Sunday assorted links


More surgery is being performed with the patient awake and looking on, for both financial and medical reasons. But as surgical patients are electing to keep their eyes wide open, doctor-patient protocol has not kept pace with the new practice. Patients can become unnerved by a seemingly ominous silence, or put off by what passes for office humor

I had an operation on my toe a couple months ago and stayed awake during it for precisely this reason. The podiatrist and especially anesthesiologist were eager to put me under, but I wanted to avoid running up the (absurd) costs any more than I had to. The anesthesiologist wasn't even necessary, but he owned the surgical suite where the procedure was done, so he was in the room and (still) billing something.

While the procedure occurred I was thinking about all the papers and articles about healthcare economics I'd ever read.

Yes, thank god for this article. I've always said anesthesiologists are worse than useless. That said, I don't think anyone should care what is said, they can insult the patient the entire time as long as they don't overcharge.

Hello Dan. I have to defend my anesthesiologist colleagues because unfortunately I think they do not nearly get enough respect that they deserve from the public, as your comment illustrates so well. Anesthesiologists are probably not necessary for routine procedures and indeed nurse anesthesiologists are increasingly taking over routine procedures. However, for complex cases, guess who saves the patient if they crash on the table? It's certainly not the surgeon. Anesthesiologists are masters of physiology and a well trained anesthesiologist is the difference between a patient dieing on the table or not. In summary, anesthesiology can be very routine and formulaic and probably below the pay grade of a physician, however if things go south, you absolutely need a well trained person to save the situation. The entire field is moving in the direction of taking on complex cases where their skills can be best put to use.

Likely they will be the 1st part of the surgical team who is automated away.

An uncle of mine was an accomplished anesthesiologist.

Sir! I demand you stop impersonating me!

This is absurd YOU are the imposter! I shall destroy you!

When I had my colonoscopy, I asked them not to use one of the drugs they were planning to use which induces memory loss. The drugs they did use had no perceptible effect, and next time I'll ask not to have any drugs. It wasn't anywhere near as bad as I expected, nor was the pretreatment with the drink. The whole thing went smoothly. The worst part was the doctor talking about his recent vacation the whole time he was examining my colon.

In college in the 1970's, my neuroanatomy professor had just come back from China enthusiatic about acupuncture anaesthesia, but she did mention that even in China it was not effective on some small percentage of surgical patients so they used regular anaesthesia on them. My theory is that you can tolerate a considerable amount of surgery without intolerable pain if you don't freak out, and treatment with acupuncture by solemn doctors assuring you it will work but regular anaesthesia is standing by induces enough calm for what is essentially anaesthesia-free surgery.

Haven't there been studies about applying hypnosis to some surgeries?

I did the no sedation colonoscopy. No problem. You get up, put your clothes on, and drive back to work.

(1) I encountered an eruv in Newton, MA years ago, witnessing a carefully-maintained wire that did not seem to have any logical use. It took me a long time to finally sleuth out what is was. In this case I eventually figured out it was a sort of "anti" eruv: within the main eruv there was a large lake (Crystal Lake) that for some complicated rules was not allowed to be part of the eruv, so there was an extra loop of wire that encircled the lake. I've learned that since then the status of Crystal Lake has changed and the "anti" eruv is no longer needed.

Which brings me to my question: as long as you're flouting the spirit of the rule as they are, why not make a huge eruv? You know, one so big that the entire area not included in it is about a square foot? expect religious superstition to be rational ??

It's already irrational once they've done this. I'm asking why they haven't taken it further to rid themselves fully of the inconvenience

The rules include a maximum amount of continguous uninhabitable/inaccessible space which means large bodies of water must be excluded. Interestingly if the water is used as a reservoir for drinking water then it can be included.

Is that why Isreal desalinates water from the Meditteranean? The first part of the assertion might stop mathematicians to claim that since the earth is spherical, topologically any eruv small or large should enclose all earth surface. The second assertation might provide a loop hole that since the Meditteranean is connected to the rest of the large oceans such that any inland lakes are small in comparison so that the topological argument is still valid.

So you're saying there would be no problem making a rectangle from Denver to the East Coast?

This is no doubt the Crystal Lake that Jason comes out of--you know, with the hockey mask, from the Friday the 13th movies.

3. Obviously yes. Obamacare managed to balance interests of the moment, was immediately hated, but then so would any plan that balanced need to pay with reluctance to pay.

The new status quo is being stuck at that past balance, that local maxima, and being unable to do global optimization.

Global optimization requires too much honesty.

Why can't you say "creative destruction death panels to kill and chop up and sell body parts of the poor to the rich"?

When you call for treating people like cars, then people are property that is creatively destroyed for profit when the property fails to pay a positive return.

Oddly those who use as the slogan "right to life" merely advocate creating new property which, like all property, has no "right to live" unless able to generate a market rate of return as property.

I think he's talking more about operations of the system, in relation to management sort of stuff, funding formulas, incentives (etc.) of differnet actors. And not about treating people like cars or cows.

The larger shell game is the game or mortality. We're all going to die. But we all want to live as long as possible, as long as it's on someone else's dime. So the shell game is to shift the cost of paying for our own denial of mortality onto a different group of people. As long as someone else gets screwed nobody has to be the asshole who says "Hey, you're going to die. Suck it up."

Stop using my name, imposter!!!

Well, 60% of the population at least are closer to death than life because of their preexisting condition of being unproductive and unable to generate a positive balance sheet. Liberals have made those under the age of about 15 big money losers in developed nations, but even in conservative Africa those younger than age 6 cost more than they are worth, unless they survive long enough to gain five years work experience by say age 12. The rate of destruction was so high that producers of workers pumped out people with preexisting helplessness in hopes 1 out of 3 or 4 would survive the conservative health care system to become productive. But it was leftist handing out free health care that changed that balance, flooding Africa with a huge number of unproductive people who burden the African economy.

With free health care, luck, lots of money lots, those closer to death become net positive return people who are now moving away from death. They are productive enough to buy the things needed to be healthy, food and health care. But after two decades, the are increasing overcome by the preexisting condition of time that moves people back to death, at a rate that traditionally was determined by their rate of return.

Given the productive people are only that after being worthless, and will soon become worthless again, their self interest is in reducing the competition during their productive years, requiring either higher child mortality, or birth control provided to their peers who by preexisting condition of being female causes them to be unproductive while adding to the burden of the unproductive.

Further, those who are productive will not properly value their productive and kill themselves when they become worthless. Thus they begin to rationalize forcing the productive to support them.

Like, "I paid to support you for 20 years of you being worthless, so you owe me 20 years paying to support me while I am worthless."

"Liberals have made those under the age of about 15 big money losers in developed nations, but even in conservative Africa those younger than age 6 cost more than they are worth, unless they survive long enough to gain five years work experience by say age 12."

I have been assured by a very knowing American of my acquaintance in Rio de Janeiro, that a young healthy child well nursed is at a year old a most delicious, nourishing, and wholesome food, whether stewed, roasted, baked, or boiled; and I make no doubt that it will equally serve in a fricassee or a ragout.

Baked? I doubt it

Parents often have children because they are an investment, a very long term one. Children increase the chances you will have someone who will care for you, and help you out with medical bills, in your old age. Of course, at some point the parent (and/or their kids) has to make a cost-benefit analysis as to whether he is better off living another couple of years and spending his grandkids college fund.
Our whole system is set up to that somebody ELSE's grandkids pay to keep you alive that last couple of years. While of course means that children will exist to become spomething like collectively owned workhorses that exist to keep elderly people alive an extra couple of years, even if it fucks their chances for educational attainment.
I mean, literally, Medicare IS sucking resources away from education, and yet, we're told we need an ever increasing number of babies to keep it from going bankrupt.

Cost per capita vs life expectancy.

We can absolutely live as long for less. We can probably even live longer for less. We just can't do it, as #3 says, while pretending it is someone else's problem.

Flashback to 2010:

Pragmatists said "just pick a plan from any nation in a better position, and just do it."

Fast forward to 2017:

Throw hands in the air because "we suck, and Obamacare is the best we can ever do."

We know why America spends more of healthcare than other countries. It's because (a) someone else always pays for it and (b) that someone else is never allowed to say no.
Other countries spend less per capita because they have rationing. However, that rationing also comes at a price.

IMO, the only moral system is the one where individuals must make their own choices- and bear the costs of those choices. That doesn't mean they can't have insurance. It just means they have to pay for their own insurance. (In a properly functioning insurance market where the insurer can't wiggle out of contracts and where the term of the contract reasonably covers the expected lengths of treatments.)
If you didn't bother to buy insurance, even catestrophic coverage, and then you get stage four cancer, well, it's your choice if you want to blow your entire's families savings trying to live a bit longer. That isn't a cost that the rest of society is morally obligated to bear.

The irony here is that the American right (including libertarians) keep on rejecting cheaper options because they are not (from their perspective) morally pure.

Maybe low cost has a moral purity of its own.

You're talking about utilitarianism.
In that case, in a theoretical single payer system, what's the utility of keeping Down's Syndrome babies alive? KIt definitely isn't the lowest cost option.

Utilitarianism does not imply any specific Downs prescription. It just provides a framework for discussion.

(Our Downs neighbor had it together enough to be the main caregiver for her ageing mother. Not always a burden.)

3. What Americans have to pay for health care should be a function of how American they are. My great, great, great, great grandfather fought in the Revolutionary War. As his descendant, I deserve health care without charge. First generation Americans, on the other hand, should pay for their own health care because they are less American. Those in between my deep Americanness and first generation (not really) Americans should pay for part of health care based on a scale of Americanness. There, I've solved the health care dilemma.

I propose health care payments should be based on good looks, or lack thereof. Thus mine would be be very low cost, as would my family's.

When there is a conflict of opinion, I will be the final arbiter.

#3 was specifically an indictment of "the American Middle Class" and their alleged selfish, shortsighted cultural attitude toward health care and personal responsibility.

Typical leftish class warfare thinking, composed entirely of empty rhetoric. Totally ignores Federal Government domination of the American health care system.

It is a critique. All you need to defeat it is an actual healthcare plan that can (a) become law and (b) not lead to ruin in the following election.

Show us.

LOL. The voters don't want to be reminded of the fact that they're all going to die. And that 90% of all health care spending is a grand game of playing chess with death that we're all destined to lose.

That is not actually as bright as you think. Life expectancy has a concrete meaning, and there is a rich literature on influences.

"Longer life and lower cost" should not be a hard sell.

Longer AVERAGE life. Maybe not yours, specifically.

Thing is that when people think socialized medicine, they think "government is going to pay for my treatment". They don't want to face the inevitable reality that someone is going to say no to them.

So really the ONLY question is WHO should be the one who says no? If we're going to control costs at all, that is. Should it be a decision made by some collective governmental body based on a society-wide cost-benefit analysis, or a decision made by individuals based on their own private cost-benefit analysis?

Maybe this is why there don't seem to be any other intelligent civilizations within radio distance. Any sufficiently intelligent species becomes so hyper-aware of it's own mortality, that they eventually consume all available resources attempting to live forever.

"But the requirement of compassionate health care policy is a policy with few beneficiaries. (For a determined libertarian, this means placing very high expectations on charity.)" is "Typical leftish class warfare thinking"

Or are you thinking old age is the only reason people need "The American middle class does not believe in saving up for health care expenses. The idea that you should have $10,000 – $15,000 set aside for the occasional acute medical episode is abhorrent. The idea that you should save up for the inevitable medical expenses of old age is abhorrent. We are not Singapore."

Unless you want the health care of Africa, "old age" starts before birth. The cost of an alarming number of people at age 10 in the US far exceeds $50,000. A significant number of people have $50,000 medical bills by age 30. In Africa the medical costs are much lower because you die before 5 and then 30 when you experience the inevitable "acute medical episodes".

Honestly, is society morally obligated to pay for the medical expenses of severely disabled children?
I mean people who are never going to live productive lives, who are destined to be institutionalized.
I don't mind if their parents and relatives or charities pick up the bill, but why is this something that the government should be paying for?

Again, healthy children are long-term investments, mostly for their parents. Personally, I would rather have parents pay their kids medical bills and reap the rewards than have children be some sort of herd of future workers to be raised by the government so they can be put to work in the salt mines paying for Social Security later in life. Im other words, I'd rather have a system in which individuals make choice for themsleves and those they love, than an impersonal bureucracy in which people are merely resources to be exploited.

Once upon a time, families raised their children while simultaneously caring for their elders. Unfortunately, this scenario inhibits the growth of consumer capitalism. People buying shoes for the kids and grub for grandma and grandpa don't have much left over for bass boats, DVD players and trips to Cozumel. Some other method is required. Since the law requires that children be supported until they're complete adults, it's the old folks that get put on the dole. That's the way it is when the state becomes the head of the family.

Considering it as random chance.

It's only a very recent thing that simple genetic diseases with even just one simple variant can in some cases be identified with relatively high accuracy.

So when someone has a kid with Downs, it's not fair for the parents to have to face the full burden of this.


Well, presumably someone has to be taxed to pay for grandpa and grandpa anyway, so where is the extra money to spend on DVD players and trips to Cozumel supposed to come from? I don't see how there's a net increase in spending without borrowing from the future.
Our entire system is set up so that elderly people can blow the grandkid's inheritance without ever admitting to themselves that's what they are doing.

@Troll me,
I don't get you at all.
The fact that we can identify downs syndrome in utero makes it MORE fair for them to bear the burden, not less. Parents have a choice about whether they want to bring a Down's baby into the world. It's not fair for them to impose that burden on the rest of us. Okay, yes, I get that not *all* Down's cases are severely mentally retarded. However, even those who are high functioning aren't ever going to earn more than minimum wage. If you want to have a Downs baby, fine, you pay for it. There's no benefit to society from providing lifetime healthcare to that kid. They are never going to be a net positive tax contributor.

Hazel - it sounds like you're demanding that people get an ultrasound and abort babies that you think are unfit.

A few short skips and a jump and you're a eugenicist Nazi who just stays out of the active killing. Because once you're mandating ultrasounds for the purpose of determining who is worthy of staying alive, slippery slopes ...

I know that's not a fiar characterization of you as a person. But in terms of the argumentation and what it would lend itself to if put into practice.

Well, come ON. You're a libertarian and what you say amounts to mandatory genetic testing of fetuses! Mull on that, and then try to tell us that an extra few hundred bucks a month for parents of downs kids is really something to worry about. Waste at the DC metro alone probably eats up more resources.

If you want to have a Downs baby, fine, you pay for it.

Where on earth do you go from "society isn't going to pay for your Down's Syndrome kid" to "you’re demanding that people get an ultrasound and abort babies that you think are unfit. "

Or are you saying that having a Down Syndrome baby is a RIGHT, equivalent to free contraception, which imposes a positive duty upon others to enable you to have it?

I'm not saying that that's what you mean.

I'm saying that that's what it would mean for practical purposes. (I just have a hard time seeing how it would be different for practical purposes.)

Going back to first principles, consider the reason that banks initially because useful at a macro level. Risk pooling. (Later, the ability to distribute credit in an economy through free and profit-seeking organizations was also recognized as useful.)

If you want people to have children, and specifically want to promote this (2.1 per couple on average to account for the number of drunken escapade cliff-falling episodes prior to child bearing, etc.), one of the most obvious ways to do this cheaply is to take advantage of risk aversion inherent in most human decision making by risk pooling. Risk pooling can be in the form of wage insurance, or assistance if the development process does not proceed smoothly in the womb or after. (I prefer to ignore explicitly genetic questions for now, which Downs is not, making it a very particular type of case.) In short, anything that capitalizes on the different between expected values and risk aversion, something that a risk pooler such as the government or a large bank is able to do.

If the plan is for all individuals or households to be atomized and completely self sufficient, all manner of theoretical arugments can be easily mustered to demonstrate that this is highly suboptimal from a resource allocation efficiency perspective. Risk pooling is efficient. Risk pooling does not work when set up to exclude anyone who sees the risk come to fruition, because that is not risk pooling.

Random thoughts: I sort of split the middle between you two. Yes, I think society has an obligation, but principally because its priorities and policies seem to favor that expensive-to-care-for child over the healthy never-born. 10 billion people are never going to routinely genetic test their babies. Once a baby with severe defects is born, I find it hard to believe parents, in the US anyway, have much control over its future. Even if they are presented with a choice re a humane death versus suffering and intervention in those early days, it's a choice they probably should not be asked to make.

Just because prenatal testing leads to a traumatic decision where Downs syndrome is concerned, nothing ever being black-and white, I think it needn't be as difficult with more severe defects. It would help if it was not cast as a tragedy. To fetishize extreme disability is not the same thing as upholding the value of life. And the moral calculus is just so altered when medical advances make possible the survival (but only that) of a child that once would have been cradled and hopefully loved for probably only a brief time.

I understand the foregoing paragraph would be read with outrage from by both a Ross Douthat on the one hand and a SJW on the other. When that is the case, I think it's time to consult common sense and instinct.

It has been the "correct" thing to do for so long that it no longer seems like a "choice," but delaying reproduction as long as possible is another decision women make that is not free of consequences when it comes to the incidence of Downs (and perhaps other birth defects, too, I believe).

@Troll me,
I don't think people should be incentivized to have babies at all. I don't buy into the idea that the government should promote an ever growing population.
It is far from clear to me that more babies are beneficial to society.

Anyway, the fact that you can accurately test for genetic disorders means that it's NOT a "risk". Risks are unknowns. When someone has a baby and refuses to get tested they are being willfully ignorant, thus imposing a risk on society without consent. If someone gets tested, knows that the baby has a genetic disorder, and has it anyway, that's not a "risk". They KNOW they are imposing a cost on society. If you want to pay those costs yourself, fine, go ahead. Note: I'm talking about known cases of disability, not risk factors, everyone's got risk factors. If you know you're going to give birth to a disabled baby and you choose to have it anyway, that's a choice you made. You're free to make that choice, but you're going to have to pay for that disabled baby's care. Make your own cost-benefit analysis and choose. It's not like civilization is going to come to an end if parents privately make their own decision to abort disabled babies.

@Troll me,

I suppose in the rare instance where someone gets tested, it comes up negative, and the baby ends up disabled anyway, THEN you could make the argument that society should pick up the cost. As the testing gets more accurate and ubiquitous the number of missed cases should be vanishingly small.
And of course this is only if you buy the idea that society should incentivize reproduction. If having a kid is just something adults do for fun or self actualization, then they are responsible for the risks they take.

@ peri. Yes, this issue where formerly a parent was allowed to just not feed the child they did not want, or not allocate large resources to its survival, changes a lot of things.

On the one side, you have people saying "life is sacred, you cannot do any of those things", but then these people are mostly situated in the same political camp as those who prevent mutual assistance towards doing so. Those who hold both perspectives can only argue "they should have kept it in their pants", along with complete refusal to admit that this view is of basically no practical use (ESPECIALLY considering that most who follow both of those very often also have aversion to contraception availability ...).

There are those who see this as a source of genetic degradation. That's dumb. The saved lives we're talking about right now, I don't think these are people that are likely to find someone who wants to have children with them.

The moral calculus is very different when you're weighing school uniforms for child 6 and child 7 versus food for child 8 that will never be able to attend school. When all these options and more can be easily afforded at the same time, perhaps at a cost of a few less F35s per year at the system level, well, the moral calculus is different.

A "risk" is something with a defined probability of a negative event occurring. This is different from "uncertainty". Most finance books will discuss this with rigorous definition at a fairly introductory level, and this is a major topic in second year economics and again in core courses at the graduate level.

Also, genetic tests are not as accurate as the people who market them would claim. There have been several studies demonstrating that claimed genetic indicators actually have a fairly high false positive rate. Maybe give it another decade or few.

Kind of quibbling on words, but it's not sure that we're talking about quite the same thing.

On the matter of whether reproduction should be a concern of the state, I follow the words of a former prime minister of Canada who is widely hated on the basis of having broken certain rights which in fact only exist because he pushed through a constitution at a later date which formed the basis of those rights they recall as having been violated ... ... the words being "There's no place for the state in the bedrooms of the nation".

But so long as there are no strategies which are effectively in maintaining prosperity and stability in a time of declining population, the objective of maintaining at least stable population is quite sensible I think.

Really, I don't want the government involved even a tiny bit. Child care or parental leave supports would promote child bearing, but this can be supported through the principle that men and women should tend to have similar opportunities for practical purposes. So, then, both men and women should be able to benefit from parental leave to spend time with young children. But the idea of this existing for the purpose of state management of reproduction? Definitely bothers me.

I think the government-sanctioned "12 weeks" or whatever it is of childbirth leave is absurd. It establishes, in a way government has no business doing, the idea that spending time with your child is an occasional, special thing to do. That it should be someone's job but definitely not your job. And it does so in ridiculous fashion: there are a whole lot more 12-week periods in a child's life when the presence of a parent would matter than that initial period when the infant sleeps most of the time. But of course, it's not really for the child, it's for the parent, who will not be sleeping well enough to be worth anything at work.

Better to invite Grandma to stay with baby and spend that 12 weeks searching high and low for someone nice to take care of your child.

Or skip it and get that work/life routine in gear.

1. What that article left out was that many Jews (usually ultra-orthadox) do not accept the eruv as a valid loophole, and even within the eruv will not carry anything on the sabbath. They won't carry their own keys, wallets, or even push strollers.

Also the Rabbis that maintain and check the wires can sometimes get into all sorts of trouble because a watchful policeman or utility worker is unaware and thinks they are doing nefarious things with the utility poles.

Is that why the LA eruv is a physical ring of metal mesh fence? Last I heard they ran out of money (lost a major sponsor) to maintain it. It might be interesting to watch when there is a strong solar flare. Interestingly the White House is near a segment of the DC eruv which hopefully is not metallic which might be used for EMF snooping ...

Their ancestors were happy to accept eruvim, but all of a sudden in the last 50 years everyone wants to be stricter than Moses.

Americans, and especially health care providers, do not want to think of health care as a commodity.

This is true, but the US is hardly the only place where it holds. I don't see why it contributes to specifically American health care issues.

We have an eruv here in Bala Cynwyd.

Please don't link to sites like mental floss..

Especially when it was taken directly from business insider.

I second the motion. There are a small number of websites that actually crash my browser, and mentalfloss is one. It's like stepping on a landmine. If I stop the load really fast, I can prevent it from happening.

Apparently Trump is throwing Ryan under the bus. I am sure low-information Trumpians will go for it, but I am not sure what it buys.

Will the House snap-to and follow Bannon's next orders without question? Or will open warfare in the House scuttle dreams of tax reform?

Which "base" is even the "base" right now.

Only base people betay their friends that way.

Re: 2
Back in '88 as an infantryman in West Germany, I developed an ingrown toenail infection after a 20+ klick foot march. I watched an enlisted medic remove 1/2 my big toenail under a local anesthetic. He'd done this procedure several times...
Healed up fine in a couple weeks with regular bandage changes. I may have been given antibiotics.

I told this to my doctor and he was horrified. It's probably a felony in most states for a non MD to do anything similar. Which is another reason medical costs are insane...

There is an eruv in Irvine, CA (obviously set up by a conservative Jewish congregation). Funny thing about the eruv placement is that the synagogue of the liberal congregation (just down the road from a couple of conservative synagogues) is excluded from the eruv by only the width of a street.

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