrupted communications paralysis set in'. To adapt the not inappropriate language of industrial organization, this was 'line management', and it provided no mechanism by which the views of 'junior line managers' could be relayed back to head office.86 Partly for this reason, the proponents of a more technocratic approach made slow headway against the traditional believers in war as a moral rather than material contest.87 Too much emphasis was placed on morale, courage and discipline; not enough on fire-power and tactics." pg 305

"These German tactical strengths were rooted in a distinctive military culture. According to Dupuy, the German military establishment had 'discovered the secret of institutionalizing military excellence'.109 Martin Samuels likewise points to a distinctively German philosophy of combat, which acknowledged its fundamentally chaotic character.'10 This in turn influenced the way command structures evolved. The Germans favoured 'directive command' (task-oriented and decentralized decision making, flexible at all levels) whereas the British preferred 'restrictive control', which deliberately discouraged initiative."1 Differences in training also followed logically from this. German 'chaos theory' demanded a high level of training to promote adaptability; the British approach required only obedience. Moreover, the German officer did not stop learning on obtaining his commission; the officer corps was meritocratic, and dud officers were ruthlessly weeded out."2 This line of argument has been further developed by the work of Gudmundsson on stormtroop tactics, which (he argues) depended for their success on the existence of a 'self-educating officer corps'."3 pg 309

If that's not enough, there's plenty more backup in the book. It's a good read, I recommend it.

That's very interesting! My understanding of World War 1 is from Tuchman's The Guns of August and Clark's The Sleepwalkers, and both of those don't seem to rate the Germans as being more flexible at the beginning of the war than the British.

There's endless more stuff to read! I only made it through half of TGoA, and didn't know about TS. Thanks for the tip!

It’s almost as if heavily regulated and entrenched organizations with limited competition develop complacency.

Then we already know the next steps: ships will be rust-free, but nothing that isn't immediately obvious will work.

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