A better way to schedule preventive medical care?

Today my doctor told me that pap smears are no longer included in annual physicals.  This isn't the thing where pap smears are now once every three years, it means that they're apparently now considered a completely different test.  Because doctors aren't allowed to bill for more than one issue per appointment, this means that if I want an annual physical and a pap smear, I have to make two appointments.  Apparently OHIP is kind of cracking down on multiple issues in one appointment, and auditing doctors to make sure they don't treat patients for what they weren't booked in for.

I was googling around the idea, and apparently the intention is to cut back on the tests and examinations done during annual physicals because they've found that the tests have little to no benefit for healthy people.   Apparently studies have found that the people who diligently go in for annual physicals tend to be a healthy demographic for whom the tests don't turn up anything because they're healthy. Meanwhile, the less healthy people are already going into the doctor regularly for all their various health problems, so there's little benefit to a schedule physical this month if they just saw the doctor last month and are going to see the doctor again next month.

Which I'm fine with.  Because I don't actually want an annual physical.  Or a pap smear.  What I actually want is my birth control pills.

For my entire on-the-pill life, an annual physical and/or pap smear has been the gauntlet I have to run to get my birth control prescription renewed.  This doctor books physicals far in advance, which I didn't know at the beginning, so I called when I had a month of birth control left and was told it would be six to eight weeks.  When I told them I was running out of birth control, they booked me in for an appointment, where they gave me a three month prescription and then scheduled me for a physical, which I had to have before I could get a whole year's worth.

I don't think this is unique to my doctor.  At various times I've read discussions about whether birth control pills should be available over the counter, and in them doctors have said one of the reasons they like them to be prescription is it gets a sizeable proportion of their patients in for their annual physicals.  (You may remember we discussed how 1/3 of all Canadians use prescription contraception.)

Without getting into the (important) question of whether a physical is in fact necessary for birth control, this gave me a broader idea of how they can make the health system much more user friendly for patients and doctors.

Step 1:  Completely abolish annual physicals
Step 2:  Completely abolish the one issue per appointment rule
Step 3:  Create a system where whenever you come into the doctor for a specific issue, you also get all the preventive tests and examinations you're due for, based on your specific medical situation, and any other care your doctor feels you need.

So, in my case, I'd call the doctor when I'm running low on birth control pills.  The receptionist (perhaps with the assistance of a computer program designed to track these things) would see that it's been 12 months since I had blood work so I should probably get it done again, but it's only been 34 months since I had a pap smear so I'm not due for that.  Then it would book appointment length accordingly.  (Perhaps it could also add some extra time to the appointment if the patient hasn't been to the doctor in X months.) 

The doctor then sees me to renew my birth control pills, and also offers all the tests and examinations for which I'm overdue, and offers any other care that he feels would be appropriate.  And I am permitted to decline tests and care that are unrelated to the birth control pills and still receive my pills.

This will make things easier for the patient.  No more having to keep track of your preventive care schedule and call the doctor and make the right kind of appointment.  You just call the doctor when you need to go to the doctor, and they'll give you all the care you need, not just for this one issue but for everything.

It will also make things easier for the doctor.  You treat the patient in front of you for everything they need treating for, without worrying about whether it falls under the issue for which they made the appointment.  You can use your professional judgement without worrying about administrative matters.

And it will save the health system a little bit of money by creating a scenario where patients get their preventive tests and examinations sometime after their due, rather than right on the button of when they're due.  The current system normalizes coming in every 12 months for various examinations.  But if it's 12 months plus whenever the patient has an issue for which they need to see the doctor, some patients will be coming in after 14 months, some patients will be coming in after 2 years.  The healthier the patient, the bigger the interval between when they come in.  But it's self-selecting, so the patients are still getting care whenever they request care.

Of course, doctors can still have patients with chronic issues or high risk factors come in on a regular basis for monitoring.  And they'd still have the option of influencing the frequency with which patients come in with the length of the prescription they issue.

This leaves the question of whether anyone would slip through the cracks.  Under this model, anyone who wants to see the doctor for a specific issue will see a doctor when that specific issue arises.  Anyone with a chronic issue or high risk factors or complex needs who needs regular monitoring will get regular monitoring as required by their doctor. Anyone who takes medication on a regular basis will see the doctor whenever they need their prescription renewed. 

So that leaves people who don't have any specific issues for periods of over a year, don't have any ongoing medications, and don't have any conditions that need monitoring, as well as people who don't go to the doctor when they have an issue they need to go to the doctor for.

I think the people who don't go to the doctor when they have an issue aren't going to go for preventive annual physicals, so this wouldn't affect them.  So that just leaves people who don't have any specific reason to go to the doctor during periods of over a year.  Things They Should Study: is there anyone who's healthy enough to fall into this group but unhealthy enough that they have something just waiting to be caught by their annual physical?

Journalism wanted: how can people who find themselves in Amanda Todd's position get their tormenters in trouble without getting themselves in trouble?

Amanda Todd was coerced into exposing herself on a webcam when she was 12 years old.  She was a legal minor and she was below the age of consent, so surely that was illegal on the part of the coercer.  And, of course, having the pictures in his possession would have counted as possessing child pornography.

Then, when she was 15, someone tried to convince her to expose herself again, threatening to distribute her previous pictures if she didn't.  Blackmail is illegal (it's covered in the Criminal Code under "Extortion"), plus he was trying to coerce someone who is underage and under the age of consent to appear in child pornography, and threatening to distribute child pornography if she didn't comply.

It sounds like it should have been quite easy to report the blackmailer to police and put an end to Ms. Todd's troubles.

However, according to the story, the police knocked on Ms. Todd's door at 4 a.m. to tell her that her photo had been distributed. 

If I were a teen in Ms. Todd's position, that fact alone would be disincentive to going to the police.  The knock at the door at 4 a.m. would lead me to conclude that I couldn't expect the police to have compassion for me as a victim.  (At the absolute bare minimum, if the victim doesn't yet know they're a victim, why not do them the small decency of letting them get a full night's sleep?) It would lead me to conclude that the police wouldn't care about protecting me from the wrath of my parents (because a 4 a.m. knock at the door would result in my parents being tired and cranky and frightened, which would mean emotions are running high), which could be a reason to actively avoid police involvement if I had abusive parents.

Therefore, I think it would be helpful if some of the media coverage told teens in Ms. Todd's position how they could get help without getting into trouble.  Can you report it to the police without involving your parents?  Can they investigate it if you report it anonymously through Crime Stoppers?  What kind of evidence do they need?  Screen shots?  How can you avoid the 4 a.m. knock on the door?

Similarly, what should you do if you're an adult and a kid comes to you with this kind of problem?  How can you get the perp in trouble while minimizing the awkwardness and humiliation to the kid?

I also think, if they haven't done so already, the police should come up with a way for minor victims to report their victimization without the involvement of their parents, if they prefer not to involve their parents. Victim Services counsellors should also be trained and available to help minor victims tell their parents if they want, but parent-free reporting should still be possible.  And if it turns out that it is in fact possible to report that you've been a victim of a crime without involving your parents, police and media need to publicize this fact and give specifics.

What if food bank clients could buy extra food via food banks?

Two pieces of common knowledge:

1. Donating money to food banks is more efficient than donating food, because they can use the money to buy food bulk and/or wholesale.
2. Sometimes food banks run low on food.

Suppose you're going to a food bank because you can't afford enough food to get your family through the month. And suppose this happens to be a time when the food bank is running low on food, and they don't have enough to give you (or they don't have enough of what you need to give you). And suppose you have a little bit of money, just not enough to get through the month. What if you could give the food bank what money you have, and they could buy food for you at much better prices?

Of course, it's debatable whether this is ethical. Letting people buy better treatment from food banks doesn't seem entirely consistent with the spirit of food banks. But, on the other hand, saying "If they have extra money they should be donating it when the food bank is short on food!" seems very nearly victim-blamey. Perhaps the solution would be somewhere in the middle - X% of clients' donations go to general food bank coffers, Y% can be used for the donor-client themselves. But that seems a bit paternalistic, like parents who dictate how much money their kids need to give to charity.

I don't have answers, but I think it would be interesting to study and do projections (if they haven't already), and perhaps do a temporary pilot project to see what happens.

What if they deliberately inflated grades in gym class?

Every once in a while, people talk about making gym class mandatory throughout high school to improve the population's fitness. As I've blogged about previously, before we even get into the instrinic humiliation gym class, making it mandatory every year would be rather harmful academically.

First of all, having another required course to take every year eliminates the option of taking some other course that might be academically useful. Imagine if you're trying to get into some demanding university program, and you don't have room for Biology AND Chemistry AND Physics AND Calculus AND Computer Science because you have to take gym.

Secondly, making the class mandatory brings down the average of students who aren't particularly good at athletics (who should be the target audience of any such initiative, as those who are good at athletics are much more likely to already be involved in athletics). This would be harmful to non-athletic students' university and scholarship applications. For example, I did my very best in gym class every day, and all I got to show for it was a begrudging C. (And I suspect the teacher was only passing me at all because I was doing my best). In comparison, simply showing up in calculus or physics class and not putting in any effort would earn me a B, and simply showing up in French or German class and not putting in any effort would earn me a low A (and doing my best would get me a high A in all these classes). So, if the class were mandatory, it would lower my average, make me less attractive to universities and reduce my scholarships, all in service of a subject that's not only irrelevant to my future academic and professional career, but actually prevents me from taking another course that is relevant to my future academic and professional career. That's downright punitive!

But what if, instead of making gym class mandatory, they made it an easy A? Suppose showing up and doing the sport of the day was enough to earn you a low A-. Students are graded on a curve relative to each other within the A range of percentages, but the lowest mark you can possibly get for showing up and participating is a low A-.

This would give all students who can't normally earn an A effortlessly incentive to take gym every single year, to bring their average up for university. Students would still retain their positions relative to each other because the better performers would get high As and the worse performers would get low As, but gym class would have a positive effect on many people's averages, and no particular detrimental effect on anyone's average.

Inflating the grades may also be useful from a public health perspective (which is relevant since the whole idea of making gym class mandatory comes from a public health perspective). Because my very best efforts got me only a begrudging C, I reasonably conclude that my objective skill in sports is mediocre. If someone asked me to be part of their sports team, I'd be reluctant to do so (again, putting aside personal inclination) because I'd assume I'd be a liability for the team. However, if my best efforts had gotten a respectable B, I'd assume I'm more or less average and therefore no more of a liability than anyone else. You can see how this might affect a person's inclination to play sports later in life.

In all of this, there's still the question of Kinesiology class. I don't know how it works now, but when I was in high school, the OAC (Grade 13) gym class was called Kinesiology, had a stronger classroom component than the gym classes in the lower grades, and was preparation if not prerequisite for studying Kinesiology in university. I googled a few university Kinesiology programs, and they had multiple academic prerequisites (none of which were a high school gym or Kinesiology course), which suggests that, if high school Kinesiology still exists, the classroom component is academically relevant and would suffer from being inflated. Therefore, I propose that, if there is academically relevant material, only the in-gym component should be subject to grade inflation. That way, the students' relative marks will reflect their grasp on the academic material.

Understand, I'm not actually objectively advocating for inflating people's grades in gym class. However, from time to time, people advocate for using gym class as a public health tool, most often by suggesting that it should be made mandatory every year throughout high school. If they're going to insist upon manipulating the curriculum to achieve public health goals, I think grade inflation would be more effective and more just.

What if Barrett's esophagus isn't actually a problem?

I previously came up with the idea that medical science should come up with a way to install stomach lining in the esophagus to protect it against acid reflux.

In some reading I was doing today, I discovered that the changes to the esophagus that constitute Barrett's esophagus are actually making it closer to stomach lining than to esophageal lining.

So what if Barrett's esophagus isn't a problem?  What if it's just the esophageal equivalent of a callous?

The reason why Barrett's esophagus is even a thing is that it's considered a precancerous condition, in that a large percentage of esophageal cancer patients have Barrett's esophagus.  Because of this, a diagnosis of Barrett's esophagus triggers a more active esophageal cancer screening protocol.

But I really am beginning to suspect that Barrett's esophagus itself isn't actually a problem, it's just a correlation.  Fortunately, science does seem to be working in that direction.  Most of the papers I see recently emphasize how few Barrett's esophagus patients (usually stated at only 1%) go on to develop esophageal cancer, and science does seem to be looking at it as correlation instead of causation.  Hopefully researchers will focus on better pinpointing the actual root cause that differentiates that 1% within the next 10 years and spare me any unnecessary scoping.

What if buses stopped at every other stop?

This idea was inspired by the comments thread here (but is unrelated to the post itself). People were discussing how some transit routes have stops relatively close together, which slows things down because the vehicle has to stop so much. Some suggested spacing stops further apart, others thought that this would place too much of a burden on people with mobility issues.

But what if we kept all the stops, but had each vehicle only service alternate stops. The first bus of the day would stop at the first, third, fifth etc. stops, the second bus of the day would stop at the second, fourth, sixth etc. stops. Each individual bus would travel the route faster (which would make this technique useful for bus routes that are most often used to travel all the way across town or connect to the subway), and any user who carries a cellphone (to check NextBus) and for whom walking to the next bus stop is feasible would not be inconvenienced at all.

Just visualizing it in my head, it also seems like it would reduce bunching, although I can't actually prove that to you. For this reason, it also occurred to me to apply it to streetcars, but I don't think they can pass each other on the tracks. Transfers would be a problem under current policy, but the transfer policy could be easily changed.

This wouldn't work with infrequent bus routes, but if you've got a bus every 10 minutes it should increase convenience for the majority of users without too much inconvenience for the remaining users. Of course, the question is whether we want to be conveniencing the able-bodied on the backs of those with mobility issues, even if overall it is for the greater good.

What if you could join other people's pension plans?

Given the trend away from defined-benefit pension plans and the resentment by some people who don't have defined-benefit plans to those who do, I wonder if it would be possible to create a mechanism for anyone to join any existing pension plan.

Outside members would pay in however much they wanted to (and perhaps could use the contributions from their defined-contribution plans), and get returns commensurate with those contributions on the same scale as employee members. They'd be charged a management fee for this (akin to mutual funds), which would cover the cost of administering their membership plus a small profit. The employer would not pay anything towards the outside members, of course, they'd just be along for the ride.

Here's an example of how it would work, using numbers that make the math easy and don't reflect the ratios of actual pension plans:

An employee of Acme Inc. who earns $50,000 a year contributes $5,000 a year to the pension plan and the employer also contributes $5,000 a year to the pension plan, for a total of $10,000 in contributions a year. The employee then gets a pension of $1,000 a year for each year of service when they turn 65. So if they have 35 years of service, they get a pension of $35,000 a year.

If an outsider joins the Acme Inc. pension plan and contributes $10,000 a year for 35 years (plus the management fee), they'll also get a pension of $35,000 a year when they turn 65. If they choose to contribute only the $5,000 that the employee would be paying in, they'd get a pension of $17,500. If they choose to contribute $20,000, they'd get a pension of $70,000.

Possible variations: employees can also choose to pay more in and get a bigger benefit. So if the employee in the first example chooses to pay in $10,000 instead of $5,000, the employer would still pay in the same $5,000 for a total contribution of $15,000, and, after 35 years, a pension of $52,500.

This would be advantageous for everyone who doesn't have a defined benefit pension plan, because they could buy into a professionally-managed pension plan instead of having to figure out how to manage their retirement planning themselves.

It has the potential to be slightly advantageous for the employees, because they have more money being paid into their pension plan, plus they have outsiders who are now invested in not cutting back their pension plan. If they're public sector, they also have the advantage of less resentment from the public, because anyone can just join in.

It has the potential to be slightly advantageous for the employer, because they would be making a small additional profit from the management fees. In addition, people would be more likely to seek out pension stability during difficult economic times, and work tends to slow down during difficult economic times, so the employer would get this extra income (and a bit of extra work processing applications for its employees) when things slow down. The employer would also be seen to be providing a valuable public service and could probably swing some tax writeoffs from their pension management expenditures (if there isn't already some provision for that, it seems like the sort of thing that would be implemented shortly after joining other pensions became possible.)

It would be advantageous for the plan itself, since there are more investment opportunities and better rates if you have more money to invest.

It would be advantageous for employees who are downsized from the employer, since they'd have the option to keep building up their pension even if they can't find equally pensionable work.

And it would be advantageous for all workers everywhere, because it would lessen the idea (among those very loud people who have this idea) that providing a defined-benefit pension is wasteful and irrational, and call the bluff of people who think that it shouldn't be provided to some workers because it isn't provided to all workers.

Potential pitfall: it might dissuade employers from providing new defined benefit plans.
Potential mitigation: a) Is anyone even providing new defined benefit plans? b) Would it matter if you could just buy into an existing plan?

Potential pitfall: Would it give outsiders control over the plan? I've read that some employers won't let the employee proportion of the contributions exceed 50% (even when they employees offer to pay more to keep the plan afloat, the employer says no) because that would mean they'd have to turn control of the plan over to the employees.
Potential solution: Outsiders sign a contract saying they don't get a share of control over the plan, they're just along for the ride.

"You're welcome" vs. "No problem" revisited

I've blogged before about the nuances of "you're welcome" vs. "no problem" as a response to "thank you".

But reading this story from Not Always Right gave me some sudden insight on why the "you're welcome" people don't like being told "no problem": they want it to be a problem!

They seem to be interpreting "you're welcome" as "you are welcome [in the sense of "entitled"] to impose upon me by making this request of me", and see a "no problem" as implying that they are not entitled to that. "No problem" is equalizing, "you're welcome" is subservient.

I use "no problem" specifically because it is equalizing, in an attempt to neutralize the burden of gratitude in the other party. I'm saying "It's okay, we're cool, you don't owe me any gratitude, I'm not putting this on your tab." This is what I like in customer service and in life in general, so I try to give it to others.

It makes me feel welcome in the literal sense, the same way I'm welcome in, say, my parents' home. I'm totally allowed to walk in and fix myself a drink and rummage through the fridge. In a customer service context, it makes me feel like they're giving me good service because I'm just as cool as they are, not because I'm above them. Because they like me, not because they are obligated to serve me. They're saying "Hey, it's you! How are you doing? Do you want a coffee?" rather than doing their job and rolling their eyes at me when I leave. And, while it is totally their prerogative to just do the job and roll their eyes at me when I leave, I'd much rather have them like me.

But the "you're welcome" people don't seem to care about that, they seem to prefer to be treated with deference, liked for their position rather than for themselves.

Things They Should Invent Words For

We've all heard the expression "privatizing profit and socializing risk". The phenomenon I want to make a word for is similar, but I can't seem to structure an analogous expression. It's a sort of socialization of the requirement for expertise, but not precisely.

One example of the phenomenon is pensions. They seem to be moving away from defined benefit pensions, where experts manage it for you, to defined contribution pensions, where they give everyone a little bit of money and tell them to go manage it themselves.

Another major example comes from from job searching. Based on what my parents and grandparents tell me, employers used to be willing to hire unskilled labour or workers with a lot of potential but no particular experience in the area (and they tended to look upon university degrees as potential), and then let them learn on the job or train them up so they could eventually move up the ladder and do better-paying work. But in my own job hunting experience, I find that most employers want workers who already have the very specific skills and experience required for the position - even when it's something easily learnable like proprietary software. And, on top of that, employers have been known to reject applicants who have education that isn't strictly required for the job.

This also reminds me of how every once in a while you hear employers in the news saying that they can't find enough skilled workers, but these complaints about the lack of skilled workers seem to be reaching my ears far more readily than information about what kind of skills which employers need, and how to go about acquiring these skills, and how to figure out which of those jobs you'd be a good fit for rather than picking some skilled trade at random.

Anyway, the general concept I want to coin a word for is this sort of increasing expectation over time that individuals who are not involved in organizations or fields of expertise are independently responsible for developing knowledge of the needs of those organizations or the skills of those fields of expertise, whereas historically the larger organizations were more willing to make the effort to integrate and orient people.

I'm not explaining this as well as I should be. Coinages and better explanations welcome.

The disparity between the size of glasses and the size of standard drinks

Reading about a game on the LCBO website that tests how well you can pour a standard drink, I was reminded of the first set of wineglasses I ever purchased.

I had one or two wineglasses among my worldly possessions already, but I wanted to get some that matched. They were cheap, from the dollar store or something, but they were decently nice-looking and I quite liked them. We christened them with a lovely glass of wine that gave us quite a happy buzz indeed. The next day, I got home from work and poured myself a glass of wine, and...discovered that there wasn't even one glass left in the bottle? How could that be? The two of us had one glass each the previous day, there are five glasses in a bottle, where did the rest of the wine go?

Turned out they were oversized glasses. When you filled them to a reasonable-looking place, they contained two standard drinks of wine (unlike my previous glasses, which, when filled to a reasonable-looking place, contained one standard drink of wine.) No wonder we got such a good buzz on the previous night! There hadn't been any serious consequences to that little adventure, but what if those glasses had been used to serve to someone who had been driving?

This gets me thinking that it would be useful if glasses intended for alcoholic beverages were only available in single standard-drink sizes. Of course, oenophiles would probably complain because they like those oversized bowls so you can get the nose of the wine. So what if there was a line on the glass itself indicating how far to fill it for one standard drink? What if the box they come in or the bottom of the glass was marked with a warning label saying how many standard drinks it holds?

This would probably still garner complaints about the government meddling in commerce and whatnot, so here's a faster and easier solution that should offend no one: the LCBO should give away free glasses. They should be simple but attractive, of decent quality, and sized to make it impossible to accidentally overserve. They should be available in any quantity up to whatever constitutes a normal set of glasses like you might find in a wedding registry. You can just walk in and pick them up, no drama, and perhaps they could even include them with purchases as a value-added bonus at the beginning. Drinking glasses are cheap (I've bought them commercially in a set for as little as 50 cents a glass), the LCBO's profits are high, and hindering accidental overserving surely falls within their social responsibility mandate. The fact that they're given away for free at the place where you go to buy alcohol anyway means that people would have to make more effort to get oversized glasses than to get standard-sized glasses, so more responsible drinking is easier than less responsible drinking.

Personally, I'd still prefer if all alcohol glasses commercially available had to be sized to a standard drink, but I think a lot of people would complain. Giving them away at the LCBO would get the job done for people who don't care what kind of glasses they use and people who do want their glasses sized to a standard drink, without giving those who want non-standard glasses any reason to complain.

What if the library gave patrons credit for early returns?

One thing that surprised me in discussions of the library charging for holds that aren't picked up is the number of people who are annoyed not just by people who don't pick up their holds, but by people who pick up their holds on the last day before they expire, or keep library materials check out right up until the due date.

I don't consider this a problem myself and I don't know if the library considers it a problem, but nevertheless my shower gave me an idea to address it:

What if libraries gave patrons credit for holds picked up early or books returned early? For example, using amounts that make the math easy and might not necessarily be the optimal ratio, suppose they credit one cent to your account for every day before the deadline that you either pick up a hold or return an item. Late fines are currently 10 cents a day, so this would mean that if you're a cumulative total of 10 days early in circulating your material, that will cancel out one day's late fine.

The big question here is whether circulating material faster is more important to the libraries than the revenue generated by fines. I don't know the answer to that question.

The other question is whether this would motivate people to game the system by taking out material they don't want and returning it right away. This incentive could be partially mitigated by allowing the credits to only offset future fines and you still have to pay fines already incurred. People could still game the system, but how many people are organized enough to game the system in anticipation of future late fines but not organized enough to get their books back in time? I don't know the answer to that question.

But if it turns out it actually is important for the library to encourage faster circulation of materials, this could be a starting point for brainstorming.

A little less conversation: building better consensus-building

One thing I find absolutely tedious about watching youtubes of Occupy is the people's mike. It takes such a long time to say anything! This also echoes something I find tedious about municipal politics: live, in-person consultations where anyone gets to get up and talk. Again, it takes such a long time! Surely it would be faster, easier, and more convenient to have everyone submit their ideas in writing - reading is faster than talking, and the writing process tends to result a more organized deputation than extemporizing does.

But, at the same time, there's a certain democracy to everyone getting up and having their say in full that we don't necessarily want to lose. So how can we make the general process of public consultation faster and easier and less tedious without making it less democratic?

Here's what I've got so far:

We start with a whiteboard, which can be either literal, virtual, or metaphorical depending on what's needed. For a set and reasonable period of time, everyone writes on the whiteboard every factor they can think of that needs to be taken into consideration for the issue in question. Each factor only needs to appear on the whiteboard once, no matter how many people think it's important (we'll address the number of people who think it's important in a minute.) So even if every single person in the room thinks it's important for the new widgets to be backwards-compatible with existing widgets, only one person needs to stand up and say so or send in an email saying so for it to get written on the whiteboard.

This is also a question and answer time. Anyone can post or ask a question, and anyone can answer or expand on anyone else's answers. All questions asked and all answers given are recorded on another whiteboard for everyone's review.

After the period of time for contributing to the whiteboard is over, there's a voting period. During the voting period, everyone votes on each factor on two axes: Agree/Disagree and Important/Unimportant. You can cast a neutral vote by abstaining. Once all the votes have been tallied, you can see what the collective's priorities are. Then they can take action to implement everything that gets a high number of Agree and Important votes and avoid everything that gets a high number of Disagree and Important votes. Things voted Unimportant but with a clear Agree or Disagree consensus will be addressed if doing so doesn't interfere with the things voted Important. Things voted Important but without a clear consensus could be subject to further discussion/dissection, or looked at in terms of how they related to other Important factors with clearer consensus.

Whiteboard and voting will be made as accessible as possible. The whole thing could be online if everyone involved has internet access, but if that's difficult for anyone then in-person, telephone, write-in, and any other kind of input method people might require should be allowed.

The enormous advantage of this method would be that it eliminates duplication. Instead of having to hear (or even read) dozens of impassioned pleas on the importance of backwards-compatibility, only one person has to bring it up and the importance will be made clear in the voting phase. At the same time, if one lone maverick is insistent that the widgets should glow in the dark, it's right up there with all the other idea and will stand and fall on its own merits. If other people think it's a good idea, it could go through even though that one guy doesn't have very much reach.

This method of consensus-building is far from perfect, but I'm putting it out there as a starting point. Improvements welcome.

What if patients were allowed to deprioritize longevity?

They recently changed breast cancer screening guidelines, reducing screening in areas where it hasn't been proven to reduce mortality.

What bugs me about this is they're only looking at mortality. The reason why I'd be particularly concerned about breast cancer as compared with other cancers is I don't want to lose my breasts. I like my breasts and I want to keep them. If I'm going to be moved to take any particular measures to avoid breast cancer, it's going to be because I want to keep my breasts, not to avoid dying. However, we don't have the information to make that decision. They didn't look at whether early detection reduces the need for mastectomies, or, for that matter, chemotherapy. (I'd also very much like to keep my hair and continue my 17-year non-vomiting record.)

This is similar to my attitude towards GERD. I've been thinking about it pretty much non-stop for the past three months, and I've concluded that I'd very much prefer being able to eat exactly what I want for 100% of my life, even if it means my life is much shorter. I'd rather die at 50 having eaten exactly what I want every single day than live to 100 without eating anything that makes me happy. (Unfortunately, this isn't quite an option, because the disease manifests itself as difficulty eating. If I get esophageal erosion or Barrett's esophagus or esophageal cancer, I will be physically incapable of eating pleasurably.) However, the general medical approach assumes that dietary restrictions are a perfectly reasonable first step in preventing what might ultimately develop into esophageal cancer, and I can't find any sign that medical science is even thinking about working to eliminate the need for dietary restrictions.

As a patient, I'd really like to have the option of choosing to have my medical care not focus on keeping me from dying, and instead prioritize getting the most out of whatever time I do have. (And I want to be able to define "getting the most out of" for myself, so that it includes such fripperies as pleasure and vanity.) This would require not only the consent and cooperation of my medical team, but also the consent and cooperation of medical science. My doctor can't change my breast cancer screening protocol to maximize my likelihood of being able to keep my breasts unless medical science does research into whether screening helps avoid mastectomies, not just prevent death.

At this point, some people reading this are probably thinking "But...I want to avoid death!" And I know that with breast cancer awareness specifically, some people are really bothered by campaigns that focus on the fact that breasts are awesome rather than the fact that cancer can be fatal. So I'm not saying that patients shouldn't be able to prioritize survival and longevity. I'm just saying that we should have a choice. If you want to live to 100 no matter what, medicine should help you. If I don't have a problem with dying younger because it will spare me Alzheimer's, medicine should help me get what I want out of life.

From a disgustingly pragmatic point of view, allowing patients to deprioritize longevity might also save the health system money. Why pour resources into extending the lives of people who don't care if their lives are extended? (You might say "To keep them from dying of something complicated and expensive," but who's to say they won't die of something complicated and expensive decades later anyway? (Someone really should do research on that.)) There's the potential to save a few patient-decades of care with the full consent of the patients, and actually make them happier while doing so.

What if quality of housing counted towards section 37 community benefits?

I was looking at City of Toronto documents for a proposed development, and I was surprised to see that the developer had to contribute a certain amount of money as "community benefits" to various projects in the area. Turns out this is set out in section 37 of Ontario's Planning Act. In basic terms, it means that if developers want more height or density than normally permitted, they have to give something back to the community in exchange. In the documents I was looking at, they suggested contributing money to parks or streetscape projects.

But what if developers could contribute their community benefits through quality of housing?

For example, what if they provided more family-sized suites, or lower prices, or more energy-efficient housing, or some combination of the above? What if they provided some of the suites for use as public housing? What if they reserved a certain number (or even all!) the suites for purchase by owners rather than investors or agents who are just going to buy and flip or rent them out for profit?

As an area resident, I find it beneficial to increase the supply of suites that meet my needs, even if I'm not immediately in the market for moving. If the supply increases, that might drive down prices, thus reducing my rent increase as well as making it easier to buy.

There would need to be measures to make sure that they don't introduce crappy housing as a baseline, upgrade it to normal housing, and call it a community benefit. There also need to be measures to make sure that this better-quality or better-value housing benefits actual residents, rather than getting snapped up by investors.

Off the top of my head, perhaps quality of housing could be measured relative to the rest of the neighbourhood. If it's basically the same as the rest of the neighbourhood, you get fewer points than if you're introducing the first building in the neighbourhood to have central air conditioning. This is analogous to how the City might try to encourage grocery stores to move into neighbourhoods that are food deserts, but wouldn't take any particular measures to encourage grocery stores to move into neighbourhoods that already have a couple of grocery stores.

To keep investors and flippers from yoinking better-value housing, perhaps the amount of community benefit credit the developer gets for building lower-priced units could be based on the number that are still occupied by the original owners after a certain amount of time. The flaw here is that the developers don't have much control over what people do with their units after they buy them, but they do have the power to stop these kinds of marketing techniques and instead focus on the actual community they're becoming a part of.

The dialogue surrounding development and intensification all too often seems to disregard the fact that what they're building are people's homes, and the people who live there will be citizens, constituents, and community members. I'd really like to see analysis of a development's impact on "the community" include the people who will be living there.

Half-formed idea: how to incentivize clinical testing of alternative medicine

I previously came up with the idea that they should incentivize clinical testing of natural remedies and other alternative medicine.

Here's about half a solution: everything that has been clinically proven gets covered by OHIP.

The advantage for practitioners of alternative medicine and for patients is that treatment is no longer limited by the patient's budget. Patients can receive - and practitioners can be paid for - what treatment is needed.

The advantage for social responsibility is that this makes it easier to get things that have been tested than things that haven't been tested.

The advantage for OHIP is that alternative medicine would probably be in many areas cheaper. Pharmaceuticals and medical technology can be hellaciously expensive. If herbs or acupuncture can be proven to do just as good a job, even if it's in just 10% of situations, that would save significant money.

This would mean that OHIP would have to cover a wider range of things than it currently does, such as medication and dental care. But that's a good thing - everyone needs those things and they represent significant expenses for people who don't have benefits through their jobs. Broader coverage would be more in line with OHIP's actual mandate.

One change that would be necessary is coming up with a mechanism for OHIP to cover over-the-counter medications. Many of them have been clinically tested, and we don't want to clog up the health care system by forcing people to go to the doctor for a prescription for vitamins or decongestant. But that shouldn't be too difficult to work out. Our health cards have magnetic strips, so why not just swipe them at point of sale?

In this plan, things that have not undergone any clinical testing will still remain available and paid for at the patient's expense, like they are now. Things that have gone through testing and have been proven ineffective but harmless will also continue to be available at the patient's expense. Only things proven to be actively harmful will be pulled. So, for proponents of alternative medicine, there's no downside unless they're peddling snake venom.

The missing link in this plan is still funding and facilities for conducting the research in the first place. It's likely a significant start-up expense and I doubt there are labs just sitting around waiting to be used. They'd still have to work out that part.

Is medical science working to eliminate the need for virtue?

The lifestyle changes that I've been whining about are considered, both by conventional and alternative medicine, to be the first step in treating the condition. The standard way of thinking is maybe they'll be all you need, and that would be a good thing. Medication and procedures are intended for more extreme cases, where lifestyle changes don't work.

This has me wondering: is anyone in medical science even thinking about it the other way around, i.e. can we invent a medication or procedure that would make the lifestyle changes unnecessary? Just make you not reflux at all, so you can have as much acidic food as you want?

(I haven't done extensive research this far, but what information I have suggests that medication for GERD are unsustainable in the long term because they can deteriorate your bones, and available surgeries might not necessarily last the rest of your life and might need to be redone. If you know of a medication or surgery that actually does stop GERD without lifestyle changes, please post it in the comments, I beg of you!)

This also reminds me of smoking. If you smoke, you're supposed to quit. There are tools to help you quit. But is there, or is medical science working on, a way to counter the harm done by cigarettes? Smoke a cigarette and then taken an anti-cigarette pill or something?

I've never heard of anything like this for anything.* Is that because science hasn't yet figured out how?

Or is that because of the Protestant-work-ethicish societal attitude that we should all just Be Good and Virtuous if we want our lives to work well?

I find myself wondering if that's true. So many of the people I've whined to were all "Oh, it's no big deal, you just have to make a few changes." But that's what's making me unhappy!

You'd think capitalism and big pharma would get behind this. Now, instead of people buying cigarettes, they can buy cigarettes AND anti-cigarette pills. Come on, get on it, our economy needs a boost!

*Update: I can think of one example: the morning-after pill. Another possible example is insulin, but I don't think diabetes management is quite up to the point where you eat whatever you want and then take the corresponding amount of insulin. Unless, of course, it is, in which case more power to you!

The problem with conventional thinking about machine translation

Reading In the Plex, Steven Levy's fascinating biography of Google, I came across the following quote from machine translation pioneer Warren Weaver:

When I look at an article in Russian, I say, "This is really written in English, but it has been coded in some strange symbols. I will now proceed to decode."

I can tell you with absolute certainty that this is incorrect, and people who don't find themselves able to get past this way of thinking end up being very poor translators.

A more accurate approach would be "This idea really exists in a system of pure concepts unbounded by the limits of language or human imagination, but it has been coded in a way that one subset of puny humans can understand. I will now encode it for another subset of puny humans to understand."

To translate well, you have to grasp the concepts without the influence of the source language, then render them in the target language. You're stripping the code off and applying a new one.

If you translate Russian to English by assuming that the Russian is really in English, what you're going to end up with is an English text that is really Russian. Your Anglophone readers will be able to tell, and might even have trouble understanding the English.

The Russian text is not and has never been English. There's no reason for it to be. The Russian author need never have had a thought in English. He need never have even heard of English. Are your English thoughts really in Russian? Are they in Basque? Xhosa? Aramaic? Of course not! They're in English, and there's no need or reason for them to be in any other language.

This is a tricky concept for people who don't already grasp it to grasp, because when we start learning a new language (and often for years and years of our foray into a new language) everything we say or write in that language is really in English (assuming you're Anglophone - if you're not, then, for simplicity's sake, mentally search and replace "English" with your mother tongue for the purpose of this blog post). We learn on the first day of French class that je m'appelle means "my name is". But je m'appelle isn't the English phrase "my name is" coded into French. (If anything is that, it would be mon nom est.) The literal gloss of je m'appelle is "I call myself", but je m'appelle isn't the English idea "I call myself" coded into French either. If anything, it's the abstract idea of "I am introducing myself and the next thing I say is going to be my name" encoded into French. The French code for that concept is je m'appelle, the English code is "my name is".

I'm trying to work on a better analogy to explain this concept to people who don't already grok it, but here's the best I've got so far:

Think of the childhood game of Telephone, where the first person whispers something to the second person, then the second person whispers what they heard to the third person, and so on and so on until the last person says out loud what they heard and you all have a good laugh over how mangled it got.

What Mr. Weaver is proposing is analogous to trying your very very best to render exactly what you heard the person before you say.

But to grasp concepts without the influence of language and translate well is analogous to listening to what the person before you said and using your knowledge of language patterns and habits to determine what the original person actually said despite the interference.

Which defeats the purpose of Telephone, but is the very essence of good translation.

This should be a tweet, but I can't get it down to 140

I find myself wondering how people who truly, genuinely believe in and fear hell can bring themselves to have children. Because bringing a child into a world where hell exists introduces the possibility that the kid will go to hell someday.

I did once yearn to have children, I did once genuinely fear hell, and I do have your basic adult hormonal child protection instincts, which I'd imagine are massively stronger when it's your own child.

It's perfectly normal protective instincts to be willing to risk one's life to save one's child's life. But, for those who believe in it, the threat of far is vastly worse than the threat of death. Death is a sudden extinguishing of life, while hell is eternal torture without hope of reprieve. Religious traditions with a strong fear of hell do tend to contain the idea that it's your religious duty to have children. But if any parent would risk their life for their child's life, wouldn't they also risk hell to save their child from hell?

It is true that parents tend to think "But MY child will be GOOD," but your basic human decency isn't usually enough in hellfearing religions. Religious traditions with a strong fear of hell also tend to make it difficult to get into heaven. The slightest lapse of virtue can send you to hell, and in some cases even a virtuous life with improper rites can send you to hell. Thinking back to my previous mindset of hellfear and adding protective instincts, the risk of having a child go to hell far outweighs the biological/hormonal yearning to have a baby and any other benefits of procreation that I can think of.

I wonder what other factors there are for hellfearing parents that outweigh even the horrors of hell?

Building a better long-term care model

Reading this article about a woman who doesn't want to leave the hospital because there are no openings in her preferred nursing homes and she doesn't want to go to the first available nursing home, I've been thinking about how to improve the current system. Here's what I've come up with:

What if being transferred to a long-term care facility didn't ever have to be final?

You can make a list of the facilities you want and rank them in order. You're immediately put into the available facility on your list that you've given the highest ranking. If none of the facilities on your list are available, you're put into the first available bed.

HOWEVER: After you get put into the first available bed, you're still in line for the facilities on your list. When a bed becomes available in one of them, you get moved there. And even after you're placed in a facility on your list, you still get informed of openings in facilities that rank higher on your list with the option of transferring there. In other words, if your #3 facility has an opening first so you're placed there, but then your #1 facility subsequently has an opening, you get the option of transferring to your #1 facility.

You can put however many facilities you want on your list, and rank them however you want. You can have every facility in the province ranked in order of preference, or you can have 12 facilities ranked equally, or you can have 2 facilities in first place and 5 in second place, or whatever you want.

Possible variations:

- Patients who are currently placed in a facility that's not on their list have precedence over patients who are currently placed in a facility that is on their list. For example, if I'm currently in my #5 choice and you're currently in the first available bed in a facility that isn't on your list, and I'm ahead of you on the waiting list for a facility that's #1 on both our lists, you get admitted to that facility first.
- Exceptions can be made to the "first available" rule under specific circumstances (for example, if the first available facility has been found in violation of regulations, if the first available facility is inaccessible to the patient's support people, etc.)
- The patient (or, if the patient is not competent to make decisions for themselves, their representative) can veto any placement proposed under this system.
- Before the patient loses their faculties, they can include in their power of attorney guidelines dictating circumstances under which the representative may or may not change the patient's priority order. For example, the representative might be permitted to change the patient's priority order if a new facility is built that didn't exist back when the patient was still competent, but might not be permitted to make changes solely for financial reasons.

I have no idea how much of this is or isn't a good idea. It seems like it would get appropriate care to as many people as possible and preferred care to as many people as possible, but there could easily be flaws that I'm not seeing. It would be cool if they could do projections on this model and see if it would work.

Building a better Senate

As I've blogged about before, there are things I like and dislike about the Senate. The things I like tend to be those that provide a counterpoint to the House of Commons, while what I don't like tends to be when the Senate blindly rubber-stamps the House of Commons, without using the safety net afforded by their unelected nature to provide true sober second thought. So I was disappointed that recent discussions of Senate reform have the Senate either becoming more like the House of Commons without a clear differentiation between the two, or simply want to outright abolish the Senate without introducing sober second thought elsewhere.

So I've started brainstorming some ways to make the Senate more of what I like about the current system with less of what I dislike about the current system and about others' ideas for reform. Here's what I've come up with so far:

What if senators had to be non-partisan?

Currently, senators are affiliated with a political party (generally the party that appoints them, although I think there might be a few individual exceptions.) This is a hindrance to sober second thought when they vote along party lines.

What if we took the complete opposite approach and outright prohibited partisanship in senators? They aren't allowed to be members of political parties, they aren't allowed to donate or work in support of parties or candidates, and people who have engaged in these activities within a certain period of time before appointment are not allowed to be senators. These kinds of standards exist for certain types of high-profile or influential public service positions, so it seems feasible to extend them to make a non-partisan senate.

What if senators could not serve under the prime minister who appoints them?

A problem with the current system is that senators might feel beholden to the PM who appoints them. To solve this, what if prime ministers appointed senators to replace those retiring under the next mandate? Under this model, Stephen Harper would look at which senators will be retiring in 2015-2019, and come up with a short list of possible replacements. The flaw in this plan is that prime ministers can serve multiple terms, so it might not be entirely effective.

What if senators were drawn out of a hat?

Currently, prime ministers appoint one senator to fill each senate vacancy. What if, instead, they selected a number of people for a senate candidacy pool, and then whenever a vacancy comes up, they draw a name at random from this pool of candidates? All candidates appointed by all prime ministers remain in the pool until they reach the age of 75, unless they do something really bad that merits elimination from the pool (this would be carefully defined in the law.)

What if senators were picked at random from the general population?

Instead of the prime minister appointing people, what if we had "senate duty" along the lines of "jury duty"? People are selected at random from the voter list and told to report to Ottawa for a year or five years or some other defined term for senate duty. Relocation expenses are covered, you get a senator's salary, and maybe they have a rule that your employer has to keep your job waiting for you like with the military. I can make an argument for making senate duty mandatory, and I can make an argument for letting people who aren't interested simply opt out. There would also have to be a way to screen out people who aren't mentally competent etc., although they probably already have something like that for jury duty.

What if Senate votes were secret?

It would certainly be more difficult for senators to be beholden to their political masters if no one knows how they voted (or perhaps even how many votes for or against each bill got). This might sound like a bad thing because it's less transparent, but it would also provide a counterpoint to the House of Commons where there are open votes and party discipline.