Thoughts on this citizen's mind (rianjs.net (Hanser)) by Rian

The Obama transition team has a website up at change.gov, as many of you may know. Specifically, they have a section where you can share your thoughts with the transition team. I don't know if they are actually reading these submissions, but I wrote one up anyway. I'm sharing it here…

I'm going to set aside my inner cynic that someone will actually read this, and talk about what has been worrying me as a concerned US citizen. I know that there is only so much an administration can do to solve the myriad problems we face, and that trying to tackle too much at once is a recipe for universal failure. Therefore prioritization is obviously key.

My primary overarching concern over this country has been any lack of a long-term strategy. I don't mean for one specific area like the economy or healthcare, but I mean *any* kind of long-term strategy for *anything.* Thus far, it seems as though we've been shifting aimlessly from one priority to the next, dictated to us often by market prices of various commodities and shifting popular wants.

That's no way to run a country.

This list is not in any kind of prioritized order because I think all are equally important at the end of the day:

1) Education: The US has been falling behind in the ability of our high school graduates to afford and go to college. This is happening even as the entry-level requirement for many jobs is having a college degree (even though the particular job may not actually warrant it).

Almost universally, my college professors have publicly lamented the fact that high school graduates are not prepared for the intensity of the material that they face as freshmen in college. As a smart, in-touch individual, I know for a fact that my math was not up to par, and I went to an excellent public high school and graduated in the top 10% of my class. Our state colleges and institutions do a spectacular job, and we should continue to invest in them, but if a student is incapable of succeeding there thanks to a poor secondary education, something is wrong. Accountability in secondary schools is very important. Maybe we need better ways to measure student performance, I do not know. Something must be done, however, because we are falling behind countries like India whose high school students are better prepared for college than ours.

The gap between boys and girls continues to widen. While we've done very well by our girls in the last 20 years, our boys have languished. Education should not be a zero-sum game wherein one sex succeeds at the expense of the other. We have neglected boys and focused all of our efforts on girls, and this is neither fair nor desirable. Both sexes can succeed together, and our educators need to remember this, and not just recommend a visit to a pediatrician or psychiatrist for our boys because stimulant ADHD medication isn't the universal diagnosis and answer.

2) Healthcare: The US lacks any kind of long-term healthcare strategy or vision. While I believe that some form of universal healthcare coverage is both necessary and desirable, President-Elect Obama should stop saying that every person will be able to get health coverage like members of Congress have because this is not possible, nor is it desirable. When and if universal coverage happens, there will still be two tiers of healthcare. A basic, public tier, and a second private tier that citizens may opt to use if they desire to pay more. Please keep in mind that I say this with no malice toward the currently uninsured. My dad had a heart attack this past spring and waited 36 hours before going to the ER — because he knew that he would end up $50-80K in debt. (And he did.)

Secondly, politicians need to stop conflating the idea of universal health coverage with universal health access. The two are not the same. Just because you are covered doesn't mean you can see a doctor. We don't have enough doctors and physician extenders (Nurse Practitioners, Physician Assistants) in this country to see everyone, and going to the ER is not the answer either: they're already overcrowded.

Massachusetts is experiencing this now. While we are often looked to as some kind of model for the rest of the country, the reality is that our system is far from perfect. It's costing the taxpayers boatloads of money because healthy people that can afford to pay are NOT signing up at nearly the rates that the unhealthy poor are. After all, if you're healthy, you don't need preventative care, the colloquial thinking goes, and even if you do, it's cheaper to pay out-of-pocket to see a doc than it is to pay a high monthly premium. In Massachusetts, the accounting math isn't working out as expected because of this particular adverse selection catch-22. Complicating the financial problem, there are not enough primary care physicians in this state to see the massive influx of new patients which highlights the second point I made: coverage does not guarantee access. That means they go to the ER, which is inherently more expensive than an ambulatory office visit.

To reform healthcare meaningfully, you need to do it in a multi-phase manner:

1. Attract the best and brightest back into medicine. That means making the idea of practice attractive which means real, honest-to-God tort reform, not lipservice. When a physician is paying more to medmal companies than s/he is taking home, there is a very serious problem. Talk about a disincentive to practice.
2. Along those lines, we need more primary care physicians. That means paying them more. Right now, the RVRBS is stacked in favor of specialists, and members of the committee are appointed for life (stupid idea). PCPs do more patient visits than specialists on the order of 8:1, but they are not represented in anywhere near this ratio in the RVRBS committee. That means that procedures are over-valued and cognitive specialties (primary care, rheumatology, endocrinology, etc., etc.) are undervalued because it is difficult to measure the relative value of a cognitive visit. As a result, medical students are gravitating towards specialties which pay more, and the free market is not allowed to compensate for the relative lack of PCPs because the way reimbursement is calculated is fundamentally flawed. In the long-run, this means more expensive healthcare because patients will be seeing specialists instead of PCPs, simply due to lack of PCP supply.

Senator Obama has advocated investing in technology, which is very necessary, but electronic medical records and other efficiency concerns are not a panacea, either. The entire system is broken from top to bottom and improving efficiency in a superficial fashion will NOT solve the huge, underlying problems. A study recently published estimated that only 50 cents of every dollar spent in the name of healthcare is spent on patient care. That's a bigger problem than mere technological inefficiency.

3) Energy independence: Senator Obama has promised energy independence, and his message has not changed since his 2004 DNC keynote speech. Right now, our government is listing from priority to priority. Gas prices go up, and all of a sudden the public is clamoring for the government to "do something." Prices go down, and people stop caring, but we know that petroleum supplies are fixed and demand is effectively infinite. That means that eventually prices will go back up, and we need a long-term solution. Keeping the country's eye on the ball is the government's job, because it's clear that most private citizens cannot or will not.

Command and control government regulation is sexy and it makes it look as though government is "doing something" about our dependence on foreign oil, but a more progressive Pigovian tax is probably a better way to accomplish the goal of getting our automakers on-board with the next generation of propulsion than is mandating fuel efficiency and carbon emissions standards. Even if the money is returned in the form of an income subsidy, modifying demand is more effective than trying to legislate supply.

We need government intervention because energy independence and a healthy environment cannot be achieved by individuals acting by themselves — bless their hearts. It needs to be broad and bold in scale and impact. Replacing the light bulbs in your house and planting a few trees might be part of A solution, but it's obvious that it's not the ENTIRE solution.

4) Iraq: Iraq is the only US priority that seems to have a strategy under the Bush administration. While I believe firmly that the Iraq war was "dumb," like Senator Obama, we cannot simply leave and end up with a power vacuum in that nation. We messed it up, and now we should be on the hook to fix it. I am reminded of the lessons from the 70s in Afghanistan which allowed us to defeat the Soviets covertly, but ultimately paved the way for the Taliban because the US "wasn't in the business of nation-building". Money for war, but not for education and infrastructure-building. We can see the disastrous long-term consequences of these policy choices that we are dealing with even today.

5) Outsourcing and Globalization: O&G will continue under any administration, and we should not try to stop it. In the long run, it is good for our economy anyway. However we cannot forget the workers that have lost their jobs. Suggestions run the gamut for re-training builders and makers for the healthcare and technology sectors, but we cannot ignore the fact that people are not cattle to be herded in one direction or another. Many of these individuals don't want these jobs because building and making things is part of who their identity. They don't want to be nurses, phlebotomists and IT technicians. And they shouldn't have to be.

Instead we should gently nudge them in the direction of infrastructure repair (which needs to be a priority in the new administration) and the new renewable energy economy. With a focus on renewables and infrastructure repair, President-Elect Obama can employ the tens of thousands who have been laid off in fields that are not dissimilar to where they came from, which will keep them happier and more productive.

(Of course, if these people want to change careers completely, they should have these educational opportunities available as well, which ties into my thoughts about education.)

6) Public Service: The best and the brightest need to see government as a worthwhile place to spend their energies. The politics of the last decade has been toxic for self-actualized smart people, and they haven't wanted to go into public service. I know Senator Obama knows this, and simply by being open-minded and obviously intellectual, he has done a lot to change the stereotype of politicians and public service. For that, I am grateful, and I can honestly say that I am considering public service as a long-term career whereas under the Bush administration, such an idea would have been laughable. I know that there are many other smart people in my generation who feel the same way. For that, I am thankful.

Wow, Keith Olbermann. Just… wow. (rianjs.net (Hanser)) by Rian

Fantastic.

Fulltext.

Let's get normative! Octogenarians and heart surgery (OnThePharm (Hanser)) by RJS

Healthy octogenarians are apparently good candidates for heart surgery. Now I can't say that this surprises me. Those who take care of themselves and have good genes are experiencing longer and longer lifespans. This is basically true even in developing nations — if not to the degree that it is in developed countries. We have record numbers of people living beyond the age of 100. From a human perspective, this is an amazing achievement. But from a pessimistic, Malthusian point of view, death is useful.

Patients 80 years and older who are in overall good health are perfectly able to withstand open-heart surgery, according to the latest study of Dr. Kevin Lachapelle of the McGill University Health Centre (MUHC). His findings were presented this morning in Toronto during the 2008 Canadian Cardiovascular Congress.

"Age should not be a reason for doctors to rule out the possibility of heart surgery for their octogenarian patients," explained Dr. Lachapelle. "If patients with heart problems are otherwise in good health, this surgery can significantly improve their quality of life."

Well that's fantastic. (It really is, I'm not being sarcastic.)

Economics is fundamentally the study of the allocation of scarce resources subject to effectively infinite demand, and while we like to think that healthcare is an infinite good, it most certainly is not. Specifically, normative economics is the process of incorporating value judgments into economic arguments. Most economists avoid making value judgments because there are always exceptional cases, and because it often leads to spectacular foot-in-mouth syndrome. That said, I can't help but have thoughts that tend toward the normative when I read paragraphs like the one I quoted.

Sure, octogenarians may survive and even have a net positive outcome. But what are the opportunity costs associated with operating on individuals who have already exceeded the mean lifespan for someone of their sex? Are we operating on these folks while leaving those that are younger — and therefore potentially more productive — in the lurch? Are we forgoing an operation on someone much younger? How does the fact that the average 80 year old is not as productive as the average 40 year old factor into this equation? Generally taxpayers want something in return for their investment. Do we want the government subsidizing a procedure on someone whose primary income is their monthly Social Security check, and if the answer is yes, how do we prioritize who goes first? How do we manage that inevitable wait list? Generally we subsidize healthcare because we expect some kind of benefit in return, usually in the form of economic output.

I've worded my questions provocatively, but I don't really have an opinion one way or the other, except to say that I'm glad that I won't be the one who has to make these decisions in the coming years. These questions aren't purely rhetorical either: these are very real, difficult questions that are going to have to be addressed as we move inexorably toward some kind of basic universal health coverage in the United States.

As I pointed out yesterday, Americans don't like to be told "No," and we don't like to wait for things, and I mostly include myself in that generalization. If we postpone, or worse, opt to forgo very costly surgeries on the elderly because a cost-benefit analysis doesn't add up, will our culture be able to accept it?

My guess is no, and as soon as it happens, there will be some very ugly public political lynchings.

What are your thoughts?

Public health and entitlement (OnThePharm (Hanser)) by RJS

Cathy wrote a thought-provoking comment on my last post, so I thought I would respond to it in its own entry.

I'd imagine costs for DM2 care had risen, like everything else, but was surprised to hear the thoughts about public health & nationalized health insurance. It's been a long time since I took a public health class, but I'd been under the impression that they were cut from the same cloth. Now, that I think of it, I don't hear about Medicaid paying for diabetes education, but then, I'm not familiar with who utilizes the program, and who pays for it, whether Medicaid, Medicare, or private insurers would reimburse the provider for diabetes classes.

Because pharmacists and ancillary staff deal primarily with drug therapy, we tend to think of the rising cost of healthcare as a result of the increase in the cost of prescription drugs. However this isn't actually true. According to the CEO of Harvard Pilgrim, drug costs have been increasing at a rate of less than 5% per year, whereas medical expenses have been increasing at a rate of about 10%, so the increase in healthcare costs isn't really driven by prescription drugs as much as is commonly thought.

In the long run, drugs tend to be cost-savers rather than cost-centers when utilized correctly, but that's not news to anyone.

When you speak of $1 for public health are you saying 'education & prevention'. If so, I would agree conceptually. There are probably long-term studies that prove this beyond a doubt.

Yes, that is what I mean, but I was unintentionally vague in my first post. I consider public health to be education and prevention in the form of programs and legislation design to try to have a long-term impact. I also consider public health to be (mostly) a public good in the economic sense of the term.

But the government considers public health to be quite a bit more than that, ranging from the IHS to Medicare/Medicaid to the FDA. When you look at their FY2009 budget (121 page PDF), I would have to cherry-pick the bits and pieces that I consider public health, add up their budgets and calculate the percentage of the whole… So clearly that's not what Uncle Sam considers public health, and I should probably find a better term. "Education and prevention" like you suggested is good, but I think that's a bit limited, because I see the laws that are being passed that prevent the sale of certain types of food in public schools to be public health, as well. Then there's the work that the CDC does — particularly in containing and eradicating communicable diseases like smallpox and polio — and other things like providing clean drinking water and sanitation.

At the very least, though, I consider "public health" to be very separate from more traditional healthcare delivery.

And, so I'd venture your point is that any successful nationalized healthcare insurance-type or other type of program would need to incorporate a preventive arm with incentives for greater self-care. A lot of the obesity problem has to do with not bucking the current socially acceptable behaviors, i.e. too much availability of nutritionally cheap food, devaluation of importance of physical effort and exercise, sedentary lifestyle, plus knowledge deficits about foods and hidden human costs. Look at what happened when NYC banned trans fats, for example. I think the fallout will be realized in our lifetime, with a slowly falling domino effect.

Yes, a comprehensive wellness-type program would have to be instituted. I would go so far as to attach financial penalties to those who are wildly unhealthy. Think of it as almost like a Pigovian tax, if you will. Even if you return this money to the consumer at the end of the year in the form of an income subsidy, it's still a powerful motivator to change because there's a real financial pain associated with a specific aspect of their lifestyle. Then of course there's the perennial moral hazard problem that's never going to go away. It is true that if you are responsible for a greater part of your healthcare costs, you will go out of your way to make healthier choices to minimize the chances of becoming ill. (Just ask those who have consumer-directed health plans with high deductibles who pay out of pocket for "normal" medical care.)

But of course you need to fund pathways that would enable people to learn and make healthier lifestyle choices. You can't just take an overweight smoker who works in a coal mine and has less than a high school education and tell him to lose 100lbs or he'll pay more for his healthcare without setting a reasonable timetable and funding the education and exercise program that will help him get there. That's just rotten and doesn't help anyone.

What is troubling and will present problems in a nationalized system of healthcare is that Americans don't like to hear the word "No." We live in an entitled society where the customer is always right, and it's our God-given right to have cheap gas, drive SUVs, eat our fast food, and spend our the government's money on futile, end-of-life care. In other countries that have nationalized healthcare, there are very limited formularies in place, and many treatments and interventions aren't covered at all, or if they are, there may be a multi-month waiting period to have that procedure. That kind of rationing would be tough for America to swallow. We seem to have this bizarre notion that simply because we are living, breathing human beings, we are entitled to X, Y, and Z, and we should have it now.

Obviously we're not beautiful and unique snowflakes, and I think that the younger generations are beginning to recognize this as their thoughts linger on new ideas like "sustainability", but I get the sense that the baby boomers are going to resist these kinds of necessary limitations.

Anyway, hope I answered your question.

Cost of diabetes treatment has doubled in 6 years. Is anyone surprised? (OnThePharm (Hanser)) by RJS

Research out of Stanford USOM indicates that the total money spent on diabetes care went from $6.7bn in 2001 to $12.5bn in 2007. I can't say I'm terribly surprised. Every time you turn around, someone's hammering the dangers of monotherapy down your throat, especially when a comorbidity is present. (When isn't there one?)

However, I am pleased to see that the Stanford researchers are interested in how much of this extra cost is due to costly new medications that may or may not be worth their price — a topic too rarely discussed in the Ivory Towers of academia. They cite Januvia and Byetta as potential cost centers, but I can't help but think that they're missing the mark just a little bit. In outpatient diabetes management — and I'm going to assume that institutions and hospitals are similar — Byetta and Januvia, while successful, aren't what I would consider blockbusters. They aren't super mainstream yet.

In terms of quantity and price, the TZDs — particularly Actos, since Avandia got thrown under the bus — are far more costly. Yeah, incretins, whether direct or indirect are the new CME hotness with the associated mindshare, but compared to your TZDs, biguanides, and sulfonylureas, they're a distant a second/third/fourth fiddle in volume, if not cost.

Drug companies market these new drugs with claims of greater convenience and better control of blood sugar levels, and physicians have increasingly used them as alternatives to injected insulin, Alexander said. Insulin use has correspondingly dropped from 38 percent of treatment visits in 1994 to 28 percent in 2007.

This particular sentence bugs me because the implication is that insulin is cheaper than most oral medications. This just isn't true, particularly with the modified human insulins that can be very costly indeed. At the very least, they're on par with the cost of oral meds, and let's not forget that most people with T2DM would prefer not to stick themselves with a needle, no matter how small.

Talk of direct costs aside, it is obvious that $1 spent in the name of public health has a greater marginal utility than $1 spent on a medical intervention — be that drug therapy, a procedure, or whatever. Ben Franklin was right, after all. Unfortunately, the long-run cost savings of public health programs are notoriously difficult to measure, and certainly nowhere near as sexy as a medical intervention. Perhaps that's why public health gets shortchanged? I've spent some idle moments wondering how much money we could save if we spent a third or even a quarter as much combating things like poor nutrition and obesity as we do on direct healthcare itself.

It seems like the bulk of the money spent on prescription drugs is spent to offset the poor lifestyle choices that we Americans like to make. Unfortunately we pay dearly for that privilege. Any sort of nationalized healthcare will have to take this God-given right tendency into account.

Benjamin Franklin on vaccination (rianjs.net (Hanser)) by Rian

Ben Franklin is one of my all-time favorite historical figures; there are few people who have been universally successful in all they've done: business, politics, science, and humanitarianism. Franklin was one of these, and he's left a guidebook for those who wish to follow in his footsteps. (And really, how can you beat $2.50 for a brand-new book?)

I've been reading through it lately, and while it's easy reading, it's so chock-full of wisdom that I find it slow going. Lunchtimes and evenings find me with pencil in hand, underlining and annotating the bits that especially speak to me, and there are many.

I came across this paragraph, and I was astonished. With the anti-vaccination crazies gaining influence and mindshare, this earthy bit of common sense was a breath of fresh air, written in the 1700s by someone who knew a world without vaccines, and saw the devastation caused by these diseases — smallpox, polio, and many others — first-hand.

In 1736, I lost one of my sons, a fine boy of four years old, by smallpox, taken in the common way. I long regretted him bitterly and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way, and therefore that the safer should be chosen.

Simple and profound. Alas, I don't think the anti-vaccination types will take his advice to heart, and we are all the poorer for it.

Custom Word medical spell check dictionary updated (OnThePharm (Hanser)) by RJS

I have updated MeDic with a new version. 0.0.2 brings the dictionary from 41,009 words up to 66,239.

I have erred always on the side of accuracy, opting to omit a word when I couldn't be sure that it was correct. Users have submitted their own additions, and I have folded them in, after verifying their accuracy to the best of my ability. Many of the words are quite obscure, as most of you can imagine.

Most recently, someone from Australia has created an Australian localization for the work, and I have added that to the page as well.

I think this is a better option for students and anyone else that wants a pretty comprehensive spell check word list, and doesn't want to pay Stedman's $100 to get one. This is also much more comprehensive than those $15 shareware dictionaries that you see floating around — many of which have spelling errors. (I know, I've looked at most of them.)

MeDic is, of course, freeware. And always will be. It's also available for OpenOffice.org, for those of you who don't use Word.

If you think it's useful to you or someone you know, please bookmark it, Stumble it, or even throw me a link to the MeDic main page:

A history of debt in America (rianjs.net (Hanser)) by Rian

While going through my RSS reader this morning, I came across one of JD's daily links posts, and one of them was to A History of Debt in America. It's quite a long article, but well worth reading. Unfortunately for people like me, reading large quantities of text on a screen gets to be painful after a few minutes.

I whipped up a quick PDF of all of the pages, and Tom, the author of the article, has graciously allowed me to post it here.

It's 21 pages long, and will take you a little while to read it, but it's worth the time.

PDF link.

If you enjoyed this, you may enjoy my post on how paying off debt is like folding laundry — a behavioral, as opposed to mathematical approach to paying off debt.

Matt's back! (rianjs.net (Hanser)) by Rian

Matt, from Where the Hell is Matt is back, and it's awesome.

Here's the HD stream:

Where the Hell is Matt? (2008) from Matthew Harding on Vimeo.

I love Matt. I remember his first video from back in 2005 and 2006. Feels like yesterday.

Some of the locations in this video are:

• Papua New Guinea
• Munich, Germany
• Tongatapu, Tonga
• Chicago, Illinois
• Thimphu, Bhutan
• Mumbai, India
• Sydney, Australia
• Lisbon, Portugal
• The Demilitarized Zone, Korea

The list goes on and on. I dunno why, but it kind of brings a tear to my eye. It's just so… human.

A unanimous triump of common sense (OnThePharm (Hanser)) by RJS

Two posts ago:

Arthur Firstenberg says he is highly sensitive to certain types of electric fields, including wireless Internet and cell phones.

"I get chest pain and it doesn’t go away right away," he said.

Firstenberg and dozens of other electro-sensitive people in Santa Fe claim that putting up Wi-Fi in public places is a violation of the Americans with Disabilities Act.

Result:

The City Council has unanimously approved a plan to provide wireless Internet service in libraries and other city buildings, over the objections of those who say they are electrically sensitive.

That doesn't mean the legal wrangling is over, however.

Julie Tambourine, an advocate for the disabled and homeless, said after Wednesday's meeting that the legal analysis was flawed, because it didn't take into account those with diabetes, seizure disorders, respiratory ailments and other conditions that can be adversely affected by microwave radiation.

These idiots need to read up on the electromagnetic spectrum. Unless they're going to sit in a lead box all day long with no visible light on a carefully controlled diet, they're going to be exposed to all kinds of EM radiation, including gamma rays throughout their lifetimes. And even inside that theoretical lead box, there's no guarantee of being radiation-free.

For further comic value, these people's minds would explode if they had any idea of how many radio waves pass through their bodies each second. Theoretically, for physiologic purposes, 802.11b+g wi-fi signals (0.124-0.121m wavelength depending on channel) are no different than FM radio signals (~3m wavelength). Common sense would tell you that that's pretty insignificant.

But since common sense is often wrong, we look to the actual evidence. And the evidence in favor of wifi radiation sensitivity just isn't there.

I Was Born to be a Native Citizen of the Internet (Tiny Screenfuls (JoshB)) by Josh Bancroft

I’m re-reading the Cluetrain Manifesto for the nth time (grabbed the text from the website, dropped it into a text file, and threw it onto my Kindle). There’s something distilled and concentrated about the ideas it contains. They just ring true, even though the book was written 10 years ago (ancient history in Internet Time). I can barely get through a few paragraphs of it before my mind is swirling with ideas and things I want to write about. Maybe I should just do a “book report” on it, chapter by chapter, and write up everything I’m thinking as I go along.

I feel like I was born to be a native citizen of the Internet. I was reading the Introduction and part of Chapter 1 of Cluetrain, where Christopher Locke talks about how telling stories to each other is an ancient, intrinsic part of what it means to be human, and how when the Internet (and the Web) came along and started to flourish, people who were used to being isolated in their own homes and used as targets for broadcasters flocked to it by the millions. Why? To BE with each other. To laugh and argue and tell stories and learn and be human together.

I was born in 1976, and computers (and later, the internet) have been a part of my life for as long as I can remember. Much longer, I suspect, than most people of my age and my experience. I credit my grandfather, Dr. Ron Hansen, for that. He’s one of the smartest, most connected men I know, and from a very early age, he took it upon himself to make sure I had opportunities that most other kids just didn’t. He knew that “computers” were going to be a Big Deal(TM). And not just in the vague sense that someone might look into the future and make that (now obvious) prediction. He was a retired Air Force officer, university vice president, and research scientist, with a PhD, and his own research institute that “spawned many high-tech spin-offs, including WordPerfect, Novell, and Dynix”. He really knew what he was talking about.

I got my first computer when I was five years old. I was in kindergarten, it was 1982. It was an Atari 1200 XL (the top of Atari’s 8-bit line at the time). It had a whopping 64 kilobytes of RAM, and it took cartridges. That is, if you wanted to play Dig Dug or Pole Position, you inserted that cartridge. If you wanted to program, you popped in the BASIC cartridge. Without a cartridge inserted, the only thing the computer could do was display the Atari logo in a phasing, shifting rainbow of color. Programs were stored on and loaded from cassette tapes (later, I got a 5.25″ floppy disk drive, which was the size of a large toaster). My grandfather gave me the computer, a few games, and some books on BASIC programming, and I went to town.

I have a very clear memory of one of the first things I ever tried to do with the computer (which is what sparked me to write this). This was before the era of the personal computer, when a computer in the home, using the TV as a monitor, was still a novelty. I remember getting that first command prompt, and typing a question. Something along the lines of “who was daniel boone?” SYNTAX ERROR was the response. I was reasonably sure that wasn’t the right answer. So I tried again. When my parents (who to this day don’t own a computer) saw what I was doing, even they understood why my query wasn’t working. “A computer only knows what you tell it, what you program it with.” That made sense, and I accepted it. But I what I remember so vividly is that before someone told me otherwise, I instinctively grasped the idea of interacting with computers in the way that’s second nature today to us as “citizens of the internet”, living in the Age of Google.

I spent the following years in the isolation of pre-Internet computerdom. Playing, hacking, learning what I could. But it all felt so limited, looking back. I was restricted to book or software that I could get my hands on through my grandfather, or people he knew (many of his associates in the high tech world had a part in my geek upbringing). Entering in BASIC programs (games, mostly) by hand from books and magazines. But somewhere, in the back of my mind. there was always the insistence that we should be able to ask a computer any question, or use it to talk to any person we wanted, and it should just magically obey.

My grandfather continued to supply me with opportunities to use, play with, and be around computers, long before that was a common thing. He got me a “Franklin Ace” (an Apple II clone with a bad ground somewhere in the power supply, that delivered a healthy shock if you touched the right place on the metal case), a huge 20 pound Zenith 8086 “laptop” (one of the first with a hard drive, and a blue-and-gray 4 “color” LCD), and a succession of PCs. He made sure I got to attend summer programs, and learn a few rudimentary programming languages (I remember Pascal and Turtle Graphics). I learned DOS and Windows by messing around, reading help files, and by playing. By the time I hit my teens, he got me access to Brigham Young University computer labs during the summers. The very places that the pre-commercial, pre-consumer Internet was thriving.

I spent the summer of 1994 learning HTML and the basics of the internet in a computer lab at BYU with Paul E. Black and some of Dr. Phil Windley’s graduate students (yes, that Phil Windley). I created the very first website for the BYU Alumni Association, completely by hand. This is the current site - the Wayback Machine at Archive.org doesn’t go that far. Later, in high school (1994), I was the webmaster for the first school in the state of Utah - Springville High School - to have a website, and helped to build a site for the Springville Art Museum.

That was my first exposure to the world of connected computers, and shared access to more information than you could dream of. Web pages that could magically take you to another page just by clicking the blue underlined text. “Surfing” from one link to the next, and when you found something cool, trying to remember how you got there, so you could get back. Exchanging messages with other people, anywhere in the world, via email. Having so many choices, and so many pages to choose from, that you had to start using a directory site like Yahoo! to find what you were looking for (there were no good search engines yet - this was way before Google, and the idea that you could index the WHOLE web in one place). And, looking back, perhaps the most significant of all, in the context of connecting human beings to each other - the reason we all flocked to the Internet in the first place, before companies figured out how to make money off of it - USENET newsgroups. Precursor and grandfather to discussion forums, blogs, and social networks.

I’m going to pause the story for now - this has gotten quite long. I feel like I’m writing a book. Maybe I am. If a few little pages of the Cluetrain can draw out this much, perhaps you and I both had better prepare for a lot more writing like this. I feel compelled to write it, and it’s fun. I hope someone, anyone, wants to read it. It makes me feel more human. Maybe it will help me find and connect with people who feel the same - other native citizens (and immigrants!) of the Internet.

A smattering of images that have made me chuckle recently (OnThePharm (Hanser)) by RJS

In no particular order:

This one's for The Angry Pharmacist:

And for keagirl and Dr Schoor:

Hillary's superficial plan to "fix" gas prices (rianjs.net (Hanser)) by Rian

It seems that Hillary Clinton wants to tax big oil, but only on their record profits. She would do this to make up the revenue lost while putting the federal gas tax on hold for a while. While I'm sure this is more of a ploy to pander to voters due to her faltering campaign, the whole thing is incredibly superficial for a couple of reasons.

The first is that taxing big oil is only going to shift the cost to consumers. While you might see a temporary drop in prices at the pump, businesses typically shift such burdens on to the consumers. Doing this only makes sense for their bottom line. Beyond this, it will cause an increase in demand, causing prices to rise naturally. But then, Hillary apparently doesn't care what economists think.

Secondly, there's the temporary nature of the repeal. Reinstating the tax after it's been rolled back for a while will be unpopular on an epic scale, but I suppose Hillary is mostly going for a short-term boost to get her through to the November elections. Naturally, I've heard nothing about rolling back the tax on big oil's profits once the federal gas tax would go back into effect. That means that the consumer is going to be doubly hurt in the end anyway.

This leaves big oil's profits right where they're at now. Taxing big oil's profits isn't the answer — and neither is breaking up the oil monopolies. (Though the latter might not be a bad first step.)

The real problem is that demand has exceeded supply. This is a result of the American way of life. We depend on oil for literally everything: we are a spread out nation of roads where a child's first thought of freedom = getting their drivers' license, and whose development has, for generations, been driven by cheap oil. Every aspect of our lives is controlled by the road: everything from our food to our consumer goods arrives via truck. Auto companies have been complicit as well, and in some cases actively undermined attempts to create efficient mass transit systems that were a direct threat to their business model.

This isn't a problem that can be fixed overnight, nor is it a problem that will be cheap or easy to fix. Comparisons to European nations and Japan with their comprehensive mass transit systems are inherently flawed because of the US's relatively low population density and sheer size of our country. While effective, efficient mass transit is certainly the answer in urban and larger suburban areas, those systems do not scale well in more rural areas.

In that respect, we will always be a nation of cars — or other personal transport devices[1]. The mantra that we need freedom from foreign oil is trite, and it misses part of the point: we need freedom from petroleum in general, inasmuch as that is economically and techonologically possible. We will always be somewhat dependent on combustible fuels so long as the internal combustion engine is our primary mode of getting from Point A to Point B. (And really, aside from bicycles and our feet, there's nothing out there that's as efficient from top to bottom as a modern internal combustion engine.)

So in that respect, even if Hillary's plan had a prayer of a chance of long-term success, and if she had any ability to get it passed — which she doesn't because it's an idea for this summer, not after January — it would be like prescribing a pain med instead of removing the thorn from one's foot.

The proposal is just astonishingly dumb on every conceivable level.

I do have some related thoughts about the next ten years…

1) We'll see a small resurgence of the railroad industry. Rail travel is more efficient than air travel, and solves some of the mass transport problems presented by our spread-out nation. This will resemble the current hub-and-spoke airline system in the short term. Business travelers won't mind taking the train as much due to the ubiquity of wireless internet access and the fact that you can use cellphones while on a train. Trains don't have to be slow, either. So while you won't be taking the train from NYC to LA for a one-day affair, you might well take it from Boston to Washington DC for the same.

2) More effective car-pooling systems. Thanks to the Internet, it's easier to more effectively carpool with folks headed in your direction. This could be supplemented by mass transit systems — buses in the beginning, and trains later on — where people gather at smaller, de-centralized staging areas for a trip into the city. Many suburban areas already have these systems, but there are many, many larger cities that don't.

3) More and better research into biofuels as a replacement for traditional petroleum. This goes beyond corn-based ethanol which was a failure of epic proportions, as it resulted in increased food prices and is energy-intensive to produce. The graphic below (click for larger) demonstrates some of the more promising alternatives, particularly algae and switch grass.

(Preserved against link-rot from this article.)

I think America is getting to the point where they're ready to think about letting go of their precious four-wheeled transportation. Drive by a used car dealership, and you're likely to see quite a few gas guzzlers sitting on the lot. This alone is anecdotal evidence that the PED of gasoline isn't zero. A more formal study finds that when the price of fuel goes up and stays up by 10%, the process of adjustment is dynamic and far reaching:

• The volume of traffic will go down by roundly 1% within about a year, building up to a reduction of about 3% in the longer run (about five years or so).
• The volume of fuel consumed will go down by about 2.5% within a year, building up to a reduction of over 6% in the longer run.

The reason why fuel consumed goes down by more than the volume of traffic, is probably because price increases trigger more efficient use of fuel (by a combination of technical improvements to vehicles, more fuel conserving driving styles, and driving in easier traffic conditions). So further consequences of the same price increase are:

• Efficiency of use of fuel goes up by about 1.5% within a year, and around 4% in the longer run.
• The total number of vehicles owned goes down by less than 1% in the short run, and 2.5% in the longer run.

Prices have certainly gone up by more than 10% in the last 12 months, and the snowballing effect of this phenomenon is that many people of my generation have gotten rid of their cars where and whenever possible, and instead opt for healthier, less expensive modes of transportation: walking or biking. When they need to travel a longer distance, they rent a Zipcar.

I certainly would if it were realistic.

[1] I could see motorbikes becoming more popular, as they are in the UK, as gasoline prices continue to rise. For Americans who have not been to the UK, it is not uncommon to see motorcycles and scooters out and about, even in the rain.

Allergic to WiFi (so let's sue the city) (OnThePharm (Hanser)) by RJS

America: where's it's your God-given right to sue anyone or anything for whatever the hell you want, no matter how absurd it is.

God bless the tinfoil hat brigade:

Arthur Firstenberg says he is highly sensitive to certain types of electric fields, including wireless Internet and cell phones.

"I get chest pain and it doesn't go away right away," he said.

Firstenberg and dozens of other electro-sensitive people in Santa Fe claim that putting up Wi-Fi in public places is a violation of the Americans with Disabilities Act.

Psst, Arthur, this is what we call a somatization disorder.

Sante Fe, the rest of the country is laughing at you.

Quietly influential (rianjs.net (Hanser)) by Rian

I chuckle every now and again when I see the MSM reporting on blogs. The usual suspects almost always turn up: TechCrunch, the HuffPo, GigaOM, BuzzMachine — as well as a smattering of the hot blogs du jour. This time it was Steve Rubel's MicroPersuasion and Passive Aggressive Notes.

I must confess some incredulity, because I have never seen Ars Technica mentioned in a story that focuses specifically on blogs. This despite being relegated to merely a "blog" (albeit acknowledged as an influential one) most of the time by the mainstream media when they reference a story that Ars breaks.

Now, the HuffPo is a huge website. Probably a little bigger than Ars with 5.7M unique readers per month. TechCrunch is markedly smaller, and GigaOM is smaller still (1.37M pageviews/month or so).

It makes me wonder why these particular blogs are chosen. Is it because the stories about blogs are by their nature more noise than substance? Indeed these stories are often widely hyped when they hit and will make their way around the 'sphere several times before disappearing like yesterday's newspaper. (The blogosphere echochamber at its finest.) Ars seems to be anti-hype most of the time. It's been known to take a somewhat dim and sometimes even contrarian view to what's hot in the blogosphere this week — "The Cloud!", death by blogging! — if indeed what the blogosphere is focusing on this week is even worth talking about at all. (Usually it's not.)

So here are some sites that Business Week may want to think about including, because these sites are the real movers and shakers in the Internet publishing world. This list is by no means comprehensive, and I make no comments about their content or quality of the sites, only their size. This list isn't sorted in any meaningful way:

• High-Def digest: ~7.23M
• Destructoid: ~4.25M
• Gamersyde: ~5.17M
• SB Nation: ~8.76M
• Celebrity Baby Blog: ~8.64M
• Confessions of a Pioneer Woman: ~6.05M
• Fark: ~37.09M
• BoingBoing: ~6.93M
• SeriousWheels: ~9.05M

For comparison, TechCrunch sits at ~7.5M pageviews per month, and Ars Technica sits at ~30M.

Dude, I need a WTF stamp (OnThePharm (Hanser)) by RJS

Link.

I could stamp all the ridiculous prescriptions and fax 'em back to the douchenuggets who wrote them.

Lucky for me, I can have one made… I wonder if my company will pay for such a worthwhile piece of office equipment?

Knowing me, I'd probably go around stamping people, too.

On panic disorder and benzodiazepine use (OnThePharm (Hanser)) by RJS

I'm taking a class just for fun right now — psychopharmacology — and the discussions that crop up are quite excellent. Many of the students are prescribers in my area, and I fill their scripts on a regular basis. It makes for an interesting, voyeuristic look into their thought processes given some of the case studies. That is, I know who they are, but they don't know who I am…

This week's topic is panic disorder and relapse in patients with and without a history of substance abuse. Fun topic, really, and one close to my heart.

Case study:

[You are] working with a 32 year old man who comes to you for an evaluation of panic in August in Lowell. He meets the diagnostic criteria for panic disorder and has been experiencing untriggered episodes for the last 2 months. Name three factors that would guide your selection of medication and then discuss your pharmacologic plan for this unfortunate man.

One of the responses — by a prescriber in my area — was to encourage deep breathing, progressive relaxation, identifying triggers and avoiding the situation, CBT, and starting an SSRI. If panic continues, start a benzo.

This strikes me as fairly typical approach for a primary care provider in dealing with someone who presents during an acute panic attack, but I think that it's doing the patient a disservice. Perhaps it's also a typical response for a psychiatrist who is afraid to use benzodiazepines.

I'll post my response here, verbatim, because I think there's a deep (and common) misunderstanding of what panic is, and what having a panic attack is like.

It seems like you're thinking of panic as something that can be gotten out of, as though it's a normal fight-or-flight type response where removal from a stressful stimulus means no more panic.

This is dangerous thinking, and forgive me if I've read you wrong.

It can be harder than perhaps some practitioners think to identify a trigger. While triggers can often be identified, I think it's important to note that when a patient first presents, and you make a diagnosis of panic disorder, discovering these triggers will be more complex than simply avoiding a stressful situation, or simplifying and eliminating stressors from one's life. (Which is a very time-consuming process.)

You can't turn the ship on a dime.

Please don't fall victim to the idea that because you've been scared out of your wits a few times and your heartrate went up and your BP went through the roof that that is a panic attack. It's not. Panic attacks usually appear in a completely idiopathic manner, particularly the first time they hit. It's not an "Oh Gee, you scared me," type of thing, it's more of a "DEAR GOD I'M DYING, SOMEONE PLEASE DIAL 911" type of thing.* (The caps are appropriate there. )

Panic attacks can, and do hit without any warning in an otherwise comfortable, relaxed setting. Watching a movie in your living room, for example.

It's not like [situation] -> panic attack a few minutes or an hour later with a clear antagonist. It can come days after the stressors. It can also take a few weeks and lots of practice to build up an arsenal of effective coping mechanisms to return oneself to a calming state in the middle of an active attack.

Re: Deep breathing. This can also be problematic as at the point where one's lungs are fully inflated one can experience a PVC or PAC, which is VERY disconcerting to someone who's already acutely aware of what their heart is doing. I can actually trigger PVCs in myself by doing this.

–

I don't mean to lecture. I'm not the professor, and perhaps I've read too much between the lines of what you've written. As someone who didn't get out of bed for 3 weeks the first time I had a panic attack, I feel very strongly about the issue, and combatting it aggressively rather than taking a more laid back, it'll-fix-itself approach. Particularly this: "deep breathing, progressive relaxation, identifying triggers and avoiding the situation, CBT, [etc.]"

Those are all great long-term approaches, but the short-term is what someone with panic disorder in an active phase cares about most. Long term stuff can come after, just get me through right now.

And I am keenly aware that my personal experience should never cloud my clinical judgement inasmuch as that is humanly possible.

* I tried to dial 911 my first time, in the middle of a biochemistry lecture, no less. But I couldn't see well enough to dial the number. In retrospect, knowing what I know now, I'm glad I couldn't because that would have been a misuse of medical resources. :p

Early in panic, people are usually not capable of accessing the skills to use behavioral coping mechanisms. You usually need to halt the panic quickly and this is where BZDs are needed. Panic is such an uncomfortable and painful experience, the BZD's are in a way like pain medications in the early stages of treatment.

The more you talk, the less I believe you (OnThePharm (Hanser)) by RJS

Something I've noticed for years: the more a patient talks at you, the more likely they are to be lying. They talk and talk and talk, and nothing of substance comes out. It's a smokescreen for something else they want. They tell you their life story, and then ask for an early fill on their Vicodin as though the two are somehow related.

Do they think I'm stupid? I can't count the number of times I've put the phone down with the person still talking at me (without having said more than "May I help you?") done something, and then come back with them still blowing hot air.

The more words someone uses, the greater the chances are that they're full of shit.

This is in contrast to someone with a legitimate issue who will tell you their story in as few words as possible, and then ask what they need to do. Even people who typically blow smoke talk less when they're actually telling the truth and they have, for instance, a police report to back it up.

Every retail pharmacist in the world knows exactly what I'm talking about, and I'm sure most ED types do too. Remarkable that the bottom-feeders on the planet haven't figured out that if they just kept their mouths shut, I'd be 2-3x more likely to believe them. I would have thought such a skill would be accidentally uncovered and remembered. But perhaps idle chatter is the verbal form of a nervous twitch, and many of these folks are halfway decent candidates for the Darwin Awards anyway, so I shouldn't be surprised that they haven't learned from past successes.

In any event, they'd all be shitty poker players.

Oops (OnThePharm (Hanser)) by RJS

Absolutely perfect timing with Dr Dino's Oops Meter.

Got a phonecall from an FP's office across the street from the pharmacy. Medicaid patient had brought in his Risperdal Consta injection for his bi-weekly shot. The nurse dropped the injection in the office, which broke it, resulting in some non-emergent, but non-trivial lacerations to herself in the process.

Could we get another one? Of course, it's 4pm on a Friday, and MassHealth doesn't do lost/damaged precription overrides — if they did, their budget would probably double (TAP doesn't make this shit up, you know) — but could we pleeeeeeease try. And they would, of course, call MassHealth themselves.

Risperdal Consta is about $650 per dose.

Of course the answer was no, but with both of us on the phone, MassHealth said they could do it tomorrow (that would be today, I guess) as a once-in-a-lifetime early-fill don't-ever-ask-again override.

I'm so glad it worked out, and I feel terrible for this nurse. She's probably wishing she had dropped some cyanocobalamin instead. We'd have just given it to them for nothing had it been something like that.

Based on Dino's examples on the oops meter, I'd give this a solid 8. Right next to breaking wind in front of your boss. On the elevator.

This pharmacist is a model for how other people should win the lottery (OnThePharm (Hanser)) by RJS

Seriously:

Sporting large sunglasses, the winner, a pharmacist, came forward, but she refused to provide her name or where she lived. An occasional player, she bought the winning ticket at a gas station at 851 S. Sutton Rd. in Streamwood.

The first step wasn't to get the money. A family member referred them to Wood Dale attorney Terry Zimmer, who assembled an advisory team, including estate planner Richard Kuenster.

"I told her get an unlisted number A.S.A.P.," Kuenster said.

The team helped the family create the JYS Family Limited Partnership and put together entities to keep the winner's identity from the public, and shield the money from some taxes, creditors and frivolous lawsuits while providing for her, her husband, children and any future grandchildren, Kuenster said.

"We're so proud of them for taking that time," said acting Illinois Lottery Superintendent Jodie Winnett. "What a sharp winner we have in Illinois and we hope that the rest of our community will hear this and that they'll take a deep breath and consider protecting themselves."

I think everyone has thought about what they'd do if they won the lottery. Most of the thought cycles probably spent on how they'd spend the money, rather than on how they'd protect themselves. I've given the collection, protection, and diversification of a large sum of money some thought in the past when Powerball has gotten up into the hundreds of millions. (It's fun to dream isn't it?) The lawyer and financial advisor seemed no-brainers to me, but an estate planner didn't occur to me. Naturally, doing everything in my power to remain anonymous is also right up there, but the third-party organization as a shield was a new one, but a smart one given her profession.

Good on her.

(The press conference is required.)

–

Anecdotally, we have a past lottery winner that comes to our store, and like this pharmacist, she is very discreet, and has managed to not blow all of her winnings in spectacular fashion. Smart people do, in fact, win the lottery sometimes.

Yeah, I parked there (OnThePharm (Hanser)) by RJS

Does that make me a bad person?

HOLYSHIT (rianjs.net (Hanser)) by Rian

This isn't a real license plate, but I loved it anyway. The car is a 2007 Audi RS4, you may notice, probably one of the sexiest vehicles I have ever seen. (Though I'm partial to yellow, myself.)

Part fourteen of my license plate special series. I took all of the pictures myself in my travels.

Some thoughts on vanity license plate density.

Enjoy.

License plates, vanity plates, holy shit

SNAFU (rianjs.net (Hanser)) by Rian

Part thirteen of my license plate special series. I took all of the pictures myself in my travels.

Some thoughts on vanity license plate density.

Enjoy.

License plates, vanity plates, SNAFU

SNWDRFT (rianjs.net (Hanser)) by Rian

Hard to read but it says "SNWDRFT".

Part twelve of my license plate special series. I took all of the pictures myself in my travels.

Some thoughts on vanity license plate density.

Enjoy.

License plates, vanity plates, snow drift

PNO-GUY (rianjs.net (Hanser)) by Rian

Part eleven of my license plate special series. I took all of the pictures myself in my travels.

Some thoughts on vanity license plate density.

Enjoy.

License plates, vanity plates, piano

MEDICN (rianjs.net (Hanser)) by Rian

Part ten of my license plate special series. I took all of the pictures myself in my travels.

Some thoughts on vanity license plate density.

Enjoy.

License plates, vanity plates, medicine

LET1TGO (rianjs.net (Hanser)) by Rian

Part nine of my license plate special series. I took all of the pictures myself in my travels.

Some thoughts on vanity license plate density.

Enjoy.

License plates, vanity plates, Let it go

LNCHMNY (rianjs.net (Hanser)) by Rian

Part eight of my license plate special series. I took all of the pictures myself in my travels.

Some thoughts on vanity license plate density.

Enjoy.

Technorati Tags: License plates, vanity plates, lunch money

JEDI (rianjs.net (Hanser)) by Rian

Part seven of my license plate special series. I took all of the pictures myself in my travels.

Some thoughts on vanity license plate density.

Enjoy.

Technorati Tags: License plates, vanity plates, jedi, star wars

GOEKGGO (rianjs.net (Hanser)) by Rian

Wikipedia on an EKG.

Part six of my license plate special series. I took all of the pictures myself in my travels.

Some thoughts on vanity license plate density.

Enjoy.

Technorati Tags: License plates, vanity plates, Go EKG Go