Nobody talks about the real reason to use Tabs over Spaces - <AUTHOR> https://reddit.com/r/javascript/comments/c8drjo/nobody_talks_about_the_real_reason_to_use_tabs <comment><USER2> We discussed this 5 days ago:

[https://news.ycombinator.com/item?id=20341354](https://news.ycombinator.com/item?id=20341354)

<comment><USER3> @dang, for dupe submission, is it possible to merge the comments from later submission into the initial submission?

<comment><USER4> We do that, but usually only when the two threads were concurrent. Five days is probably too much of a stretch.

</comment></comment></comment><comment><USER5> Been saying for years that tabs are an accessibility feature. It's good to see a thread get some traction. I've never understood why people -- logical people; programmers -- are so religious about spaces, especially in the Python community.

A while back I tried to make the case to the author of Black (The python community's excellent auto-formatter) to add a "\--use-tabs" option. I was not successful; I had to fork Black to be able to use it. [https://github.com/jleclanche/tan](https://github.com/jleclanche/tan)

<comment><USER6> My impression is that many people are not confident in their understanding of tab behavior; there's a perception of them being weird, unpredictable voodoo (as exemplified by comments which imply that many programs don't support tabs well, despite that virtually all programs support tabs flawlessly, right down to notepad and standard GUI toolkit textboxes.)

I think this stems from a broken mental model, whereby tabs are regarded as "representing x number of spaces", where x is some unknown variable in the editor of whoever created the file. These people say things like "tabs are just a compression mechanism" and "tabs are inconsistent across editors". In the minds of these people, spaces have primacy, and tabs are just weird inconsistent not-spaces that catch you out.

The proper mental model, of course, is to recognize that tabs don't represent any number of spaces - they represent indents, and that's that. You could quite happily set your editor to display tabs as indents π spaces wide. It is an error on the part of the person writing the file to assume any particular tab width.

There are a few coding style conventions that break the assumption that the indentation should strictly reflect the nesting depth, like breaking up a long argument list over multiple lines and trying to line the second line up with the opening parentheses. In my view these are bad coding styles anyway and should be retired.

<comment><USER7> The issue with tabs as indent level is that there are two reasons to indent. The first is for logical scoping, where tabs do indeed make sense. An example would be

        int main(void){
            indentedStatement()
        }

However, the second is for aligning multi-line statements. Something like:

        int main(void){
            foo(bar,
                baz,
                54
            );
        }

Here, the indenting on arguments baz and 54 really should be aligned with the argument bar. If we really want to combine both use-cases that involves a mix of tabs and spaces. Tabs fist for getting the number of nested scopes, with optionally spaces to align text.

Meanwhile, mixing tabs and spaces is almost universally seen as bad. This makes sense because it is not visible where the tabs end and spaces start. This can easily lead to inconsistencies that are invisible to a writer, but are horrible for a reader with a different tab representation.

If you believe that indenting like this is a bad coding style, how do you suggest those statements should be formatted?

<comment><USER8> The solution is to mix tabs and spaces; most editors can be configured to clearly show tabs. Indent with tabs, then align with spaces. Never place a tab after a space.

If you mess up, no big problem, someone else will see it and fix it. People screw up space-alignment all the time anyway.

Or, better still, don't visually align stuff. It's annoying as hell to maintain unless you use an IDE, and has a tendency to bunch stuff up toward the right margin when function names grow long. Just start the argument list indented by one tab stop on the next line. More visually consistent too.

</comment></comment></comment></comment><comment><USER6> The reason it's more accessible is because it's The Right Way, in the same way that a text file is more accessible than a screenshot of that text file. Indentation is a _semantic_ property, not a visual one.

<comment><USER9> > Indentation is a semantic property, not a visual one.

Depending on style in can be both.

        +-- semantic
        v
        def something(with aligned,
                      list of,
                      parameters):
                     ^
            visual --+

<comment><USER5> Oh gods please don't align like this, it's just so unreadable.

Example of what that does in practice: Lines that end up wrapping almost at the end of the soft-character-limit and look like this:

[https://github.com/pennersr/django- allauth/blob/c9b31ddee81d...](https://github.com/pennersr/django- allauth/blob/c9b31ddee81d2cde06c1f686c4eb7703f916681f/allauth/account/views.py#L629-L632)

<comment><USER10> IMO it depends on the language. With named parameters it is very readable, and is my preference when you have functions with lots of parameters.

<comment><USER6> It breaks a fundamental assumption, which is that indent depth strictly reflects code nesting depth.

If you're going to do that, the "correct" way would be to indent each parameter with tabs to the same depth as the function declaration, and then use spaces to take up the rest of the space (i.e. the width of the function declaration). Which is admittedly ugly - but it's ugly because it reflects the ugliness of misusing indentation for alignment. It's slightly less ugly if you use an editor that displays tabs and spaces differently - Kate/Kdevelop use a nice discreet » character for each level of indentation:

      def hello_spam():
      »   while True:
      »   »   print ("Hello",
      »   »          "World")

The last line is visually aligned, but the semantic depth is the same.

<comment><USER11> I'd go with

      def hello_spam():
      »   while True:
      »   »   print(
      »   »   »   "Hello",
      »   »   »   "World"
      »   »   )

</comment></comment></comment></comment></comment></comment><comment><USER12> I've been a tab user since forever. The biggest issue with using spaces is not how much you indent, it's the bad pattern of aligning stuff vertically beyond a simple N-level indent.

Using spaces to align stuff on multiple lines causes multiple problems.

Any changes will affect surrounding lines. This adds busy-work to realign everything, especially if you're not using a fancy editor plugin to do it. It also makes for bigger diffs, which add pointless noise when reading diffs, and potentially unneccessary merge/rebase conflicts.

It's also assuming that the text is displayed in a monospaced font. A (very rare) few of us like to code with good looking proportianally spaced fonts instead of awkwardly spaced typewriter fonts.

</comment><comment><USER13> I've been a die hard 2-space indent person for well over a decade, but this is an argument I simply can't ignore and I feel compelled to reconsider my position. Thanks for sharing this!

<comment><USER14> Here's another argument:

If everyone uses tabs for indentation, then you can configure your editor to display that as 2 characters width, while the people who prefer 4 or 8 can do the same. No one needs to argue about how many columns of indentation there will be (1/2/4/8) since it's specified in text semantically and displayed individually. No one needs to be die-hard N-space-ists since everyone can have their way simultaneously. Even code that wasn't written by people who prefer your 2-column indent style (if they would otherwise be using spaces) will look that way to you. Everyone wins!

<comment><USER15> > _(1 /2/4/8)_

Sometimes I wonder if I'm the only person in the world with a preference for 3-character width tabs.

I also wonder if I can ever bring up this topic in public without being called perverse by other programmers. People get _really weirdly_ religious about this.

<comment><USER16> Oh, how come?

What language are you using where 3-spaces-wide tabs are more comfortable?

<comment><USER17> An indentation preference can be largely language independent.

<comment><USER18> Can be and probably usually is. However, funnily enough, I have a language- dependent preference: 2 spaces or Lisp-like languages, 4 spaces for all others.

</comment></comment></comment></comment></comment></comment><comment><USER19> I used to be a "tab person" when I started using python in 2001 - after all, it makes more logical sense and it saves bytes, what's not to like?

And then the world duly standardized on 4-spaces-per-indent.

So I've long given up and just gone with the flow. Unless big projects switch to tabs in a coordinated manner, to make a big statement, this matter is unlikely to ever be reevaluated.

<comment><USER3> Would be interesting to see a table of spaces per indent vs language or Project.

I know the Linux kernel has an 8 spaces requirement. Code has been known to be rejected based on this violation.

<comment><USER20> Linux kernel has 1 tab, which many/most would map to 8 (including me). Mapping to 8 has (and not 2 and 4) becomes relevant if you have line size limits.

<comment><USER21> That struck me as odd surely 8 is the norm - a holdover from typewriters

</comment></comment></comment></comment><comment><USER22> That's a very good argument, but I have another one, also often dismissed: if you navigate using your keyboard's arrow keys (which can be more productive than mouse/trackpad) then jumping over tabs to reach text is just way faster. Spaces kind of force you to use your mouse more.

<comment><USER23> Assuming you're not using some very basic text editor; good ones have skip word. For instance 'w' in vim, or 'ctrl + right' in vscode.

<comment><USER22> True, but nothing is simpler than an arrow key.

<comment><USER24> This is not really true; 'w' is one row up from the home row and is easily accessible with the middle or ring finger. An arrow key is a hand-shift or an awkward pinky stretch away. Vim keybindings were explicitly designed to be simpler than arrow keys once you've gotten over the learning curve.

<comment><USER22> Unfortunately vim is not very useful for coding and debugging iOS apps. Or Android, or Windows for that matter.

<comment><USER25> I haven't done any iOS development, so perhaps I'm expecting too much; but surely there is an IDE that has a vim-mode plugin? Every IDE/editor I've used—all JetBrains products, Atom, Visual Studio, Eclipse...—has a vim plugin readily available. They're rarely perfect (they tend to behave weirdly with IDE autocompletion and the like), but they're more than adequate for basic text navigation.

<comment><USER22> > but they're more than adequate for basic text navigation

I really think basic text navigation is no longer a problem since the the adoption of PC keyboards in the 1980s and 1990s. Key arrows are easy to find blindly except maybe on some screwed up laptop designs.

<comment><USER25> Perhaps our definitions of "basic text navigation" are different. I'd include capabilities such as "jump six words to the right, based on natural word boundaries" and "jump six words to the right, based on whitespace only". Oh, and "jump to the end of this statement that's enclosed by parentheses".

Not trying to start a vim-vs-whatever war here, though I suppose that's inevitable in a discussion of tabs-vs-spaces...

</comment></comment></comment></comment></comment></comment></comment></comment><comment><USER26> I do not really care for tabs vs spaces, _except_ in Python, where tabs are obviously the appropriate choice. For conceptual simplicity and orthogonality, if you want to treat python programs as text files, and deal with them using standard text processing tools, it is much more comfortable when the indentation is marked by a single character.

Apart from that, I never cared if people used spaces in other programming languages (as long as it was 8 spaces per level, of course). But this reddit post highlights an important reason to promote tabs everywhere, not only in Python.

<comment><USER27> Do you actually use 8 space indents??

<comment><USER26> Of course; I am a decent person. Let me just quote Linus Torvalds here:

> Tabs are 8 characters, and thus indentations are also 8 characters. There > are heretic movements that try to make indentations 4 (or even 2!) > characters deep, and that is akin to trying to define the value of PI to be > 3.

</comment></comment></comment><comment><USER28> _these guys have serious problems using codebases with spaces, they have to convert, do their work, and then unconvert before committing_

I used to work for a company that had automatic formatting on checkin/checkout --- everyone had his/her own formatting preferences (tabs/spaces and how many was one of them), which deviated slightly from the "official" one, but the process was basically completely automatic.

My personal preference is _one_ space --- files are just as small as with tabs, and the column counter of the editor also directly corresponds to the indent level.

Also, the lack of capitalisation and run-on sentences in a post arguing about accessibility is a bit ironic.

</comment><comment><USER29> I cannot suggest enough to avoid this debate and pass to elastic tabstops

[http://nickgravgaard.com/elastic-tabstops/](http://nickgravgaard.com/elastic- tabstops/)

<comment><USER30> I agree completely. Elastic tabstops are such an elegant solution to the whole debate. It turns the tab character into what it should be semantically, a character to denote alignment, just as it is used in a wysiwyg word processor.

When supported by the editor, it also allows the user to align columns using a proportional font instead of the fixed-with fonts we have to use now.

The concept has been discussed on HN earlier, but the accessibility argument is something that I hadn't considered or seen anyone discuss.

<comment><USER31> Why is this dead? It provides a commentary on the feature linked.

</comment></comment></comment><comment><USER32> Use tabs for indentation, space for alignment, why do it anyway else?

I especially like Linus Torvalds view on indentation:

 _" Tabs are 8 characters, and thus indentations are also 8 characters. There are heretic movements that try to make indentations 4 (or even 2!) characters deep, and that is akin to trying to define the value of PI to be 3.

Rationale: The whole idea behind indentation is to clearly define where a block of control starts and ends. Especially when you've been looking at your screen for 20 straight hours, you'll find it a lot easier to see how the indentation works if you have large indentations.

Now, some people will claim that having 8-character indentations makes the code move too far to the right, and makes it hard to read on a 80-character terminal screen. The answer to that is that if you need more than 3 levels of indentation, you're screwed anyway, and should fix your program."_

[https://github.com/torvalds/linux/blob/master/Documentation/...](https://github.com/torvalds/linux/blob/master/Documentation/process/coding- style.rst)

</comment><comment><USER33> Something that I feel gets overlooked in tabs versus spaces is that a tab generally has a specific semantic meaning (increase indent by one) whereas a space's meaning depends on how many spaces you are using to indent and a single space has no meaning on its own (unless you are indenting using only one space).

As a side note: I wish that JavaScript had a utility like the "indent" utility in Unix for precisely styling C code. Prettier is close; however, it cannot be customized in the detail that I would like.

<comment><USER34> > however, it cannot be customized in the detail that I would like

That's the whole point. Why is what you want better than what the formatter says?

<comment><USER33> I don't mean customized by an individual user, I mean customized by the team to fit their style guidelines.

</comment></comment></comment><comment><USER35> This is a decent argument but calling it "the real reason" takes away from it.

</comment><comment><USER36> Yes, it's pretty obvious that Tab is correct since it has semantic meaning (tab = indent), is one character and has configurable width.

</comment><comment><USER37> I kind of feel that source code needs to take a tip from HTML and apply a style-sheet. Have editors parse the code and display according to the user's preferences.

<comment><USER38> Exactly. Maybe a browser extension to pretty-print spaces to tabs, or sites like Github/SO can offer a built-in option.

<comment><USER37> I'd go even farther than that. Prefer {}, BEGIN/END or indented code? Prefer && and || or AND and OR? Prefer infix a+b+c or LISP style +(a,b,c)?

Pick one and the editor will show and edit code that way. The underlying code files remain unchanged.

<comment><USER38> Wouldn't LISP style be (+ a b c) though?

<comment><USER37> You may be right. I don't actually know LISP.

</comment></comment></comment></comment></comment><comment><USER39> I totally agree, as a dyslexic big pieces of text look like a garbled mess. I need > 2 spaces to be able to navigate a file with code with any speed.

Tabs for indentation, spaces for alignment looks to me like the best of both worlds.

<comment><USER21> The problem I have (also a dyslexic) with tabs vs spaces is you cant (normaly) see tabs.

The old school 80 column fixed layouts like Fortran had did have its advantages.

<comment><USER26> > The problem I have (also a dyslexic) with tabs vs spaces is you cant > (normaly) see tabs.

There is probably no editor program in your computer right now that is not able to display tabs visually.

<comment><USER21> Yes I know but I am not working with with those fugly show white space settings turned on.

Like one of the previous commentators I am a dyslexic and I find displayed tabs CR etc very visually distracting

<comment><USER40> VSCode doesn't display the CR and with the boundary setting doesn't show whitespace when it's a single space between words.

</comment></comment></comment></comment></comment><comment><USER41> Tabs v spaces should be an argument that we are long past by now, our editors no longer bound by the limits that once fueled such arguments.

Your editor should automatically purge all whitespace and format according to your settings and language canonical form. Whether tabs, spaces, curly braces on the end of line or next line, and on and on.

Go coming with go fmt is one of the great things about the language because instantly so many color of the shed arguments were vanquished.

</comment><comment><USER42> I generally don't like using tabs, as I find having two characters for whitespace leads to annoying inconsistencies. However, were a team member request I use tabs for accessibility reasons, I would have no issue complying.

That aside, I don't feel that this particular argument any stronger than any personal preference, let alone some kind of be-all final reason.

Generally whenever more than one space is used consecutively it is intended for indentation purposes - thus an equivalent solution to the accessibility problem is to just configure the editor to render consecutive spaces differently.

The post author calls for more editors to support adjusting tab widths showing that using tabs isn't automatically an accessibility win - spaces users could just as easily call for more editors to support custom ligatures to help the visually impaired.

<comment><USER10> I actually find having a separate character for indentation is a strength of tabs rather than a detriment. Tabs tell you how the lines in your program relate to one another, and spaces tell you how things relate within a given line.

On top of that, I think the strongest argument for tabs is efficiency. space- indented code uses 3 times as many bytes to represent a level of indentation than tab-delimited code. That might not seem like a lot, but spread over all the commits in all the codebases using spaces, it seems pointless to use all that extra disk space for no reason.

I think the real problem is that the default tab width for web interfaces is 8 spaces. If it were a more reasonable 4 characters wide, I doubt it would even be an issue.

</comment></comment><comment><USER43> Despite adding a valid perspective, this is mostly clickbait.

A file is just a storage format. The real issue is that IDE's don't render files according to user preferences, be them TABs or spaces, or PascalCase vs snake-case. When saving they convert back. No need to "get everybody on the same page" and in the process create winners and losers.

Unlike laws (or like laws), technology has the capacity to create win-win situations. This is a good example. So the real question is why we insist on debates, instead of actually doing our jobs. Congress can only solve so much.

</comment><comment><USER44> That is a pretty good point. As a rubyist, I always use and advocate two spaces - but if I ever find myself on a team with visual impairments, I'll be sure to ask whether tabs would be useful to the team. I'm a big believer that Team-level consistency is far more important than Universe-level consistency, and silver bullets kill.

That said, I'm intrigued - surely this must be a solved problem at this point? Anybody aware of any good text editors / editor plugins that allow you to modify the visual spacing of start-of-line spaces?

<comment><USER6> It is a solved problem! Just use tabs. Almost every editor supports adjustable-width tabs. Why go out of your way to avoid tabs, and then make spaces behave like tabs?

</comment></comment><comment><USER45> An excellent argument. I've been mostly agnostic about the tabs-vs-spaces debate, as long as we just pick one and stick with it everywhere consistently and never ever mix the two. I've had this feeling lately that maybe tabs might be more appropriate than spaces, but never felt strongly about it, and everybody has settled on spaces, so lets just stick with that.

But in light of this argument, yes, lets move to tabs instead. More control for the user in how you actually display them.

</comment><comment><USER46> Nobody talks about the fact that git can convert tabs to spaces and vice-versa on the fly so the whole discussion is irrelevant :-)

[https://stackoverflow.com/a/2316728](https://stackoverflow.com/a/2316728)

</comment><comment><USER47> > _one of them uses tab-width 1 because he uses such a gigantic font-size_

But if they use a "giganting font-size" to see the letters, spaces would still be proportionally gigantic. Why would they need to have custom indent size, since everything will play along with their font-size choice?

That is, why someone might want to use gigantic fonts but constraint that gigantic-ness to the actual letters, and not the indents too? Isn't it equally important to see indentation clearly?

<comment><USER48> Why challenge someone's self-selected, battle-won access solutions before you spend time with them understanding their choices?

<comment><USER49> For me the challenge is part of understanding choices. I don't think of challenge as conflict, but as a way of looking at different possibilities to learn more about why.

<comment><USER31> There are many ways to pose a challenge.

> I don't think of challenge as conflict

Agree, but I like to think of it as retrofixing your reasoning for the different view: "You tell me A, but I used to believe B because of C, D, etc. Can we investigate whether my reasoning was lacking, those are also in conflict with A, A and B are not actually in conflict, or B has a validity not influenced by A"

<comment><USER49> I like this symbolic way of putting it. I struggle with communicating that in a way that is non-threatening to people who are sensitive or defensive of their supporting beliefs E,F, etc for why A.

</comment></comment></comment></comment></comment><comment><USER50> M-X tabify had two benefits. Firstly it more than halved assembly source paper tape. And secondly atleast Olivetti Teletype interpreted a TAB as a silent jump, instead of 8 bang-bang-bangs of empty spaces.

</comment><comment><USER51> That's the kind of practical real life inclusivity that I think should be pushed instead of the "being offended by theoretical straw men" code of conduct nonsense.

But I won't hold my breath.

</comment><comment><USER52> Surely version control solved this issue. Use whatever you like. Have a standard for the repository itself. Auto-convert if and when necessary.

</comment><comment><USER53> It's always fun pasting tab-indented code into the MySQL client...

<comment><USER54> Then fix the mysql client...

</comment></comment><comment><USER55> Most decent editors can operate with tabs or spaces functioning identically, so this is mostly a moot point. With that in mind, spaces are easier to display in tools that don't handle tabs well, so using spaces is still the right approach in my estimation.

<comment><USER18> And yet these visually impaired people apparently pleaded with the OP not to take away their tabs.

Almost every program to edit text has a tab stop setting, but only the most advanced dev tools allow you the same control over spaces. Anecdotally, I've been struggling to get emacs to indent a certain language correctly for me (I want it to use two spaces in a place where it only uses one, I'm not really an emacs person so figuring out how to fix it is too much effort for me), if I were to switch to tabs, that would be easy: just set the tab width and be done with it. I don't have any experience with screen readers, but it would seem to me that they should have an easier time with tabs too.

<comment><USER49> I wish the story had described the editors used by the two visually impaired coders. It seems odd that they are using an environment that doesn't up/down convert easily. It mentioned they were forced to do this like it was a manual process.

Free IDEs like VScode do this, and it works with screen readers. Although from the description of their screens with large fonts and wide resolutions, I don't think they were using screen readers.

Since the article is missing this bit, I can't help that fear that all three would have benefited from knowing how to config editors to get around this problem.

<comment><USER5> No IDE I know of can reliably convert spaces to tabs in a display mode only (= without actually causing code changes).

<comment><USER18> Also, not every space necessarily should be converted to tabs, especially if you follow the "tabs for indentation, spaces for alignment" mentality: you will want everything up to the indentation level converted but not everything after. I'm sure some editors can do this, but many also definitely can't. Tabs just work, everywhere.

</comment></comment></comment></comment></comment><comment><USER56> I hope this is the seed to stop spaces nonsense..

</comment><comment> master-litty [redacting]

<comment><USER57> Eyes don't get worse from use.

If you strain your eyes because of the lighting conditons, your eyes get fatigued but it has no detrimental long time effects.

<comment> master-litty Thank you, I seem to be severely misinformed. Redacting my original thoughts now.

I have very poor vision and have been told by two different optomotrists that for me, personally, my vision will worsen as I strain my eyes. I never thought to wonder if this was different for anyone else -- One of those things it seems.

</comment></comment></comment><comment><USER58> There is no debate... every rational person knows tabs are better.

</comment><comment><USER59> Spaces are for people who understand addition. Tabs are for people who understand multiplication. ;-)

</comment><comment><USER60> \t saves bytes compared to n*' '. there is literally no other reason to do this. for 'style' both can be implemented to do the same and most editors these days can replace one with the other and have configurable tabs, or 'use spaces instead of tabs' options. in reality, if for example you sent a lot of documents over the wire, or store a lot of documents on disk, using /t compared to spaces can save a lot of bytes on disk or network... (looking at the uncompressed case...)</comment>


Analytics has become useless - <AUTHOR> https://www.bugmuncher.com/blog/analytics-is-useless/ <comment><USER2> I'm impressed that they're spamming you via the search terms. It's like a new unblockable form of native advertising.</comment>


Doctors, Revolt - <AUTHOR> https://www.nytimes.com/2018/02/24/opinion/sunday/doctors-revolt-bernard-lown.html <comment><USER2> Health care and education are IMO the next two major car wrecks coming for America. Both are like patients with similar symptoms (indicative of the general disease of America.)

\- They treat the customers like replaceable widgets

\- Costs are spiraling out of control. ($2-3000/day hospital, $3.4 TRILLION in total health spending [this equals the entire federal budget])

\- Doctors / teachers often don't seem to communicate / care. (Friend's mother was recently in hospital, multiple doctors thru a single day, each one had to completely relearn what was going on.)

\- The infrastructure systems are counter motivated (hospitals, drug companies, ect.. are profit not care motivated corps w/ "high" administrative overhead, schools are often public, yet view students as revenue and spend large amounts on noneducational costs to attract "talent". [$500k-$1.5M admin salaries])

No wonder many just want to self educate these days, and their health would be about as well served going to a shaman who cared about them.

<comment><USER3> > Friend's mother was recently in hospital, multiple doctors thru a single > day, each one had to completely relearn what was going on.

What's the alternative? 24 hour shifts for the doctor and the new doctor each day needs to relearn everything?

Having to relearn everything might be a problem, depending on what it actually means, but as long as we want a normal human being as a doctor, they will cycle over time as people start and end shifts, and they will need to learn what happened before their shift started (and they may receive patients from multiple doctors leaving over their shift, making 1-on-1 hand-off infeasible).

It's easy to call this out as a problem, the question is what's the alternative that's better?

<comment><USER4> In addition to this, many doctors want to re-take the history from the patients and re-examine them for themselves, rather than rely on a brief handover or potentially sub-optimal notes from another doctor. Clinical signs can be subtle, as can points in a patient's history that may point to a diagnosis. I see patients often frustrated at being asked the same questions by each doctor they see, but most of the time this is in their best interest.

<comment><USER5> Each doctor also has an incentive to re-examine the patient so they can bill for that examination.

<comment><USER4> And this certainly isn't the case in the NHS in the UK where doctors have no financial incentives interfering with their clinical decisions (barring saving the service money). What you describe is a pitfall of private medicine.

<comment><USER6> > And this certainly isn't the case in the NHS in the UK where doctors have no > financial incentives interfering with their clinical decisions (barring > saving the service money)

This meme really needs to die. The NHS has _massive_ financial incentives that impact clinical decisions. In fact, you literally go on to mention as such in your next sentence.

It turns out that having an incentive to "save the system money" results in a different set of clinical decisions. And no, those don't always work out in favor of the patient. (They're particularly problematic for the patient in cases of long-term care, which is why the NHS does rather badly on complicated and chronic conditions like treating cancer compared to the US and other countries).

<comment><USER7> _This meme really needs to die. The NHS has massive financial incentives that impact clinical decisions._

Not to mention that many if not most NHS-employed doctors run private practices on the side. Some only spend a day or two a week on their NHS duties. Others such as GPs are NHS-branded, but every GP practice is a private business that bills the NHS for time and materials.

<comment><USER4> In a discussion of NHS vs private practice, the fact that some (certainly _not_ most) NHS-employed doctors also do private work, has no baring on the incentives placed upon them within their NHS employment.

I am certainly not saying the NHS system is perfect, and all private medicine is bad, so if that is the impression you got then perhaps I was unclear.

In almost every single clinical situations within an NHS hospital that I have seen or can think of, the clinicians treating you will not receive any extra money, bonus, promotion, etc. for the treatment they provide you or do not provide you.

I have lived in countries with more private systems, where there is a direct relationship between what treatment/investigations you receive and what money ends up in the doctors pocket. For example, a private doctor in HK referring for not-strictly-necessary-but-ultimatelhy-clinically-justifiable MRI scans at a private MRI clinic which, provides a percentage of the (expensive) scanning fee back to the referring clinician. Contrast that in the NHS, no one gets given money for sending a patient for an MRI scan, and in fact, if it isn't going to change the management of the patient, the request is likely to be refused to constrain resources. In the HK system, neither the doctor nor the MRI provider is incentivised to not do the scan, quite the opposite.

The NHS system is not perfect, but pointing out different the pros and cons of different incentivisation structures that do have an impact on patients is not something that is a "meme that needs to die"…

</comment></comment></comment></comment></comment></comment></comment></comment><comment><USER8> Let's be careful about nostalgia for the "good old days" of medical practice. Keep in mind that standardizing medical care process has done more to get physicians to WASH THEIR HANDS than all kinds of exhortations about relationships, partnerships, and healing. And washing hands has, since Semmelweis's discoveries 150 years ago, been known as the easiest way to promote healing that medical people don't do.

Why do the overnight shift of nurses take vital signs every four hours? So they catch rapid unexpected changes in patient conditions more quickly. Put more crudely, so they don't accidentally leave a corpse in a bed for the next shift. Having to write, or type, the patient's blood pressure into a log is a way to help the overnight nursing shift remember to pay detailed attention to each patient, at least for a few moments. If their instructions were "stop at each door and listen for the patient breathing" those nurses might well miss important changes.

Hospital care these days is not only about the towering figure of the heroic superhuman doctor, Harvard Medical School lore to the contrary notwithstanding. It's about all the folks who look after patients, from the community primary care doctor to the RN, to the chaplain, to the "hospitalist" physician, to the person who cleans up, to the person who maintains all the electronic gear. The challenge is getting all these people to cooperate with the patient and for the patient's benefit.

The superhuman healer approach to medicine demands superhuman people to be doctors. They aren't, any more than the rest of us are. They have to sleep, and to eat, and to see many patients. So, a good hospital needs to be organized like a good company: where each person's skills and passion complement the others, and gets an extraordinary result from a collection of ordinary people. The buzzword for that is "synergy." Good discipline--good and predictable process--is part of synergy.

And, at the end of all that excellent care on our behalf, each and every one of us will become a corpse. A nineteen-year-old with a broken leg can be cured. A 90-year-old with cancer and pneumonia, not so much. It doesn't matter how towering a figure the doctor is, or how kind the nurse is.

A radical move in medicine would be to come to terms with death as a natural part of life rather than as a failure of the system.

<comment><USER9> >Why do the overnight shift of nurses take vital signs every four hours? So they catch rapid unexpected changes in patient conditions more quickly.

The first sentence of the second paragraph of the article you seemed to have avoided reading says:

"Checking things like temperature, blood pressure and respiratory rate every four hours on hospitalized patients has been the standard of care since the 1890s, yet scant data indicates that it helps."

<comment><USER4> > yet scant data indicates that it helps

But this is not the case. In the UK, these observations are entered into a proforma by the nursing staff which allows them to calculate a "National Early Warning Score". Based on the patients score, the nurse __has to __escalate to an appropriate team and the doctor on the appropriate team __has to __take the referral.

Not only does this help identify deteriorating patients, but it helps to fight human factors like "I don't want to call such and such a doctor because they are always rude on the phone so I'll just leave it and hope it gets better"

In terms of actual data, we have a national body (NICE) that provides guidelines and recommendations based on appraising the available data and research. For NEWS scores, see:

For an overview: [https://www.nice.org.uk/guidance/cg50/chapter/1-Guidance#phy...](https://www.nice.org.uk/guidance/cg50/chapter/1-Guidance#physiological- observations-in-acute-hospital-settings)

For the full report and evidence used to compile the guideline: [https://www.nice.org.uk/guidance/cg50/evidence/full- guidelin...](https://www.nice.org.uk/guidance/cg50/evidence/full-guideline- pdf-195219037)

</comment></comment></comment><comment><USER10> Hospitals should post prices of their procedures in the lobby. A surgeon gets $500 to repair a hernia and the hospital pulls in $5k for the ancillary services. The surgeon has to see the patient,make the diagnosis, provide the treatment, provide the aftercare and be the 'face'. The hospital-insurance complex has managed to create this fantasy world with complicated rules and somehow have sequestered themselves from the free market. They set their own prices and by virtue of being of local monopolies thwart the ability of the individual to choose. Hospitals have become like cable companies.

<comment><USER11> It's not like hospitals are wildly profitable to run though? I think the inflated costs are due to the little understood phenomenon of "cost disease" rather than owners of hospitals extracting outrageous rent for themselves as I think you are implying.

<comment><USER12> You're correct about the spread of cost disease, it has essentially reached every corner of US healthcare. The part that hospitals are particularly guilty of, is unnecessary admin expense inflation. The US education system has seen an almost identical problem. Building buildings that aren't needed, hiring 10x the admin staff that the system had 30 or 40 years ago, etc. It's the system rewarding itself, bureaucrats hiring more bureaucrats, playing lords as they go on building sprees that aren't needed. There are very few readily available levers in the US healthcare system, that can be used to properly pull back against such cost spirals and spending behavior.

<comment><USER13> Last time I was out the hospital they had robots running around to just to pick up towels. Robots are great and all, but that's a symptom of not managing costs.

<comment><USER10> thank you all for your input. The hospital you linked in Asia. It seems that SE Asia has leapfrogged us in the concept of capitalism and the free market. Indeed, it is a 'free-for-all' in terms of lack of regulation, but certainly it is not 'free care for all'. Here in the US, The medical-industrial complex has seen how other industrial complexes deal with our government and are trying to mimic that gravy train. I still remember articles about the $500 hammer, and $2000 toilet the Navy had purchased in the thousands.

We need to get back to our roots. A free market where people can buy what they want when they want it. Health care insurance is an oxymoron. Everyone gets sick. There is no probability of someone NOT using the system. The minute you try to amortize the costs over time or large populations to provide services, there is infinite demand.

Insurance would make sense for events that are RARE. House fires, automobile accidents, gun accidents, etc. (BTW, why isnt gun insurance mandatory? That way everyone could be happy- you could still buy a gun as long as you paid your $5000 premium. The insurance companies could make more money, there would more 'gun control', and the money could go to the emergency rooms that take care of shooting victims. But OH NO! Hospitals would figure out a way to spend that money too and it would never be enough!! Maybe the gun insurance premiums could be given to the victims !)

Anyway, there is no easy fix until we start to force our politicians to GET OFF THEIR ASSES. It particularly annoys me that they offer 'thoughts and prayers' after each mass murder and do nothing else. They should be in Florida digging the graves. Representing their constituents properly.

</comment></comment></comment></comment></comment><comment><USER14> >Despite his reputation, Dr. Lown was treated like just another widget on the hospital's conveyor belt. "Each day, one person on the medical team would say one thing in the morning, and by the afternoon the plan had changed," he later told me. "I always was the last to know what exactly was going on, and my opinion hardly mattered."

yes, this is what it is like to be a patient at a hospital these days. And good luck if the patient wants to speak to a physician. and don't ever go to a teaching hospital if you have the choice. some intern will have the brilliant idea to adjust every medication you are taking.

<comment><USER15> You have to bring an advocate who is able to sniff out bullshit, establish rapport with senior nursing staff and be a pushy asshole when necessary.

A modern hospital is a zero trust environment.

</comment></comment><comment><USER16> The health sector is the Afghanistan of the tech business. It's entire history is of empires arriving to solve its problems, and after a decade and massive losses, they leave, mystified at how something so contained could be so intractable. The only people who survive there are the ones who don't try to change it.

When you can send your diagnostic images to get a consult from 2 clinics in India and an expert system for less than the price of a three block ambulance trip in the US, prices for domestic care will come down.

<comment><USER17> not sure where your confidence comes from, though i hope you are correct. i don't see it yet though.

in the US healthcare market the payment model will have to change before Indian healthcare market prices have an impact.

in other words, US legislation that takes money away from the current system of providers would need to be passed. (i mean, why doesn't the US medicare/medicaid system take advantage of the lower costs you're describing by flying US patients to hospitals in other countries for major, expensive procedures and other treatments? they could save a lot of money, but US law does not currently allow payment to providers all over the world.)

US hospitals, doctors, pharma, etc have created a closed system wherein they are the only service and product providers. i think they like that aspect of the current system. they've built themselves a moat and globalization cannot enter.

<comment><USER16> Tell me more of your impregnable fortresses and unsinkable ships.

I agree that the barriers you mention are real, but those are in the domain or class of solvable problems. Apps like Figure1 are a good example of how doctors are moving around this.

To borrow from Nial Ferguson's new book, the big CMS/EHR players (nightingale and another one here) control the integration points and hierarchical relationships, but I think they are vulnerable to networks.

</comment></comment></comment><comment><USER18> >The medical team was concerned that because Dr. Lown was having trouble swallowing, he was at risk for recurrent pneumonias. So we restricted his diet to purées. Soon the speech therapist recommended that we forbid him to ingest anything by mouth. Then the conversation spiraled into ideas for alternative feeding methods — a temporary tube through the nose followed, perhaps, by a feeding tube in the stomach.

Maybe not the main point of this article, but there are numerous occasions where I've encountered just this. Allied health professionals, all of whom are very well intentioned, making recommendations that physicians readily follow without taking into consideration the needs or desires of the patient and family. If as a physician you are being advised to declare a patient NPO or to send them off to a skilled nursing facility instead of home - please remember that this is just a recommendation and that it's your job to look at the patient as a whole, including their general medical condition, likelihood of their family supporting them, etc. before following through.

</comment><comment><USER19> Going to a doctor in America, for whatever reason, the first thing that happens is that a nurse comes and takes your blood pressure. I wonder why? Never happened to me in Europe.

<comment><USER20> Two reasons. First, it's a clinical quality measure that needs to be collected by law. The government mandates that you collect certain data about X% of patients you are in contact with and transmit that data to relevant parties or else you will be penalized financially by Medicare.

Also, BP, weight, and temperature are important diagnostic indicators

</comment></comment><comment><USER21> For better or for worse, everything in America is a business -- healthcare is no exception. Helpful to keep in mind when you think about potential improvements or solutions.

<comment><USER22> " _everything in America is a business_ "

If by "business" you mean a public/private hybrid in which profits are privatized while losses are socialized, then you are correct, in so far as health care goes. And that seems to be the model that is now being adopted in more and more areas of economic activity.

<comment><USER23> I don't like that wording because it implies that hospitals somehow benefit from government involvement; in reality, it just sucks for everyone. In general, I agree - very few medical institutions in the US actually get to be private.

I will say that truly private medicine is, in my reasonably broad experience, excellent. I use a private subscription-only medical service in the US which is excellent (and procedures are generally cheaper than they would be in a public hospital, whether I'm paying with insurance or out of pocket), and my experiences with private medicine in SE Asia and Mexico have been excellent (and affordable) as well (to a greater degree than can be explained by labor cost differences).

<comment><USER24> > it implies that hospitals somehow benefit from government involvement

But they very clearly do. A huge proportion of their income comes from government sources (Medicare/Medicaid/VA), they are subsidized by tax exemption for health spending, and government grants them the power to deny competitive entrants into their markets via "certificates of need."

<comment><USER6> > But they very clearly do. A huge proportion of their income comes from > government sources (Medicare/Medicaid/VA)

Hospitals _lose_ money on Medicare and Medicaid patients on the margin. They have to overcharge private insurers to make up the difference.

It's so bad that Medicare has not one but _multiple_ programs to compensate hospitals that don't see enough private patients to make up the difference, because otherwise they wouldn't be able to sustain themselves on Medicare reimbursement rates.

I don't know why you're even mentioning the VA; it's not relevant here at all.

<comment><USER24> Hospitals are obviously capable of accounting such that Medicare patients are money-losers on the margin, but they keep taking them for some reason.

> I don't know why you're even mentioning the VA; it's not relevant here at > all.

Normal non-VA hospitals accept VA patients and are reimbursed for them.

<comment><USER6> > Hospitals are obviously capable of accounting such that Medicare patients > are money-losers on the margin, but they keep taking them for some reason.

You seem to be under the impression that there's some deception going on here. There's not, and it's pretty plainly evident. Medicare's reimbursement rates are below COGS. Hospitals control neither of those two things (Medicare sets rates by fiat, and if hospitals could lower COGS by paying vendors less, they would).

As for why they keep taking them - they oftentimes have no choice, legally. Though, incidentally, in recent years, we've started to see hospitals find more creative ways to close their doors to Medicare patients for this exact reason.

> Normal non-VA hospitals accept VA patients and are reimbursed for them.

The number of VA patients hospitals see is negligible. The amount of revenue they receive, proportional to the number of patients they see, is even less.

</comment></comment></comment></comment></comment></comment></comment><comment><USER25> Stories like this are not uncommon in so-called developed countries. Makes you realise why medical tourism industry does so well. From my own experience i would prefer to return to Guangzhou or Shanghai for procedures rather than anywhere else. Not really that much cheaper but at least i can determine up front the size of the bill. Added to that is that in spite of factory-scale medical care in China(remember there are basically no private medical practices - all doctors are linked with hospitals), they are actual (in my personal experience) quite caring and dont charge unnecessarily.

But as with all things YMMV.

</comment><comment><USER26> Healthcare in the US has left the era of the small business and is entering the era of the nameless corporation. What wal-mart did to all of the mom-and- pop shops is happening to healthcare. Except that instead of lowering prices, it is raising them

Physicians have gone from small business owners to rank and file employees of large corporations. The burnout that is increasingly common among physicians is not unlike that of american office workers in the 1990s.

I'd love for the next stage of the evolution of healthcare to see physicians as customer focused, tech savvy entrepreneurs

</comment><comment><USER27> > To restore balance between the art and the science of medicine, we should > ... make room for training in communication, interpersonal dynamics and > leadership.

How would this help solve the problem the article started with, that patients don't heal because they're deprived of sleep by being woken up every 4 hours? It's a problem everyone knows about (I saw complaints about it online years ago) -- so it's not directly a communications problem. Leadership I can see: it seems needed to dig the system out of an inadequate equilibrium ([https://equilibriabook.com/molochs- toolbox/](https://equilibriabook.com/molochs-toolbox/)) but that's pretty different from college courses in leadership.

<comment><USER28> Proper communication includes proper action respecting that communication.

</comment></comment><comment><USER29> As a survivor of stage IV cancer, I can say my experience strongly mirrors that. I would go further to say that the assembly/widget mentality in a health care setting made it difficult for some of the staff to see me as a human. Abuse or care-full neglect (is that a thing? working on the words) is, in my experience at least, common.

It's not to say I don't appreciate being alive, but we can do better for those suffering.

</comment><comment><USER30> It is a nice coincidence that a video by an educational YouTube channel Kurzgesagt discusses homeopathy and why it still remains popular—hypothesizing that one reason may be that their practicioners pay good attention and affection to their patients. [https://m.youtube.com/watch?v=8HslUzw35mc](https://m.youtube.com/watch?v=8HslUzw35mc)

</comment><comment><USER31> This article and the comments here combine to illustrate for me the difficulty of making healthcare work in all the different ways it has to. I read the article, and I think, "Yeah! That's the kind of healthcare I want!" I read the comments with contrary opinions, and I think, "Those are great points — these counter-intuitive practices make sense when you need healthcare to scale." I talk to my wife, a physician, and I hear about what results in the rare cases when these protocols and consultations don't happen, and I think it's a wonder that hospitals function at all.

I think it's not a matter of finding _the_ solution to the problem, but a maximization problem, where we have:

\- patients who need to be cared for as human beings and allowed to make their own informed decisions, but who are generally not experts in medicine

\- physicians who have more patients than they can keep in their minds at once, and who are reliant on nurses and computerized systems to keep patients breathing and not get sued, but who are also skilled, highly-educated professionals whose human judgment is frequently superior to any algorithm

\- nurses who are both underpaid and responsible for more than their training considered

\- hospitals that need to pay the bills, pay salaries, attract new physicians, etc.

There are so many conflicting aspects of this problem that any simple solution is probably unrealistic.

</comment><comment><USER32> This article might also help too: "Life in Yorkton before Medicare came along" [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1269399/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1269399/)

</comment><comment><USER33> "[W]e should curtail initial coursework in topics like genetics, developmental biology and biochemistry, making room for training in communication, interpersonal dynamics and leadership. Such skills would [...] strengthen our ability to advocate for health care as a human right and begin to rectify the broken economics and perverse incentives of the system."

In other words, train doctors to be social justice activists rather than scientists? No thanks.

</comment><comment><USER34> Article does not address the problem why the doctors' behave this way: insurance companies.

Unfortunately, treating makes more money than curing and the United States is scared to death of what shall they do with all that free time if they actually do cure, while other countries do not work themselves to death because they do not have an artificially controlled supply of Doctors...

<comment><USER35> This is an absurd and oft-repeated claim that taps into variations of the conspiracy thinking around 'doctors keeping the cure for cancer (or insert other condition here) secret' because powerful lobby groups insist that there is more money to be made in 'treating' than 'curing'. It is patently untrue.

Firstly, it assumes that neither doctors, nor the scientists and researchers working in the companies and universities that drive medical progress forward, have an ounce of self-respect for either themselves, their family members or members of the community - because if true, either family members and themselves would never get cancer or other chronic diseases that we 'treat', or if they are somehow as vulnerable as the rest of the population to these conditions, that maybe there is a secret stash of 'cure' somewhere that they allow out to the people in the know. The conspiracy goes deep...

Secondly, it throws out the window all the evidence around what we can actually cure and what health policy seeks to do. We have an entire field of medicine called preventative medicine that aims to stop conditions before they happen, by lobbying governments to ie. Ban or decrease rates of Smoking and alcoholism, to provide safe needle exchange so IV Drug Users don't get bloodborne diseases, to improve exercise rates, to provide vaccination programs - all of which stop disease from happening. The fact of modern life in a western country is that most of the burden of disease is related to lifestyle factors or age related - Osteoarthritis (Age and Obesity), Cancers (Lifestyle risks and age), Diabetes (Diet, exercise, genetics) Cardiovascular disease (Exercise, Age, Lifestyle risks, diet).

It also ignores the tremendous advances that are _still_ occuring. When I was in my final year of Medical school, 5 years ago, Metastatic Melanoma was a condition with an average survival of 6 months. It is now (thanks to some incredible, and incredibly expensive drugs - don't get into a debate about cost here, I live and practice in Australia and the cost for a patient is capped at $46.60 per year as it is on the PBS) more of a chronic disease with average survival in the 4-5 year range. Incredible, and this progress occured in 5 years. Similarly, Hepatitis C, a condition that in it's chronic form invariably results in liver cirrhosis and failure, can now be cured - this was unthinkable 5 years ago, and is now a fact, with a 12 week course of medicine.

Please inform yourself and don't just trumpet that which you hear on the internet. Your ignorance is not as valid as my knowledge and to assume that in your version of this myth that insurance companies (but in the more common version of this myth, Doctors, Pharmaceutical Companies etc) are primarially interested in keeping the population teetering on the edge to milk them dry is disingenuous.

<comment><USER34> > Your ignorance is not as valid as my knowledge and to assume that in your > version of this myth that insurance companies (but in the more common > version of this myth, Doctors, Pharmaceutical Companies etc) are primarially > interested in keeping the population teetering on the edge to milk them dry > is disingenuous. You really know how to talk to people haha. It seems like > you were triggered by something I said even though it did not apply to > you.Take a breath. It is okay for other people to have different viewpoints > on the medical industry in the United States.

>This is an absurd and oft-repeated claim that taps into variations of the conspiracy thinking around 'doctors keeping the cure for cancer (or insert other condition here) secret' because powerful lobby groups insist that there is more money to be made in 'treating' than 'curing'. It is patently untrue.

Where are your sources? I never stated that they are hiding the cure for cancer? It is a fact that treating vs curing is a business model in the United States. The U.S outspends everyone yet gets them same results >[https://www.npr.org/sections/goatsandsoda/2017/04/20/5247741...](https://www.npr.org/sections/goatsandsoda/2017/04/20/524774195/what- country-spends-the-most-and-least-on-health-care-per-person)

It is also true that privacy data laws and business models are impeding the impact of disruption in healthcare where technology is disrupting every other field. ([https://www.bloomberg.com/news/articles/2017-11-28/alphabet-...](https://www.bloomberg.com/news/articles/2017-11-28/alphabet- s-deepmind-is-trying-to-transform-health-care-but-should-an-ai-company-have- your-health-records))

I never mentioned anything about Australia, I was talking about the United States. I cannot speak for Australia.

>Please inform yourself and don't just trumpet that which you hear on the internet.

The fact that medical records are not electronic being a standard is laughable. I cannot speak for anyone else but the United States. HIPA laws are one of the reasons which makes it harder for researchers and doctors to actually get data they need to develop cures because of the need an individual signature for everyone.

Regarding Supply of Doctors >In the United States, the supply of doctors is tightly controlled by the number of medical school slots, and more importantly, the number of medical residencies. Those are both set by the Accreditation Council for Graduate Medical Education, a body dominated by physicians' organizations. The United States, unlike other countries, requires physicians to complete a U.S. residency program to practice. (Since 2011, graduates of Canadian programs have also been allowed to practice in the U.S., although there are still substantial obstacles.) This means that U.S. doctors get to legally limit their competition. As a result, U.S. doctors receive higher pay, and like anyone in a position to exploit a cartel, they also get patients to buy services (i.e., from specialists) that they don't really need. ([https://www.politico.com/agenda/story/2017/10/25/doctors- sal...](https://www.politico.com/agenda/story/2017/10/25/doctors-salaries-pay- disparities-000557))

Limits on the supply of doctors a conspiracy? >[https://mises.org/library/how- government-helped-create-comin...](https://mises.org/library/how-government- helped-create-coming-doctor-shortage) >[https://skeptics.stackexchange.com/questions/4561/does- the-a...](https://skeptics.stackexchange.com/questions/4561/does-the-ama- limit-the-number-of-doctors-to-increase-current-doctors-salaries) >[https://www.quora.com/Who-or-what-controls-the-number-of- med...](https://www.quora.com/Who-or-what-controls-the-number-of-medical- doctors-in-the-U-S)

It is also a fact that insurance companies are the most powerful lobby in the United States. >[https://www.cbsnews.com/news/ex-dea-agent-opioid-crisis- fuel...](https://www.cbsnews.com/news/ex-dea-agent-opioid-crisis-fueled-by- drug-industry-and-congress/)

Business Model Point >Imagine a portable, low-intensity X-ray machine that can be wheeled between offices on a small cart. It creates images of such clarity that pediatricians, internists, and nurses can detect cracks in bones or lumps in tissue in their offices, not in a hospital. It works through a patented "nanocrystal" process, which uses night-vision technology borrowed from the military. At 10% of the cost of a conventional X-ray machine, it could save patients, their employers, and insurance companies hundreds of thousands of dollars every year. Great innovation, right? Guess again. When the entrepreneur who developed the machine tried to license the technology to established health care companies, he couldn't even get his foot in the door. Large-scale X-ray equipment suppliers wanted no part of it. Why? Because it threatened their business models. ([https://hbr.org/2000/09/will-disruptive- innovations-cure-hea...](https://hbr.org/2000/09/will-disruptive-innovations- cure-health-care))

<comment><USER35> > The fact that medical records are not electronic being a standard is > laughable. I cannot speak for anyone else but the United States. HIPA laws > are one of the reasons which makes it harder for researchers and doctors to > actually get data they need to develop cures because of the need an > individual signature for everyone.

In the US it is a standard that Medical Records are digitised. Unfortunately the existing eMRs are so awful that they decrease efficiency, so much so that many american clinics are removing them - [0, 1, 2]. If you think that the limiting factor on advances in medical research are access to digital records, you are severely misguided.

We have the same control on medical school spots in Australia. We train 1 per 6,285 people per year. You train 1 per 16,150 (roughly). However you also have Nurse Practitioners and a range of other allied health professionals and are a huge importer of overseas Doctors. It's not an ideal solution for the country. In Australia the medical colleges can limit training positions and this cartel behaviour has been the focus of the ACCC a number of times. On the other hand, How can you ensure that people are appropriately trained in the field they are representing, and going to be a net positive to patient safety? I have some ideas that I will be trying if I get to Series B.

I can't speak to your inventor of the X-Ray machine but would suggest that if in the last 18 years he has still been unable to get a market for it, or to launch it himself, than probably the technology has other problems than having a distributor. Disruptive technologies always find a way.

Let's be very clear: there are a lot of problems with healthcare, particularly in the United States. One of the biggest problems worldwide is that healthcare is a demand-inelastic good. When someone needs it, they will pay whatever they can to get it. In my opinion the US model is so completely fucked that the only way I see it being fixed is by transitioning to a post-scarcity economy. An illustrative example: When I was undergoing my medical school elective in Boston in 2013, which under Romney introduced State-wide access to insurance, I observed people accessing their care inefficiently. For example, Tram Drivers coming to Beth Israel Deaconess to have their Lipoma operated on by the Professor of Plastic Surgery at Harvard, because they had insurance. Normally this patient would have presented to the County Hospital, which in the US is the most efficient provider of care, but because they were able to access insurance, they wanted gold-plated healthcare. This is an example of 'universal care' twisting the market forces even more, as the most efficient providers of care are put under more pressure.

[0] [https://www.fiercehealthcare.com/it/study-docs-spend-more- ti...](https://www.fiercehealthcare.com/it/study-docs-spend-more-time- computers-than-patients) [1] [https://www.fiercehealthcare.com/practices/unhappy-ehr- one-p...](https://www.fiercehealthcare.com/practices/unhappy-ehr-one-practice- ditched-it-and-went-back-to-paper-records) [2] [https://twitter.com/gphymel/status/952559168975769600](https://twitter.com/gphymel/status/952559168975769600)

</comment></comment></comment></comment><comment><USER36> Imagine if something like "Chinese Citizens, Revolt" appeared in the headlines.

</comment><comment><USER37> So once again, and as usual, the missing ingredient ends up being human leadership, not technology.

</comment><comment><USER38> > implying doctor's don't want 6-figure salaries

The manufacturing operations-ization of hospitals is both good and bad. Good because that means we have standard care (as desired by regulators and single- payer advocates) but bad because doctors lose the ability to perform customized care solutions.

I'm in favor of single-payer but we have to guard against turning healthcare into a manufacturing operation while also bouncing out bad actors and poo- quality physicians.

<comment><USER26> The issue with hospitals controlling healthcare is that they are the group with the least incentive to lower the cost of care

Hospitals account for the largest chunk of healthcare spend (30%). Hospitals make money by increasing inpatient admissions, particularly for profitable surgeries. The standardization of care in hospitals is intended to maximize profit under the constraints of various regulations around readmissions penalties, reimbursement limited length of stay, etc. If you look at the financials of public hospital companies like HCA and Community Health and Tenet, their major metrics are growth in admissions and surgeries. Even non profit hospitals are driven by this

The expansion of hospitals into owning tons of formerly independent specialist and generalist physicians is scary. Once in a hospital's system, these physicians act as loss leaders funneling patients into the hospitals profit center

Having hospitals in charge of the healthcare system is like having a fox in charge of the proverbial chicken coop</comment></comment>


How Renaissance Painting Smoldered with a Little Known Hallucinogen - <AUTHOR> https://hyperallergic.com/399385/how-renaissance-painting-smoldered-with-a-little-known-hallucinogen/ <comment><USER2> Just in case anyone's reading this and thinking _" man, I've got to get me some of that sweet ergot"_: that's probably not the best idea.

 _" The symptoms [of ergotism] can be roughly divided into convulsive symptoms and gangrenous symptoms._

 _" Convulsive symptoms of ergotism_

 _" Convulsive symptoms include painful seizures and spasms, diarrhea, paresthesias, itching, mental effects including mania or psychosis, headaches, nausea and vomiting._

 _" Gangrenous_

 _" The dry gangrene is a result of vasoconstriction induced by the ergotamine-ergocristine alkaloids of the fungus. It affects the more poorly vascularized distal structures, such as the fingers and toes. Symptoms include desquamation or peeling, weak peripheral pulses, loss of peripheral sensation, edema and ultimately the death and loss of affected tissues..."_

[https://en.wikipedia.org/wiki/Ergotism](https://en.wikipedia.org/wiki/Ergotism)

<comment><USER3> if you want the good parts of ergot and you extract them you get...

LSD

</comment></comment><comment><USER4> _See also_ S4E13 ("Never Again")[0] of _The X-Files_.

There is also a common theory that the Salem witch trials were at least in part motivated by ergot, but there is at least a circumstantial case[1] against it.

[0]: [https://en.wikipedia.org/wiki/Never_Again_%28The_X- Files%29](https://en.wikipedia.org/wiki/Never_Again_%28The_X-Files%29)

[1]: [http://www.pbs.org/wnet/secrets/witches-curse-clues- evidence...](http://www.pbs.org/wnet/secrets/witches-curse-clues- evidence/1501/)

</comment><comment><USER5> Or: how modern rationalists reinterpret historical records of psychic imagery through a matierialist causality predicated on psychadelic chemicals, because 1960s.

<comment><USER6> Are you suggesting that Bosch would have had no knowledge, or that outbreaks during his life would have had no influence on his work? He was from a town with a church dedicated to Saint Anthony, who was associated at the time with ergot poisoning. The paper isn't even suggesting that he consumed ergot (as that would have likely killed him), but that feverish hallucinations of its victims may have influenced his visions of hell.</comment></comment>


Ask HN: How to scale a development team? - <AUTHOR>

My company's development team is about 50 strong, we've grown organically over the past 10 years, and overcome some growing pains during that time.
We're at a stage where, before further expansion, we can review our structure. I'd like to get some feedback from HN on how best to arrange a fast growing development team.
I have seen 3 patterns practiced each with their own strengths and weaknesses. I'm sure there are plenty more.
* Superman. Each sub team has an individual who acts as Project Manager/Line Manager/Tech Lead. This works very well in a small sub team (maybe 4 strong), working in a relatively small dev groups (maybe 20), but is difficult to scale.
* Double Act. Have two roles in each sub team, a Project/Line manager and a dedicated Tech Lead. This relieves pressure on the individuals in question and works better in larger sub teams (say 8 strong) in larger dev groups (say 40). Good for feedback and direction, but can be hard to restructure sub teams without significant discontinuity to team members.
* Program Manager. Have a dedicated Program Manager take care of the project side, let the sub team handle their own technical leadership in an adhoc fashion and have a more distant Development Manager responsible for overall tech direction and line management of a number of sub teams. Good for structural flexibility and cross sub team continuity but the distance of the Dev Manager means sub team problems can take longer to be spotted and resolved.
What are your experiences and what have you seen work best?
Many thanks
Neil <comment><AUTHOR> I should add that I'm coming at this from a SaaS perspective where it's vital to release early and often. It would be unusual not to put out something new on a weekly basis. If we make a mistake we can lose a lot of money but no horses will die.</comment>


The Weight I Carry - <AUTHOR> https://www.theatlantic.com/health/archive/2019/01/weight-loss-essay-tomlinson/579832/ <comment><USER2> Being significantly overweight is really tough. Body issues and shame make it so much harder. I wish people would understand that better. There's a pretty nasty cycle of looking in the mirror, feeling like shit, eating to not feel like shit (the key problem step - note that it never actually works), looking and feeling like shit because you eat too much.

I've lost 70 pounds in the last ~7 months. 50 pounds to go. I'm successful for the first time because I've gotten over my image issues, I've accepted that losing weight necessarily involves being hungry at least some of the time, and I had a 'spiritual' experience.

They're damn right that it gets harder to lose weight every time you do. My metabolism is miraculously "efficient". The insight is that you have to accept that and eat to the amount that hits your goals, not try to find some miracle diet.

Also, IME, exercise makes me hungry for more calories than I burn. Exercise to get healthy, treat the metabolism boost as a bonus. Exercise does not cancel out foods (this is speaking to fat people like me - if you've been skinny your whole life your body probably works differently).

<comment><USER3> > Exercise to get healthy, treat the metabolism boost as a bonus. Exercise > does not cancel out foods

Thank you! Exercise should be completely supplemental to overall health, not to lose weight. The amount of times I've seen people eat an awful meal while trying to lose weight because they "worked out extra hard" is astonishing.

Losing weight is almost completely related to what you put in your body. While you _can_ certainly lose weight from exercise, it's by far not the most profound way to do so.

Congrats on your weight loss by the way, former fat kid myself, I know it's not an easy process and keeping it off is just as hard!

<comment><USER4> Yep, it's the food. I took up running four years ago, but saw no real effect on my weight. (Def helped me from getting winded and made hiking fun, etc. — so exercise is cool, no doubt).

I had a medical emergency early last year that caused me to cut my food intake (I feared too large of a meal would cause another medical emergency). So I looked at the plate of food in front of me, measured out what I thought was a "reasonable amount", and ate only that. No seconds.

Within two or three months I dropped 20 pounds.

Had surgery at that point. After surgery I no longer worried about medical emergencies so I resumed my original eating habits.

And steadily put the 20 pounds back on.

</comment></comment></comment><comment><USER5> I feel for the author. I have also struggled with my weight my entire life. At my heaviest, I was 265lbs. I definitely struggled, and continue to struggle with body issues. I was definitely addicted to food and was an emotional eater. I literally had a term called "stress cheeseburgers" as when I was stressed that's what I'd do.

I finally decided to make a significant change last year. It started with me doing meal prep for my lunches. Previously I would eat out for lunch every day, and I would never make good choices. I was able to lose about 35lbs by just doing that and making no other changes in my life.

In August, I decided to start the keto diet. I started not for the weight loss reasons, but for the lifting of the "brain fog". I didn't realize how much carbs controlled my life until then. Eating keto 100% changed my life for the better:

* My relationship with food has completely changed. I am now concerned about what I'm eating, nutritionally speaking, instead of just quantity and taste. I am eating a lot more whole foods.

* My overall pain level has gone down significantly (I have back problems).

* I literally crave vegetables. My first couple of weeks I ate nothing but bacon and other unhealthy meats. After a while, all I wanted was a big plate of broccoli!

* I have much more energy and mental clarity. I also noticed my recovery time from working out is lessened.

As of this morning, I weigh 196lbs. I don't know how long keto is sustainable for, but I plan on sticking to this for the long term. If I do stop, I will definitely apply the lessons I've learned from going keto: mostly eat whole foods and carbohydrates that have nutritional value.

<comment><USER6> For me, with keto, I have much less of a hunger feeling, making things more manageable (As I've said in another thread). Agree with the mental clarity also.

How did you stick with it though? I can do the diet, but find it hard to do with social stuff. For me, doing keto was quite a lonely thing.

<comment><USER7> how long did it take you to go into ketosis - im on day 10 and still havnt not gone in (im not really overweight)

<comment><USER8> How are you testing... urine strips? For me, I can feel the difference in my brain when I change over. It's subtle, but I'd compare it to the change in feeling when you drink caffeine after not drinking it for too long.

<comment><USER7> im also drinking exogenous ketones too now

</comment></comment></comment></comment></comment><comment><USER9> I've been 400 pounds most of my life. I empathize with every single sentence in this article and cannot imagine making myself write something like this. The vulnerability is incredible.

I'm really glad that exercise is being called out as useless to treat obesity more and more. I hope that trend continues and things like Michelle Obama's "Let's Move" campaigns never happen again.

Carbohydrate addiction is no joke, even though most don't believe it exists.

<comment><USER10> While I agree exercise isn't very effective to treat obesity, it is still healthy for you to exercise, even if it's not going to help you lose weight. There are a lot of people who are overweight who have healthier hearts and lungs then normal weight people due to exercise.

<comment><USER11> I can not give you more +1s. If your goal is to be healthy, and not necessarily be pretty, exercise is integral. You can be skinny and be unhealthy. You can be overweight and be heart-healthy, if you exercise.

I am obese according to the BMI, but I run 3 times a week and my resting heart rate grazes into the "athlete" territory. My doctor is very happy. But I don't look it, that's for sure. I do not like running. I see it like brushing my teeth. I don't like it, but I do it because I have to if I want to maintain my body.

<comment><USER12> Are you concerned about your joints? Running is pretty hard on the knees even for skinny people.

<comment><USER13> I have always felt that this is a myth or misconception. Humans probably evolved as distance-running specialists [1] so it would be pretty strange if our knees were some sort of exhaustible resource as seems to be the popular idea. If people have trouble with their knees, I think there are lots of potential explanations, for example running too far or too fast before building fitness, which includes conditioning of stabilizer muscles in the knees, or poor running form caused by lack of fitness or encouraged by modern running shoes. I'm a bit biased, but I don't like to see the sport of running blamed for these things.

[1] [https://en.wikipedia.org/wiki/Endurance_running_hypothesis](https://en.wikipedia.org/wiki/Endurance_running_hypothesis)

<comment><USER12> Humans also evolved to be pretty much useless after their children (or maybe grandchildren) are self-sufficient, so being mostly immobile in your fifties is probably of little concern to evolution.

</comment></comment></comment></comment></comment></comment><comment><USER14> I found this study from 1973 interesting where an extremely obese individual performed a supervised fast for about a year and dropped from 456 to 180 pounds.

> A 27-year-old male patient fasted under supervision for 382 days and has > subsequently maintained his normal weight. Blood glucose concentrations > around 30 mg/100 ml were recorded consistently during the last 8 months, > although the patient was ambulant and attending as an out-patient. Responses > to glucose and tolbutamide tolerance tests remained normal. The > hyperglycaemic response to glucagon was reduced and latterly absent, but > promptly returned to normal during carbohydrate refeeding. After an initial > decrease was corrected, plasma potassium levels remained normal without > supplementation. A temporary period of hypercalcaemia occurred towards the > end of the fast. Decreased plasma magnesium concentrations were a consistent > feature from the first month onwards. After 100 days of fasting there was a > marked and persistent increase in the excretion of urinary cations and > inorganic phosphate, which until then had been minimal. These increases may > be due to dissolution of excessive soft tissue and skeletal mass. Prolonged > fasting in this patient had no ill-effects.

> During the 382 days of the fast, the patient's weight decreased from 456 to > 180 lb. Five years after undertaking the fast, Mr A.B.'s weight remains > around 196 lb.

I don't know why I haven't seen more studies where extremely obese individuals just stop eating.

[0] [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2495396/pdf/pos...](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2495396/pdf/postmedj00315-0056.pdf)

<comment><USER15> > I don't know why I haven't seen more studies where extremely obese > individuals just stop eating.

Primarily because it's not considered medically safe, and a study along those lines would be too dangerous to the patients to be permitted.

In this particular case, the 27yo male patient informed the doctors of his plan and said, "This is what I'm doing, you can monitor me or not." They didn't propose the study themselves.

<comment><USER14> It may be dangerous. But I imagine being 400+ pounds is even more dangerous, especially at an advanced age. Experimental treatments that may be more risky should be encouraged. Otherwise being that size is a death sentence.

<comment><USER16> One can imagine what one likes, of course. I personally prefer to base medical decisions on, well, medical advice than on mental meanderings. And the medical advice leans the other direction[1].

> Otherwise being that size is a death sentence.

Being any size is a death sentence. Balancing tradeoffs more or less well determines the appeals process length.

[1] People quibble with for all sorts of reasons, some of them even somewhat reasonable. But

> Experimental treatments that may be more risky should be encouraged.

Eh? Do whatever you like with your body, and more power to you. But this is the same flavor of ignorant social pressure game the anti-vaxxers get up to, and is deeply irresponsible.

<comment><USER14> Body mass index (BMI) is associated with a reduce lifespan.

Compared to a normal-weight BMI, a BMI of:

40-44.9 leads to a loss of life of 6.5 years

45-49.9 leads to a loss of life of 8.9 years

50-54.9 leads to a loss of life of 9.8 years

55-59.9 leads to a loss of life of 13.7 years

Assuming a 445 pounds at 6 feet tall is a BMI of about 60, at about the top of the highest range. I think extreme obesity is a big enough health risk that it should be studied with more experimental treatments

[0] [https://journals.plos.org/plosmedicine/article?id=10.1371/jo...](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001673)

</comment></comment></comment></comment></comment><comment><USER17> This guy sounds a lot like me at my heaviest (468# at 6'1" tall). I have a lot of correlated health issues, the bad knees predate the extreme obesity, and recently discovered via elimination diet that I am allergic to legumes and have trouble with grains in general. I went keto last year (mostly eggs, meat, greens and sometimes nuts and cheese).

Without trying much I dropped to under 380... where I've hovered mostly for the past year. When I'm strict and track I get closer to 350#, but getting below that has been incredibly hard.

Everything I've read and understand leads me to believe that longer fasting periods are what I need to do to break through this. But I tend to get fidgety around day 5 and stop early. I also do pretty consistently when I only eat one meal a day.

I don't think it's for everyone, and it isn't magic. More fat is more sating, and a lot of disinformation starting in the 60's has now been disproven. I do think that the majority of human kind was keto for significant portions of the year for most of human history. I feel that refined sugars are the single biggest factor in terms of obesity, followed by refined grains and vegetable oils.

In general, low fat and lots of sugar has spun society into obesity. Not understanding the role of hormones, or underestimating their effects are another compounding issue. Doctors need to start testing against resting insulin levels as part of a regular checkup. They need to push for changes in diet over supplemental insulin. And absolutely need to convey the message of why refined sugars (mostly the fructose component) are bad for you.

</comment><comment><USER18> I found one of his fears interesting:

> I've never been anything but fat. Is there something in the fat version of > me that also makes me likable and creative and a decent human being? Are the > best parts of me all knotted up with the worst? Is there some way to > untangle it and keep just the good stuff? Most of the time I think of my fat > as a husk—something I have to shed so the best part of me can come out. But > sometimes I wonder if I'm more like the shells you find on the beach, where > the outer part is the attraction, and the animal inside is dull and > shapeless.

<comment><USER19> I think this observation can resonate with anyone who has struggled with changing a of themselves that is so big it is part of their identity. For example people who are chronically depressed sometimes believe (including myself in the past) that taking pills to not be depressed will remove their intellectual edge and prevent them from having the insight of an outsider. It's objectively false, you actually get smarter since the depression isn't interfering with pursuing intellectual interests anymore.

</comment></comment><comment><USER20> Naltrexone and Bupropion. It doesn't make the other parts of losing weight unnecessary, but it does make it easier to handle cravings. I don't care that I'm getting some willpower in a bottle - I'd simply like to weigh less.

Two years ago, I was ~300. I had been constantly gaining weight since I started taking Seroquel. I also had ankle surgery (unrelated to my weight), and was completely bedridden for 6 months, then in PT for another 5. After that, my doctor put me on those two medications.

I still had to be careful about what I ate, but the occasional snack was occasional; I could eat something bad for me once a week and not lost much progress. After a while the exercise was more pleasant, too.

I hit 220 a few months ago. When I switched jobs and stopped taking the two medications (doctor and I just wanted to see if the weight would stay off without them), my weight jumped back up to 250, but stabilized there. A good bit less than the 300. I started taking the two medications again, and now I'm losing it again.

<comment><USER21> Out of curiosity - when you stopped taking the meds, do you feel like there was some residual craving-preventive effect that remained? I'm surprised medications like this aren't prescribed more frequently, and my assumption is that payers / doctors aren't keen on having their patients use it indefinitely (which I'm not sure is necessarily a bad thing, if there are no side effects)

</comment></comment><comment><USER22> I really hope that we start putting some social pressure on parents of very young obese children. It's obvious to me that getting your child obese and getting them set in the habits that will keep them that way is miles worse than things we have already weeded out with social pressure, like smoking in the car with children in it.

</comment><comment><USER23> I have always been underweight before putting on more muscle just a few years ago. While I logically understand the challenges of being overweight or obese, nothing I've heard or read really drove just how much it weighs on you not just physically but emotionally quite like this article.

</comment><comment><USER24> I've been way too close to 300 pounds for all of my adult life. This article really hits home hard. I can completely empathize with every statement the author made. I have realized his same struggles with weight loss and how hard it is to keep the weight off. I've had some success with Keto, but I seem to love eating carbs way too much to stick to it for longer than 3 months. I've told myself I'm trying a similar approach to the author: trying to do just enough to reduce slowly, but honestly to me it feels like a cop out. A way I can say that if I mess up then it's OK because most days I'm doing right. Hopefully some day I can finally snap myself into a life-changing mindset.

</comment><comment><USER25> I think we need to start treating extreme obesity as an addiction. No one in their right mind tells an alcoholic to "just moderate yourself". I think the decisions of food need to be taken out of the hands of the obese. Eat what you're allotted, we promise its enough, and nothing else.

I recommend people lose weight via fasting until they're "normal" weight. Best done with doctor's supervision, but it basically boils down to eat nothing, drink only 0 calorie drinks and take a daily dose of multivitamins and get some sodium + potassium.

      Barbieri took vitamins on various occasions throughout the
      fast, including potassium and sodium supplements.

      He was allowed to drink coffee, tea, and sparkling water,
      all of which are naturally calorie-free. He said there was
      the occasional time that he'd have a touch of sugar or milk
      in tea, especially in his final few weeks of fasting.

      At the end of his ordeal, Barbieri tipped the scales at 180
      pounds. Five years later, he'd still kept almost all the
      weight he'd lost off, weighing in at 196 (89 kg).

[https://www.sciencealert.com/the-true-story-of-a-man-who- sur...](https://www.sciencealert.com/the-true-story-of-a-man-who-survived- without-any-food-for-382-days)

</comment><comment><USER26> I began reducing the carbs in my diet due to what I believe is gluten intolerance. I'm basically doing a Paleo diet. I've lost 25 lbs in the past 3 months, and feel great. I have no cravings. I'm done eating sugar and any high carb food (pizza, etc). My wife feels that I'm very regimented but my intolerance to gluten makes me so. I feel better and hope to have a longer life as a result.

</comment><comment><USER27> I feel like one of the best things you can do if you're trying to lose weight is to consciously avoid the urge to finish everything on your plate. Try to habitually leave some food on your plate. I call it leaving an offering to the food gods. I think this leads to better mindfulness about what and how much we are eating.

<comment><USER28> While it might help with eating less, it does mean you're deliberately wasting food (unless you collect all the scraps into leftovers for a later meal), which is... not good.

Try deliberately reducing your serving size instead.

<comment><USER27> Yes, you should do that. But, many times you will end up with too much food anyway. When possible, save food, rather than throwing it away, but it's better to waste food than to add to a weight problem.

</comment></comment></comment><comment><USER29> Here's my understanding, based on a fair amount of reading and thought. First of all, condemning someone for being fat is rarely if ever useful.

In terms of what is useful the first thing is that people need to be eating a diet that is very low in processed carbohydrates, with lots of fiber and moderately low calorie foods, and they should eat until they are full, instead of counting calories.

Now people's bodies are different, so this won't work for everyone, but for most people it will.

If someone isn't eating this way, it is either because they don't know that is the way to go, or they do but they have other problems, like psychological issues, so they need to try to deal with them, if possible.

That's pretty much it.

<comment><USER30> > and they should eat until they are full, instead of counting calories.

I am curious why you say this. In my experience counting calories works great to put into perspective the caloric cost of everything you consume. You don't have to always do it, but do it for a while and you can eyeball pretty well if you can or cannot handle something in your diet.

<comment><USER29> Be aware of calorie content of different foods is essential for choosing a healthy diet. But what people usually mean by counting calories is setting a goal for how many calories you eat a day, and then eating only that much, even if it leaves you hungry. That does not work over the long term for most people.

What does work much more often is focusing on eating foods that are filling but low or moderate in calories, and eating when hungry.

</comment></comment></comment><comment><USER19> I personally enjoyed this article and I wish more people would write things like this. Just reading someone eloquently list their thoughts and anxieties about a certain issue really makes you feel not alone if you are going through the same thing. There was a paragraph where he questioned whether he would lose the good parts of himself by losing weight and I've had that same type of thinking applied to so many other aspects of my life, not necessarily weight, but mental illnesses that I sometimes believe give me insight I wouldn't otherwise have.

<comment><AUTHOR> I was a bit astonished by how the article started: that this was the first time the author had confronted his weight problem in writing. This is someone who has had a long award-winning writing career in newspapers and online, who has had no problem writing about many other subjects. Just goes to show how deep the personal shame he has felt his whole life.

</comment></comment><comment><USER31> We've all be gamed by the food industry for years. We should be eating mainly vegetables, some fruit and a little meat.

Hardly anyone eats lots of veg because they taste bland compared to the other processed treats we are sold. It suits the food industry to sell us processed food because it is cheap, it has a long shelf life and they know it tastes so good we will eat loads of it.

I'm not blaming them, they are businesses with a profit to make, but somehow doesn't feel like a fair fight.

</comment><comment><USER32> It is a complete lifestyle change (nutrition and exercise)...plain and simple. Any other approach sets you up for failure (I need to lose x pounds for new years, I need to lose this for an event, etc).

It is also very much discipline (not motivation..) and hard work to get started and maintain for a while. Like pretty much anything. But after a few years of feeling great you will wonder why you ever lived your previous life.

At least in my experience :)

<comment><USER27> It might be discipline, but it can't come from a feeling of depriving yourself. It has to be associated with positive feelings, or most people can't stick with it.

</comment></comment><comment><USER33> Watch the Fed up documentary, explains it so well that no matter how much we try, exercising and eating less wont work. Our environment is saturated with products now which almost all have added sugar, only way is to look at ingredients and change your environment, dont bring these things home and instead bring better stuff home thats not got added sugar.

<comment><USER34> > no matter how much we try, exercising and eating less won't work

How can that be? If you burn more calories and you take in less calories, then surely at some point your body must start to lose mass. At very least is the equation that you're breathing out carbon and you're not getting that mass back from anything apart from what you eat.

<comment><USER35> Because all of this is regulated by hunger. If you move more, you get hungrier.

The issue in the case of most overweight people is that their body is trying to maintain a set point at a high level of body fat. Hunger serves to maintain this weight set point.

The way to sustainable weight loss is to eat in such a way that the body starts to target a lower set point and decreases hunger.

Obviously this also results in less calories taken than expended, but if it were as simple as a math formula most people would have six packs.

</comment></comment></comment><comment><USER27> It's hard to lose weight.

<comment><USER36> And even harder to not find it again.</comment></comment>