Heathpack 

I rode. It did not rain.

Heathpack 

Lol my clients don’t want to run tests, they want me to make my best guess from the clinical symptoms, I spend a hour fully discussing all the drawbacks to guessing in the absence of tests, and they think fair recompense for that should be around $85. Oh yeah, and can you call and go through all that with my brother, because I neglected to tell you this isn’t even my dog.

kidding/not kidding

PS I am old school too. I like tests when they make a difference to what I’m gonna do. I don’t like tests when they don’t change what I’m going to do, put my patients at risk and cost a lot of money. I get frequent referrals “for an MRI”. Um, yeah. An MRI is indeed indicated to diagnose the patients condition. But the patient is an 18 year old Pekingese who has been in heart failure three times in the past 6 months. And we need to anesthesize him to do an MRI. How about we think twice about anesthetizing that dog at all? Let alone to diagnose a brain tumor which would require surgery or radiation therapy to treat, neither of which is practical in a dog with severe heart disease (due to the need for more anesthesia), not to mention is not curative. Oh yeah. And pretty darn expensive.

MoAlpha

I don’t know. I am not very well informed, but I have heard arguments and experience for and against. It’s also it’s easy for me to say, working in an economically unconstrained setting. All I know is that the perverse incentive to over-test and over-treat has to be removed. Another related beneficial effect of capitation-based systems is price transparency.

MoAlpha

You operate in a real market! Think it would work for humans if everyone started the game with enough chips?

Heathpack 

It’s a great school adjacent to a dicey area. If she’s interested in film though you’ve got to argue that LA is the place to be.

LA is full of cool interesting stuff, she’d meet a lot of unique people, and the weather is great.

It would be pretty tempting to go for it.

Velo Vol 

Goats make funny noises, though.
???

How is this a problem?

UPDATE:

big john

I've been out 1 year this month. My smog license and ASE certs are all expiring. If I ever go back it will be out of desperation.

sfrider 

Thank you! I have a Lezyne CNC pump but absolutely hate the stock head. Ordered the Hirame...

datlas 

You’re welcome. The internet says you need a clamp but mine worked fine without.

MoAlpha

A lot of docs are shockingly poor at evaluating facts and prone to follow recipes mindlessly or fall victim to biases.

LAJ

Silly mouse with sillier questions.

Heathpack 

Im not sure what you’re asking.

The thing that makes what I do an no-go for humans, I think, is that there’s some things that we don’t treat at all due to costs but we have the option for euthanasia, or sending to a GP who might be able to do something with lesser expertise, or maybe cutting corners that really shouldn’t be cut. There’s not tons of that in Neuro because almost nobody besides a neurologist feels ok about treating Neuro cases.

But some things should really not be done in a general practice setting. A dog with a hemoabdomen from a ruptured splenic mass for example- that dog benefits from the ability to cross match, from having whole blood on hand for a transfusion, from pressor drugs and the expertise in using them, from 24 hr icu care, from a surgeon who can dog that surgery fast. Some GP vets have all those things, but most don’t.

So it’s really expensive to do those cases right, but if owners can’t afford it, we in specialized vet med can euthanize or try to stabilize and send to a cheaper place and hope for the best. We (as boarded specialists) are ethically/legally held to a higher standard of care so we can’t really just do less ourselves (well we can but there’s serious limits).

What do you do if that’s your cousin Joe with that hemoabdomen and he doesn’t have the $7000-$10000 on hand at that exact moment to pay out of pocket (yeah that’s about what it would cost, and the owners likely will have had no forwarding of a problem)? You can’t euthanize Cousin Joe. And you can’t send him somewhere to get lower quality care at a cheaper price. So the vet med model doesn’t really work for humans. Maybe you could take some elements of it and apply it to human medical care.

Plus I cannot tell you how much time is spent in our practice talking about money. Maybe 15% of the time? It’s not a very good use of a medical professional’s time actually. But I do need to be personally involved in it, because if people can’t afford option A, Ive got to have a back and forth conversation with them about the alternatives and what that would cost and so on.

kissTheApex

seedsbelize

I’ve read “On the Beach” based on your mention a couple of weeks back. It is definitely an interesting book and like you said, “fitting to the times”... Thanks

Heathpack 

I came here to post about my ride.

I wanted to do a long one but my legs were tired from yesterday’s kinda hard ride. So a la bigjohn I decided to ride to Acton.

This is a maybe 27 mile slight uphill ride and then a 27 mile slight down hill coming back. Normally it’s a headwind out/tailwind back but today the weather pattern was reverse. You could realistically do an pretty steady effort both out and back.

I never get assigned from coach the long zone 2 ride but I have heard LAJ kvetch about them, so I figured here was my chance to see what was up with that. Now cycling wise, I don’t find LAJ to be a complainer but how hard could a zone 2 ride be?

I spent 2:15ish pedaling constantly (pretty much) in zone 2 going out. Jeez why was that so hard. I was really happy when I got there, and took a little socially distant break on the side of the road eating my raisins.

Then back at it going home into that headwind. Another hour of steady zone 2, wow this is tiring!

Thankfully I got a flat when I got back into town. Too tired to really investigate and I didn’t bother to take my sunglasses off so I neglected to realize my tire was cut, I just saw a drop of sealant and thought I might be able to limp it home by putting more air in the tire. “Limping it home” was a valid excuse for respite from the endless zone 2 pedaling. I had to stop and top off my tire twice more and finally called for a pick up 30 min later.

So the moral of the story is: yes a long constant zone 2 effort is weirdly taxing in a way that it logically seems like it shouldn’t be.

Bah Humbug

We really should push everyone to learn statistics instead of shoving everyone towards calculus, which is almost useless for most people. I took AP stats in high school, which was one of the biggest and best in CT, and the teacher didn't even understand it. Now here I know people who don't understand that you can in fact draw conclusions about huge populations from a sample of 5000, if it's well-selected. He just refuses to believe it, and simultaneously says he's a "numbers guy".

Not surprisingly, he also doesn't understand the concept of flattening the curve. And still calls himself a "numbers guy".

Trsnrtr

Those are the ones we remember. Kudos.

LAJ

I'm sorry about the flat, but it sounds like it was opportune, in a sense. Nice ride, regardless!

Like you say, how hard can 71% be? When you don't coast, hard as hell. I have stages of endurance rides.

Stage 1. My legs are tired from the last week of on the bike work, and I have no idea if I can get 4.5-5 hours out of them.

Stage 2. In the groove. Heck, I can hammer this out with energy to spare. Only 3 hours to go.

Stage 3. 1.5 hours of this garbage left? Holy crap. I wonder if Mrs. LAJ can find me in the middle of this hell, if I were to give her a call.

Sage 4. I got this. Only 45 minutes to go. Who put this hill here?

big john

That ride can vary so much depending on the wind. You are exposed to it more than on some rides where you get a respite because of hills or turns. My friend lives in Canyon Country and he is good at reading the wind predictions by the hour because they do tend to switch direction mid day.

Sorry about the tire.

MoAlpha

Agree. Most people live by their biases and ****ty intuitions and failure to understand probability is almost universal. Daniel Kahneman got a Nobel prize for showing what hard wired dopes we are. Stats is a way of and seeing the world as it actually is and those who learn and practice it come out way ahead. I suck at the mechanics, but I do understand the principles.

datlas 

You mean I should not follow my gut???

sfrider 

All this trainer riding has been great for my power numbers, but not having done anything much over 2 hours for a while really has me worried about my endurance. Planning to do 65 hilly miles tomorrow...

MoAlpha

You don’t have a gut, flaco. I have heard that the three most dangerous words in medicine are, “in my experience.”

Bah Humbug

What gut, beanpole?

MoAlpha

Oh, it was just a provocative question. As you know, the orthodox conservative critique of the US health care system is that government intervention and lack of competition have destroyed the market for care and that restoration of personal responsibility, competition, and transparency will drive prices down to the point where care will be affordable. I always thought that concept was a bit like the market for veterinary care.

Of course, even Friedrich Hayek thought health care should be gov’t subsidized.

Sorry. No more politics.

Heathpack 

Omg I am so hungry.

Glazed ham is out of the oven, resting.

Scalloped potatoes are in the oven, cooking.

Biscuit dough ingredients are ready to go.

House smells really good.

I am drinking a glass of wine, as an apertif.