Why isn’t there more telemedicine?

Austin Frakt tells us:

The biggest hurdle may be state medical boards. Idaho’s medical licensing board punished a doctor for prescribing an antibiotic over the phone, fining her $10,000 and forbidding her from providing telemedicine. State laws that restrict telemedicine — for instance, requiring that patients and doctors have established in-person relationships — have drawn lawsuits charging that they illegally restrict competition. Georgia’s state medical board requires a face-to-face encounter before telemedicine can be delivered, while Ohio’s does not.

A study by Julia Adler-Milstein, an assistant professor at the School of Information and the School of Public Health, University of Michigan, found that such state laws and medical board requirements influence the extent of telemedicine use by hospitals. While 70 percent or more hospitals in Maine, South Dakota, Arkansas and Alaska use telemedicine, only 13 percent in Utah and none in Rhode Island do, for instance.

In a passionate commentary on the establishment’s hesitancy to embrace telemedicine, David Asch, a University of Pennsylvania physician, pointed out that the inconvenience of face-to-face care limits its use, but arbitrarily and invisibly. The costs of waiting and travel time and those borne by rural populations with poor access to in-person care don’t appear on the books. “The innovation that telemedicine promises is not just doing the same thing remotely,” Dr. Asch wrote, “but awakening us to the many things that we thought required face-to-face contact but actually do not.”

Here is the full NYT account.


One question I have w.r.t. telemedicine is whether there's some simplish gadget that would pretty reliably take a few standard measures for the doctor. Like, I have a themometer and a blood pressure cuff at home, which together will give temperature, blood pressure, and pulse (and will note some kinds of arrythmias, but I don't know how well that feature works). I wonder if someone could package a single gadget together that would make it relatively easy for a patient or untrained family member to collect the kind of basic information a doctor would want for a general-purpose kind of televisit. (I imagine one of the main purposes of such a call or video conference or whatever is to give the doctor a chance to say "you're too sick for this, you need to get to a hospital/doctor's office/something now.")

There are new devices coming out all the time. Most use cell phone technology. Some are on the market, some are still experimental. For instance there is an adapter that can take a blood sample, hook to your cell phone and send your medical doctor your blood glucose reading. The medical technology field is starting to add more and more devices that can connect to your phone.

The problem is the FDA does not believe in magic, so that lack of faith has made Elizabeth Holmes' innovation fail to work.

We need to get rid of the FDA to restore the healing power of voodoo, faith healing, freak show medicine men, and of mercury and radium!

Reminds me of Uri Gellar blaming his failure to bend spoons with his mind and other supernatural feats on Johnny Carson's negative thoughts. Theranos is likewise unable to get its blood tests to work even when using FDA approved blood testing machines because the FDA refuses to believe Holmes can do the improbable.

This is just an anecdote, so take it for what it is worth. A few years ago, my uncle had a stroke and leaving his condo became difficult. But he needed to have regular testing to monitor a condition. This meant traveling to the doctor's office on a weekly basis. So he had the idea to purchase the same device his doctor uses, do the test at home and provide his doctor with a reading. He would come in to have the device recalibrated on the doctor's schedule, which less than once a week, He contacted the manufacturer (one of the industry leaders) and they were onboard with the idea. In fact, they were enthusiastic. But the doctor kiboshed the whole project. I can't remember the reason he gave.

Liability? Basing treatments on the results of tests performed by non-certified people is problematic.

Not relevant to the conversation albatross. Next time stay on topic. okay?

Thanks for your input, I'll give it all the attention it deserves.

I'm not sure what Frankie V is talking about. I thought albatross's comment was relevant and I for one take his side

He must be a doctor or someone who works in the industry who feels threatened by technological advancement. That's my guess.

"Maine, South Dakota, Arkansas and Alaska use telemedicine, only 13 percent in Utah"

Surely this is mostly a reflection of what percent of the people live in remote, rural locations? Utah is 91% urban, the other four all under 66%.

1. The coverage and reimbursement is shit.
2. Most "simple things" that are covered by telemedicine (like pharyngitis, uri, uti) require diagnostic tests that you can't do with a camera.
3. The visits where telemedicine is appropriate (behavioral health, most follow ups) are not covered.
4. See #1.

#3: Not at all appropriate for some mental health visits. I cannot check your muscle tone and reflexes via telemedicine currently. I also cannot yet smell the alcohol on your breath, or the body odor when have been depressed enough to not bathe for a week. It is also hard to examine you for track marks. Etcetera

Is the BO thing really used that often? Track mark inspections involve holding body parts up to the camera. Tox screens can be done, too.

Yes with some populations it is an important indicator of functioning.

"Tox screens can be done too." Maybe. Depends on where the person is. Some telemedicine visits are done from the patient's home or other location where a screen can't be done.
How characteristic of American medicine it is to order a tox screen and spend some bucks when if you were there your nose might tell you drinking was current for no additional cost.

Yeah. I'm not saying telemedicine can or should be the mode of all behavioral health care. But I do think it can it be stand in sometimes, especially when it's a patient in an area who might not otherwise be able to drive 70 miles every week.

Not all and maybe not the initial visit but a large number of them could be treated over the phone if the option was available.

I've met some very happy people with BO. I mean, wasn't it in vogue for some hundreds of years in Europe that bathing was for poor people, and association of powerful perfumes with wealth and power contributed to the expansion of some perfume markets?

What does muscle tone have to do with mental health? Also, reflexes - isn't it likely that some people just don't like to be pushed and prodded? Shouldn't you inform them of the potential diagnoses of non-cooperation so you're actually evaluating their reflexes and as opposed to compliance with people whose "authority" they may not respect?

I'd be interested to hear some well-reasoned opinions.

My view is that much of psychiatry involves diagnosing as "mentally ill" where people are just non-conformist. And yes, I've definitely met people whose non-conformity is to the extent that integration into society is difficult nigh on impossible. But I think it would be more constructive to discuss with them the realities of social expectations, etc., than to give them brain numbing drugs and diagnoses which may castrate them socially and serve to discredit anything they say.

Pathologically increased muscle tone is a very common side effect of some antipsychotic medication and sometimes of antidepressants such as Paxil. Decresed muscle tone and reflexes can be seen in those taking excessive doses of opiates, benzodiazepines, muscle relaxers etcetera. BO can be a personal preference, but it can keep you from obtaining and maintaining employment and many social relationships. Perhaps it shouldn't but it does. Tourette's is often comorbid with OCD and ADHD. A non-invasive neurological exam can be extremely important for some.

BTW Big Pharma is trying to convince your doctor to "augment" your antidepressant with expensive antipsychotics, often before trying safer alternatives like psychotherapy, counselling, life-style changes etc.

Pshrnk: thank you for providing interesting, informed and detailed input to this discussion.

All sounds relevant. On the matter of BO, some people just don't know, whether because they don't realize their own smell is unpleasant and/or because no one ever really communicated this expectation to them.

I'm teaching in China now. One of my classes, one student stunk so bad that the entire back of the classroom stunk. Since I only meet each class twice a week, and they have a head teacher who's supposed to take responsibility for a lot of stuff, I just figured someone who eventually do something about it. About 2-3 months into the year, I asked my TA about what might be a culturally appropriate way to address the situation. She looked SHOCKED that someone would think they should mention such a thing (saving face and outward demonstration of respect is a big thing in China, by the way).

I asked her to tell the head teacher about it, and expressed the critical importance that a student in the class needed to be aware of these social expectations, and what it would mean for their life if they couldn't adjust. Nothing happened. Some weeks later, when there were some minutes for exercises, I would go to the back of the classroom and try to sniff out the source, but the whole back of the class stunk so I couldn't figure it out. Eventually, I would go around the back of the class, making minimal show of sniffing around, and then would mutter "someone needs to take a shower." Some weeks later, the situation was resolved, to the extent that my nose tells me he's showering perhaps a couple times a week rather than every few months.

It concerns me to think that this sort of observation could contribute to a mental health diagnosis, unless it was CLEARLY linked to a pattern of depression and.or extreme lack of self care (to be differentiated from asceticism or just not being too stressed about satisfying conventions, with full awareness of potential social costs). I was recently reading the diagnostic manual, and it stuns me to think that things like not cleaning your room, not working hard enough, etc., are explicitly cited as criteria leading to a diagnosis of mental illness. I do not doubt that many psychiatrists are able to take this holistically as a part evaluating a general situation, but it seems rather obvious that some will be trying to figure out "what's the diagnosis" from the moment someone walks in the door, rather than seriously trying to evaluate if the context of the person's life, and not a mental health issue, is in fact the causal factor which explains the "symptoms".

Tourette's, I think, has gotta be an easy one. Personally, I've got a pretty foul mouth in company that will tolerate it, but there was a student at my highschool who had Tourette's. Not a bad kid, actually, but hard to see through all the virtriol.

So, here's what I see as the problem, and at a profession-side level (but not all psychiatrists) this is a major abrogation of society-wide expectations.

When we discuss "mental health care", I think a lot of people imagine that someone with specific problems goes to a psychiatrist, someone who they can trust to disclose many things about themselves, for the purpose of being able to devise a strategy to deal with their crap, or to overcome some genetic and/or developmental issues. And yes, I think people understand that sometimes this will involve pills.

But I think a lot of people in the profession, when someone walks in the door, they're primed to want to answer the question "what's his mental illness classification?" and not "what's up with this guy, is there anything I can do to help?" Instead of getting help, the individual walks off with a bottle of pills and a mental health label that is damaging to confidence and potentially discrediting at any time in the future if they are subject to some sort of abuse.

I know there are some good apples. And some just have too high workload. Some others just don't give a crap. But I sincerely believe that some of most evil people on the planet are in the profession.

The lunatics are running the asylum and all. The diagnostic manuals are basically a recipe for political repression in the absence of due process. I don't take issues with people who readily acknowledge that a lot of it is holistic, but IT IS PSEUDO-SCIENCE, and I think for a lot of stuff that's giving it too much credit. And any psychiatrist who feels like they are being attacked for saying so, they are the problem.

I can sympathize with the situation, since a decent share of my work relates to economics. People accuse economics of not being science all the time, yet there are very highly science-y expectations of the field from many quarters. How do I respond? "Good point. do you have any better ideas? It's better than astrology".

Given the broad delusions of scientificness in the field of psychiatry (I know there are exceptions where there IS real science establishing diagnoses), by their very own criteria it would be arbitrarily easy to pen down some minor personality flaws and confine most of the profession to the mental ward until they can come around and admit they are delusional.

4) There are infrastructure costs up front that can be significant, like running fiber if rural and high quality video devices.

I like the Kaiser on-call nurse. Sometimes she'll(*) say don't worry. Sometimes she'll recommend something over the counter. That is all in line with the over the counter and prescription distinction though.

I am sure Idaho would have no problem with an over the counter recommendation. The question becomes what "prescription" really means. Including what drug doctors could do with "telemedicine."

* - It always has been, I wonder if there are any "he" on-call nurses, and if they don't direct me to them, given my demographic.

When your headache was an early meningitis and the over the counter recommendation by phone was to take two aspirin Idaho will have a big problem with it.

The only exposure I had to Health Care was in the back room, in the lab.

So I don't know, is there a difference legally between a nurse talking about a headache and a doctor, on the phone?

When telemedicine is done in a rural area because no doctor or PA is physically located there (which as I understand is most telemedicine) a nurse can still do the physical exam and report to the doc on the camera.

Being in the same room as a doctor doesn't diagnose meningitis either, you have to get a spinal tap. Either case the doctor will go down a checklist of symptoms and if you fit refer you to a place to get a spinal tap. You may as well get that referral on the cheap through a phone-call.

You also look for signs. Sometimes a seasoned clinician will investigate further just because some appears "very ill" to them. I will grant you that with a 4K system properly set up and calibrated we might be able to see some signs even better than being there.

I personally walk patients from the waiting room to the office, so I can observe, naturalistically how they get up, walk, turns corners and sit down without them usually realizing their exam has already begun.

Perhaps it would be useful to inform them that the way they walk, turn corners and sit down might inform your diagnosis? You might give them a crash course on the acceptable ways to walk and sit, in order to ensure that they don't just have non-Victorian ways of moving, as opposed to coordination issues which might signal some motor coordination issues.

You might also be interested to learn about the difference between physical disability and mental disability.

Often, even the second of these has nothing to do with "mental illness", but rather some sort of impairment (genetic or otherwise, perhaps due to an accident, for example) in cognitive development. In an experience working in a summer camp which alternated between weeks of physical disability and mental disability campers, understanding that physical disability need not imply mental disability was basically the first and most important part of training.

I can hardly imagine that you are not aware of such things. But in my opinion the tendency to scan memories of mental illness diagnostic criteria are liable to be the first point of reference for people in this pseudo-science pseudo-medicine job, as opposed to considering non-mental health explanations such as "he's just different, well at least I should ensure he's aware of this" or health or developmental reasons which explain observations may not in fact warrant a diagnosis of "mental illness".

I know I know. People who do your job hate it when people question their authority or point to the basically non-existent scientific criteria for many classes of diagnoses.

I move like a camando at a cocktail party.

Actually I don't, that's just a funny like from an old Road and Track review. Some car supposedly did.

Well Troll Me.... there is a reason why DSM-5 criteria, for all their genuine flaws, usually include that a symptom must be distressing to the patient. I certainly often see people with abnormalities (statistically speaking). I ask them if the abnormalities bother them in any fashion. Usually, if they are not bothered by an abnormality I teel them, "then it doen't bother me either." Obviously there are exceptions such as recommending that the 2 fifth a day drinker decrease/stop before it damages their body.

Yes, it strikes me as though you are one of the folks who uses the manual responsibly.

In some things I'm researching, it is patently obvious that Soviet-style political psychiatry (and how the most powerful political entity in the history of the planet is always behind the Russians is something I find very lacking in credibility) ... is being applied to highly nefarious ends, for example in relation to technologies which make use of the "microwave auditory effect" and those who seek to disclose the use of neuroweapons against them.

Any psychiatrist who is unaware of the existence of such technologies is liable to be a "useful idiot" (or worse) in the political repression. And it is happening right here, right now, across the Western world. (I know, I know, any talk of conspiracy without courtroom-ready proof is "evidence" of "schizophrenia" ... but isn't that SUSPICIOUS?)

Anyways, I'm just finishing up a 400-page reporting document for such "targeted individuals" of "organized stalking" and "electronic harassment" to document their experiences in a credible manner. Obviously (?) I'm not just making this up out of thin air.

Someone who spent years learning foreign languages, studying music and working on agricultural advancement in developing economies doesn't just out of nowhere up and spend the next year working on a glossary of all terms relating to neuroweapons and psychological warfare, establishing reporting mechanisms for reporting abuses of them, or produce an anti-brainwashing guide.

But honestly, given the way these strategies are being applied, if I were to walk into your office and say exactly what's happening, even armed with 200 pages of scientific references, patents, references of military and intelligence research projects, in addition to thousands of claims, statements and books by numerous whisteblowers from the NSA, CIA and FBI, etc., your training is such that I believe it would be an enormous act of willpower to refrain from penning down "delusional and schizophrenic following a psychotic break".

Hey, if you want the easy life, just play along, no? But you know what they say about good men doing nothing ... I would consider it as a service to humanity were your colleagues to merely be able to openly discuss the reality that the "microwave auditory effect" has been proven able to remotely beam voices into people's head since the 1970s.

As a consumer I want to know what Medicine can really do? I had a 4 year old with high fever, headache and ear pain. To use the telemedicine provided by my national level insurer cost me a co-pay of $30 to have someone tell me they couldn't do anything for me and that I could either wait till Monday to see my child's pediatrician or I could go to urgent care. They did not provide better information on upping doses of over-the-counter meds or anything.

Maybe there is a benefit for those in rural areas who need to see a doctor for a check-up on chronic problems, but it certainly doesn't appear to be of value for acute problems.

To be fair, people pay much higher co-pays to be told the same thing by an in-person doctor.

Frakt is one of my favorites but he didn't quite get this one right. First, physicians are regulated and licensed by the states, and telemedicine is considered the practice of medicine; hence, a physician located in one state where she is licensed and "treating" (via telemedicine) a patient located in another state where she isn't licensed is practicing without a license. The telemedicine model act would solve this problem by having the states which adopt it apply reciprocity: if state A allows physicians in state B to treat patients in state A via telemedicine, then state B will reciprocate. The problem is that not all states are created equal. Florida has lots of patients, lots of patients with insurance (Medicare), and the physicians in Florida aren't too keen on sharing them with physicians in, say, Massachusetts. Second, most states (maybe all states) require a physical examination of a patient before prescribing a narcotic. Treating a patient via telemedicine isn't enough to satisfy this requirement. The way to address it is for physicians in different states to cooperate and provide the necessary physical exams. Of course, that takes us back to the Florida problem. Some states have attempted to avoid (evade) the problem by allowing non-physicians to conduct the physical exam. Okay. Here's my take: telemedicine (virtual medicine) is not a substitute for the real thing as a general proposition. Instead, it can be used in limited circumstances, such as in rural areas with a shortage of physicians and, more importantly, to deliver high quality specialty services as, for example, the country's best oncologists located in Boston treating cancer patients in Florida. This would accommodate both the physicians (who might prefer to reside in Boston) and the patients (who might prefer to reside in Florida). But it would be limited to specialty services. For those who follow this sort of thing, it would accommodate Dr. Emanuel's idea of having "centers of excellence" provide high quality care across states and regions. I suppose I could mention another solution to this problem: end the regulation and licensing of physicians.

Jack boot big government takeover of the entire economy would fix the problem.
Eliminate all State boundaries so the Congress and Federal executive and courts make and enforce all laws and regulations.

Then the president by executive action could require gigabit fiber installed to every address in the US with a high quality telecommunications terminal including medical sensors be installed at a single price at every house with lifeline service for the poor subsidizing the price to $10 for the poor. And with no States all doctors would be licensed by the Feds to practice everywhere in the US and probably the universe.

National Licensing.

I think most physicians would rather live in FL and treat patients who are in Boston.

Actually Boston may have a problem of being too attractive to doctors.
On average doctors make less in Mass than any other state.
It is generally attributed to the point that there are so many doctors in the state.

Hmmm, so there are actually some negative effects to government regulation of physicians and health care. What a remarkable finding.

Perhaps some curious economist could look further into the medical field for other possible drawbacks from government regulation. Maybe this general regulatory issue even extends to other professions and industries? It's certainly virgin territory for academic exploration.

Yeah, government regulation is what makes Holmes blood test innovation not work, even when done with FDA approved test equipment....

Can't possibly be the result of poor testing, poor quality and reliability testing, and worse, totally incompetent management of quality and reliability controls resulting in FDA approved equipment failing, even when operated by independent test labs paid 5 times as much as Theranos charged for the blood test,....

Yep, let's free innovators less brilliant than Holmes to bring back the highly effective mercury and radium cures. Better yet, the coca, poppy, and cactus derived feel good medicines. Better living through chemistry!

But, but , but the market believe in Theranos!

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This story is missing an important part of the debate by skipping over the abortion issue.

Abortion by telemedicine?


Correct. An important element of the opposition to telemedicine, at the state level, has been pro-lifers specifically looking to limit the practice of non-surgical abortion, which has massively grown in popularity because it is generally safer, more convenient, and cheaper to use the drugs (generally, a two-pill regimen) than to have a doctor doing a physical procedure in the earliest phases of pregnancy. Since there's no particular need for a doctor to do an examination before prescribing the pills, it's a natural fit for telemedicine--you go to a clinic, speak with a doctor on the phone, and take the pills (in reality, even talking to a doctor is probably unnecessary in most cases). Since making abortion itself illegal is still prohibited under the current Supreme Court, abortion opponents have sought to use TRAP (targeted regulation of abortion provider) laws as an end-run around the constitutionality issue, and restricting or regulating telemedicine is a good example of that strategy.

Can't they just...exempt abortion from telemedicine?

Oklahoma's radical leftist big government liberal legislature has just passed a law to have doctors spend a year in jail and thus become felons denied a license to practice medicine in the State which is already short of doctors.

Those radical leftist big government liberals are harming health care in Oklahoma and is going to drive out all doctors!

Do you mean making it illegal to do telemedicine abortions?

The answer, obviously, is "yes," and some states have attempted precisely those bans, but they invite litigation (I'm not sure what the current state of play is in those specific cases), since abortion-by-telemedicine happens beneath the traditional Supreme Court cutoff, i.e. pre-viability. Moreover, you run into the larger problem, which is that the whole point of the TRAP strategy is to say that you are totally not trying to prevent doctors from being able to perform abortions or women from accessing them--this was why we ended up with the hilarious spectacle in the Hellerstedt SCOTUS case, back in March, of the conservatives saying that they were shocked--shocked!--that anyone thought that the Texas law at issue, HB2, was intended to force the closure of abortion clinics. That was the furthest thing from the legislators' minds; they would never pass a law intended just to shut abortion clinics. The transcript of that section of the oral arguments is pretty amusing; just jump down to Justice Alito's comments.

The problem with Telemedicine is that they may use physicians based in India or Cuba, leading to large closures of Country Clubs and Golf Courses.

Ha. Of course they'd still have to be licensed by a US state medical board.

This exists already for radiology. There are groups/corporations in Australia which read x-rays/CTs/MRI done by radiology technicians during off-hours in the US. Nighthawk Radiology Services is one.

Reading an x-ray and reporting the results back to a patient's physician who is licensed in the US and who actually sees the patient in person is not the same as a doc in India, unlicensed in the US, directly providing a patient's care and getting reimbursed for it via telemedicine.

Telemedicine raises the question of what exactly do doctors do and what can be done in person and what needs to be done in person with the doctors hand on your body or looking into something.

My experience is that most encounters are asking questions and ordering tests,

Unless the doctor ask you to

"Bend over and take a deep breath.

There, now you can go.

See you next year."

"most encounters are asking questions and ordering test".....part of why we spend so much on health care. Much more testing than physically examining these days.

I think a lot of people commenting here are confused. Telemedicine is not just telephone medicine. Usually, it actually involves someone seeing a physician over a video conference connection. The patient is usually in some sort of clinic with nursing staff but just no physician available.

I guess calling in a prescription is technically telemedicine, but that's been happening for decades.

The doctor in Frakt's article offered her services through a company that was bought by Teladoc. From their website it sounds like you have the option of either making a videocall or regular phone call without needing to visit a clinic. Am I missing some fine print?

Yeah, this case was a telephone situation, but the telemedicine I am aware of is almost always done via video conference. For example, I don't think any state Medicaid department pays for doctor phone calls, but they do reimburse for video consultations. But maybe the phone version is more prevalent than I thought.

Traditionally, doctors don't get paid for time spent on the telephone. Charles Krauthammer, who is a psychiatrist, wrote a column in the 1990s recommending that they do get paid for telephone time:


When I had non-Hodgkins lymphoma, I hired a general oncologist to help me choose among three clinical trials for NHL. We met once and then I paid him for his telephone time after that. Since I'm still here 19 years later, I'd recommend that.

It is still difficult to get paid for telephone time, but it would be very beneficial to change that.

> Why isn’t there more telemedicine?

Because it would increase the supply of medical care relative to demand, decreasing the cost, and the AMA has always been about restricting supply.

Their first big act was to lobby to restrict the number of doctors. They did this with legislation to grant licences to only a few university run medical schools. Then those schools started buying up all the non-licensed schools bringing them under the license. Seeing how this was not the AMA's desired result, they them lobbied to have the number of doctors these licensed schools can teach capped. To this day the AMA sets this cap.

They are a rent seeking organization and have ruined the medical sector, and now the entire economy.

In other countries, there is no regulatory burden to telemedicine but yet it is not more widely used. I think medicine is more a meta-heuristic than a science and physical contact between patients and doctors is underrated.

Is this in part due to the war on drugs?

I think so. Lots of "doctors" would be happy to run a pill farm through their cell phone while lounging on Waikiki Beach.

Though note that I don't think this is a good reason for restricting telemedicine.

The combination of a more advanced Watson for diagnostics an telemedicine along with the health pills that help prevent the major diseases from beginning in the first place should mean that by 2025 there will be far fewer doctors, nurses and pharmacists. The AMA can only block these advances for so long.

I've occasionally practiced telemedicine (psychiatry), and I love it. I'd guess ~80% of psychiatric patient encounters can be done via telemedicine. Pay and reimbursement is the same for office visits, patients love it due to the convenience. The % of visits to an internist that could be successfully done is probably less.

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(1) Yes, Kaiser Permanente has a great telephone advice nurse program. It's really come in handy a few times when our little one seems sick or hurt but we're not sure. Just imagine the lines in pediatricians' waiting rooms if parents couldn't call first for help!

(2) I had a personal hygiene problem in junior high, high school, college and graduate school. Like many (but not all or even most) people with that problem, I was seriously depressed during that time.

That's not an excuse, though it is an explanation. I'm very sorry for everyone I inconvenienced during those years.

BO should be approached much more compassionately than it commonly is (assuming my experience is a guide)...but it should never be ignored. Not even if the individual is OK with being ostracized as a result. For one thing, it's unpleasant for everyone else. For another thing, studies are now showing that unpleasant odors actually change people's decision-making processes by making them more judgmental. Bottom line: BO is a serious externality that needs to be internalized one way or another.

(3) You know what's the next tech frontier? Video hearings. We've already got a few of those, and as videoconferencing technology broadens we'll see more. Hopefully one day if we have to sue or complain about someone -- or even answer civil or criminal charges -- in another state we'll be able to testify and show (not to mention submit) evidence from the comfort of our homes and offices.

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