There's a very noisy bumble bee banging against my window.

I feel like saying, "Idiot. The other window is the one that's open. Can't you remember where you came in?" Except that of course, it's a bee. With a bee-sized brain. So of course it can't remember where it came in.

My second thought was, "Gee, neither of my cats are interested enough in that moving buzzing thing to come investigate? Odd." Then they strolled over, and have been staring avidly at the moving buzzing thing ever since.

It's buzzing at the window with all my art glass in front of it, so I'm rather glad the cats are being mellow. If they were jumping and diving on my glass, I'd have to relocate all three of them (both cats and the bee).

Perhaps I should go help the poor bee out. Show it where the exit it. And perhaps not. Bees have stings, and it is a good show.

I signed the formal offer letter today from Weill-Cornell Medical Center. It's at 68th St and York Ave. on the East side of Manhattan.

I am very pleased about this job. It involves patient care (in the inpatient setting) and teaching for about 75% of my time, with the other 25% dedicated to whatever informatics seems useful to the hospitalist team of which I will be a member.

Not to mention, it's more money than I've ever made before, since it's my first full time job as a doctor no-longer-in-training. And Cornell has great benefits. And the people I'll be working with are nice and smart and fun to talk to, at least from what I saw in the interview.

I am very very pleased. My anticipated start date is May 15th, assuming that all the appointment paperwork goes through in reasonable time. I'll be both on the faculty and the staff at Weill Cornell Medical College. Again, assuming all the paperwork goes through, my faculty title will be Assistant Professor of Medicine, and my clinical title will be Assistant Attending Physician.

I'm really excited about this. I'll have to review my medicine, since I've been doing mostly non-clinical work (and a tidbit of clinical stuff) since mid-2005, but still. Patients. And Teaching. And Patients. And cool co-workers. And even some time for informatics.

I'm not sure it gets better than this, although I'm sure I'll find something I don't like about it sooner or later. I already know that during my clinical months, I'll be working two out of four weekends. I agreed to that, and it's fair and necessary for patient care, but I suspect I'll get tired of it fairly quickly.

So, the big remaining question -- when I go apartment hunting, do I look on the East Side, near work, so I can walk to and from work, or do I look on the West Side, where all the fun stuff is, and just plan to bus to and from work?

On Lunacon: I was a lamer, and didn't reserve a hotel room. Does anyone have a hotel room they're willing to share at Lunacon? I'd prefer a bed, and I'll happily pay half the room fee to get a bed, but if we can get a cot or there's room for my to bring my (queen sized) air bed, that'd work too. I'm quiet, non-smoking (and I hope you are too), and not planning to share my bed with anyone else.

On I-con: I've got one free membership. (Well, two actually, but one of them is for me). Anyone want it? First to claim gets it.

As some of you know, I play a lot of computer games when I'm procrastinating and generally being a lamer.

My favorite place to get 'em from is http://www.bigfishgames.com/

Well, since I get a lot of games from them, they like me rather a lot. Recently, they sent me two free game coupons to give to friends that have to get used by the end of February.

Not only did they say, "Give these to a friend.", but they're for two games that I already have, so the free game coupons don't do me any good.

The first is Build-a-lot, where you build and sell houses and try to make lots of game money.
The second is Mystery Case Files: Madame Fate, which is largely a hidden object type game, interspersed with some clever puzzles.

Both of them are, in my opinion, quite good.

To get the games, you're going to need to either have or create an account with Big Fish Games, and you're going to have to download both the game and their game installer.

That said, if you're interested, comment on this post. The first person to ask for each game will get the game coupon from me. If I don't know your e-mail address or snail mail address, then leave me one or the other so I can get the game coupon to you. I'll screen comments so the whole world won't be able to get your contact info.

Mary Chungs (464 Massachusetts Avenue) 7pm tomorrow (Sunday).

Wow, long time no post.

The important stuff: I'm visiting Boston this weekend. If you want to see me in Boston, please e-mail or call me. If the only phone number you have for me starts with 646, that's the landline back in NYC and won't reach me. If you have a 347 cell number, that's deprecated. If you have a 917 cell phone, that's the one I have with me. E-mail might be easier. *grin*

I am going to the DeCordova outdoor sculpture garden and museum tomorrow (Saturday) and will be meeting folks there at 1pm. It's a great place for small folks to run around and climb on _some_ of the sculpture, and for adults to walk, talk, and either admire or make snarky comments or both about the sculpture.

I am also calling a dim sum run at Chau Chow City on Sunday at noon.

I would love to meet folks at either location. If you want me to look for you, then e-mail me to let me know that. If you want to just show up, that's fine too, but then the onus is on you to look for me.

Other life details:
*Finished my fellowship at the end of August. I'm official a MD MA as opposed to just a MD.

*Still job hunting, but had a good interview Monday and have two more interviews likely in the next few weeks, so with luck I'll be employed before my target date (end of November).

*The paper I submitted to AMIA was not only accepted last June, but I found out last week that it's a finalist in the student paper competition, which means (a) AMIA pays for my conference attendance and (b) I get to give it twice at the conference instead of just once and (c) it's a nice honor.

If you want to know more, then e-mail me, call me, or show up at the DeCordova on Saturday at 1, or at Chau Chow city on Sunday at noon.

Take a picture of yourself right now. Don't fix your hair... just take a picture. Post that picture with no editing. Post these instructions with your picture.

Here's my entry. That arm leading out of the picture is attached to the mouse which I used to click the save picture button on my quickcam.

My desktop blue screen'd of death this morning with a fatal registry corruption error.

On the upside, my computer had been acting flaky for weeks, so I'd backed up the "My Documents" and the "Application Data" folders last night, and I'd already planned that the big task this coming weekend was a complete re-install.

But I was planning to reinstall FRIDAY, not today.

Feh. PITA. And if my backups (which I can't see right now since they're on the 2nd internal hard drive) are in any way shape or form corrupted, I'll move from annoyed to really royally pissed off.

Ah well. Life (and computer crashes) happen.

I've been making a list of what to reinstall -- Firefox and its extensions, the VPN software I use to get into the hospital, Office 2007, Thunderbird, iTunes, antivirus software, undated drivers for all my peripherals, software to make nightly backups to the second drive, any games I'm actively playing (including the BFG client and the RealArcade client), fanficdownloader, googlesync, the iPhone bookshelf ebook loader...

And to not install since I don't need it right now, but maybe to install later: eclipse, mysql, apache and php

And to not install since I've outgrown it: palm software

And to not install b/c they suck resources and don't make me happier: google desktop search, microsoft desktop search, any site-specific "toolbar"

Can anyone else think of any must-have software that I should plan on installing into my soon-to-be fresh clean system?

*sigh*

Wow, my last post was way back on June 15th. What's happened since then:

1. Baitcon
I went to Baitcon. I had a good time. My pleasure was slightly limited by having to give myself shots of neupogen every morning, and the resulting side effects, but overall, 'twas lots of fun, with much good ice cream, and a road trip on Saturday to see glass blowing, where I amused myself by knowing what the blower was doing. Thank you to quietann, PhilTheBald, Jen and Anne T for keeping me company while I was self injecting. Thank you to sauergeek for picking me up at the train station, dropping me off at the train station, doing all the driving during our Saturday road trip, doing the lion's share of the campsite set-up and tear-down, and putting up nicely with a sore, tired and intermittently cranky Jiapa.

2. Glass blowing
I took a glass on Glass Blowing. I made 6 of the 8 class sessions, which was not as many as I wanted to, but more than I was afraid I could make. I made some really pretty glass, and had a good time, and if you come visit me in NYC, I'll show it to you. In the fall, when it's not so hot, if I have a job that is compatible with taking more glass blowing classes, I'll be taking more glass blowing classes.

3. Donated Stem Cells.
The Monday after Baitcon I donated stem cells. That's why I was taking the neupogen during Baitcon, which is a medicine that sends a signal to my bone marrow to rev up the engines and make lots and lots of white cells now. When it said lots, it meant lots... by the time I donated that Monday, I had a full order of magnitude more white cells than usual. This explains why I was so tired at Baitcon -- my body was taking all the energy it usually uses for doing other things, and spending it on white cell construction. On Monday I had to wake up early to get a central line placed, and then was hooked up to the pheresis machine which filtered out the white cells to give to my (hopefully) lucky recipient. I hope some 42 year old woman with AML is currently growing a nice healthy immune system that looks just like mine.

I gotta say, I HATE the feeling of being on the pheresis machine. The anticoagulant they use so that the blood flows smoothly binds to calcium. Different people have different reactions to low calcium, but I had 'em all. Lips were numb and tingly, hands were numb and tingly, stomach was queasy and unhappy and then I started having palpitations and chest discomfort too. Just oodles of no fun. I brought calcium candies with me, but couldn't even begin to catch up. They ended up giving me 6 units of IV calcium during the course of the 5 hour pheresis, which nicely took care of all the symptoms except my hands. It took 6 hours _after_ they unhooked me from the machines before my hands started feeling normal again, and since they'd said it would take 20 minutes, I was getting pretty scared.

Luckily, I felt half as bad the next day, and only half as bad again the day after. By the end of the week I was pretty much back to normal, except for a cute little scar on my neck from the central line which I view as a badge of honor.

If someone else needs my stems cells again, I'd do it again. I just don't have it in me to say, "No, you don't get a chance to live because I don't want to be uncomfortable for a week and miserable for a day", but at the same time, I kinda hope I don't get asked again.

4. Found a Writing Partner.
The paper that has been making me miserable for almost a year is now thoroughly revised and in the hands of my advisor. Yes, it still needs to be cut, but on the whole, I'm quite pleased with it, and it's much better. The paper I'm presenting at a conference this November was revised and resubmitted on time. Next up: the IRB, and the cancer symptoms study that I did 2 years ago and never submitted for publication. Writing Parters are a Very Good Thing (tm).

Some things I can write w/o a partner, but anything long or with a poorly defined audience, I just do much better with a writing partner. Next time I need to write something long, I'll just look for a writing partner right off the bat and save myself months of misery.

5. Started Job Hunting
I'm interviewing with some folks at Columbia tomorrow, and some other folks at Columbia on Friday, and then with some folks over at NYU the following Friday. If any of ya'll know of jobs that have 20-50% clinical time and 50+% time implementation and improvement of clinical systems, and need someone who can actually work with both clinicians and technical people and translate fluently between them, and is willing to pay the price to hire someone who both a board certified internist and has a masters in informatics, please let me know. I'd prefer a job in Manhattan, since I'm in love with NYC, but if a job like that is available in the Boston area, it's certainly worth a look.

6. Renewed my BLS (Basic Life Support aka CPR) and am half-way through renewing my ACLS (Advanced Cardiac Life Support aka How to Run a Code) certification.

7. Turned 37 on July 16th and celebrated by going out to an ok movie and a great dinner (Telepan in NYC near Lincoln Center -- highly recommended). Received an absolutely gorgeous piece of art glass from my parents. Beautiful and new -- I've never seen anything quite like it. It makes my hands happy just to touch it.

8. Replaced my 3 year old palm TX and my cell phone with a new iPhone 3g. I love it. It does everything I want in a pda. The only downside is that I have to carry the charger with me everywhere and plug it in wherever I go, since it's good for about only about 3-4 hours of active use. It could do standby a whole day easily if all I wanted was to use it to make and receive phone calls, but it's a drug reference and a calculator and an ebook reader and a map and a web browser and a game machine, etc and it gets used a lot.

9. Worked 58 hours in the last 4 nights, admitting patients to the hospital. 'twas fun. And it pays for my new iPhone.

10. Still overweight. Still not exercising. Still single. Still intending to do something about those problems RSN.

You may say, "You're a doctor. You work in a big hospital. You're going to loose patients from time to time." You'd be right, except for one minor detail. For the last 2.5 years, I've been working as a hospitalist. Our mandate is to take the _less_ sick patients. When someone is really sick, they get given to a different team of doctors.

Last night, the ER asked me to admit a gentleman with renal failure who needed dialysis. He was, at that time, right on the edge of being too sick for the hospitalist service. Unfortunately, the hospitalist team was the only team with doctors (me) available. Anyone else was going to have to wait until the next shift of residents came on at 8am. I told the ED to treat some of his numbers and that if he looked better in a few hours, I'd take him.

Then I went to look at him. And I started talking to his family. And I started thinking about his care. I hadn't formally admitted him, but my other patients were tucked in, and he was interesting and he had a involved and devoted family, so I spent a bit of time explaining renal failure to them and getting to know him and them better. Effectively, even though he wasn't formally on the hospitalist service yet, both I and the ER resident were acting as if it were just a matter of time until we got his repeat labs back and I admitted him.

We both forgot one of the major rules of sick patients, "If the patient has bad kidney disease, and looks sick at all, he is probably much sicker than he looks."

The repeat labs were worse, not better, and he started to develop other complications. The medicine consult resident was called to evaluate him for an ICU bed, and as it became extremely clear that he was not coming to my service, I wandered off to see my other patients and then to take a nap.

When I was finishing my shift this morning, I decided to stop by the ER to see how he was doing, since according to the computers, he was still in the ER. Unfortunately, he was no longer in the ER, and a nurse told me that he had passed away about an hour earlier.

He was really sick. I'm not surprised. It's just sad.

Yowza.
The plastic covering the window gap between my air conditioner and the window frame started flapping.
The cats looked up, then ran in the other direction.
The plastic flapped harder.
I moved some of my glass from in front of the plastic to another window, and pondered moving other items.
The wind blew harder.
Some wooden panels (doors?) flew down the street, bouncing off the cars.
A few car alarms joined the chorus.
The trees leaned, and shed branches.
Neighbors started looking out their doors and windows, whooping with the wind.
Lightning flashed, with thunder, but no rain yet.

I've seen the aftermath of windstorms, but for some reason, I've never watched 'em up in real time. It's impressive.

As ya'll know, I collect glass. I've got some very nice pieces that I love dearly.

And now... I'm making it too. I took a "taste of glass blowing" class over the weekend in blowing glass, and I had such a good time that I'll be signing up for another class (Introduction to Glass Blowing I) that meets every Monday and Wednesday evening for the month of June.

The glass studio / school is in Brooklyn. Anyone wanna take the class with me?

Oh, here are the pieces I made my first day. The second day they gave us color to play with, and I'll be picking up those pieces tomorrow.

I got called today -- I'm a match for a woman with AML. They want a peripheral stem cell donation, but barring something screwy in my physical exam, I'll be taking 5 shots (one/day) of a medicine to boost my stem cell production, and then I go in and let them filter lots of yummy stem cells from my blood and give it to this other woman who, with luck, will develop an immune system that looks JUST LIKE MINE, as opposed to her current one, which looks like CANCER.

It's tentatively scheduled for sometime in mid-June. The donor coordinators will let me know more when they know more. I already know she's on some research protocol where they want either a unit of blood or a donation of T-cells before the stem cell donation. I'd better really start taking my iron now, if I'm going to be giving a unit of blood too.

So thanks, the_minx_17 for motivating me to join the donor registry!

Ya'll saw my cat health post last month. We never did figure out what was wrong with Barley, but we're now calling it a Therapeutic Barium Swallow. Whatever was upsetting his stomach was apparently fixed by the generous coating of barium it received.

He's been home and healthy and eating just fine since the day after my last cat health post.

The following week both cats had their annual physicians and were fine. Jane was 12 lbs 15 oz, which is some fantastic intentional weight loss from 16.9 lbs last year. Barley was a bit less, and both were healthy and got their shots and all was fine.

A bit more than a week ago, Jane started to seem off. She's basically a lazy cat who is happy to lie on the sofa or my bed all day every day, but she was eating less and sitting more. And then Barley started to eat her food, indicated that she wasn't defending it. Throughout this, I kept checking on her, and she was well hydrated, and her personality was intact. She didn't vomit or get the runs; she wasn't coughing or sneezing. She was just passive.

And then last night she started giving this little wince/whine every time she moved. And last night, Barley slept on HER spot on the bed. So this morning we took one of the emergency vet spots. She was 11.9 lbs. She'd lost close to a pound in three weeks, but he couldn't find anything wrong with her except that her lower back hurt.

Well, her lower back has hurt for years. She had a spine film which was unrevealing. We tried NSAIDS which made her puke a lot and get very dehydrated. Since she hasn't been unhappy, and has been able to go anywhere she wanted except for the table with Barley's food bowl and up the ladder to the loft, I decided not to do the next step, steroids, since her appetite was more than fine. At that time I was trying to get her to lose weight, and I didn't want to give her a med that would make her hungry and increase her chances of developing diabetes. Besides, I was wondering if her back pain was due to her being a almost 17lb cat on a 10lb cat frame.

Things are different now. She's a lot closer to her goal weight. She's not eating more than I'd like; she's eating less than I'd like. And she looks like she's in pain when she walks. So when the vet offered her a steroid shot this morning, I took it on her behalf.

Today, for the first time in a week, when I went to the food bowl and made food bag noises, she walked over (I've been carrying her over for the last few days) and scolded me to put the food down faster. She's eating. She's grooming herself more. She's shifting position more often. She just made a few small jumps. She still spends the vast majority of her time on the sofa, but that's largely because she likes it there. I think tonight she'll defend her spot on the bed again.

I don't know how much of this improvement is because the steroid shot is fixing the problem, and how much is because the steroid shot is masking the pain and stimulating her appetite, but regardless, it's a change I'm happy to see.

I'm heading out to Seattle on Thursday, May 1st. I'll be there until Monday, May 5th. This will be my first visit back to Seattle since I left to move to NYC in 2005.

I'll be staying with waterfaery, her husband, child and au-pair. I've got someone to watch my cats, a print-out of the transit route to EWR (since I don't feel like dealing with being the first to be picked up on SuperShuttle this time), and my plane tickets.

I don't have a rental car reservation yet, or any specific plans for Seattle, other than to hang out with waterfaery & co, stock up on my supplies of Garlic Spread from Garlic Garden, revisit the two glass galleries near Pike Place Market, and relax. Oh, and maybe go back to the Asian Art museum. I miss it. And maybe revisit the Capitol Hill library where I heard Octavia Butler do a reading. And my favorite Thai restaurant that was 5 blocks from my old apartment. I wonder if they're still open, and if they still do a better tofu Pad See Ew than I've found anywhere else.

*happy sigh* I think it'll be a good visit.

If there's anyone in the Seattle area who wants to see me, that'd be great. Please let either me or waterfaery know so we can coordinate.

[Written Thursday, but for some reason, not posted then]
Barley hasn't eaten more than a couple bites, if that, since Monday. He also threw up a bunch, although the last time was yesterday morning.

Yesterday, we went to the vet and he had blood work and xrays and exams and IV antacids to the tune of $515.

Today, he still wasn't eating, so we went back to the vet and he had more x-rays, and is now being admitted for IV hydration and a barium study, with the possibility of an endoscopy +/- exploratory surgery if he doesn't start getting better, to the tune of even more money.

And yet ... his personality is intact. He still climbs the ladder to the loft, multiple times/day. He still climbs into my lap when I'm at my computer. He moves a bit slower, but still, other than the whole not eating thing, he seems just like himself. I almost feel as if he can't possibly be sick enough to need a kitty hospitalization, except that, of course, not eating at all is definitely a sign of something Not Right.

So, he's in kitty hospital, and I'm hoping it turns out to be Not Serious or at least Curable.

*sigh*

[Friday update]
Per the vet, the barium study showed nothing abnormal and he ate breakfast today. They're keeping him tonight for some more IV hydration and b/c I'm on duty at the hospital, but if he's still doing okay, I'll be taking him home tomorrow.

I really hope this was the kitty equivalent of a stomach bug, but since he's 11, I really couldn't ignore it. Damn, having cats that you love is expensive.

gravitrue complained about the systemic inefficiencies in health care, and asked whether a national insurance plan would do anything to help these inefficiencies. He said:

When I was growing up, my doctor was one of three in a practice. They had a secretary and an X-ray machine in the office. If I got sick, they could see me within 48 hours. If my doc was out, one of the others covered. This kind of clinical care is way the hell more financially effective than my current options of "wait six weeks for a pcp appointment" or "go to the emergency room".

I've so far spent three months and used four hours of doctor time (with three different docs) just to get someone to regularly write me a maintenance prescription for a psych drug I've been on for over two years. Which hasn't happened yet, and will require at the very least another intake visit with another doctor which may well take another four to six weeks to schedule. That's just broken, and I have to ask if my spending another $125/month is likely to fix it or more likely to make it worse.

I started to write an answer, and it got long, so I decided to make it another post.

There are many different kinds of systemic inefficiencies, and some of those will, in fact, be helped a great deal by a single payer or near-single-payer system.

One inefficiency is that not all doctors take all insurances, and each year at renewal time, both employers and employees switch insurance providers, seeking the cheapest premiums. In addition, each year at renewal time, the insurance companies try to gouge the doctors harder ("This year, instead of paying 65% of your bill, we'll pay only 58%"), which means that each year, some doctors decide not to take some insurance companies. This means that each year, many patients change their PCP in order to have a PCP that accepts the insurance provided by their employer.

A new patient appointment takes a lot longer than an old patient appointment, which right there, reduces the number of available urgent care appointments.

In addition, there are a relatively large number of drugs, including both psych meds and chronic pain meds, that most PCPs are reluctant to provide on the first appointment. They want to have an established relationship with a patient before providing these meds. They want to have some idea of how reliable a historian and medicine-taker the patient is. They want to reduce the probability that the patient is getting their drugs from multiple different sources. This means that for many people on chronic pain or psych meds, they have to overlap their old and new doctors, often paying out-of-pocket for whichever one isn't covered by their insurance, in order to not have a medication gap. If folks weren't switching insurance companies, they wouldn't have to switch doctors, and we wouldn't have this particular inefficiency.

A second form of systemic inefficiency is the shortage of PCPs. Not doctors -- we've got plenty of doctors. We are, however, extremely short, relative to other developed countries, in PCPs. In part, this is a prestige thing -- being a neurosurgeon or a pediatric cardiologist or some other specialty that takes years and years to qualify for is more prestigious than being a PCP. In part, this is a lifestyle thing. Dermatologists and Podiatrists and Allergists and Anesthesiologists and Radiologists are, by and large, able to predict their hours. These hours tend to be during normal working hours, which allows them to do things with their friends and families on nights and weekends. PCPs, however, are often on call on nights and weekends. A large part of this, however, is compensation. I don't have the time/space/energy to go into the historical reasons why PCPs are relatively under compensated compared to sub-specialist doctors, but they are, to a fairly dramatic degree. If you could double your annual income by specializing in something other than being a PCP, wouldn't you? This relative shortage of PCPs explains why, when you do have to switch doctors, it can be very very difficult to find one who is accepting new patients. A national insurance plan won't fix this problem in the short term, but in the long term, by adjusting relative compensation, a national insurance plan, like a single payer system, can make it more profitable to be a PCP relative to some of the sub-specialists.

A third form of systemic inefficiency is closely related to the second. It has to do with the traditional way doctors appointments are scheduled. Everyone knows that their doctors are booked for 3 months out, so everyone schedules their next appointment when leaving from their last appointment. There is a significant no-show rate, since appointments are generally booked 3 months who, and who knows what urgent event (child's play, deadline at work, etc) will come up and make any given patient unable to keep an appointment.

I heard an interested lecture on queuing theory a few weeks ago. The speaker (and her graduate students) had modeled a doctor's office appointment schedule using just-in-time scheduling. Very few people were given appointments for months in advance. Folks who needed an appointment for several months out were told to call closer to their appointment, and then added to a "call to remind" list which reminded them to make their appointments a few days before they needed to see the doctor. Folks who needed urgent care appointments were able to call up and get them, either the same day or the following day. There was some unused doctor time, where no one called up to make an appointment for a particular spot, but surprisingly enough, assuming the pool of patients was large enough (and not too large), the unused doctor time was less than the no-show rate for a traditional "schedule-three-months-in-advance" style of practice. Now that we have various technical tools to make this kind of practice easier to maintain (eg, on-line schedulers, automated e-mail and voice mail reminder systems), I think we're going to see more and more of this just-in-time style of appointment scheduling.

Note that this just-in-time scheduling doesn't really work when the practice is too large. If the practice is too large, there are always going to be a few patients who can't get an appointment in a day or two, so they take an appointment further out. Repeat this over several weeks to months, and ta-da, we're back at the 3 month lead time scheduling, or if the office just won't make 3 month out appointments, we're stuck with several folks who just can't get in to see their doctor. Sound familiar? If we have more PCPs, it will be easier to use just-in-time scheduling for appointments.

So, will buying into a national health insurance plan help with the systemic inefficiencies in current outpatient medical practice?

It should help with the doctor-hopping that folks are forced to do.

In the long term, it might help with the shortage of PCPs.

I think technical improvements in scheduling systems will have a faster impact than increasing the supply of PCPs for the scheduling inefficiencies, but in the very long term, if the national health insurance plan compensation is tweaked to bias toward more PCPs, then that should also help with the scheduling problems.

[Edit: The natural corollary of the high no-show rate is that, if your schedule is flexible and you want a doctor's appointment soon, call their office, ask if they could let you know if there are any cancellations, and leave your phone number. Your odds are pretty good, especially if the office has a fee for no-shows, but no fee for last-minute cancellations, and a reminder system so that folks know they need to cancel.]

I have a PC laptop which is over 3 years old now and getting to feel slow & creaky. I also have a PC desktop which rocks (and runs XP). I am repelled by everything I've read about Vista, and find the elegance of the Mac OSX very attractive.

I am currently a student and get a student discount on any Apple purchase prior to August (when I become a non-student). I went to the Apple store today to play with one of the macbooks and one of the macbook pros.

You'd think, on a 17" monitor laptop, they'd have room for page up/page down and home/end. I use those key combinations a lot on my PC. Apple does have key combinations that serve those purposes, but they're combined with the open-apple key, not the control key, and the open apple key isn't where my pinky is used to finding the control key. You can also do those functions using the multi-touch features on the track pad, but of course, my fingers aren't used to that. Plus, I kept hitting my thumb just below the click bar on the track pad, probably because my thumb is used to the relative distance between the click bar and the edge of the laptop on my old laptop.

All this drove home to me in a very visceral way -- if I move to a Mac Laptop, I am really going to have to relearn a large number of things that have become automatic. And I don't really want to. I am, apparently, now an old fuddy-duddy. I remember the days when I had two macs, two PCs and two suns on my own little class C connected via an ISDN line, and I just hopped blithely between platform. Apparently, I knew them all so well that I didn't have to do any conscious adjustment when moving between platforms. And apparently, I've lost that. A mere decade living a PC-only life (modulo the occasional ssh to a unix box), and poof, my internal Apple compatibility goes bye-bye.

I'm still planning to get a mac laptop. As soon as a I finish the papers I'm currently procrastinating on, I'm off to the Apple store. But I'm thinking I'll need to allow a fair bit more time to get used to the different work environment, and to research and decide how to configure my mac.

My questions:

1. Is my distaste for Vista and my theoretical attraction to the unix under-pinnings sufficient reason to make my next laptop a Mac?


2. Should I get a big Macbook Pro, consider it essentially a portable desktop, and plan on using the iPhone anywhere I don't want to lug a laptop, or should I get an itty bitty MacBook which is more portable, but has a lot less screen real-estate? (I use lots of screen real-estate at home with my 2 20" monitors).


3. Does anyone have particular recommendations for the PC to Mac migration?

1. PDA / Smartphone

Currently, I have a palm TX and a cell phone. My cell phone probably has other functions, but the only functions I use on it are placing and receiving phone calls, and the rare text message. My TX's power button died a few weeks ago. I can still turn it on by pressing one of the control buttons, and then wait for it to turn itself off due to inactivity, but I can tell that this is the beginning of the end. I need to decide what to purchase to replace it when it finally dies for good.

My palm has a number of applications that get used regularly, 2 of which are absolute requirements.

• Epocrates: This drug reference is a killer app. I would not want to practice medicine without it.


• Mobipocket: This is an ebook reader.

There are also a number of applications, which are used relatively frequently, which I would also like to have:

• A sudoku player


• A solitaire player


• A restaurant guide


• A memo pad


• A calculator


• A medical calculator like medcalc (which has more formulae than the medical calculator which comes with Epocrates)
  

Finally, there are a number of sort of half-baked applications that I might use more often if they were easier to use:

• A diet tracker -- in an ideal world, it would sync gracefully and be extremely easy to add items and run quickly


• A calendar -- in an ideal world, it would sync automatically with my google calender in real time


• A contacts list -- in an ideal world, it would maintain synchronization with my cell phone in real time, and be easy to add to either on my computer or on the PDA.


• A task list -- in an ideal world, it would maintain synchronization with my desktop in real time.


• An e-mail client -- again, in an ideal world, this would maintain synchronization with all my e-mail accounts


• A web browser -- in an ideal world, this wouldn't depend on wifi access, and would render a LOT faster.

I have been quite jealous of my friends with the smartphones with the unlimited data contracts. They can check gmail, go to the zagat web site, etc. It's just that all of their devices have significantly smaller screens than my 320x480 TX, and I really don't think anything smaller than 320x480 would be useful for the kind of intense ebook reading I do on my device. I haven't been able to justify purchasing a smart phone w/o planning to have it replace BOTH my TX and my cell phone.

I have looked at the Kindle and the Sony E-book reader and a number of other ebook dedicated devices, but again, I can't justify purchasing a device just for ebook reading and carrying something else around for Epocrates.

I know that the iPhone is releasing their next release, with multiple available applications, in June. I know that Epocrates will be available for the iPhone.

I have to assume that an ebook reader will be available. With luck, it will be something even better than mobipocket. Mobipocket seamlessly converts web pages and text files to ebooks with their free converter. It also provides a format that is used by several commercial sites, including Baen's Webscriptions, the new Tor ebook giveaway, and several non-commercial sites, such as manybooks. However, I'm not as attached to mobipocket the software as I am to Epocrates. Mobipocket hasn't been updated in a while. Its e-book management tools fail for large numbers of e-books. It doesn't have any mechanisms to sort books by more than one feature, to see the book size when not sorting by size, to edit meta-data on the PDA device, to mark a book as un-read once it's opened (even if you haven't read more than the title page), or to classify more than one book at a time. The fact that every time I leave mobipocket to use a different application, and then go back into mobipocket and want to view the library, it has to regenerate the entire freaking library by reading in the meta-data files for every single e-book one at a time, with a remarkable (>20 second) lag drives me nuts. I'm looking forward to seeing what's available on the iPhone.

I also have to assume that a sudoku player will be available, preferably with a large library of games at different difficulty ratings, or a fast puzzle generator which can accurately generate to a particular difficulty level.

With the almost-always-connected (except in the subway or on planes or when deep in a shielded building) features of an iPhone, I suspect that maintaining synchronization for contacts, calendars, task lists, etc will be a lot easier.

I don't really care about music. I mean, I like it, but I don't tend to listen when I'm out and about. My computer often plays music when I'm working, but I tend to turn it down/off when I really need to concentrate. The mp3 player and the video player features of the iPhone strike me as nice frosting, but not enough to significantly affect my purchasing decision.

So, after all that, my plan and my question:

I am planning to hope/pray that my TX lasts until June, and then, when the next rev of the iPhone is released, and when I see that both Epocrates and a robust e-book reader are available, to purchase an iPhone.

Can anyone think of a device/platform that would satisfy my need for both Epocrates and an ebook reader, and my desire for the above function set other than an iPhone? Has anyone heard anything about Palm coming out with a new device with a larger screen and almost-always-on connectivity that would satisfy me (cuz I haven't)?

I was talking to some folks while at Lunacon a couple weekends ago, like I frequently do in other contexts, about the Obama Health Plan and the potentially fatal flaw I see in it, so I thought I'd write it up for my LJ and see what my LJ reading friends think about my thoughts. *grin*

Don't get me wrong. I'm an Obama supporter. I may think that Hillary Clinton's health plan is better, and if she's nominated, I'll certainly vote for her, but I'd much rather Obama was nominated, for the following reasons [side track #1]:

1. Obama's emphasis on hope and his "Yes, we can!" slogan are a lot shorter, sound-bite wise, than Kennedy's famous line "Ask not what your country can do for you - ask what you can do for your country", but he manages to communicate the idea that if we all pitch in and work hard we can do anything and solve any problem. He's the first politician I've seen in a long while who doesn't communicate either "Don't worry your pretty little head about the complicated issues; just trust me" or "The problems aren't solvable; live with it." This message of empowerment, together with the need and expectation that everyone will pitch in, is a very powerful and attractive message.


2. By electing a biracial man with ties to Indonesia and Kenya, we, the voters, can instantly send a message to the rest of the world that we are over (or at least recovering from) our self-centered "only the USA matters" viewpoint.


3. Hillary, no matter how much I respect her intelligence and hard work, has too many enemies on the right that will fight her no matter how excellent her proposed legislation is, just because they don't like her. This means that even if, in my opinion, her health care plan is better, it will also have less chance of passing.

And so we come back to health care plans. My understanding is that both Hillary and Obama are proposing a nationally available health insurance. This is NOT nationalized medicine or a single payer system. Instead, this is health insurance that people can buy, made available in competition with the various private insurances. The big difference is that the cost to the consumer for this health insurance will be affordable even for people with expensive illnesses, and the cost will also be adjusted for income so that even poor folks will be able to afford this insurance.

Rather than having to be employed to purchase company-subsidized health insurance, or very healthy and willing to pay a lot to purchase private insurance as an individual, this health insurance will be available for everyone. The details of what exactly will be covered by this national health insurance is still to be determined, but it's probably safe to assume that it will cover basic health maintenance (ie, an annual physical), most vaccinations (possibly not some of the newer, less proven ones), urgent care (stitches, ear infections, etc), medications, and catastrophic health events. Depending on who gets their hands on it when its being formed into legislation, it may be fairly comprehensible, but more likely will be as confusing as most insurance plans when figuring out exactly what is and isn't not covered, and exactly what the co-pay or co-percentage is. Oh well. The point is that it will offer affordable coverage to everyone.

Now comes a very serious question: If it is too expensive for the health insurance companies to cover sick people and poor people, whose health care costs more than they can afford in premiums (either because their care is expensive, or because they can't afford much), how on earth is the government going to be able to afford to offer this insurance?

It's a serious question. They can't just jack up the price for the healthy folks too much, or the health folks will all go buy cheaper private insurance or choose to go without insurance rather than pay what they perceive as uxorious rates.

The national health insurance plan will save some money because it won't need to make a profit. Insurance company profits jack up premiums a fair bit, and this national plan won't have to deal with that. In addition, it won't need as complicated a sales force, since the pricing schema will, we hope, be fairly simple. At least, the prices won't need to be adjusted too much for pre-existing conditions. With luck, it'll be able to copy the low overhead of medicare.

This national health insurance plan will get some money from the healthy poor folks who didn't used to have insurance at all, and now do, but not a whole lot, since poor folks will be buying this insurance at a discount. Frankly, even healthy people need annual physicians and are at risk for an acute event, so covering even a perfectly healthy person isn't free.

What both Barak Obama and Hillary Clinton are hoping and planning for is that the hoards of uninsured folks who are unemployed, partially employed (part-timers often don't qualify for corporate health insurance) and employed at small businesses will sign up for the national insurance plan. In addition, they're hoping that some of the large businesses will switch to this national insurance plan. These healthy members will partially subsidize the poor and chronically ill.

They're also hoping that with a huge pool of members, this national insurance plan will be able to negotiate good rates for the various medications and health services.

I expect that the government will have to subsidize this national insurance plan in order to keep the insurance rates low enough to attract consumers, especially in the beginning. I anticipate that the first folks to sign up will be those who have on-going medical expenses and can't qualify for private insurance, i.e. the chronically ill and medically expensive. Ideally, as more people, especially healthy people, sign up, the amount that the government needs to subsidize will go down.

Unfortunately, that means that the highest expense will be up front, just when we're facing financial crises at home (mortgage and investment companies) and huge expenses abroad (Iraq war). I don't envy either Barak or Hillary as they try to push this insurance plan forward. If they say it won't cost anything, they're lying and their opponents will call them on it. The best they can say is that it will be expensive to begin with, but will hopefully grow self-sufficient, and that it will overall reduce health care costs, since taking care of end stage disease is almost always more expensive than early stage disease. (Unless the end-stage is dead, in which case it's really fairly cheap. *wry grin*). This national insurance plan should also put a large dent in the ER over-crowding problem, since all those folks using the ER for urgent care will now be able to get preventative care, as well as outside-the-ER urgent care from their PCP.
However, in order to make this hypothetical national insurance plan self-sustaining, it is absolutely necessary that SCADS of healthy people sign up and pay the premiums, not just the poor and chronically ill.

Hillary Clinton takes the paternalistic viewpoint that the American people, or at least lots of the healthy ones, will choose to value something else (bigger apartment, newer car, food!) more than health insurance. She wants to mandate that anyone who doesn't have some sort of health insurance MUST sign up for something, be it a private insurance policy or the new national health insurance plan.

Barak Obama believes in the educated consumer. He believes that if health insurance were reasonably priced, almost everyone would sign up, and he'd have the scads of people needed to make a national health insurance plan fiscally viable without using any coercion.

I don't think he is correct. I wish he were, but I don't think he is.

The problem, as I see it, is the perceived value of health insurance vs the cost. The cost is not zero. At a bare minimum, healthy people should consume an annual physical, together with any needed immunization, plus a bit more to cover their risk for an acute event. To quote the National Coalition on Health Care: "The annual premium that a health insurer charges an employer for a health plan covering a family of four averaged $12,100 in 2007. Workers contributed nearly $3,300, or 10 percent more than they did in 2006. The annual premiums for family coverage significantly eclipsed the gross earnings for a full-time, minimum-wage worker ($10,712)."

Let's say coverage for 1 person is $3k rather than $12K for four people, and then let's assume that because of economies of scale and no need for profit and collective bargaining and perhaps a bit of government subsidization, the price comes down to 1.5K. That's about $125/month. That may be a very optimistic estimate (50% off), but lets make it.

$125/month is a lot of money. For someone who is concerned about their health, or scared that an acute health event would seriously impact their life, it's worth it.

For someone who is young and healthy, they might prefer to spend $125/month on something more immediately useful.

For someone who doesn't like doctors or health care, they might prefer not to spend $125 on something that reminds them of their mortality.

I have seen many patients in the ER who are covered by some form of health insurance and still don't take their medications. A lot of medical conditions don't have any serious symptoms until the disease is rather advanced. The first symptom of hypertension, if you never check your blood pressure, can be a heart attack or a stroke. The first symptom of type II diabetes, other than peeing a lot, being thirsty a lot, and maybe finally loosing a bit of weight, all of which can be ignored for years, can be irreversible nerve, eye, kidney or heart damage.

[Note: This does not mean that the bad consequences happen immediately; it means that folks with other priorities can ignore minor symptoms until it's just TOO late.]

My concern is that folks who have priorities other than their health will not sign up for this national health insurance policy. They will continue to get sick, and continue to drain resources from the health care system and to crowd up the ER with their problems that are only urgent because they were ignored for so long.

My hope, and Obama's hope, is that this group with a different priorities will be a small minority. My fear is that the human tendency to place greater weight on immediate consequences rather than long term consequences will ensure that this group with different priorities is way too large.

If Obama wins, and if he passes a national health insurance policy that is not mandated, I strongly hope he has other mechanisms to ensure a large spread. Perhaps an excellent marketing team? A mechanism to enroll everyone automatically who isn't otherwise covered, and make it opt out? I guess we'll wait and see.