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> well, they absolutely know what they are doing

My grandfather had neighbours whom he routinely looked down upon because of their alcohol problem.

Very late in the life of one of their children I talked with him and found out he was a really smart guy, knew a lot of IT stuff, 3D design an all, but he simply lucked out in late 90's Romania, used a lot of alcohol and could not pull himself out of it. He died because he was drunk and after loading a wagon of wood for my grandma he struck his head on the pavement. My father insisted he went to the hospital because he has not feeling well but the guy refused. He died a couple of days later because of brain hemorrhage, in his early 50s.

Another guy in the village, a really helpful fellow, you would never believe it by his appearance or demeanor, but he was a retired secret-service officer and used to brief the president.

A female child development therapist that made a bad impression on myself(she seemed fixated on puzzle solving) was later recommended by others as an expert in her field.

So yes, everybody can have a bad day and its really easy to misjudge someone by their appearance.

I’m reminded of when I was in college in Model U.N., there was one guy in the group who presented very socially awkward (his posture made him look like a question mark in profile, he was kind of physically awkward, didn’t participate in the social activities of the club). My senior year, I was the secretary-general¹ of the club. We’d finally let him chair a committee at our annual conference that we held for Southern California high school students. I was walking from committee room to committee room during the conference checking on how things were going and when I looked in on his committee—well, he was totally rocking it. I realized we had squandered his talents for four years because of surface appearances.

⸻

1. The pretentious way that Model U.N. clubs name what’s effectively the president.

I think this largely depends on the definition of "know".

E.g., when I used to work as a doctor in hospital, the last thing I would describe my colleagues as would be incompetent or un-knowing. They all "knew" stuff. Heck, they had to pass stringent exams, and were still accountable to several agencies to ensure being up to date.

The thing is, 50% of what they "knew" was wrong. And if you looked a bit under the surface, what one person "knew" was very different, and often contradicting what the other one "knew", even though they both "knew" stuff. And after many years, I've come to the conclusion that the number one cause of modern disease is iatrogenic, but most doctors seem not to want to admit this, and stick to what they "know" from textbooks instead. This is something I now "know".

And that doesn't even take the whole "is 'know' a binary or fuzzy concept, and if it's the latter, how much 'know' counts as actual 'know'" argument into account to begin with.

So, I hear the argument that "maybe OP is just an impostor projecting their views in a world full of experts" (wildly paraphrasing, obviously), but I also think you're perhaps being a bit too rigid here in discounting that expertise is a relatively fuzzy term.

what is an example of a modern disease whos main cause is iatrogenic

I was also curious, so looked it up on Wikipedia:

> Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence.[1][2][3] First used in this sense in 1924,[1] the term was introduced to sociology in 1976 by Ivan Illich, alleging that industrialized societies impair quality of life by overmedicalizing life.[4] Iatrogenesis may thus include mental suffering via medical beliefs or a practitioner's statements.[4][5][6] Some iatrogenic events are obvious, like amputation of the wrong limb, whereas others, like drug interactions, can evade recognition. In a 2013 estimate, about 20 million negative effects from treatment had occurred globally.[7] In 2013, an estimated 142,000 persons died from adverse effects of medical treatment, up from an estimated 94,000 in 1990.[8]

https://en.wikipedia.org/wiki/Iatrogenesis

I know the word has a definition.

I wanted to know what tpoacher's lived experience and personal observation was to cause him to make the statement.

Doctors are great if you have a problem doctors are great at. Otherwise for something like CFS the best resources are CFS communities and a doctor without all the answers, willing to help you explore.

>Doctors are great if you have a problem doctors are great at.

This is tantological- but it has some great depth. I'd like to quote you on this, if I may.

Almost tautological: because it is not “doctors are great at helping with any medical problem”. And by great I don’t mean cure anything, but give the best outcome possible with technology and budget for the person.

I appreciate that you are using exageration to make a point, but it's worth noting for the record that iatrogenicity is hardley the number one cause of modern disease. Having a medical problem is a prerequisite to the chance of iatrogenic harm after all. Furthermore, a patient can suffer from iatrogenic harm even if everything was done correctly, and does not imply that someone didn't "know" something correctly.

It is not intended as an exaggeration. Though I fully admit I'm using 'iatrogenic' in the broader sense of "things people do or have done to themselves for the sake of treating or preventing a condition, perceived or otherwise". This includes alternative therapies, over the counter medications, etc. So I fully agree if your perception of iatrogenic was only things like "removed the wrong kidney", then I can see why you might have thought I was exaggerating, since that is indeed pretty rare, and there are safeguards in place for that kind of thing.

The statement is not intended as an attack against the medical professions or the effectiveness of medicine. It is intended as pointing out my observation that, typically, a doctor would list such iatrogenic causes very low on their list of differentials to consider, preferring to consider 'textbook' causes first. However, my own experience (which, is medical, but admittedly "anecdata") is that at present, iatrogenic causes are very relevant, and at least as likely, if not more, to yield a relevant diagnosis compared to textbook stuff in a high proportion of presentations.

A classic example of this is doctors treating symptoms by adding more medication/treatment options, rarely removing medications/treatments that may be causing those symptoms in the first place. Especially if that medication was started by a different specialist. It usually takes several rounds of inconclusive investigations and experimenting with treatments before altering an existing medication is even considered.

At the very least, having a "exclude iatrogenic causes first, before moving on to 'classic' stuff" is a good mindset to have.

> Furthermore, a patient can suffer from iatrogenic harm even if everything was done correctly, and does not imply that someone didn't "know" something correctly.

There's a popular quote often said to medical students when they start: "50% of what we'll be teaching you will have become obsolete or proven wrong by the time you graduate; unfortunately we don't know which 50%.".

> , I've come to the conclusion that the number one cause of modern disease is iatrogenic

Do you have non-anecdotal evidence for this claim? It sounds rather far-fetched.

Politicians, on politicized issues, come across as children. But I was amazed to discover, in a document discussion non-politicized legislation, they were well-informed and sensible, and, as you say, supported by extremely capable members of a bureaucracy. Each conclusion was tempered by how confidence levels in its supporting material. In other words, it was just what you'd want it to be. Also, clearly written and a pleasure to read.

They are only idiots on stage. Which says something about our democracy.

OTOH mathematically speaking, if you don't perfectly know what you are doing... you you don't know what you're doing.

> They are only idiots on stage. Which says something about our democracy.

1. Savvy across the organization adds like resistance in a parallel circuit: the org as a whole is slightly less savvy than the biggest doof therein.

2. Restated: people scale poorly.

3. In the government case, minimizining flailing and tyranny equates to minimizing the size of government.

4. We seem to trend the opposite direction from (3).

> 3. In the government case, minimizining flailing and tyranny equates to minimizing the size of government.

Whoa there. There are plenty of very small governments that have plenty of flailing and tyranny. In the limit, if government is just one guy, he clearly won't have clue about 99% of what he's doing, and will be extremely easy to corrupt since he has no-one else to hold him accountable.

If you want to have even a chance of having a competent government you need at least three fully independent branches of government with their own internal systems of accountability.

I could just as easily argue that you need to maximize the size of the government.

The problem is you hit issues both at the small and the large end. It's like goldilocks. You shouldn't minimize or maximize. You should aim at just the right size for the country/region you're trying to govern.

What's WAY, WAY more important is HOW you govern.

What's really scary these days is how many people think we'll solve all our problems if we just make government smaller and smaller. I guess so much time has passed since the various parts of our government was set up that we've kind of forgotten why the government is the way it is.

Not that we shouldn't have a process that trims down parts of government that has become redundant. But we should have a deep understanding of the problem that part of the government is solving before doing so.

> What's really scary these days is how many people think we'll solve all our problems if we just make government smaller and smaller.

And what’s really really scary is how many people, at least in the US, worry about government being too small when in reality it has been almost monotonically growing since the 1960s. Non defense federal spending as a share of GDP is bigger than the 1960s. And state and local government spending has grown twice as fast as GDP since 1960.

I think people confuse Reagan’s rhetoric with the reality that Democrats controlled the House, and thus spending bills, his entire presidency. The Reagan era was a period of government retrenchment in the same sense as Biden is the second coming of FDR.

As with other things, quality matters more than quantity. A village elder or city mayor are just as fallible as a parliament, or a king and his council. The mechanism of corruption may vary with historical circumstance, culture, and/or technology. But at the end of the day, if the "people in charge" are unaccountable and have no desire to exercise their power for the common good, there is no system of checks and balances that will save such a government from collapse.

> What's really scary these days is how many people think we'll solve all our problems if we just make government smaller and smaller.

You said "solve". I said "minimize". Details matter, boss.

>Savvy across the organization adds like resistance in a parallel circuit: the org as a whole is slightly less savvy than the biggest doof therein

That seems like a very bold premise to me.

> the org as a whole is slightly less savvy than the biggest doof therein.

I've seen about 220 'orgs' from the outside in, interviewed a few thousand people in those orgs and have done the write up on the state of affairs. I've yet to find a single example that would support this claim, where did you get this from?

Personal observation of Congress.

Well digitalization in Denmark is an absolute train wreck of ill thought out decisions. To such a degree that the people in charge of it are either dumb or have ulterior motives. Having worked with bureaucrats as an external consultant and as someone that provided information to the answers for minister questions, I have a much different opinion of our dear bureaucrats.

They might be smart, but it has no impact on the quality of their work. Right or wrong, good or bad, non of that has any bearing on how they do their work. They want to get stuff done. Without getting in any political trouble. In a way that can be claimed as a win (if it actually is a win is immaterial).

Sometimes the idea is to do things wrong and then use that experience to do things correctly later and if possible use events to sweep aside the current political order.

> Well digitalization in Denmark is an absolute train wreck of ill thought out decisions.

Yes, and it’s also competing with Estonia at being the best in the world.

One of the things that burned me out was actually the poor decision making, from my technical point of view mind you. I’ll simplify what I mean by a made up example of a platform selection process. Your organisation needs a headless CMS, your external consultants tells you this, your tech staff tells you this and even your friends from competitors that you network with privately tell you this. The issue is that your company strategy is to rely as little on internal IT resources as possible, and any available headless CMS (because you can’t outhouse the data) requires technical talent. So what do you do? Well, you pick something else, like Wordpress, the Microsoft powerplatform or similar, and you do fine. The solution is shit technically, but it also works good enough while achieving its primary strategic goal within your organisation.

Public sector digitalisation is that, except a billion times more complicated and with the added bonus of having changing political leadership. For a few years we had a designated minister in Sophie Løhde, who setup a branch of the digitalisation ministry to build a cross sector national enterprise architecture inspired by the one they run in the municipalities (KL) called rammearkitekturen. The group had an extreme amount of talent and improved on the 20 years of KL work so much it was like the whole thing went from the stoneage to the spaceage in less than a year. Then Sophie Lødhe got a different job, the task force was disbanded and everything related to governance went back to the municipalities (KL and KOMBIT) whom through out the process had suffered from an extreme inability to kill their darlings.

I mean, that’s just a glimpse of it, but you don’t have to work with other European countries for very long until you relive just how awesome digitalisation is in Denmark by comparison. Part of my current job is dealing with the fact that FTP is still a very common data transfer channel in Germany and France, and I didn’t miss that S in SFTP, because that’s something even massive tech companies that shall remain unnamed hadn’t heard about until I asked them why it wasn’t encrypted.

Here we run into the philosophical question of what it means to "know what you are doing".

On the one hand people may have the best of advice and make decisions that are extremely clever in a specific context. And on the other the world is fundamentally too chaotic - the most important factors are generally unknowns or unanticipated.

The author is not talking about the same standard. "Knowing what you're doing" means that you're familiar with a situation and you know exactly the correct course of action. This is not the case for most things in adult life (especially politics), in which every problem is a new problem, for which you use heuristics to converge to a solution, that isn't perfect, but at least tries something out.

I also prefer your comment to the post. The most successful people in business I know are very bright and hard workers. I like the fact that the writer of the original article is showing some humility. I don't think we should signal however that anyone can succeed in business by bluffing it. I say, have a go at business but don't give up the day job if you can't afford it.

They know what they are doing in their immediate context, they follow the rules of their bureacuracies but have no idea nor possible idea of the consequences of their policies. And their being "well-meaning" has a very narrow scope limited to their immediate social and economic class.

> A more accurate way to view the world would be that most people don’t know exactly how they are going to execute their long term plans, but almost every successful adult I have ever met did have both a plan and a genuinely good idea on how to execute it.

Yes, absolutely. I think there is a specific niche of motivational "you can do it!" stuff which basically boils down to "everyone is winging it, so fuck it", and it's dishonest. Few hard things are achieved with this attitude, even if sometimes it's true that you improvise a lot.

Beautifully written post by the way, it really nails down some major points that I find more motivational than the original post.

Another one I’ve seen is interpreting the statement “if you have an imposter syndrome, you can’t be an imposter” as “if you feel like an imposter, you can’t be an imposter”. I’m sure that approach can have the effect of temporarily helping someone’s self-esteem, but it’s based on highly questionable reasoning.

I’ve been fairly close to the digitalisation agenda in UK public sector, and apart from pockets, I find it hard to be so generous.

Horrible outsourcing deals with the usual suspects and enormous failed programmes are still the default.

Reading the parent comment about Denmark made me sad. I feel that in the UK we have smart, dedicated, well intentioned people just like Denmark, but if the NHS RiO system and Track-and-Trace are anything to go by we are plagued by massive corruption in the IT sector.

This is the country of Alan Turing, Sir Tim Berners-Lee and Acorn RISC Machines. We need a new broom on public IT. I think we also need an outright ban on using Microsoft and other Big Tech contracts and a policy to rebuild skills and bring them back in.

One of the most disgraceful episodes of late was the UK basically outsourcing our whole intelligence show to Amazon. Our corrupt minister Priti Patel sold out MI5/6/GCHQ. For over a year she has refused to answer questions on the decision, her connections and kickbacks.

I think the bigger problem is the consultancies and system integrators.

The government sign huge outsourcing which propose large, expensive, long waterfall style projects with outdated architecture etc.

Time and time again these programmes fail, but the government money just keeps on flowing.

FWIW, I've done some work in the UK public sector, including but not limited to the NHS.

In my experience, any time the tech folks were in-house, the "doer class" (i.e. the boots-on-the-ground engineers) were some of the smartest, most motivated individuals I've worked with, who pretty consistently gave great output (for e.g., shipping products, system design, software architecture, balancing tech debt with delivery velocity) in the face of almost uniformly painful obstacles, like the tooling they could work, or being jerked around by changing political priorities.

OTOH, any time the tech folks were a long-term outsourced arrangement, you could expect to find (WITHOUT EXCEPTION) ridiculous amounts of cruft, hacks and frankly unacceptable shortcuts in the tech systems and interfaces, and the few people of this ilk that I did deal with, were entirely focussed on Goodhart's Law-ing their way to their next gig. (TBH, I can't really blame the individuals as they're merely responding in the most rational manner to their incentives).

> I think we also need [...] a policy to rebuild skills and bring them back in.

Absolutely 100% agreed, but I suspect we lack the political will/vision, and the requisite leadership/management abilities to be able to do this in a manner that doesn't just result in the next round of useless bungs to politically connected mates.

P.S.: Entirely off-topic -- do you compose your replies in Emacs or something like that? Or at least resort to using semantic line breaks? (https://sembr.org/) I ask because your comment looks fine on the website, but shows line breaks after sentences in an HN reader app that I use.

> In my experience, any time the tech folks were in-house, the "doer class" (i.e. the boots-on-the-ground engineers) were some of the smartest, most motivated individuals I've worked with

Lions led by donkeys as they used to say.

> I suspect we lack the political will/vision, and the requisite > leadership/management abilities

I'll differ a little here. I think we can have capable people at all levels and I am generally confident in the UK to come through in the end. We can do good leadership too. The reason the donkeys won't carry their load is that they're corrupt, undisciplined and disloyal. They're there to serve us but we forget who holds the stick.

> manner that doesn't just result in the next round of useless bungs > to politically connected mates.

Precisely. My guess is Nick Clegg and Priti Patel are the tip of a gargantuan iceberg. We're becoming a vassal state to the third richest "nation state" on Earth [1], because they have our politicians in their pockets.

[1] The combined wealth of Google, Microsoft, Apple, Amazon and Facebook now places them collectively above Russia as the number three "superpower". https://www.wired.co.uk/article/big-tech-geopolitics

> P.S.: Entirely off-topic -- do you compose your replies in Emacs or something like that? Or at least resort to using semantic line breaks? (https://sembr.org/) I ask because your comment looks fine on the website, but shows line breaks after sentences in an HN reader

Yes, Emacs, Well spotted. Yet another fingerprint to watch for! :)

RiO isn't an NHS product, it's made by Servelec who sell it to some NHS organisations. Yes, it's terrible.

https://www.servelec.co.uk/product-range/rio-epr-system/

The bureaucrats one has to deal with as taxpayer, insuree, petent, or immigrant are different kind of bureaucrats from those holding high positions and advising to them. That's how one gets idea that they don't know what they're doing, they job is to push you away, hold you back. The second kind though... yes it takes enormous volume of cunningness, insight, non-public information to acquire and expand position of power.

Yes I agree, that it is easy to assume people are not clever but you only have to see most Politicians after they leave Government to hear how (usually) perceptive, articulate and intelligent they are - which presumably is how they convinced people to vote for them.

However, Government is like a big corporation with extreme levels of power and corruption in every country. It is also largely unique in that the Prime Minister/President can't just get rid of people they don't like or are not very good at their job, the voters recruited them! So then you balanbce priority, idealism, party politics, saving-face, money, making yourselves look powerful to the world, trade agreements and loads of other things. To be fair, it is remarkable we get anything useful out of it.

> be that most people don’t know exactly how they are going to execute their long term plans

That’s “not knowing what you’re doing” and not really different from “fake it until you make it” either.

If you don’t have a really concrete plan to achieve a certain goal, you quite literally don’t know what you’re doing.

"Fake it until you make it" involves bluffing and deception. Which is very different to asserting that we are all just muddling along, doing the best we can.

> adults are supposed to have the answers for everything, which isn’t true

That's the gist of all of it. No one knows what are they doing because the adults actually don't have all the answers, on the other hand smart people know what they want to achieve and they have idea and a plan for it and simply try their best. They know what are they doing in the context of their understanding, idea and desires, it's just that their understanding and ideas have limits.

I agree with you. One other point I would like to make is that it seems a lot of decisions are made after a lot of fatigue-inducing processes, which just seem to lead to a lot of compromises nobody really wants, but that also no one wants to rebuke, since the process to arrive to the decision was already too drawn-out.

The person drowning looking for help can become the person in the know with a plan. Easy to forget we were all babies once and learned everything from others. Attitude of course makes a difference. So does luck.

Ex-British politician, Rory Stewart, said that (paraphrasing from memory) that every time he started to understand about a ministerial appointment, he would get promoted to another department.

Danmark vs Britain. From what I read occasionally in Dominic Cumming's blog, Boris isn't particularly good at using the bureaucracy.

Absolutely true, the most realistic post about business that I've red in time

you are complaining about Boris, you have to see here in Spain to Pedro Sanchez, it's a completely mess

Given even just Johnson’s COVID history — banned unnecessary gatherings under penalty of fines with a large publicity campaign, attended at least eight of the at least sixteen unnecessary gatherings at No. 10 (including his birthday and a Christmas party), caught COVID and almost died from it, repeatedly asserted that there had not been any party and that if that no rules wrote broken, was fined for breaking the rules, and still hasn’t resigned — I dread to think what you have in mind for Mr Sanchez.

What's this fuss about parties and rules? If these are biggest issues you worry about, then your country is being run by some very good politicians who ensured that there are no other bigger problems for you to worry about.

That's an interesting take on subverting the rule of law. Most law breaking in Western Democracies by first ministers is probably not as obvious?

Johnson also, with the help of the Queen, unlawfully prorogued (ie ended the session of) parliament in order to avoid democracy acting against him.

He lost two previous jobs for lying (in politics and journalism; you have to try really hard to lose a post for lying in either occupation it seems). Apart from his handlers I can't see how anyone would employ him for any role.

He's very bright, his team manipulate the news/news cycle in similar way to Trump, and it's documented fact that he purposefully plays the fool.

first world problems. lol

Not to defend Johnson, but DC has an axe to grind.

That the UK government basically knew what they were doing may have been true 5 years ago. Today, not so much.

Do you think? They're starting to cut into our human rights, and workers rights, they've brought in measures to stop democratic protests, stripped public services, they've increased tax on the poor and removed tax from business/rich (cutting tax on Champagne whilst lecturing the populace on the need for austerity was a particularly evil-villain twist); they straight up funneled £Billions out of the Exchequer under the guise of PPE payments and then just said that the whole scandal want going to be investigated, they clearly had arrangements with the Met to allow them to avoid the law ... they seem to be doing exactly what they intend, making oodles of money.

They removed EU oversight and loaded top civil service positions with yes-men.

They've achieved a lot, all to the detriment of the country and regular people. What makes you say they don't know what they're doing?

I don't disagree with any of the above. But it is probably at least as much down to incompetence as greed. Please don't try and tell me that Nadine Dorries is some sort of evil genius.

I had very different experiences.

I worked for an acronym company in which the majority of "leaders" were smart, driven, capable, and despite mistakes that anyone can make, it would have not been fair to call them incompetent.

Some were incompetent, they got promoted into positions of responsibility and power when the company was scaling up so fast that they could not hire externally for those positions fast enough, and the internally vetting was weak. Then, they created their "network of power" within the company and they went on working incompetently for a few years. And then there were people like my former boss who are idiots with an academic title of some weight. Many such cases.

I then worked for a huge company, but not an acronym one, and at the Director/VP/C- level there are pockets of incompetence that are difficult to explain to others and to accept as possible.

CTOs that know little about technology, VPs that ask LinkedIn for surveys of employer retention to make the case that they were not losing more people in a year than, say, Google, but not accounting for the fact that we could not hire anyone for months while Google is so worried about false positives that they reject plenty of very viable candidates. The same slides presented at each all-hands meetings not to reinforce the vision or goals, but because they are too lazy to prepare new slides for an audience of 500 people, who looked at themselves asking: again?

One might say that they are competent at navigating company politics, which is like saying that the employee sleeping with their bosses are competent at getting promotions.

When I worked in academia (not in the US, if that matters), there were plenty of tenured professors that I would say were in the bottom 5 or 10% in terms of competence, research plans, management of students and postdocs, when compared to all postdocs in the same research area. Useless professionals that schemed their way through academia. And everybody knows that, but people who are inside have nothing to gain by exposing them, and people who leave academia they say, well, not my problem anymore, f them.

In my home country, the vast majority of politicians are incompetent outside of their core competence, which is getting votes.

I was under the impression, when I was younger, that I was wrong whenever I saw someone in a position of power, be it in the private sector or public office, who I saw as incompetence. How is it possible, I was asking myself, that somebody can get promoted, assigned huge responsibilities, be accepted by their peers when they are not at their level or at the level of competence required by their position. But it is very possible and in reality quite frequent.

>>> when you're held accountable by an entire country...

This is blatantly untrue.

Heck, the infamous trifecta Bush-Blair-Aznar led their countries on a war that destroyed a country and costed many human lifes, based on what we know were lies and invented data. What consecuences did they face?

And that's just an example. I can show you as many corruption cases as you want, and see how the subjects go on with their careers untouched.

OP wasn't saying that all people are always held accountable for all of their actions but the Iraq war caused a massive problem for Labour at the polls that they never really recovered from. Also, the incessent onslaught of media vultures trying to stir trouble for a headline will certainly make it harder for people to make decisions that they believe to be right because most people won't understand all of the variables and will cause massive criticism.

Until we are front page news for being "naive", "stupid", "arrogant", "monster", we can't really understand the pressure that Governments are under.