At a company I worked for there were many unwritten rules; not unreasonable but not necessarily published. One of them concerned the ALL email group, and that was "don't use it". Common sense would tell you this, but apparently we recruited from colleges where common sense was not widely taught. So June, we'd start getting email for "Looking for a cheap Apartment", and "Couch for Sale". Laughter ensued as we pictured this poor, innocent engineer getting an email from a Senior VP explaining to them the error of their ways.
The problem is that the question of whether it was a statement of opinion or fact is what needs to be adjudicated. The text in question doesn't say "I believe" or I think"; it says it isthe dirtiest restaurant he's ever seen. The wording is ambiguous - if taken literally, the Plaintiff would need to find the other restaurants the defendant has seen and compare filth levels. If they find one that's dirtier, then the defendant was stating an untruth. Or it could just be an opinion. But that's what the case was about. I don't say the case has merit, but it's there.
As for 1st amendment considerations, it wasn't political speech or the other categories most often associated with it.
The only people who have the ability to resuse to testify or give evidence are priests, spouses, and various other job classifications. As far as I know, ISP owner isn't one of them.
A subpoena is a subpoena. I will agree that courts have been issuing them inappropriately in some cases, but I don't see how this qualifies.
Well, this isn't going anywhere. I still believe you are missing the fundamental point. It's odd, given that a paper I found online of yours is remarkably logical, even though it argues a possibly unpopular point.
As for the ad hominem about "I don't blame your provider for practicing defensive medicine given your responses in this thread", nice try, but my wife took him there for the first 2 visits, and she is FAR from an intimidating presence. I'm actually a relatively good patient myself - I certainly look online and do some self diagnosis but if the provider tells me it's wrong, I don't go looking for another provider. I'm paying him for his expertise; why would I insist I know more when I patently don't? Yes, I know people do - witness parent insisting their child has ADD when he's really just obnoxious. Similarly, I have had clients, including doctors, tell me in detail how I should build their buildings. But I'm being paid to provide my expertise, and I try to return the favor. But that doesn't mean that I believe the medical profession, as a whole, is behind the times in management an professional practice.
1) Typically that kind of thing gets you fired, as it is prima facie evidence of not having followed the checklist. For that matter, in FDA regulated manufacturing, it's against the law as well.
2) Poorly - witness the doctor I've been arguing with. But in this particular study, the doctors didn't do the checklist, someone else did.
3) That's exactly where checklists help the most - routine activities and standard procedures. They become SO routine that they almost operate subconsciously, so the conscious mind is free to focus on other things. If it gets interested in something, it can override the part of the brain going on autopilot, and steps get skipped. Have you ever gotten in your car and started driving and forgot your seat belt, or headlights, or forgotten to disengage the parking brake? Those are automatic routines too, and people forget them - not frequently, but it happens.
I really am scratching my head over England and Australia. It almost seems like they see the US going down a path and are racing each other to beat us to the end.
I just posted this in the story on Australia. Who else did I miss - Bermuda? the Virgin Islands? The Falklands?
"Yet another reason that they can be ill suited to critical care settings. Often you don't have time to 'stop and fix the problem'. I treated a man about two years ago who came in to the ER screaming "I can't breathe" repeatedly. I got report from EMS that he had collapsed at home and that he had prostate cancer. 30 seconds after he arrived his blood pressure dropped like a rock and his pulse disappeared. That's ALL the info I had to go on.
I made the literally split second decision to use a medicine called TPA because I thought it was quite likely given that scenario that he has a pulmonary embolus. There are other things that could have been going on, but this was likely and treatable with TPA. The check-list before administration of TPA is as long as your arm, and the nurses are 'empowered to' refuse to give it unless the checklist has been completed.
Fortunately the nurses that night trusted my judgment and gave the medicine. If we'd waited for the checklist he would be brain dead by the time he received it. He regained his pulse but wasn't breathing, so he was intubated and he was place in the ICU that night. I went up to check on him a day later and he was awake in bed, sipping juice. Three days later he was out of the hospital on long term blood thinners to prevent another clot like the one that almost killed him.
Check lists can be helpful, but they are not a panacea and can themselves cause injury, illness, and death. What is most important is to have a skilled practitioner who knows when you should use them and when not to. "
You took a guess. Educated, but a guess. And you guessed right. What if you had guessed wrong? He might be dead and you wouldn't be bragging here but signing an affidavit in a lawsuit. You are perpetuating the mystique of the Doctor as Omniscient. I'm not impressed. Everyone in the studies in TFA (you did read it, didn't you?) was a highly trained professional. They KNEW how to do their jobs. But they still made mistakes. And when they implemented checklists, the rate of adverse outcomes dropped. Dramatically. This is basic stuff, but you act like it's all handwaving and a plot to take away your autonomy.
As for my son's illness, I originally believed it WAS viral on Sunday, and we gave it 'till Monday to straighten out. So we took him to the Doctor's office and THEY diagnosed the ear infection. We called them up and THEY told us to take him off the meds and bring him in the next day. As for your statement about practicing "evidence based medicine", again, color me unimpressed - it doesn't sound like you were practicing it when you guessed about the pulmonary embolus.
I'm an engineer. If professional engineers used the same methodology as the medical profession, buildings would be falling down, airplanes falling out of the sky, boilers exploding, and people dying in job lots. The medical profession is the only one in which the practitioners can make repeated mistakes, costing people their health and their lives, and still retain their positions of status and respect. It's time for your profession to grow the hell up and join the REAL world of science and engineering.
You may be an award winning doctor, and very good at what you do, but you could be the poster child for what's wrong with the medical profession today. Let me know where you practice so I can avoid it.
That's NOT the type of checklist in question Checklists aren't necessarily algorithm - "If X, prescribe Y". A checklist is "Did you do all these things you are supposed to do." So a checklist would not say "Give ACE-Inhibitor for so and so condition", it would say "Did you check for any contraindications for the drug you are going to prescribe?"
Another point about checklists not being a procedure is that, if you can't check off all the boxes, you STOP and fix the problem or abort the procedure. So if a checklist says "Verify the IV machine is operating correctly" and it isn't, you go get a new one, and THEN you check it off as done. That checklist won't go into the procedure for swapping out equipment (there would be a different procedure), but is simply waiting for the check box to be initialed.
I used to work at a nuclear powerplant, so I know a bit about procedures and checklists. I would WRITE the checklists for the work, and it would say things like "Lubricate equipment in accordance with Procedure LUBE-1" or "Verify equipment has been tagged out". I would have liked a checklist in my doctor's office when the nurse neglected to take my son's temperature - I guess she didn't feel it was necessary. Of course, when the PA remembered he was being treated for AN INFECTION (this was the 3rd trip), she called the nurse back in to do it.
I'm sympathetic to your concern with rigid procedures - the aforementioned infection is a perfect case. My son prestented with an ear infection on Tuesday, and amoxicillin was prescribed. That night he got hives, so we dosed him with Benadryl and he was OK until the morning when we took him back (this was the first time he ever reacted to the amoxicillin). So he goes back to the doctor's office, but now he doesn't have a temperature, so they can't give him a replacement antibiotic. Guess what - 2 days later it's now pinkeye AND an abscess in a wound in his mouth (braces). So they have him on some nasty antibiotic that tastes absolutely putrid, and he missed a week of school. The PA's blind following of the algorithm of "no temp, no antibiotics" was stupid and dangerous. Bad procedures and blind adherence are problems in ALL industries, including nuclear power - remember TMI? But that's not a reason to reject checklists, or even procedures for that matter.
I really am scratching my head over England and Australia. It almost seems like they see the US going down a path and are racing each other to beat us to the end.
And while I think that there are a lot of potential problems with 'cookbook medicine' there are also a lot of potential benefits. Its like any tool that can be used to help or hinder the practice of medicine. For example, an EMR that reminds me my diabetic patient is overdue for annual eye screen and should be on an ACE-Inhibitor is a great idea. However if the same system forces my hand on the ACE-I when I know that patient has had multiple episodes of fainting due to low blood pressure (which an ACE-I would exacerbate) its a problem. Similarly, if I spend all my time inputting data into the EMR it becomes more of a hindrance than a help.
In the case of ICU checklists, nurses every year are required to do more and more documentation (an average of 18 pieces of paper for a new non-ICU admission to my hospital) and every checklist or additional page you add to that is taking time away from patient care. So what sounds like a great idea may in fact cause worse outcomes because it puts the nurses focus on a paper rather than their patient.
Thereby pointing out the main problem with checklist implementation - user compliance. Users tend to be resistant about checklists for 2 reasons: 1) "I know better than the checklist" (your ACE-Inhibitor example) 2) "I don't have time" ("if I spend all my time inputting data into the EMR it becomes more of a hindrance than a help.)
Aside from the fact that the current types of EMR's are NOT the checklists the study examined, if a checklist or procedure is incorrect, it needs to be fixed, not skipped or ignored. Likewise if you don't have time or resources to perform the checklist, it's a management problem, not a checklist problem.
Checklists are not going to save the health care system, but resisting them for actual procedures and specific, recurring situations is cultural inertia.
I never said that America's Army wasn't propaganda, and neither has the Army - it was CREATED as a recruiting tool. It made it's message penetrate by wrapping the propaganda around a somewhat decent FPS, and gave it away for free - again, all overtly.
So instead of building on that penetration, the Virtual Peace folks basically started over, wrapping propaganda around an educational tool. But the successful games cited wrap the learning around something else - puzzles, whatever. Virtual Peace is a wrapper around a wrapper - there's no driver inside to hook people, AND they are pretending it isn't propaganda.
Great - NOW I lose my mod points! Hundreds of thousands of years of human history agrees with you - 30 years of bong smoking idealism thinks you are an unevolved warmonger.
Pass me that rock, will you? I'm tired of saying "Nice doggie..."
I don't think that is the "conflict resolution" these people have in mind. Khrushchev made a play and was told "get the missiles out of Cuba or you're fucked", and he blinked. I seem to remember a shitload of warships involved as well.
Mind, I don't disagree with your basic premise - conflict resolution in which violence can be involved is a useful skill. But I don't think that's what the game authors mean.
But the ones you listed don't have an overt propaganda mission (ok, "educational aim"). This is "Make Learning Fun"! - which generally isn't a very good way to teach.
If they wanted to actually get their point across, make it an expansion module to America's Army where you get promoted to a position that actually needs these skills to win the game. Think Petraeus in Iraq.
Can someone give me an example where "conflict resolution skills" has had ANY effect on the world stage? This seems like the "Wage Peace" bumper sticker for the electronic age - nice saying, but there's nothing actually there.
1) Gimp is nice 2) Gimp gets better with time 3) Gimp's interface is horrible 4) Gimp's interface gets better with time 5) Gimp doesn't have CMYK support 6) This is not important to a whole lotta people 7) But it is a show stopper for some 8) iterate until hell freezes over
You forgot: 9) Gimp has a stupid name 10) Tough shit, that's the name the developers picked.
No, I think it's an excellent idea. Motorcyclists aren't covered under PA's Catastrophic Insurance Funds, or whatever it's called. So the Legislature has basically said: "If you are an adult, go ahead and kill yourself".
It's a step BACK from the Nanny state, and I applaud it.
Slashdot Mirror
Fixed that for ya'.
At a company I worked for there were many unwritten rules; not unreasonable but not necessarily published. One of them concerned the ALL email group, and that was "don't use it". Common sense would tell you this, but apparently we recruited from colleges where common sense was not widely taught. So June, we'd start getting email for "Looking for a cheap Apartment", and "Couch for Sale". Laughter ensued as we pictured this poor, innocent engineer getting an email from a Senior VP explaining to them the error of their ways.
I mean, without such emails how are the professors to know that their penises are too small?
The problem is that the question of whether it was a statement of opinion or fact is what needs to be adjudicated. The text in question doesn't say "I believe" or I think"; it says it isthe dirtiest restaurant he's ever seen. The wording is ambiguous - if taken literally, the Plaintiff would need to find the other restaurants the defendant has seen and compare filth levels. If they find one that's dirtier, then the defendant was stating an untruth. Or it could just be an opinion. But that's what the case was about. I don't say the case has merit, but it's there.
As for 1st amendment considerations, it wasn't political speech or the other categories most often associated with it.
The only people who have the ability to resuse to testify or give evidence are priests, spouses, and various other job classifications. As far as I know, ISP owner isn't one of them.
A subpoena is a subpoena. I will agree that courts have been issuing them inappropriately in some cases, but I don't see how this qualifies.
Well, this isn't going anywhere. I still believe you are missing the fundamental point. It's odd, given that a paper I found online of yours is remarkably logical, even though it argues a possibly unpopular point.
As for the ad hominem about "I don't blame your provider for practicing defensive medicine given your responses in this thread", nice try, but my wife took him there for the first 2 visits, and she is FAR from an intimidating presence. I'm actually a relatively good patient myself - I certainly look online and do some self diagnosis but if the provider tells me it's wrong, I don't go looking for another provider. I'm paying him for his expertise; why would I insist I know more when I patently don't? Yes, I know people do - witness parent insisting their child has ADD when he's really just obnoxious. Similarly, I have had clients, including doctors, tell me in detail how I should build their buildings. But I'm being paid to provide my expertise, and I try to return the favor. But that doesn't mean that I believe the medical profession, as a whole, is behind the times in management an professional practice.
1) Typically that kind of thing gets you fired, as it is prima facie evidence of not having followed the checklist. For that matter, in FDA regulated manufacturing, it's against the law as well.
2) Poorly - witness the doctor I've been arguing with. But in this particular study, the doctors didn't do the checklist, someone else did.
3) That's exactly where checklists help the most - routine activities and standard procedures. They become SO routine that they almost operate subconsciously, so the conscious mind is free to focus on other things. If it gets interested in something, it can override the part of the brain going on autopilot, and steps get skipped. Have you ever gotten in your car and started driving and forgot your seat belt, or headlights, or forgotten to disengage the parking brake? Those are automatic routines too, and people forget them - not frequently, but it happens.
"Which brings me to my next concern... are they going to try to make me take off my tinfoil hat for the picture too???"
Your tinfoil hat is visible? Jeez, what are they teaching kids these days?
I just posted this in the story on Australia. Who else did I miss - Bermuda? the Virgin Islands? The Falklands?
You took a guess. Educated, but a guess. And you guessed right. What if you had guessed wrong? He might be dead and you wouldn't be bragging here but signing an affidavit in a lawsuit. You are perpetuating the mystique of the Doctor as Omniscient. I'm not impressed. Everyone in the studies in TFA (you did read it, didn't you?) was a highly trained professional. They KNEW how to do their jobs. But they still made mistakes. And when they implemented checklists, the rate of adverse outcomes dropped. Dramatically. This is basic stuff, but you act like it's all handwaving and a plot to take away your autonomy.
As for my son's illness, I originally believed it WAS viral on Sunday, and we gave it 'till Monday to straighten out. So we took him to the Doctor's office and THEY diagnosed the ear infection. We called them up and THEY told us to take him off the meds and bring him in the next day. As for your statement about practicing "evidence based medicine", again, color me unimpressed - it doesn't sound like you were practicing it when you guessed about the pulmonary embolus.
I'm an engineer. If professional engineers used the same methodology as the medical profession, buildings would be falling down, airplanes falling out of the sky, boilers exploding, and people dying in job lots. The medical profession is the only one in which the practitioners can make repeated mistakes, costing people their health and their lives, and still retain their positions of status and respect. It's time for your profession to grow the hell up and join the REAL world of science and engineering.
You may be an award winning doctor, and very good at what you do, but you could be the poster child for what's wrong with the medical profession today. Let me know where you practice so I can avoid it.
That's NOT the type of checklist in question Checklists aren't necessarily algorithm - "If X, prescribe Y". A checklist is "Did you do all these things you are supposed to do." So a checklist would not say "Give ACE-Inhibitor for so and so condition", it would say "Did you check for any contraindications for the drug you are going to prescribe?"
Another point about checklists not being a procedure is that, if you can't check off all the boxes, you STOP and fix the problem or abort the procedure. So if a checklist says "Verify the IV machine is operating correctly" and it isn't, you go get a new one, and THEN you check it off as done. That checklist won't go into the procedure for swapping out equipment (there would be a different procedure), but is simply waiting for the check box to be initialed.
I used to work at a nuclear powerplant, so I know a bit about procedures and checklists. I would WRITE the checklists for the work, and it would say things like "Lubricate equipment in accordance with Procedure LUBE-1" or "Verify equipment has been tagged out". I would have liked a checklist in my doctor's office when the nurse neglected to take my son's temperature - I guess she didn't feel it was necessary. Of course, when the PA remembered he was being treated for AN INFECTION (this was the 3rd trip), she called the nurse back in to do it.
I'm sympathetic to your concern with rigid procedures - the aforementioned infection is a perfect case. My son prestented with an ear infection on Tuesday, and amoxicillin was prescribed. That night he got hives, so we dosed him with Benadryl and he was OK until the morning when we took him back (this was the first time he ever reacted to the amoxicillin). So he goes back to the doctor's office, but now he doesn't have a temperature, so they can't give him a replacement antibiotic. Guess what - 2 days later it's now pinkeye AND an abscess in a wound in his mouth (braces). So they have him on some nasty antibiotic that tastes absolutely putrid, and he missed a week of school. The PA's blind following of the algorithm of "no temp, no antibiotics" was stupid and dangerous. Bad procedures and blind adherence are problems in ALL industries, including nuclear power - remember TMI? But that's not a reason to reject checklists, or even procedures for that matter.
"Eric Holden could be his Attorney General"
One assumes you mean Eric Holder, and short of finding pictures of him fucking his dog, he's in.
I really am scratching my head over England and Australia. It almost seems like they see the US going down a path and are racing each other to beat us to the end.
Thereby pointing out the main problem with checklist implementation - user compliance. Users tend to be resistant about checklists for 2 reasons:
1) "I know better than the checklist" (your ACE-Inhibitor example)
2) "I don't have time" ("if I spend all my time inputting data into the EMR it becomes more of a hindrance than a help.)
Aside from the fact that the current types of EMR's are NOT the checklists the study examined, if a checklist or procedure is incorrect, it needs to be fixed, not skipped or ignored. Likewise if you don't have time or resources to perform the checklist, it's a management problem, not a checklist problem.
Checklists are not going to save the health care system, but resisting them for actual procedures and specific, recurring situations is cultural inertia.
Wow - usage went from 1 to 4! Outstanding!
I never said that America's Army wasn't propaganda, and neither has the Army - it was CREATED as a recruiting tool. It made it's message penetrate by wrapping the propaganda around a somewhat decent FPS, and gave it away for free - again, all overtly.
So instead of building on that penetration, the Virtual Peace folks basically started over, wrapping propaganda around an educational tool. But the successful games cited wrap the learning around something else - puzzles, whatever. Virtual Peace is a wrapper around a wrapper - there's no driver inside to hook people, AND they are pretending it isn't propaganda.
No, heroism is going from ordinary to extraordinary. Going from scumbag to ordinary is reform.
Great - NOW I lose my mod points! Hundreds of thousands of years of human history agrees with you - 30 years of bong smoking idealism thinks you are an unevolved warmonger.
Pass me that rock, will you? I'm tired of saying "Nice doggie..."
I don't think that is the "conflict resolution" these people have in mind. Khrushchev made a play and was told "get the missiles out of Cuba or you're fucked", and he blinked. I seem to remember a shitload of warships involved as well.
Mind, I don't disagree with your basic premise - conflict resolution in which violence can be involved is a useful skill. But I don't think that's what the game authors mean.
But the ones you listed don't have an overt propaganda mission (ok, "educational aim"). This is "Make Learning Fun"! - which generally isn't a very good way to teach.
If they wanted to actually get their point across, make it an expansion module to America's Army where you get promoted to a position that actually needs these skills to win the game. Think Petraeus in Iraq.
Can someone give me an example where "conflict resolution skills" has had ANY effect on the world stage? This seems like the "Wage Peace" bumper sticker for the electronic age - nice saying, but there's nothing actually there.
You forgot:
9) Gimp has a stupid name
10) Tough shit, that's the name the developers picked.
"(Still a dumb as shit idea, right big ben??)"
No, I think it's an excellent idea. Motorcyclists aren't covered under PA's Catastrophic Insurance Funds, or whatever it's called. So the Legislature has basically said: "If you are an adult, go ahead and kill yourself".
It's a step BACK from the Nanny state, and I applaud it.
"The law says you got to wear a helmet making it impossible to either drink coffee or fix your make-up depending on gender/sexual preference."
Oddly enough, the state of Pennsylvania repealed its helmet law a few years ago, the only exception being passengers under 16.
Yeah - he got his travel itinerary from Mark Rich.