They ask the same questions and put you on your prescription. If it doesn't work for you, go to a doctor. You're no worse off than before and definitely no less supervised, unless you have some special doctor which follows you around all day and makes house calls for you.
The main risk of hormonal contraceptives is having a stroke. If you make a mistake, and have a stroke, you could wind up with half your body paralyzed for the rest of your life.
And then you could add that the life expectancy in Cuba is higher than the U.S., and the infant mortality is lower.
http://www.nejm.org/doi/full/1... A Different Model -- Medical Care in Cuba Edward W. Campion, M.D., and Stephen Morrissey, Ph.D. N Engl J Med 2013; 368:297-299 January 24, 2013 DOI: 10.1056/NEJMp1215226
This highly structured, prevention-oriented system has produced positive results. Vaccination rates in Cuba are among the highest in the world. The life expectancy of 78 years from birth is virtually identical to that in the United States. The infant mortality rate in Cuba has fallen from more than 80 per 1000 live births in the 1950s to less than 5 per 1000 â" lower than the U.S. rate, although the maternal mortality rate remains well above those in developed countries and is in the middle of the range for Caribbean countries.3,4 Without doubt, the improved health outcomes are largely the result of improvements in nutrition and education, which address the social determinants of health. Cuba's literacy rate is 99%, and health education is part of the mandatory school curriculum. A recent national program to promote acceptance of men who have sex with men was designed in part to reduce rates of sexually transmitted disease and improve acceptance of and adherence to treatment. Cigarettes can no longer be obtained with monthly ration cards, and smoking rates have decreased, though local health teams say it remains difficult to get smokers to quit. Contraception is free and strongly encouraged. Abortion is legal but is seen as a failure of prevention.
Why do I have to pay to answer a checklist to get medication
One of the main risks is that hormonal pills cause blood clots, which lead to strokes and sometimes to death.
It's a risk on the order of 1 in 10,000 or 1 in 100,000 a year, but if you multiply that by the number of women taking hormonal pills, that's a lot of strokes and deaths. It's increased by smoking, and by certain diseases. https://en.wikipedia.org/wiki/...
In principle you could have a checklist or online algorithm for people to follow that would give them the same advice that a doctor would give them, but in reality very few people (maybe 10%) can follow self-evaluations like that, and the algorithms aren't that dependable either.
Flexeril (cyclobenzaprine) is a dangerous drug. https://en.wikipedia.org/wiki/... It's not that effective and I think you were saying it wasn't effective at all.
In some patients, particularly the elderly, it causes confusion, delerium and hallucinations, from which patients take a long time to recover, if they recover at all. An article in JAMA Internal Medicine described how the author's mother died from complications of cyclobenzaprine. http://archinte.jamanetwork.co... “Mom, you have to trust me” doi: 10.1001/jamainternmed.2015.3659
One of the problems is that we don't have good treatments for back pain. (I say this as someone who used to have back pain about once a year so severe that I couldn't get out of bed or walk down the street.) Right now, the best advice is to try to return to normal activity as best as you can despite the pain, and to console yourself with the knowledge that most back pain goes away by itself after a week to a month. But there are exceptions, which is why you can sometimes benefit from seeing a doctor. I realize that finding a good doctor is like shooting craps. But if he recommends spinal injections, I would get a different doctor.
I don't think you're suggesting that people should be allowed to buy Flexeril or other drugs after an internet consultation, but I don't think that would work too well.
I wish there was some way to make doctors more competent in dealing with back pain, but I don't know of any. As for costs, you might look at the ways other countries make medical care cheaper.
Inequality of wealth and income is greater in the US than anyplace else in the developed world. The top 20% own about 85% of the wealth. And most of that wealth is inherited. Very little comes from innovation or productive activity.
In a free market, the top 20% would own almost everything, including housing.
They would be free to come into a community in New York City, and drive the rest of us out of our homes, simply based on privilege of birth.
I don't think that's efficient. By what standard is that efficient -- maximizing GDP? Cash flow? There are other standards -- providing housing and communities for people.
Why should Chelsea Clinton come into my neighborhood, buy my building, raise the rent, drive me out, bulldoze the building, and put up a luxury building in its place? That doesn't sound efficient to me.
Middle-class public housing is not "subsidized housing."
It is a decision by middle-class people that they could get better, cheaper housing if they pay an additional $2,500 a year in taxes and $2,500 a year in rent to the City than they could if they pay $10,000 a year to a landlord.
It's like a decision for single-payer health care. The Canadian and other governments can provide health care for $5,000 a year or less. The free market in private insurance provides health care for $10,000 a year. Why would a consumer choose to spend $10,000 when the people across the border are getting the same thing for $5,000?
The question is, is it better to let the market set the price, so that only people who really want to live there will pay the price, or is it better to have a semi random mix of people who might not otherwise live there?
If you let the markets set the price, you don't get "people who really want to live here," you only get people who are really rich.
In the past, we have had a semi random mix of people. It worked well. We got Nobel laureates, and people like Andrew Grove who founded industries.
So let's continue with what worked well.
If I could get an apartment if NYC for free, I'd take it; is some sort of lottery like that really the best way to allocate housing?
The wealth of America is distributed by some sort of lottery. When you look at the economic data, a person's income is remarkably correlated with his father's income. Contrary to conventional wisdom, America has about the lowest social mobility of any developed country in the world.
Is some sort of lottery the best way to allocate wealth?
most of which have been very successful and have long waiting lists.
Wouldn't 'long waiting lists' mean that they're actually unsuccessful, in that they're not meeting demand?
They're in great demand. They're not meeting the demand because the government agencies are no longer building public housing to meet the demand. The Republicans in Congress cut off funding with for example the Faircloth Amendment https://en.wikipedia.org/wiki/... which forbid federal money for new public housing construction (while they tore down the old public housing). They've got money for war, prisons and the war on drugs but not for housing.
In New York City, we have strong public support for public housing. We tell our politicians that we would rather have housing than prisons, and the honest politicians, like Dick Gottfried, try to get it.
Unfortunately, the real estate industry (along with the financial services industry) is one of the two largest financial contributors to local politicians.
There was a time when the real estate industry wasn't quite so greedy, and even accepted public housing, but now they want to squeeze out every dollar. There's a lot of corruption in local politics, but when we had well-managed city agencies, with strong political watchdog groups, we had good public housing.
A lot of the schools, police stations, post offices, libraries, parks, and other public works that we still use today in New York City were built during the depression by the Works Projects Administration. A well-managed government can do just as well as private industry, and sometimes better.
Not to mention that "the projects" have a long history of extreme violent crime rates and other criminal activities?
You mean, quite efficient at continuing the chain of poverty, because an employer sees an address in the project and looks elsewhere? Sad, but true.
When have you actually been in public housing in New York City? They were mixed-income housing, mostly middle-class families, particularly civil servants such as police, firemen, teachers, postmen, etc., and other typical middle-class workers such as salesmen, mechanics, restaurant workers, etc. The benefit of mixed-income housing is that the middle-class residents helped the newcomers to find better jobs and get better education. There are special public housing projects like Westbeth for artists.
The purpose of public housing was not to make money in real estate. The purpose was to provide housing for the people who contribute to the economy in New York City.
The problem arose when politicians like Robert Moses tried to turn public housing into "welfare housing." Guess what? If you fill a housing project with unemployed welfare recipients, you'll perpetuate the problems of poverty.
Look, I'm not going to say that public housing is all bad, or that it can't be the most fiscally sound decision. What I am going to say is that I believe that the real way to ensure sufficient housing is to allow developers to make money. If they can make money building housing, they'll build housing. I'm not saying that you have to enable them to make a killing, but well, if you're not getting enough housing built despite sky-high prices, maybe there's a reason that can be adjusted?
I'm looking out my window right now. We're getting plenty of housing built. I see 40-story apartment buildings going up around me. The problem is that apartments rent for $3,000 or more and sell for $1 million or more. In some buidings, half the apartments are empty, owned by absentee landlords in Russia, Qatar or someplace, as investment properties. We just don't have housing that middle-class people can afford.
I know Milton Friedman's solution: move where housing is cheaper, which would be in Western Pennsylvania or Texas. Well, I don't want to move to Western Pennsylvania or Texas.
by Anonymous Coward on Tuesday June 21, 2016 @06:48AM (#52358049)
trying to see a Doctor in the UK is an exercise in frustration in trying to navigate the labyrinthine system set up to manage their 48 hour waiting targets.... you have to be really dedicated to push yourself forward to get a same day appointment... if lucky, you'll get a telephone appointment or else be seen by the practice nurse
They release appointments for the next day at 12:30pm and they go very fast...
Isn't single-payer medicine GREAT!!!
I assume you are an American anonymous coward. I wonder when the last time was that you needed to get health care in the American free market system.
The Accuracy of Dermatology Network Physician Directories Posted by Medicare Advantage Health Plans in an Era of Narrow Networks
Jack S. Resneck Jr, Aaron Quiggle, Michael Liu, BS3; David W. Brewster JAMA Dermatol. Published online October 29, 2014. doi:10.1001/jamadermatol.2014.3902
48.9% of physicians were reachable, accepted the listed plan, and offered an appointment for our fictitious patient. Many of the dermatologists listed had incorrect contact information, were deceased, retired, or had moved, were not accepting new patients, did not accept the insurance plan, or were subspecialized.
Ask the US veterans who died waiting for care from the US Department of Veteran's Affairs!
I know some veterans who go to the VA health care system. I would trade my health plan for theirs tomorrow, and they would never trade their plan for mine.
Bernie Sanders is on the Senate committee that covers VA health care, and he said that people complain about access, but once they're in the system, their care is excellent.
The problem was that the Republicans wanted to have wars but they don't want to pay for health care for the soldiers who fought that war. Their solution is, "cut the budget and privatize." Adopt the methods of our MBAs and private corporations. Give them impossible goals to meet, and if they can't meet them, fire them and hire somebody else. That worked so well for BP and Enron.
I'm not going to defend the indefensible. There were reports of veterans who had for example bladder cancer, who didn't get treated in time, and whose bladder cancer went from treatable to untreatable. But that happens (all the time) in the free market health care system, when people can't afford to go to a doctor at all. And it happened because the Republican budget-cutters cut the VA budget, under the Republican "Bricks without Straw" policy.
I do a lot of medical literature searches. The outcomes of the VA system are among the best. If you need, say, coronary bypass surgery, your chances of surviving are as good in the VA system as anywhere in the world. Including Sweden.
They've done a lot of the major studies in treating heart disease, cancer, diabetes, COPD, and all the conditions that affect veterans. If you go to a medical conference, and they're trying to decide what the best treatment is, they're always talking about the "VA study," which is often the definitive study.
Oh yeah -- the other benefit of the VA system is that when a VA doctor recommends surgery, it's because he (and his colleagues) think you'll really be better off, not because he gets a $3,000 surgical fee, like a doctor in the private sector. And they have the evidence to prove it.)
One afternoon I was feeling kind of dizzy and lethargic, probably from a lack of excercise and staring at the keyboard all day.
Out of an abundance of paranoia, I called the 800 number of my insurance company's help line, and spoke to a nurse.
I went through my symptoms, in great detail, because when you're giving a medical history (especially over the phone when they can't see or touch you), any minor detail might make a difference. I could hear her keyboard clicking in the background.
She said, "you should go to a hospital or your doctor's office immediately. You may have heart failure."
I said, "Heart failure? I don't think so. I can walk 10 blocks. I can climb 5 flights of stairs."
She insisted. She said, "You really should go to the hospital. You could die." Health professionals have the ultimate sales pitch. "You have to do this or you could die."
I said, "How do you come to this conclusion?"
She said, "Through a clinical decision-making tool."
I said, "What tool?"
She said, "Oh, it's a computerized tool."
I said, "What is the name of the tool?"
She said, "It's an internet tool."
She wouldn't tell me the name. I had to drag it out of her. I said, "Do you have a name at the top of the screen?"
Finally, she said, "Medscape."
I figured out that it was probably something like one of those Mayo Clinic consumer pages.
But she's a nurse and I'm not. Even though I was pretty sure it was BS, I couldn't take a chance and risk my life.
So I called my doctor's office and asked for an appointment. I hadn't seen him in a while anyway, and I had a few other things to talk about.
I told his secretary that a nurse had told me I should see a doctor immediately, so she booked me in the next appointment, in half an hour.
That was the one good thing I got out of the nurse help line -- an immediate appointment with my doctor.
When I told him about the heart failure, he laughed and said, "If you can climb 5 flights of stairs, you don't have heart failure."
Bottom line: in my experience, these nurse 800-numbers are BS (although sometimes just asking a question can be helpful). When you call them up with a real question, all they do is tell you to see a doctor. The strange thing is that this is a service paid for by the insurance company, which is supposed to save the insurance company money. But by sending people to the ER, she's actually costing them more money. And how much training does it take to sit at a phone and tell everybody, "You could have a serious problem. You should go to the ER immediately"? I could do that myself with a Google search.
If you make it more expensive to build housing of various types, and if you make housing worth less by adding lots of restrictions on what you can do with it, and if you restrict people's ability to make money with the housing they build, it turns out that over time, people build much less housing, because they don't see the point in going through all that hassle for less reward than they can get elsewhere with their money.
The purpose of housing is not to make money for developers. The purpose of housing is to provide a place for people to live. In New York City, the city, state and federal government at various times have built or financed public housing projects, most of which have been very successful and have long waiting lists. The housing costs the government agencies much less than private housing would have cost. When you look at the actual numbers, public housing is quite efficient and provides good housing for less cost than developers do in the free market.
Unfortunately the Republicans and greedy private developers have stopped the building of new public housing.
The obvious solution to a shortage of housing is to BUILD MORE HOUSING.
Yes, but it doesn't have to be private housing.
New York City has a long history of public housing. That's how we housed workers during WWII. It worked well in New York City, and it works well around the world.
Like anything else, there are some well-run public housing projects and some poorly-run public housing, but there's a lot of good public housing which has long waiting lists of tenants who want to get in. Many housing projects limit their rent to 30% of the tenant's income, which is a common definition of affordable housing.
The purpose of private housing is to maximize the owner's revenue. The purpose of public housing is to provide housing for people at an affordable rent.
The Republicans have passed laws against public housing, like the Faircloth Amendment, and in cities around the country, like New Orleans, they've actively destroyed public housing. (Although the Democrats have done their share.)
As Paul Krugman says, the Republicans are ideologically opposed to government, and when the government does anything well, the Republicans have to destroy it, usually by cutting its budget.
A mixture of public and private housing worked well in New York City. The working class was able to live in public housing, and the wealthy developers could build their own housing at a profit. It was a good solution. You make your fortune out of real estate, and let us have cheap housing.
Unfortunately billionaires aren't willing to merely make billions of dollars from selling luxury to the wealthy, they also want to make more billions by taking necessities away from middle-class people. In recent decades the cost of housing has gone up so much that it can be very profitable to destroy working-class and middle-class housing, and build luxury housing in its place.
The New York Times has run stories about how much of the luxury housing in New York City was bought by wealthy foreigners as safe investments, who keep them vacant. The Times found out that many of those foreigners were engaged in illegal activities, and they were able to launder their money in New York real estate because of the ability to create corporations and partnerships with secret owners.
So rent control is the second best solution. If we didn't have rent control, the long-time residents of New York City would have been priced out and their neighborhoods and social networks would have been quickly destroyed. Now that's only happening slowly.
One of the reasons I love my doctor is that he keeps two sets of records: the set that is shared with other doctors and insurance companies, and a "private notes" set that includes things that are likely to be harmful to his patients if they would be disclosed
That's right. That's a not-uncommon practice among some doctors, and a good idea. The tough question is what happens when the doctor gets a court order. I assume that some doctors would pretend that the private notes don't exist, and take a chance. It's reasonable for a doctor to conclude that his obligation to medical ethics supersedes his obligation to the law.
If I recall correctly, Massachussets General Hospital had a computer system in which there were separate systems for AIDS treatment, and for mental health treatment, so that information about stigmatized conditions could be kept confidential. I'm not sure how the details worked.
At the time I was following it, lawyers told me that you could legally see a doctor, give a false name, and pay in cash. A lot of people paid psychotherapists in cash. A lot of STD clinics allowed or encouraged patients to use pseudonyms.
One doctor told me that patients would give names like "Donald Duck" or "Ronald Reagan."
I imagined the doctor saying, "Mr. Duck? Please come into my office and we'll discuss your tests."
My understanding is that the grade school and high school nurses of years ago have been cut from the budgets of most schools. I'd be happy to find out otherwise, but I expect that only the most affluent schools have nurses.
In New York City, they don't have school nurses doing screening for vision problems any more. There was some deal recently where the City paid for an outside contractor to come in and do vision exams at an exorbitant price.
Colleges and universities don't have clinics any more, where students with a virus that's going around could spend a night or two. The schools just send them home.
I write for medical newspapers. During the AIDS epidemic, I wrote a story about confidentiality of medical records. At that time, people were losing jobs, losing housing, losing their friends, being disowned by their families who found out they were gay, and generally stigmatized, when people found out they had AIDS. All kinds of people could subpoena medical records for all kinds of reasons (divorce, for example).
I talked to a doctor, who was kind of a gay activist, and one of the few gay doctors treating AIDS. He told me, "I promised my patients that I will keep their medical information confidential. I will burn my records before I break that promise."
You can do that with paper records. You can't do that with electronic records, because there are backups.
> it's about a fucking school that wants to store private medical details
Schools need at least the student's immmunization records, doctor contact information, history of allergies, and a record of treatments received at the school.
How much information do they need? Doctor contact information and immunization should be enough. Very few schools treat students at the school any more.
Read the fine print carefully, I'm sure there are loop holes the size of Montana.
One of the loopholes in HIPAA is that law enforcement has access to the medical records. Another loophole is that any judge can issue a subpoena for your medical records in a criminal or civil case if it's in "the interests of justice." https://en.wikipedia.org/wiki/...
Here's an example. Suppose you smoke marijuana at some point. Your doctor asks you about that and mentions it on your medical record, because it's clearly health-related, significant and part of a good medical history.
20 years later, you have knee surgery and you're left with severe, intractable pain. The only thing that controls it is opioid drugs. Your doctor looks at your medical record and sees that you have a history of marijuana use. There are "risk scales" that define that as "drug abuse" (for example, the opioid guidelines of the Texas Medical Society). So instead of simply treating your pain with enough opioids to control the pain, your doctor makes you sign a "pain contract" which requires you to take regular drug tests, and has the provision that he can abandon you and expel you from his practice if you fail a drug test or violate any of the other provisions in the pain contract. Instead of controlling your pain down to 2 on a scale of 10, he only controls it down to 5 or 6 on a scale of 10, and leaves you to suffer in pain. These are the actual provisions of "pain contracts," and a history of marijuana use in your medical record can cause a doctor to define you as a drug abuser, and make it difficult or impossible for you to get drugs to control your pain.
http://journalofethics.ama-ass... Veterans Health Administration Policy on Cannabis as an Adjunct to Pain Treatment with Opiates Michael Krawitz AMA Journal of Ethics. June 2015, 17(6):558-561.
Your medical record contains information about all kinds of aspects of your personal life.
For example, a good medical history would include information about your sexual practices. In some states, normal teenage sexual behavior would be a felony, and some anti-abortion prosecutors have subpoenaed medical records of teenage girls who got abortions, and women who had late-term abortions, in order to find somebody to prosecute. http://www.slate.com/articles/...
The underlying assumption is that all income is the property of government, and allowing you to keep a portion of it is generosity on the government's part..
No. The underlying assumption is, government is entitled to part of your income. Your ability to earn that income is the result of investment made by the government in law enforcement, property rights enforcement, maintaining civil courts. When you have a contract with someone, that party does not default because you have government standing by you with a big baseball bat to enforce it. It deserves a cut on the money you make on that contract.
To put it another way, the underlying assumption, as Adam Smith put it, is that those who get a greater benefit from society have a greater obligation to pay for the costs of running society.
"The subjects of every state ought to contribute towards the support of the government, as nearly as possible, in proportion to their respective abilities; that is, in proportion to the revenue which they respectively enjoy under the protection of the state."
Well...I suppose they could do something radical and say, try to educate/better themselves and get a fucking JOB and pay their own way, no?
Real unemployment (as measured by taking the inverse of the labor participation rate) is at levels not seen in this country since the great depression. Last year a net million jobs were created, yet the number of people seeking employment (unemployed or underemployed) did not change. The fact is that there are no jobs, especially for the barely educated. Your two year college degree might get you a job flipping burgers. A four year degree might get you a job managing the guy flipping burgers.
Because there were about 30,000 deaths a year recently from opioids in the US.
This widely-reported number deliberately confuses
--people who take heroin to get high
--people who take prescription drugs without a prescription to get high
-- people who were appropriately prescribed opioids and died anyway
-- people who were appropriately prescribed opioids but given doses that were too low and got additional drugs somewhere
-- people who were prescribed opioids but couldn't afford them so they used cheaper heroin, etc.
It is a legitimate problem, but the Drug Enforcement Agency runs things and their solution to all problems is to put people in prison. When you've got a hammer, everything looks like a nail.
You could get a rational discussion of the problem in those silly European magazines like Lancet, BMJ or New Scientist. Unfortunately some of the Europeans are following the American example of stupidity.
I would recommend that you never tell your doctor that you use marijuana.
That will usually go into your medical record, because it's part of your medical and social history.
Now with electronic medical records, anybody with access can do a text search for "marijuana" and find it.
The most obvious problem that I can identify is that years later, you might have a legitimate need for opioids.
For example, hip and knee replacements are very painful. In order to be successful, they require physical therapy, which is also very painful, and often can't be done right without opioids. (See Jane Brody's story in the New York Times about her own knee replacements.)
If your medical record mentions marijuana, that can set off some (unscientific) guidelines for using opioids, which require that you sign a "pain contract." You have to take (unnecessary and expensive) drug tests, with (unnecessary and expensive) doctors' visits, with lower doses than would be medically appropriate, and they can discontinue opioids if you test positive for marijuana. Normally it would be a violation of medical ethics to abandon a patient, but these pain contracts allow doctors to unethically abandon a patient if they violate some of these provisions.
The Veterans Administration just backed off on one of those pain contracts after a veteran sued them. But not everybody can afford a lawyer.
http://journalofethics.ama-ass... Veterans Health Administration Policy on Cannabis as an Adjunct to Pain Treatment with Opiates Michael Krawitz AMA Journal of Ethics. June 2015, 17(6):558-561.
If a doctor specifically asks about marijuana, I think a good answer would be, "You can't guarantee me that this information will be confidential, right?"
Slashdot Mirror
They ask the same questions and put you on your prescription. If it doesn't work for you, go to a doctor. You're no worse off than before and definitely no less supervised, unless you have some special doctor which follows you around all day and makes house calls for you.
The main risk of hormonal contraceptives is having a stroke. If you make a mistake, and have a stroke, you could wind up with half your body paralyzed for the rest of your life.
And then you could add that the life expectancy in Cuba is higher than the U.S., and the infant mortality is lower.
http://www.nejm.org/doi/full/1...
A Different Model -- Medical Care in Cuba
Edward W. Campion, M.D., and Stephen Morrissey, Ph.D.
N Engl J Med 2013; 368:297-299
January 24, 2013
DOI: 10.1056/NEJMp1215226
This highly structured, prevention-oriented system has produced positive results. Vaccination rates in Cuba are among the highest in the world. The life expectancy of 78 years from birth is virtually identical to that in the United States. The infant mortality rate in Cuba has fallen from more than 80 per 1000 live births in the 1950s to less than 5 per 1000 â" lower than the U.S. rate, although the maternal mortality rate remains well above those in developed countries and is in the middle of the range for Caribbean countries.3,4 Without doubt, the improved health outcomes are largely the result of improvements in nutrition and education, which address the social determinants of health. Cuba's literacy rate is 99%, and health education is part of the mandatory school curriculum. A recent national program to promote acceptance of men who have sex with men was designed in part to reduce rates of sexually transmitted disease and improve acceptance of and adherence to treatment. Cigarettes can no longer be obtained with monthly ration cards, and smoking rates have decreased, though local health teams say it remains difficult to get smokers to quit. Contraception is free and strongly encouraged. Abortion is legal but is seen as a failure of prevention.
Why do I have to pay to answer a checklist to get medication
One of the main risks is that hormonal pills cause blood clots, which lead to strokes and sometimes to death.
It's a risk on the order of 1 in 10,000 or 1 in 100,000 a year, but if you multiply that by the number of women taking hormonal pills, that's a lot of strokes and deaths. It's increased by smoking, and by certain diseases. https://en.wikipedia.org/wiki/...
In principle you could have a checklist or online algorithm for people to follow that would give them the same advice that a doctor would give them, but in reality very few people (maybe 10%) can follow self-evaluations like that, and the algorithms aren't that dependable either.
Flexeril (cyclobenzaprine) is a dangerous drug. https://en.wikipedia.org/wiki/... It's not that effective and I think you were saying it wasn't effective at all.
In some patients, particularly the elderly, it causes confusion, delerium and hallucinations, from which patients take a long time to recover, if they recover at all. An article in JAMA Internal Medicine described how the author's mother died from complications of cyclobenzaprine. http://archinte.jamanetwork.co... “Mom, you have to trust me” doi: 10.1001/jamainternmed.2015.3659
One of the problems is that we don't have good treatments for back pain. (I say this as someone who used to have back pain about once a year so severe that I couldn't get out of bed or walk down the street.) Right now, the best advice is to try to return to normal activity as best as you can despite the pain, and to console yourself with the knowledge that most back pain goes away by itself after a week to a month. But there are exceptions, which is why you can sometimes benefit from seeing a doctor. I realize that finding a good doctor is like shooting craps. But if he recommends spinal injections, I would get a different doctor.
I don't think you're suggesting that people should be allowed to buy Flexeril or other drugs after an internet consultation, but I don't think that would work too well.
I wish there was some way to make doctors more competent in dealing with back pain, but I don't know of any. As for costs, you might look at the ways other countries make medical care cheaper.
Inequality of wealth and income is greater in the US than anyplace else in the developed world. The top 20% own about 85% of the wealth. And most of that wealth is inherited. Very little comes from innovation or productive activity.
In a free market, the top 20% would own almost everything, including housing.
They would be free to come into a community in New York City, and drive the rest of us out of our homes, simply based on privilege of birth.
I don't think that's efficient. By what standard is that efficient -- maximizing GDP? Cash flow? There are other standards -- providing housing and communities for people.
Why should Chelsea Clinton come into my neighborhood, buy my building, raise the rent, drive me out, bulldoze the building, and put up a luxury building in its place? That doesn't sound efficient to me.
Middle-class public housing is not "subsidized housing."
It is a decision by middle-class people that they could get better, cheaper housing if they pay an additional $2,500 a year in taxes and $2,500 a year in rent to the City than they could if they pay $10,000 a year to a landlord.
It's like a decision for single-payer health care. The Canadian and other governments can provide health care for $5,000 a year or less. The free market in private insurance provides health care for $10,000 a year. Why would a consumer choose to spend $10,000 when the people across the border are getting the same thing for $5,000?
The question is, is it better to let the market set the price, so that only people who really want to live there will pay the price, or is it better to have a semi random mix of people who might not otherwise live there?
If you let the markets set the price, you don't get "people who really want to live here," you only get people who are really rich.
In the past, we have had a semi random mix of people. It worked well. We got Nobel laureates, and people like Andrew Grove who founded industries.
So let's continue with what worked well.
If I could get an apartment if NYC for free, I'd take it; is some sort of lottery like that really the best way to allocate housing?
The wealth of America is distributed by some sort of lottery. When you look at the economic data, a person's income is remarkably correlated with his father's income. Contrary to conventional wisdom, America has about the lowest social mobility of any developed country in the world.
Is some sort of lottery the best way to allocate wealth?
Many people want to live in NYC and SF because that's where the jobs are.
They are communities where you can build entire industries.
Do you need an art director? In NYC I can walk into a bar and find a dozen.
most of which have been very successful and have long waiting lists.
Wouldn't 'long waiting lists' mean that they're actually unsuccessful, in that they're not meeting demand?
They're in great demand. They're not meeting the demand because the government agencies are no longer building public housing to meet the demand. The Republicans in Congress cut off funding with for example the Faircloth Amendment https://en.wikipedia.org/wiki/... which forbid federal money for new public housing construction (while they tore down the old public housing). They've got money for war, prisons and the war on drugs but not for housing.
In New York City, we have strong public support for public housing. We tell our politicians that we would rather have housing than prisons, and the honest politicians, like Dick Gottfried, try to get it.
Unfortunately, the real estate industry (along with the financial services industry) is one of the two largest financial contributors to local politicians.
There was a time when the real estate industry wasn't quite so greedy, and even accepted public housing, but now they want to squeeze out every dollar. There's a lot of corruption in local politics, but when we had well-managed city agencies, with strong political watchdog groups, we had good public housing.
A lot of the schools, police stations, post offices, libraries, parks, and other public works that we still use today in New York City were built during the depression by the Works Projects Administration. A well-managed government can do just as well as private industry, and sometimes better.
Not to mention that "the projects" have a long history of extreme violent crime rates and other criminal activities?
You mean, quite efficient at continuing the chain of poverty, because an employer sees an address in the project and looks elsewhere? Sad, but true.
When have you actually been in public housing in New York City? They were mixed-income housing, mostly middle-class families, particularly civil servants such as police, firemen, teachers, postmen, etc., and other typical middle-class workers such as salesmen, mechanics, restaurant workers, etc. The benefit of mixed-income housing is that the middle-class residents helped the newcomers to find better jobs and get better education. There are special public housing projects like Westbeth for artists.
The purpose of public housing was not to make money in real estate. The purpose was to provide housing for the people who contribute to the economy in New York City.
The problem arose when politicians like Robert Moses tried to turn public housing into "welfare housing." Guess what? If you fill a housing project with unemployed welfare recipients, you'll perpetuate the problems of poverty.
Look, I'm not going to say that public housing is all bad, or that it can't be the most fiscally sound decision. What I am going to say is that I believe that the real way to ensure sufficient housing is to allow developers to make money. If they can make money building housing, they'll build housing. I'm not saying that you have to enable them to make a killing, but well, if you're not getting enough housing built despite sky-high prices, maybe there's a reason that can be adjusted?
I'm looking out my window right now. We're getting plenty of housing built. I see 40-story apartment buildings going up around me. The problem is that apartments rent for $3,000 or more and sell for $1 million or more. In some buidings, half the apartments are empty, owned by absentee landlords in Russia, Qatar or someplace, as investment properties. We just don't have housing that middle-class people can afford.
I know Milton Friedman's solution: move where housing is cheaper, which would be in Western Pennsylvania or Texas. Well, I don't want to move to Western Pennsylvania or Texas.
by Anonymous Coward on Tuesday June 21, 2016 @06:48AM (#52358049)
trying to see a Doctor in the UK is an exercise in frustration in trying to navigate the labyrinthine system set up to manage their 48 hour waiting targets.... you have to be really dedicated to push yourself forward to get a same day appointment... if lucky, you'll get a telephone appointment or else be seen by the practice nurse
They release appointments for the next day at 12:30pm and they go very fast...
Isn't single-payer medicine GREAT!!!
I assume you are an American anonymous coward. I wonder when the last time was that you needed to get health care in the American free market system.
http://archderm.jamanetwork.co...
The Accuracy of Dermatology Network Physician Directories Posted by Medicare Advantage Health Plans in an Era of Narrow Networks
Jack S. Resneck Jr, Aaron Quiggle, Michael Liu, BS3; David W. Brewster
JAMA Dermatol. Published online October 29, 2014. doi:10.1001/jamadermatol.2014.3902
48.9% of physicians were reachable, accepted the listed plan, and offered an appointment for our fictitious patient. Many of the dermatologists listed had incorrect contact information, were deceased, retired, or had moved, were not accepting new patients, did not accept the insurance plan, or were subspecialized.
Ask the US veterans who died waiting for care from the US Department of Veteran's Affairs!
I know some veterans who go to the VA health care system. I would trade my health plan for theirs tomorrow, and they would never trade their plan for mine.
Bernie Sanders is on the Senate committee that covers VA health care, and he said that people complain about access, but once they're in the system, their care is excellent.
The problem was that the Republicans wanted to have wars but they don't want to pay for health care for the soldiers who fought that war. Their solution is, "cut the budget and privatize." Adopt the methods of our MBAs and private corporations. Give them impossible goals to meet, and if they can't meet them, fire them and hire somebody else. That worked so well for BP and Enron.
I'm not going to defend the indefensible. There were reports of veterans who had for example bladder cancer, who didn't get treated in time, and whose bladder cancer went from treatable to untreatable. But that happens (all the time) in the free market health care system, when people can't afford to go to a doctor at all. And it happened because the Republican budget-cutters cut the VA budget, under the Republican "Bricks without Straw" policy.
I do a lot of medical literature searches. The outcomes of the VA system are among the best. If you need, say, coronary bypass surgery, your chances of surviving are as good in the VA system as anywhere in the world. Including Sweden.
They've done a lot of the major studies in treating heart disease, cancer, diabetes, COPD, and all the conditions that affect veterans. If you go to a medical conference, and they're trying to decide what the best treatment is, they're always talking about the "VA study," which is often the definitive study.
Oh yeah -- the other benefit of the VA system is that when a VA doctor recommends surgery, it's because he (and his colleagues) think you'll really be better off, not because he gets a $3,000 surgical fee, like a doctor in the private sector. And they have the evidence to prove it.)
One afternoon I was feeling kind of dizzy and lethargic, probably from a lack of excercise and staring at the keyboard all day.
Out of an abundance of paranoia, I called the 800 number of my insurance company's help line, and spoke to a nurse.
I went through my symptoms, in great detail, because when you're giving a medical history (especially over the phone when they can't see or touch you), any minor detail might make a difference. I could hear her keyboard clicking in the background.
She said, "you should go to a hospital or your doctor's office immediately. You may have heart failure."
I said, "Heart failure? I don't think so. I can walk 10 blocks. I can climb 5 flights of stairs."
She insisted. She said, "You really should go to the hospital. You could die." Health professionals have the ultimate sales pitch. "You have to do this or you could die."
I said, "How do you come to this conclusion?"
She said, "Through a clinical decision-making tool."
I said, "What tool?"
She said, "Oh, it's a computerized tool."
I said, "What is the name of the tool?"
She said, "It's an internet tool."
She wouldn't tell me the name. I had to drag it out of her. I said, "Do you have a name at the top of the screen?"
Finally, she said, "Medscape."
I figured out that it was probably something like one of those Mayo Clinic consumer pages.
But she's a nurse and I'm not. Even though I was pretty sure it was BS, I couldn't take a chance and risk my life.
So I called my doctor's office and asked for an appointment. I hadn't seen him in a while anyway, and I had a few other things to talk about.
I told his secretary that a nurse had told me I should see a doctor immediately, so she booked me in the next appointment, in half an hour.
That was the one good thing I got out of the nurse help line -- an immediate appointment with my doctor.
When I told him about the heart failure, he laughed and said, "If you can climb 5 flights of stairs, you don't have heart failure."
Bottom line: in my experience, these nurse 800-numbers are BS (although sometimes just asking a question can be helpful). When you call them up with a real question, all they do is tell you to see a doctor. The strange thing is that this is a service paid for by the insurance company, which is supposed to save the insurance company money. But by sending people to the ER, she's actually costing them more money. And how much training does it take to sit at a phone and tell everybody, "You could have a serious problem. You should go to the ER immediately"? I could do that myself with a Google search.
If you make it more expensive to build housing of various types, and if you make housing worth less by adding lots of restrictions on what you can do with it, and if you restrict people's ability to make money with the housing they build, it turns out that over time, people build much less housing, because they don't see the point in going through all that hassle for less reward than they can get elsewhere with their money.
The purpose of housing is not to make money for developers. The purpose of housing is to provide a place for people to live. In New York City, the city, state and federal government at various times have built or financed public housing projects, most of which have been very successful and have long waiting lists. The housing costs the government agencies much less than private housing would have cost. When you look at the actual numbers, public housing is quite efficient and provides good housing for less cost than developers do in the free market.
Unfortunately the Republicans and greedy private developers have stopped the building of new public housing.
The obvious solution to a shortage of housing is to BUILD MORE HOUSING.
Yes, but it doesn't have to be private housing.
New York City has a long history of public housing. That's how we housed workers during WWII. It worked well in New York City, and it works well around the world.
Like anything else, there are some well-run public housing projects and some poorly-run public housing, but there's a lot of good public housing which has long waiting lists of tenants who want to get in. Many housing projects limit their rent to 30% of the tenant's income, which is a common definition of affordable housing.
The purpose of private housing is to maximize the owner's revenue. The purpose of public housing is to provide housing for people at an affordable rent.
The Republicans have passed laws against public housing, like the Faircloth Amendment, and in cities around the country, like New Orleans, they've actively destroyed public housing. (Although the Democrats have done their share.)
As Paul Krugman says, the Republicans are ideologically opposed to government, and when the government does anything well, the Republicans have to destroy it, usually by cutting its budget.
A mixture of public and private housing worked well in New York City. The working class was able to live in public housing, and the wealthy developers could build their own housing at a profit. It was a good solution. You make your fortune out of real estate, and let us have cheap housing.
Unfortunately billionaires aren't willing to merely make billions of dollars from selling luxury to the wealthy, they also want to make more billions by taking necessities away from middle-class people. In recent decades the cost of housing has gone up so much that it can be very profitable to destroy working-class and middle-class housing, and build luxury housing in its place.
The New York Times has run stories about how much of the luxury housing in New York City was bought by wealthy foreigners as safe investments, who keep them vacant. The Times found out that many of those foreigners were engaged in illegal activities, and they were able to launder their money in New York real estate because of the ability to create corporations and partnerships with secret owners.
So rent control is the second best solution. If we didn't have rent control, the long-time residents of New York City would have been priced out and their neighborhoods and social networks would have been quickly destroyed. Now that's only happening slowly.
Jimmy Breslin, the New York Daily News columnist, was the first to discover the ascendency of Chinese science students in NYC.
He saw that the top scorers in the computer game machines at Bronx High School of Science all had Chinese names.
One of the reasons I love my doctor is that he keeps two sets of records: the set that is shared with other doctors and insurance companies, and a "private notes" set that includes things that are likely to be harmful to his patients if they would be disclosed
That's right. That's a not-uncommon practice among some doctors, and a good idea. The tough question is what happens when the doctor gets a court order. I assume that some doctors would pretend that the private notes don't exist, and take a chance. It's reasonable for a doctor to conclude that his obligation to medical ethics supersedes his obligation to the law.
If I recall correctly, Massachussets General Hospital had a computer system in which there were separate systems for AIDS treatment, and for mental health treatment, so that information about stigmatized conditions could be kept confidential. I'm not sure how the details worked.
At the time I was following it, lawyers told me that you could legally see a doctor, give a false name, and pay in cash. A lot of people paid psychotherapists in cash. A lot of STD clinics allowed or encouraged patients to use pseudonyms.
One doctor told me that patients would give names like "Donald Duck" or "Ronald Reagan."
I imagined the doctor saying, "Mr. Duck? Please come into my office and we'll discuss your tests."
My understanding is that the grade school and high school nurses of years ago have been cut from the budgets of most schools. I'd be happy to find out otherwise, but I expect that only the most affluent schools have nurses.
In New York City, they don't have school nurses doing screening for vision problems any more. There was some deal recently where the City paid for an outside contractor to come in and do vision exams at an exorbitant price.
Colleges and universities don't have clinics any more, where students with a virus that's going around could spend a night or two. The schools just send them home.
What happens when the patient shows up unconscious in the emergency room?
I write for medical newspapers. During the AIDS epidemic, I wrote a story about confidentiality of medical records. At that time, people were losing jobs, losing housing, losing their friends, being disowned by their families who found out they were gay, and generally stigmatized, when people found out they had AIDS. All kinds of people could subpoena medical records for all kinds of reasons (divorce, for example).
I talked to a doctor, who was kind of a gay activist, and one of the few gay doctors treating AIDS. He told me, "I promised my patients that I will keep their medical information confidential. I will burn my records before I break that promise."
You can do that with paper records. You can't do that with electronic records, because there are backups.
> it's about a fucking school that wants to store private medical details
Schools need at least the student's immmunization records, doctor contact information, history of allergies, and a record of treatments received at the school.
How much information do they need? Doctor contact information and immunization should be enough. Very few schools treat students at the school any more.
What HIPAA guarantees does CareMonkey make?
Read the fine print carefully, I'm sure there are loop holes the size of Montana.
One of the loopholes in HIPAA is that law enforcement has access to the medical records. Another loophole is that any judge can issue a subpoena for your medical records in a criminal or civil case if it's in "the interests of justice." https://en.wikipedia.org/wiki/...
Here's an example. Suppose you smoke marijuana at some point. Your doctor asks you about that and mentions it on your medical record, because it's clearly health-related, significant and part of a good medical history.
20 years later, you have knee surgery and you're left with severe, intractable pain. The only thing that controls it is opioid drugs. Your doctor looks at your medical record and sees that you have a history of marijuana use. There are "risk scales" that define that as "drug abuse" (for example, the opioid guidelines of the Texas Medical Society). So instead of simply treating your pain with enough opioids to control the pain, your doctor makes you sign a "pain contract" which requires you to take regular drug tests, and has the provision that he can abandon you and expel you from his practice if you fail a drug test or violate any of the other provisions in the pain contract. Instead of controlling your pain down to 2 on a scale of 10, he only controls it down to 5 or 6 on a scale of 10, and leaves you to suffer in pain. These are the actual provisions of "pain contracts," and a history of marijuana use in your medical record can cause a doctor to define you as a drug abuser, and make it difficult or impossible for you to get drugs to control your pain.
http://journalofethics.ama-ass...
Veterans Health Administration Policy on Cannabis as an Adjunct to Pain Treatment with Opiates
Michael Krawitz
AMA Journal of Ethics.
June 2015, 17(6):558-561.
http://www.nytimes.com/2016/03...
Patients in Pain, and a Doctor Who Must Limit Drugs
By JAN HOFFMAN
New York Times
MARCH 16, 2016
Your medical record contains information about all kinds of aspects of your personal life.
For example, a good medical history would include information about your sexual practices. In some states, normal teenage sexual behavior would be a felony, and some anti-abortion prosecutors have subpoenaed medical records of teenage girls who got abortions, and women who had late-term abortions, in order to find somebody to prosecute. http://www.slate.com/articles/...
The underlying assumption is that all income is the property of government, and allowing you to keep a portion of it is generosity on the government's part. .
No. The underlying assumption is, government is entitled to part of your income. Your ability to earn that income is the result of investment made by the government in law enforcement, property rights enforcement, maintaining civil courts. When you have a contract with someone, that party does not default because you have government standing by you with a big baseball bat to enforce it. It deserves a cut on the money you make on that contract.
To put it another way, the underlying assumption, as Adam Smith put it, is that those who get a greater benefit from society have a greater obligation to pay for the costs of running society.
"The subjects of every state ought to contribute towards the support of the government, as nearly as possible, in proportion to their respective abilities; that is, in proportion to the revenue which they respectively enjoy under the protection of the state."
https://en.wikipedia.org/wiki/...
Well...I suppose they could do something radical and say, try to educate/better themselves and get a fucking JOB and pay their own way, no?
Real unemployment (as measured by taking the inverse of the labor participation rate) is at levels not seen in this country since the great depression. Last year a net million jobs were created, yet the number of people seeking employment (unemployed or underemployed) did not change. The fact is that there are no jobs, especially for the barely educated. Your two year college degree might get you a job flipping burgers. A four year degree might get you a job managing the guy flipping burgers.
If you want a job flipping burgers today, you need a law degree. http://www.nytimes.com/2016/06...
Because there were about 30,000 deaths a year recently from opioids in the US.
This widely-reported number deliberately confuses
--people who take heroin to get high
--people who take prescription drugs without a prescription to get high
-- people who were appropriately prescribed opioids and died anyway
-- people who were appropriately prescribed opioids but given doses that were too low and got additional drugs somewhere
-- people who were prescribed opioids but couldn't afford them so they used cheaper heroin, etc.
It is a legitimate problem, but the Drug Enforcement Agency runs things and their solution to all problems is to put people in prison. When you've got a hammer, everything looks like a nail.
You could get a rational discussion of the problem in those silly European magazines like Lancet, BMJ or New Scientist. Unfortunately some of the Europeans are following the American example of stupidity.
I would recommend that you never tell your doctor that you use marijuana.
That will usually go into your medical record, because it's part of your medical and social history.
Now with electronic medical records, anybody with access can do a text search for "marijuana" and find it.
The most obvious problem that I can identify is that years later, you might have a legitimate need for opioids.
For example, hip and knee replacements are very painful. In order to be successful, they require physical therapy, which is also very painful, and often can't be done right without opioids. (See Jane Brody's story in the New York Times about her own knee replacements.)
If your medical record mentions marijuana, that can set off some (unscientific) guidelines for using opioids, which require that you sign a "pain contract." You have to take (unnecessary and expensive) drug tests, with (unnecessary and expensive) doctors' visits, with lower doses than would be medically appropriate, and they can discontinue opioids if you test positive for marijuana. Normally it would be a violation of medical ethics to abandon a patient, but these pain contracts allow doctors to unethically abandon a patient if they violate some of these provisions.
The Veterans Administration just backed off on one of those pain contracts after a veteran sued them. But not everybody can afford a lawyer.
http://journalofethics.ama-ass...
Veterans Health Administration Policy on Cannabis as an Adjunct to Pain Treatment with Opiates
Michael Krawitz
AMA Journal of Ethics.
June 2015, 17(6):558-561.
If a doctor specifically asks about marijuana, I think a good answer would be, "You can't guarantee me that this information will be confidential, right?"