As I mentioned earlier, I’m starting to rev up the studying for the licensing exam. A lot of the studying takes the form of practice questions. They’re actually a lot of fun to do: they force you to think actively about the clinical scenario, keep you on your toes, and make it near-impossible for your eyes to glaze over as you semi-consciously read the same page for the 10th time in a row as your eyelids begin to feel heavy, droop, and you start to….
Yikes! Where was I? Right! The Cavalcade is back! Since I’m sure that most of you don’t believe me when I say that doing practice questions is actually fun, I’m going to use this opportunity to try to convince you. With the aid of sophisticated, peer-reviewed psychometric techniques (or not), I have converted each entry into a USMLE-style “single best answer” multiple choice question. Let’s see how you do!
Cavalcade of Risk: Step 1
Instructions: For each of the following test items, select the one answer that best answers the question posed in the stem.
From Boomer at Boomer&Echo: Which of the following behaviours of financial advisors correlates with the lowest risk of defrauding investors?
a) Claiming to have secret/exclusive insider tips that “your broker doesn’t want you to know.”
b) Counseling clients that investments with higher expected returns tend to be riskier.
c) Offering to move your money offshore to avoid taxation.
d) Pressuring you into making a hasty decision on an “exploding offer.”
e) Charging abnormally high membership fees.
From Ken Faulkenberry at the AAAMP Blog: If shares of the Notwithstanding Blog Internet Empire (NBIE) earned a 8% return in 2011 and exhibited a beta of +1.2 relative to a benchmark of shares in all medical blogs that collectively earned a 5% return, then:
a) The alpha for NBIE in 2011 was +2, making it a good investment.
b) The alpha for NBIE in 2011 was +3, making it a good investment.
c) The alpha for NBIE in 2011 was -3, making it a bad investment.
d) The alpha for NBIE in 2011 was -6.8, making it a bad investment.
e) The alpha for NBIE in 2011 cannot be calculated with this information.
From Van R. Mayhall III at the Insurance Regulatory Law Blog: Which of the following statements DOES NOT accurately characterize insurance company insolvency:
a) Most state-based insurance guaranty associations are more comparable to private member-based associations than true state agencies.
b) Insurance companies are subject to unique state-based insolvency protocols in lieu of entering the federal bankruptcy system.
c) Payouts from state insurance guaranty associations are subject to statutory caps.
d) Insurance guaranty associations are intended to provide “bailout” financing to prop up faltering insurers.
e) None of the above.
From Emily Holbrook at Risk Management Monitor: The shoe-shopping website Zappos.com recently earned positive press for:
a) Losing your examiner’s personal information, along with that of millions of other customers.
b) Locking out customers from your examiner’s home country for 4 days after a data breach.
c) Being named in a potentially-class action lawsuit seeking damages as a result of a data breach.
d) Having “some analysts” criticize the company’s response.
e) Having “some analysts” praise the company’s response.
From Jason Shafrin, the Healthcare Economist: Medicare’s new value-based purchasing initiative, which aims to reduce payment to “low-quality” doctors, currently uses treatment costs for which of the following chronic diseases as an element of its cost measure (as distinct from its quality measure):
b) Alzheimer’s disease
d) Lung cancer
e) Breast cancer
From Louise Norris at Colorado Health Insurance Insider: Colorado’s Medicaid program has recently undergone much change and provoked a great deal of controversy. What happened at the end of 2010 to put Colorado’s Medicaid program on better financial footing?
a) Successful negotiations to lower the fee schedule for physicians’ services.
b) A 55% increase in enrollment relative to 2007.
c) A one-time $13.7 million grant from CMS.
d) New dedicated revenue from a sales tax increase.
e) The introduction of Medicaid Managed Care programs.
From Dr. Jaan Sidorov, the Disease Management Care Blog: Which of the following is an accurate characterization of Dr. Sidorov’s assessment of Health Insurance Exchanges (HIEs) and recent Kaiser Health News commentary on the subject?
a) The left is doing their best to nurture this fledgling institution to maturity in anticipation of the PPACA’s full rollout.
b) It’s reasonable for consumers to spend more time shopping for consumer electronics than for health insurance.
c) Government-run HIEs will eventually match the ease-of-use and “cool” factor of iPhone apps and online purchasing aids.
d) Multiple insurance options on HIEs include variations in provider tiers, out-of-pocket costs, and exclusions.
e) Consumer expectations for HIEs will eventually be exceeded.
From Julie Ferguson at Workers Comp Insider: Doctors’ deaths differ from the deaths of other Americans in that:
a) Doctors often choose to forgo lifesaving chemo, radiation, and procedures.
b) Paradoxically, doctors often do not have access to the full range of lifesaving technologies as the rest of society.
c) Non-physicians tend to be more ready to accept death.
d) Doctors have a cultural bias against accepting death that isn’t shared by society at large.
e) Non-physicians who choose to fight their disease are often pressured by friends and family to be serene in the face of death.
Of course, since you read all the entries, you don’t need one! But just in case: B; A; D; E; C; C; D; A.
As always, it’s an honour and a pleasure to host the Cavalcade of Risk! If this is your first time at the Notwithstanding Blog, or if you’re coming back after a prolonged absence, I encourage you to take a moment and poke around some of other posts here. From health care policy to health professions training (i.e. medical school), I’ve got it covered.
The 150th(!) Cavalcade will be hosted on February 8th at My Wealth Builder.
This was going to be a post about science-based medicine and the law. Really. I still might write it, maybe even tonight. But before I could get started, I cleared my comment spam. Among the usual expected unsavoury entities hawking the usual unsavoury wares, I found two recent spam comments from professionals who really should know better.
I think the law bloggers handle this better than we on the medical side do. There are plenty of social media evangelists in both fields who can be found online treating new technology as an end and not a means, promoting the ideal of “saying anything” over “saying something,” and generally clogging the ‘tubes with tweets, blog posts, and comments that barely even try to masquerade as anything beyond marketing. At least there are some lawyers out there willing to call “shenanigans” when they see them.
I have yet to see a physician call out his/her colleagues for scammy/scummy behaviour online. Not like some of the blawgs do. Take Ken and Patrick at Popehat, for instance. They’re brutal, and rightfully so. As another blawger, Eric Turkewitz, puts it: “when you outsource your marketing, you outsource your ethics“.
I am no luminary in the medical profession. Given that I blog pseudonymously, you can’t even be sure that I am a medical student. I claim no special authority to make pronouncements on medical ethics. I don’t need to. The following statement should speak for itself:
If you are a medical professional, comment-spamming blogs is not an acceptable marketing tactic. If you find yourself keeping company with SEO hucksters and vendors of penis-enlargement pills, you’ve made a wrong turn somewhere.Your online obligations don’t end at HIPAA.
Dr. Michelle Scott Tucker of Castle Hill Pediatrics, Carrollton, TX: you wanted search engine visibility. You got it.
These marketing shenanigans are undignified, unethical, and reflect incredibly poorly on the medical profession. I will not be associated with them. If you have a medical blog yourself, I hope you’ll join me. Make it clear to other physicians that indiscriminate spamming is no way to promote a practice. Call them out. Someone has to show them the error of their ways.
I will take another page from Popehat’s book and make the following offer to anyone called out for comment spam at this site:
“I will scrub this post of data identifying [you] and [your practice] on two conditions. First condition, [you] must make a sincere apology for [writing spam comments yourself, or] outsourcing [your] reputation and ethics [...]. Second condition, [you] must provide emails or other documentation identifying the marketeer [you] hired who produced the comment spam and proving their responsibility for this, so that we can alter the post to call them out by name.”
My email is in the upper right-hand corner. You know how to reach me.
I was originally going to abandon any effort to post the remainder of my coverage of the American Medical Students Association’s 2011 annual convention when it become clear that it would be so delayed that it could hardly be considered topical. A small number of readers have encouraged me to post the highlight anyways, using the arguments: better late than never; the events left to be blogged were the most interesting; and finally, I may as well “complete the chronicle.”
Below the cut, for those interested in how health policy was presented at the AMSA convention, are highlights from two events: a debate between Michael Cannon (Cato Institute) and Robert Zarr (American Academy of Pediatrics, Physicians for a National Health Plan); and a later event featuring Walter Tsou (immediate past president, PNHP).
I’m not the first person to have made this point, but a recent post on HIT/EMR adoption at KevinMD got me thinking about it again:
Many clinicians are resisting the implementation of electronic medical records and other forward-thinking technologies because they dislike change, and technology for that matter. This is likely because the technology that is being imposed on them is difficult to use, or doesn’t feel natural to them.
This is something one hears a great deal of during discussions of physicians and technology. “Physicians are stubborn and resistant to change.” Let’s be honest, who doesn’t know a physician (or 2, or 20) that fits this description?
On its own, this is not a facially illogical explanation for low EMR uptake and resistance to health IT mandates from the government. Of course, many of the prominent organizations who believe that our salvation lies in EMRs and that those pesky, technophobic physicians need to fall into line (think Commonwealth Fund) are the ones who continually remind us that the reason behind the long, inexorable march of increasing health care costs is…
… physicians’ constant readiness and willingness to adopt new technologies and innovations when they feel it will improve patient care, or the bottom line.
Having never seen anyone from these schools of thought even try to explain how these two views are compatible, I can only conclude that some hard doctrinal choices are in order.
Argument by Anecdote!
Last week, I was shadowing an older, outpatient physician in a procedure-heavy specialty who is on the voluntary faculty at SUMS, and admits to SUMS’ main teaching site. We talked for a while about the hospital/med school EMR, which we both agree is a nightmarish monstrosity. He was explaining how he was holding off on the paper –> electronic conversion for as long as possible (i.e. until the school forced him), because the product was just so terrible.
He then proceeded to show me the brand-new Siemens ultrasound system that he and his partner had purchased not two weeks ago. He explained the effort that he went through to train himself on it and its new features, and how it was already an improvement over the model he had been using previously. He then proceeded to reminisce about all of the technical wizardry that had been invented in his professional lifetime that he now uses routinely in the office, because he feels that it enhances his ability to care for his patients.
He really, really does not want to switch to the hospital EMR.
Stubborn, resistant to change, and fearful of new technology? You tell me.
Revulsion is not an argument; and some of yesterday’s repugnances are today calmly accepted — though, one must add, not always for the better. [...] In crucial cases, however, repugnance is the emotional expression of deep wisdom, beyond reason’s power fully to articulate it.
If I held myself to such high standards, I would tell you that I find the thrust of what I see as mainline bioethical thought to be “icky,” and from there res ipsa loquitur. However, I’d like to think that my distaste has more than mere “revulsion” behind it, and as such the matter is not so easily disposed of.
In the “standard” ethics and professionalism lectures, medical students are taught that medical ethics rest on three foundational pillars: non-maleficence (“do no harm”); beneficence (“do what’s best for your patient”); and autonomy (“act in accordance with your patient’s wishes”).
Who decides what’s best for the patient, or what constitutes harm? Logically, it should be the patient! When the stakes are high, so too should be the barriers for a physician to substitute his or her goals and values for the patient’s.
SUMS has a thriving medical ethics program, and we’ve had the opportunity to hear clinicians and medical ethicists from SUMS and from farther afield talk about ethical conundrums they’ve seen on the wards. Every presentation has shared one feature, without fail: it’s only an ethical conundrum (usually meriting a call to the bioethics committee) when the physician doesn’t agree with a patient’s choice, and has been unable to successfully use persuasion or coercion to change the patient’s mind.
This seems like a trivial observation at first. After all, why call the ethics committee to adjudicate a matter where the physician and patient are in perfect agreement (aside from rarer edge cases where this happens, usually involving experimental procedures)? It makes perfect sense!
What this means though, is that the medical ethicist has become the person to provide cover for a physician to override the patient’s autonomy. By virtue of selection bias in the cases they are asked to adjudicate, and the ever-present threat of regulatory capture, the role of “medical ethics” runs the risk of devolving into Paternalism 2.0. “We know what’s best for you, and if you don’t believe us, we’ll make you.” What’s more, when the medical ethicist is nothing more than the cudgel with which the physician forces his goals onto his patient, what claim does the ethicist then have to support his monopoly on decision-making in this sphere?
Admittedly, this image of medical ethics is a caricature. But to see the danger that lies in store, look no further than their cousins: the bioethicists.
At every turn I can think of, bioethics has established itself as the true “Ideology of ‘No.’” Whether dealing with BRCA gene testing for breast cancer susceptibility, assisted reproduction technologies, APOE4 screening for Alzheimer’s susceptibility, or “cosmetic” fetal ultrasound, mainstream bioethical opinion always seems to come down on the side of denying information to patients. Hardly the patient-empowering mindset that marked the field’s nascent days.
So why has the medical ethics / bioethics enterprise come to undervalue patient autonomy so extensively? I offer two preliminary hypotheses.
First is the fact that medical ethics and bioethics are situated in an academic-institutional environment that usually leans left-liberal (Progressive). Whether the institution makes the people, or the people make the institution, it comes out to the same thing: the setting is one that inculcates a predilection for top-down technocratic control. I think that this assessment is valid, regardless of what you think of the merits of different political philosophies.
The second one is, in my mind, more interesting. Public choice theory reminds us that bureaucrats, leaders, institutions, and their people do not exist in a world devoid of incentives and personal agendas. As an ethicist, when you say “no,” you entrench the need for your services… there needs to be someone with the authority to say “yes,” and what better way to establish your authority then by saying “no?” When you posit increasingly more complex models for evaluating ethical dilemmas — “autonomy, beneficence, and non-maleficence” just don’t cut it — you create an institutional need for someone with expertise in dealing with these complex rules to act as interpreter, and thereby increase your own power and prestige. Giving full weight to patient autonomy would undermine the need for your services.
This isn’t to say that ethicists make decisions with an explicit eye to entrenching their influence in the medical setting. It is, however, a reminder that we should always be asking ourselves: quis custodiet ipsos custodes? Who watches the watchers?
That, and the “wisdom” of repugnance is only as valid as the reasoning that supports it. Having “a bad feeling” about something doesn’t cut it when lives are on the line.
Like other enthusiasts of health policy, I spent plenty of time reading and thinking about the Wall Street Journal’s recent reporting on the RUC — the panel that decides how Medicare pays for physicians’ services. The existence of this system was news to many of my classmates, one of whom zeroed in on the hourly wage figures. By MedPAC’s calculation, radiologists would make approximately $193/hr if all of their work was paid at Medicare rates, compared to $101 for primary care physicians and $161 for surgeons.
Why, asked my classmate, should radiologists be paid so much relative to surgeons, given that the training length for diagnostic radiology and surgery is similar, and radiologists arguably play a smaller role in the care of an individual patient, face less malpractice risk (I might quibble with this, but I let it stand), and are able to work “better” hours, doing work that’s less physically demanding?
Now, the WSJ article helps to explain exactly how this situation has come about. The “market” for physicians’ services is one in which nominal and relative prices are set from above. They’ve been set in such a way that the “ROAD to happiness” starts with Radiology. (The “ROAD,” for those unfamiliar with the term, consists of Radiology, Ophthalmology, Anesthesiology, and Dermatology)
This lends itself to an interesting thought experiment. Would diagnostic radiologists fare this well under a market system? I think they would, and here’s why: I think that radiologists are medicine’s superstars, at least in an economic sense.
The reason that major-league athletes and Hollywood A-list celebrities command such high pay is not strictly because we as a society think they are individually more important than, say, an individual teacher or firefighter (or physician). It’s because these athletes and actors are in an industry where the consumer will pay a premium for the “best” (as opposed to minor league teams, indie movies, etc.), and in which many, many consumers can be reached at low marginal cost (cf. television, the internet). The athlete/actor doesn’t have to add a lot of value to a given person, but instead is compensated handsomely because he is able to add some amount of value to a lot of people who are willing to pay for it. Average class size in a public school may be 30, but most sports stadiums can fit tens of thousands, to say nothing of TV and radio audiences.
This strikes me as at least superficially similar to some aspects of diagnostic radiology. The use of medical imaging has exploded in the past 20 years, but it would be bold to claim that none of that increase has to do with the value that it adds to clinical decision-making and patient care (at least when used appropriately). And we as a society have decided that we want the best: that is to say, we want our scans read by radiologists.
What’s more, it’s entirely plausible that a diagnostic radiologist can add her full armamentarium of value to more cases per day than a physician in many other specialties. That it may take less time to read a scan doesn’t lessen the value added by having the scan read. The worth of the information to the patient is independent of the time it takes to derive it (within limits).
So, would radiologists still be on the ROAD in a market-based system of payment? The case in favour looks pretty good. Of course, the challenge facing American radiologists in my lifetime may not be justifying their value in patient care so much as justifying their value over and above their American-boarded Indian-based counterparts. Communications technology has helped make superstars of American radiologists… will it make them overpriced and obsolete as well?
What with this whole commencement of medical school, it’s been a while since the last edition. So I bring you slightly more than usual
Fun tidbits, health-related and otherwise, from around the ‘tubes:
- Worthwhile Canadian Initiative reminds us that counterintuitive though it may be, there is an optimal amount of forgetting. Dr. Bob Centor suggests that proposed performance payment for physicians forgets the role of patient preferences in steering therapy. Sticking with patient preferences, two posts at KevinMD argue that the long-term viability and feasibility of the PCMH care model should be determined by patient desires. That is, if the PCMH model is workable to begin with… an arguable proposition. Of course, if recent trends with retail clinics are any indicator… well, it could indicate many things. You be the judge.
- Beware economists bearing dynamic stochastic general equilibrium macroeconometric models! Beware surrogate endpoints in clinical research! Beware constitutional challenges to the PPACA! Beware Robin Hood… libertarian rebel? Beware overly alarmist bullet points!
- End-of-life spending has gotten some attention. The DMCB and Health Affairs alike aren’t convinced that reducing this spending will be easy, or that the savings are in fact possible to realize, at least as conventionally measure. Relatedly, a guest poster at KevinMD points out that in medicine, sometimes “more is more.” Not all potential cost-savings are “free lunches.”
- The Happy Hospitalist argues that data on physician reporting on impaired colleagues shows that the profession’s ethical standards are quite high. Dr. Wes points out the ethical shortcomings of conducting large-scale policy experiments without any concept of research subject welfare as found in clinical research. Arguably least ethical of this bullet point is Congressional exemption of the SEC from most FOIA requests.
- Pretty pictures! Congressional Republicans give us charts explaining new government agencies created by the PPACA and the criteria for obtaining small business health insurance tax relief under the act. The Denver Post posts some extraordinary colour photos from the Depression era. Of course, sometimes making use of pretty pictures (and text) will cause one to run afoul of the federal government, as with the ADA actions taken against universities piloting Kindle usage among their students.
- Let’s talk unintended consequences of government actions. Start by guessing which Senator takes exception to certain provisions of the PPACA? Hint: his name rhymes with “Hairy Reed.” Elsewhere, the recession has forced two entrepreneurs to decamp to Canada because of the arcana of the E-2 visa. What happened to new bond issues after the passage of the Dodd-Frank financial reform bill? Would “disaster” be hyperbolic? Becker and Posner ponder the effects of the administration’s pro-union attitude on business uncertainty and the recovery. Megan McArdle discusses the optimal level of regulatory enforcement, whereas another blogger discusses the “tyranny of big ideas” in the context of regulatory change and improving human welfare.
- On lighter notes, we have a farmer who reminds the world that old-school farming isn’t all it’s cracked up to be, and a brief history of Tibetan Buddhism that is markedly different from the sort of thing you’d probably expect.
- Rounding out this week’s edition… Medical schools, broadly speaking, do three things. They educate physicians, produce research, and care for patients. As someone just starting medical school, it’s nice to read things like this post from Dr. Centor arguing that the primary mission of medical schools should in fact be medical education.
The Happy Hospitalist has a great proposal to improve the utility of EMRs. Right now, these systems are often plagued with what one blogger calls “Copy n Paste Gone Amok Syndrome.” Reams of redundant information is copied into the EMR, and physicians who want to extract the clinically useful information from a note have to expend a lot of effort to wade through the pro forma notations that are primarily there to satisfy E&M billing requirements. If you want to get paid for that high-level patient encounter, you had best document each point of the x-point review of systems, and so on. When every physician does this for a patient being bounced around to multiple specialists (or with frequent medical contact, generally), the length adds up.
Add to this the frequent proposals that some patient behaviour or another be tracked in the EMR by every treating physician, regardless of why the patient is there in the first place. Some of this is probably a result of the trend towards overmedicalization of everyday life that we see in North America. Some of this is probably a result of medical interest group politicking that seeks to enhance the profile/prestige/importance of their constituency. Some of this is probably a result of the “what harm can come from another checkbox in the record?” mentality, coupled with the fact that this data can actually be useful to policymakers, researchers, and sometimes even patients(!). Off the top of my head, I can think of proposals for medical monitoring (or notice-taking, or box-checking) of social markers as disparate as smoking status, BMI, domestic violence, seatbelt use, and texting-while-driving.
Happy’s open-source H&P would go a long way to restoring sanity. Unfortunately, as he points out, the payment system isn’t too conducive to that sanity. When every physician has to check all of those boxes in order to get paid… they’ll get checked, and then copied-and-pasted.
In some ways, his proposal reminds me of the way that record-keeping functioned when I worked for my campus IT department. The required drop-down lists for all the data the “higher-ups” wanted to collect was kept in a separate part of each case record, never impinging on the employee-written narrative reports that contained only the vital information. They got their data, we got to see what we needed about the case’s progress and past work history, without the former getting in the way of the latter. Data collection didn’t excessively impede workflow. Win-win.
Lots of people have rightly pointed out that EMR vendors would do well to design their products based on how medical practices actually operate, instead of assuming that medical practice should be shoehorned into the constraints of the electronic record. For some good ideas, they need not look beyond their own industry’s analogues.
Fun tidbits, health-related and otherwise, from around the ‘tubes:
- How do the media deal with new research? How should the media, or anyone else for that matter, interpret new research? Unfortunately, the New York times only devotes a couple of paragraphs to this first question, but even that is enough to illuminate the complex web of incentives facing those in the science communications industry, and what it means for the science coverage that you see. A blogger at Foreign Policy provides some useful advice in response to the second question.
- The Placebo Journal Blog takes on a proposal to save family practice… by extending the residency to 4 years from 3 (in contrast, FP residency in Canada is 2 years). The comments are harsher than the post itself. A family practitioner blogging at Better Health gives an example of how opting out of Medicare can be win-win for the doctor and the patient. This strikes me as a better option than an extended residency. Even if primary care can be saved, it probably won’t happen soon enough to stave off what could be a massive increase in Emergency Department utilization by newly insured patients as a result of the PPACA.
- File these under “overutilization” for sure: Dinosaur accuses the American College of Obstetrics and Gynecology of “usurping” primary care’s scope of practice with new guidelines recommending OB/GYN visits for younger teenagers; MD Whistleblower blows the whistle on various “pre-emptive” CT scans that are being advertised to patients despite the fact that they don’t do much good for anyone.
- Science-Based Medicine writes a rebuttal to a Slate piece linked to in the last edition of AtM: Why Big Pharma should not buy your doctor lunch. SBM also featured some well-written commentary about new CMS head Don Berwick, touching on his lax attitude towards pseudoscience, and the Central Berwick Paradox of supporting unlimited patient choice and top-down government rationing. Or something like that.
- Via EconThoughts and Megan McArdle, we find a story in the WSJ describing how some unions hire non-union labour to staff their picket lines. Delicious. Less delicious is the story told by House Appropriations Committee Chairman David Obey (D-Wis) of how the White House suggested paying for spending on teachers by cutting food stamp benefits. Does anybody remember who the largest donors to federal Democrats are? I’m having trouble, but I don’t think it’s food stamp recipients.
- TJIC and Coyote Blog talk about “big picture jobs,” adding real value through real work, and what Scott Greenfield would call the “Slackoisie” that is much of my generation (I hope not to fall in with that crowd). We have critiques of recent NY Times letter-writer Arielle Eirienne, Washington Post interviewee “little-miss-altruist Beth Hanley,” and “big-picture jobs” and the people who think they should have one. They use lots of harsh words (well, TJIC does), but honestly… they’re right, painful as it may be for some of my contemporaries (heck, a number of my former classmates) to acknowledge.
- Let’s talk safety. It’s important, right? Important enough to flex some muscle and shut down a business just for the hell of it? Coyote finds that some agencies would say “yes” to that. Toyota and the NHTSA, in a move that didn’t surprise those who cared to think about the issue, announced that virtually all of the so-called “sudden acceleration” issues are attributable to driver error “pedal misapplication.” Whoops. Coyote asks “how safe is safe enough” in the context of dioxin, pointing out that new EPA efforts at regulation are probably superfluous, as is their existing safety standard. Lastly, can we afford to hire government employees to supervise children’s dietary intake? What’s scary is that there are people out there who take the question seriously.
- Doctors aren’t the only ones who deal with emergencies. There is such a thing as a legal emergency as well. Why not regulate emergency legal services in the same we that we do emergency medical care? Of course, like physicians, sometimes lawyers can be breathtakingly, hilariously incompetent.
- Economic mismanagement was a common theme this past week. From EconThoughts we have Obama’s Dirty Dozen; InsureBlog explains how his state is implementing the PPACA’s high-risk pool provision (not very well, it seems). Coyote explains why a government program’s popularity is a terrible metric by which to judge it, just as high corporate profits can sometimes spell bad news for the larger economy.
- Ending on a lighter note, we have an interpretation of Toy Story 3 as a libertarian-inspired parable, and an animation of an orthopedist consulting with an anesthesiologist. “There is a fracture. I need to fix it.“ Hilarious.