Grab bag

Jan. 5th, 2019 07:14 pm
warriorsavant: (Meh)
Herein a grab bag of posts that I'd half-written, but didn't get around to posting. Have a number of half-formed ideas and half-written posts that I'm going to finish and post. I hate back-logs.

"Papa knows…" This soon?
Read more... )

Christmas? Bah humbug (belated, but so be it).
Christmas? Bah humbug (belated, but so be it). )

Back to the future (coin names).
Back to the future (coin names). )

Software updates at gunpoint.
Software updates at gunpoint. )
warriorsavant: (Dr. Injecto)
Saw a patient recently who has rosacea, a common, an annoying, but not life-threatening, condition. I have him on Noritate (brand name for flagyl 1% cream) with good results. Price 35-45$CAN here. He ran out of it while he was vacationing in Florida. He checked US prices on line: around US$2000 for a single tube!
warriorsavant: Family Tree (Family Tree)
I'm afraid that my siblings and I are getting to the age where ailments are conversation. I'm resisting the tendency, but from the tenor of some of the conversations, I’m beginning to think Bob is in better shape than any of us. Harrumph. (Halloween being over, he’s back in the back room of my office. Evil Secretary is displeased, but realizes that he scares some of the patients. And I’m talking about adult patients. Did have a little girl today (age 8?). She was asking a million questions about things in the office, and allowed how she was very curious. After mangling a translation into French of “curiosity killed the cat,” I then allowed how curiosity was a very good thing and should be encouraged. Then I offered to show her Bob. She was most pleased and impressed.

Sibs and I were also discussing different ways of measuring intra-ocular pressure (testing for glaucoma), known as tonometry. I mentioned that I recall when air puff tonometry came in, as the hot new gizmo. (Prior to that, they numbed your eye, and pushed a small measuring rod against it. Our late Great-Uncle B was an Ophthalmologist. Quite prominent in his day, but was not big on shiny new gizmos if the old ones still worked. Part of that was his old-fashioned frugality. He was raised in the school of “you never know when the next famine (pogrom, stock market crash, whatever) was coming, so use things until they can no longer be fixed." Having been raised by Depression Era parents, we all have that streak in us. I’ve gotten away from it somewhat, and I’m not entirely pleased with that. Not sure how I’m going to teach the next generation the value of money. Just because you can afford something, doesn’t mean that you should. Back to Great-Uncle. Had a small office in his house - dunno if he actually saw any patients there, or if simply for tax purposes. Anyhow, after he passed away, we found a pair of magnifier glasses in a drawer in the living room(?). Inside was a piece of masking tape, labeled “B: better pair in office.” So we looked in the office. Sure enough, there was a pair of magnifier glasses there. Inside the case was a piece of masking tape, labeled “A: worse pair in living room.” The hat he wore to his wedding to Aunt C was older than any of his adult children. (This was his second marriage, both of them having been widowed for many years.) Yeah, there are the jokes about “I have a hat older than you kids,” he really did. BTW, I still have my original canvas duffel bag from when I was very first in the military. Newer ones (say, oh, the last 2-3 decades or so) are nylon. My last deployment, a young troop asked me, respectfully, why one of my duffels looked different. I explained, then realized that duffel was indeed older than he was. "I have boots (well, duffel bag) older than the young troops…" And was actually bringing same on a deployment.

Yeah, back again to Great-Uncle. He had a gizmo for measuring your existing eyeglass lenses, “reading” the prescription. He acknowledged that the then new-fangled (40 years ago?) electronic ones were more accurate, but pointed out that the human eye couldn’t perceive the difference, so why spend the extra money to get a new one that wouldn’t help his patients any better than the old one. I still have a quite old hyfrecator (what most people call an electric cautery) that is older than most of my Gentle Readers. (Possibly older than all of us, I don’t recall when or where I got it, but it was used then). The newer ones are slightly better, but they burn out after several years, so I keep it as a back-up.
warriorsavant: (Warriordaddy)
Hedgefund's day care class will be learning to skate. We think this is a great thing, as if they learn winter sports, they might even enjoy winter here. Since neither Nom nor I can skate, ski, or any other winter sport (well really, do any sport), we aren't the ones to be able to teach them, so it's great they'll at least get the basics at day care. (Wallstreet is the the class behind hers, so he'll presumably get it next year.) This weekend we bought her gear.

When you have children, some "helpful" person sends you one of those articles that says that it costs 28 million dollars to raise a child, from prenatal care through medical school tuition, or some such. Whatever ridiculous figure they claim, and whatever it actually costs, this ignores the key fact that you don't have to front the money at once. The doctor/midwife doesn't hold onto the kid and say "give us all the money now or we send it back." It gets paid in dribs and drabs (and sometimes flood waters) but not up front.

Still certain amounts come with some sticker shock. This is where I get all curmundgeonly and harrumph that in my day, we bought a cheap pair of skates and went out on the river/dad flooded the backyard. Uh, yeah, right. In fact, they will be practicing at the municipal arena, and since likely people will also be practicing hockey on part of it, they need helmets with face shields and other accoutrements. So, a fair wack of money at once, although the skates and helmet are adjustable so she'll be able to use them for many years.

Anyhow, it starts. Will try to keep from having them too over-programmed (some kids do a different after school activity every day), but that is more because I think that is a stupid thing to do to a kid than because of cost (although that is a consideration also). Regardless, there are things they should learn that we can't teach them, and some of that comes with a cost. How many million did you say?
warriorsavant: (Lucky Hedgehog)
If I understand it correctly (a big "if"), the core of Keynesian economics is counter-cyclical government spending. In good years, build up a stockpile of cash, in lean years spend it to stimulate the economy. Now, boys and girls, how far back can we trace the origins of the concept?

I'm going to say about 5000 years. (Maybe be off by a millenium, but no, did NOT add an extra zero or two). Ancient Egypt. Joseph and the dream of Pharaoh. "You’ll have seven fat years, followed by seven lean years." Since money didn’t really exist then (or only marginally), they banked up surplus grain.

Since then, governments mostly failed to do this properly. “In bad years, spend like a drunken sailor to stimulate the economy; in good years, spend like a drunken sailor anyhow.” Actually, as a former (sometimes) drunken sailor, I can say that is not an accurate analogy; when I ran out of money, I stopped spending. (As the saying goes, “some of it we spent on booze, some of it we spent on women, but most of it we just spent foolishly.”)

For the US, this miserable management of government finances and the economy really only dates back to the 1970s. Before then, even if hadn't heard of John Maynard Keynes, actually did pretty much follow the idea of counter-cyclical spending. The US was born in debt (revolutions are expensive), but mostly paid down the debt in good times, and ratched it up in bad times (war and economic depressions). Only under Andrew Jackson did the US eliminate the debt completelly (his one virtue as President). He was from frontier farming stock, who regarded having debt as an abomination.
warriorsavant: (Infantry haircut)
Mort Walker, the author of the comic strip "Beetle Bailey," just passed away. He had been writing the comic strip since 1950, the longest tenure of any cartoonist. I won't say it was an accurate depiction of military life, but it had its moments. In 1954 the Stars and Stripes military newspaper stopped carrying the comic strip because "it would encourage disrespect for officers"...as a result of which 100 more newspapers started carrying it. Our hero's sister, Lois, then became a character in the "Hy and Lois" comic strip, and Beetle occasionally “visited" his sister and her family.

Stripes is not longer run by the military, and more recently (during my time) carried “Private Murphy’s Law,” which wasn’t all that much positive about military life, although maybe less negative than Beetle Bailey. The cartoon that I remember most of Pvt Murphy was when he gets his annual “compare what you are earning to your civilian counterparts” info sheet. He raises his hand, “Uh, Sarge, how much does a rifleman make in civilian life?”

They did send those out, saying that although you make xxx, also consider your free health care is worth yyy, and your PX privileges are worth zzz, etc. Actually a worthwhile exercise, because the benies added up (eg I didn’t contribute any cash to the pension I’m now drawing) but it also depended on if you used the PX/Commissary frequently, and how often you got sick. Not to mention it is a bit hard to calculate how much a rifleman makes on the outside.

Hmm, come to think of it, when we were deployed in 2002-2003 (start of Iraqi Freedom), the gate guards were civilian contractors. Another of then SecDef Rumsfeld’s brilliant ideas to downsize the military to save money - by paying someone 6-figures to do the work of an Army private.
warriorsavant: (Dr. Injecto)
Yup, I'm now officially a whore to Big Pharma. Actually, have been for a while. Could say don't do it very often, but like being pregnant, it's an all or nothing. Actually, I don't believe that (about being a whore, not about being pregnant); things are conditional and relative. Also, I'm digressing.

Just got back from a consultancy panel on a certain drug for resistant hand dermatitis. I've used this drug, it is great when nothing else works. Like all Derms, I mostly prefer topical treatments (eg creams) to systemic (eg pills and injections), but I'm slowly using more systemic treatments. It's something I'm growing into. Yes, even after all these years, I continue to grow professionally. This is good, as one either grows or shrinks and dies in everything; there is no static. (BTW, apparently 20-30% of Derms in Quebec never use systemic treatments!) The purpose of this panel was to share experiences on using the medication, looking for better ways to use it, and different things to use it for. For the company, that translates to more opportunities to sell it, but if it is useful, why not? There is also a certain amount their stroking us, as we'd be considered "opinion leaders," but that only gets them so far. If I don't like the product, I don't use it, and don't teach using it - in fact, teach not using it.

So why do I do it? (Besides the money, but really not much more than spending a half day in my office.) A large number of reasons. Partly getting new and different and advanced information on a drug. It's biased info, but everything is biased to some extent, and at least their bias is out in the open. Partly I get to meet colleagues and chat with them. I'm not the most social person, but that's importantly. Following what is principally an out-patient specialty, I'm mostly in my own office. Even my days at JGH, I'm not really chatting with colleagues, we're busy seeing patients. Also, the doctors at these panels are frequently not the same ones I work with. Today I was the only McGill doctor there, and 1 of only 2 from the Anglophone community. Yes, the whole thing was in French, which was also good practice for me. Partly, I do pick up tips and suggestions from the other doctors there. Sometimes that just reinforces what I do anyhow (but good to have validation), sometimes it gives me new ideas and approaches and warnings of pitfalls.

If I wanted, I could go to something at least once/week, probably more (treated to dinner with a speaker of just to exchange ideas). The actual paid panels are less frequent, but could happen often enough. I just don't want to be away from home that much, and as stated, not that sociable. Still, it's part of keeping my place in my professional community, and adds aspects to my professional practice, so I so like to do some.
warriorsavant: (Computer-steampunk)
In the book I read recently about the history of Artic exploration (about the Franklin Expedition and the search for the fabled Northwest Passage), they touched on the provision of government services to the Innuit (or lack thereof). Without going into the vast issue of Canada's and other nations', treatment of, and relations with, their aboriginal peoples, one of the points noted was that the government, even when trying to provide services, had trouble doing so, as these were nomadic/semi-nomadic people, historically with only one name. The government pushed many of them into settlements and assigned them family names. At some point, every one of them was assigned an "Innuit Number" (I think that is what it was actually called) for government ID purposes. This was later dropped as being too intrusive & dehumanizing.

Yet, in the Netherlands (and I believe all Scandanavian countries), which are highly democratic nations, everyone is assigned a national ID number from the moment of birth. The first thing associated with that number is your APGAR score and birth weight. All your medical records, school records, and tax records are keyed to that number. That makes for great demographic studies ("…all lawyers who'd had an APGAR of 9-10 at birth, currently make more than XXX Euro/year and have a low incidence of diabetes…"). To a North American, that is horribly intrusive; to them it's simple good management. The other piece of the puzzle is how to identify who goes with that number. Again, as North Americans, we would regard a government biometric database is being too intrusive, yet in India, they have recently fielded Aadhaar, a national biometric database precisely to be able to identify people for getting government services (eg welfare, nutritional support, schooling), and it is also being used to allow illiterate people access to banking and other commercial services. As it stands now, our governments do keep biometric ID, but it's limited and not very good. Looking at my driver's license, I'm a male of a certain height and weight and hair color. Well, my weight changes, and my hair is no longer brown, and I don't know anybody who actually looks much like any ID photo they have. (I laughed to myself the last time we brought Hedgefund across a border. Now age 3 years, her passport photo was from 3 months, and the Border Agent kept looking back and forth to between the picture and her.) Add to that people whose gender has changed legally. At that point, at least in Canada, they are issued new government ID's, but how do you then use that to access an old record which was under a different name and ID. We don't have a lot of nomads anymore, but what about migrant farm workers?

Seems to me combining modern biometrics with a national ID number would solve some of the "how do you get services" (governmental or commercial) issue. On the other hand, that would allow the government and commercial ventures to compile huge amount of info on us; on the other hand, they already have that, and we as individuals don't get the benefit of it.
warriorsavant: (Composite)
It will come as no surprise to my Gentle Readers that I'm a "wee bit" obsessional. Part is my medical training, part is my Army background, and part is, well, uh, just always been that way. Believe it or not, Evil Secretary is worse than I am.

Most of our billing is paperless/cashless via the Quebec Medicare system. There are some sundry charges. Even today, some people actually pay cash for them (ask your grandparents, younger generation), plus there's always some need for petty cash in an office, so we always need to have on hand a number of small bills. For time-to-time, when I'm at the bank, I pick up a packet of small bills. Banks usually give you the money all facing the same way, and ordered by denomination. (Although I've noticed they've been getting lazy about that "all facing the same way" thing. Bah humbug on modern life, those slackers.) One time, some years back, I'd dropped the envelope of neatly-arranged bills, and being a hurry, just stuffed them back in willly-nilly. When I got to the office and handed them to Evil Secretary, she accused me of deliberately messing up the order to play with her head. No, I didn't have the time to do that. She then immediately started to put them in order. At that time, Canada was in the middle of changing over the design of the bills, so there were two different versions of most denominations in circulation. I realized that she was not only facing them all alike, and putting them in order of denomination, she was separating the old and new billls of the same denomination. I laughed at her for that.
"Oh, like you don't in your wallet?" she asked indignantly.
"No."
"I don't believe you," she scoffed.
"Really."
"I don't believe you. Give me your wallet."
I handed her my wallet. She actually pulled all the money out of it, and rearranged it. She wasn't joking, it really bugged her that my wallet wasn't in the "proper" order. I almost fell on the floor laughing.

Today, I brought in another packet of small bills for petty cash (all $5's of current design). She grabbed it and started checking if it was in order, "good, you lined them up already."
"It came that way from the bank. What are you going to do now, put them in order of serial number?"
"No," she scoffed. A moment's quiet shuffling of paper. "Hey, they are in order of serial number." She was actually delighted - and yes, she had actually checked when I'd teased her.
I looked over the bills. They were sequentially numbered. They must have been from a series of new bills that were being put into circulation. Regardless, it actually made her day that the pettty cash was in perfect order for once.
Bwahahaha.
warriorsavant: (Composite)
Medicare cut backs are getting bad here in Quebec. Instead of direct deposit in my bank account, I got paid in chickens. Well, potential chickens. Well, not from the government, directly from a patient in lieu of monetary reimbursement. Okay, what really happened was a couple who both came today as patients (paid by medicare) raise chickens and brought me some eggs. Still funny.

Years ago when I was doing refugee work, I think a patient did bring a chicken. Several brought corn - hey, they were refugees (who weren't charged anyhow), they probably couldn't afford chickens. Here in Quebec, eggs are good. Or corn. Or cannoli.
warriorsavant: (Meh)
On my professional side, I frequently get requests to do surveys, sometimes offering smallish amounts of money, sometimes offering a fair amount. I don't do them. Partly because surveys are generally annoying, and partly because "this will only require xxx minutes of your time" invariably means "3-5 times as many minutes as we'd said," and I'm really busy. Evil Secretary knows to tell them no, possibly more politely than I would.

Some marketing company hit a new low. They mailed me the 1-page survey, and enclosed a 5-dollar bill "as a token of our appreciation."

I sent it back with a note saying, "Are you for real? I don't have the time to answer surveys that offer me hundreds of dollars, much less ones that insulting tuck 5$ into an envelope. I'm returning your survey, your 5$, and adding another 5$ which you can use to buy coffee at the unemployment office, which seems to be where you're destined to end up."
warriorsavant: (Dr. Injecto)
A better title would be: Whoring Soliciting Funding

My Cutaneous Lymphoma Clinic has hosted an annual conference twice so far, and this year we are planning to do so again. Part of the event is a small, but real, officiallly gives CME conference to which the medical community is invited. For our group, the best part is getting visiting experts to come in and see our most complicated patients. On the one hand, we're part of a world-renowned medical school. On the other hand, "renowned" isn't all it's renowned to be. We're basically a small group of self-taught local experts, who only have a small percent of our time to devote to this. We're pretty good, but we can always get better. We have gotten, and will continue to get, visiting experts, including doctors who are among the top 5-10 in the world in this field. Our patients benefit from having a consultation at this level of expertise, and we learn immense amounts.

Expertise comes at a price. We have to pay their airfare, hotel, and honoraria. Neither the university nor the province gives us funds for this, and we're unlikely to pull that money out of our own pockets. Hence, I go begging for funds from "Evil Big Pharma." They're no more evil than anyone else, and part of their funds go to supporting medical education. Admittedly they do that as much for the good PR as for the altruistic joy of it, but so what? All motives are mixed, they produce drugs and equipment that are needed, and they are also supporting our educational needs. Asking for money gets easier. Last year, I approached it with fear and trembling. It just isn't - wasn't - my nature, to go up to someone and ask for five grand. Hey, it's not their money personally, and it isn't going into my pocket, but still was hard for me to do. This year much easier.
     New drug rep, "How can I be a good product representative for you?"
     Me, "Five thousand dollars to support a conference will do for a start. Make an appointment so we can discuss it. Oh, and bring sushi." (Okay, that part goes into my pocket - or rather mouth - but Evil Secretary gets her share too.)

It's interesting to see how each company approaches it, and who at the company holds the funds I need. Just this week, two different reps got back to me. One said the funds for this sort of thing come from the Sales Division, and I needed to write the lettter to her, specifically stating that she could have a table at our conference. The other said the funds comes Education Division, and I needed to write a letter to that committee, specifically stating that they would not get any promotional considerations. It's all the same to me. It's only paper (well, electrons), and we get our speakers funded. Everyone wins.
warriorsavant: (Quebec sait faire)
I alluded to this issue Jan 13. Here's the story. The current provincial health minister is named Gaetan Barrette. On the positive side, he is trying to clean up some issues with the Quebec Medicare system. On the negative side, he is not consulting with anyone before he issues his ill-thought-out fiats. Lately he has taken a page out of Donald Trump's book and is sending out late-night and weekend tweets of questionable veracity when he is annoyed by someone. Before getting into the current problems he's caused, some background is needed on how things are done here in the True North Brave and Free.

Medicare-how she works )

A consideration about any law or regulatory framework is that there are always gray areas (or grey areas as it is spelt in Canada and the UK). No matter how carefully you write the law, there are always ambivalences. Putting in more regulation doesn't eliminate those loopholes, it just creates more. Up until now, we've dealt with these gray areas by ignoring them, and everyone gives a little on their side: doctors accept that not everything is paid for, patients pay a little out of pocket for things questionably required, and the government ignores the situation.

Medicare-how the Minister is screwing things up )

I'm not sure why all this is happening. Is it purely Minister Barrette's incompetence? Is it a back-handed way for the province to dis-insure some services? (Instead of dis-insuring them, they make them impossible to get, and put the burden on the doctors to be the heavies to explain it to the patients.) Is it the companies that provide drug and supplemental insurance got tired of paying for these supplemental (but legal) charges and pressured the government to outlaw them? Always hard to know if something is driven by avarice or stupidity (my bet is usually on stupidity which is harder to outsmart than avarice). In the end, me and every other doctor will find a way to protect ourselves without hurting our patients. Like most smart people, Minister Barrette fails to account for the fact that other people are smart also, and there are more of us than there are of him, and that we're motivated because it's our livelihood.

Stay tuned to this blog for further updates.

The footnotes )
warriorsavant: (Renovations)
Nom has been on maternity leave for almost 3 years now. Not all of it paid, but has been considered an employee of a certain corporation for all this time. (Long & complicated story about all the ins-and-outs of both Quebec and corporate policy and benefits.) All of this was ending recently. By happy coincidence, her company was going through a restructuring, so she was eligible for a buy-out package. Far from a golden parachute, but a nice sum of money for several weeks.

She really doesn't want to go back to work until the children are older, a position I fully support: it is happier and healthier for both her and them to have her home. She made a good salary, and now she won't be. Being a modern woman, this does not sit well with her. Me? I'm a post-modern man (okay, I was raised in the 19th century but have some post-modern sensibilities), so what I want is for her to be happy, and whatever is best for our family. Which is to say, unlike apparently the entire western world, I consider it equally valuable for a person to be employed outside the home or to be a homemaker or some combination of the two. (Had this discussion with [livejournal.com profile] ecosopher recently.) I consider that since we are married, and therefore a unit, everything, including earning money and homemaking, is a contribution to the team. Nom is having great trouble with this emotionally. I do understand that this is an emotional crisis for her. She has been working since around age 14, and suddenly she will be "unemployed." Add to the fact that she's a war refugee (even if she was too young to remember), and financial insecurity is ingrained in her.

Even though she knew she was going to do this, she hesitated to actually sign and send in the paperwork until the last moment. It's a huge shock for her, and I understand, and was (mostly) patient.
warriorsavant: (Quebec sait faire)
In Canada, health care, a.k.a. Medicare, is mostly government run. Each province has its own system, so there are minor differences. The federal government kicks in some money to each province, and sets basic rules. In addition, the feds directly cover certain people, such as military. Canada as a whole is a balance of individualism and collectivism, and our health care system reflects that. The system is collectively paid (e.g. government run), but most individual practitioners are private. In essence, the government is the universal insurance company.

All citizens and permanent residents are covered via public money. I often remind patients that in fact it isn't "free," it's paid for by tax money, which is not free. (I usually get a blank stare in return, but that's another lecture.) Doctors can be in- or out-, but not half-half (eg can't say I'll take Medicare for you, but not you). Visits to a participating doctor (eg almost everybody) are 100% covered for anything that is not purely cosmetic. Again, the doctor is supposed to be on- or off- the system, it is not legal to charge a supplement, however cleverly you try to diguise it. Hospitalizations are covered (private rooms, and renting a TV are extra). Labs and X-Rays and such are covered if done at a public institution; at a private facility, they may or may not be covered depending on what the test is, and what province you are in. Medications are not covered outside a hospital, including medications administered in a doctor's office. That can lead to friction (eg "why am I paying for this") and also abuses (eg "Did you want local anesthesia before I remove that mole? That will be 200$"). The latter is a bit of a kerfuffle right now in Quebec, with some doctors abusing the system, and some patients/administrators claiming anything over 35¢ is abusive. Paying for prescriptions (or reimbursing medications administered in a doctor's office) is done by a mixed system. In Quebec, everyone is required to have medication insurance, either privately, or be on the government plan (which is free to the elderly and indigent). Dental is not covered, nor eyeglass prescriptions except for children. I'm not sure about ambulances. Some private plans cover these things, some don't.

The great advantage of the system is that everyone is covered, and I personally like that there is no (financial) barrier between the patient and me. Since my early practice was in the US military, that is what I am used to, and I am comfortable with this both personally and morally. The disadvantage is that since it costs nothing out of pocket to get health care, it gets somewhat over-used, and waiting time to see a doctor, or get an operation, or some tests, can be excessive. In addition, as in every country, as the population ages, and as medical technology advances, the system is going deeper and deeper into the hole financially, and might break down at some point.
warriorsavant: (HHG-Typing)
Nope, not another "doting daddy" post. It's another "serious look at socio-economics" post.

There is much brouhaha about the cost of having and raising a child. It's one of those things that people who prefer not having children throw up as a reason. According to my careful research (eg quickly googling it, grabbing whatever number looked best, then tacking on a bit more to account for my first point), it costs US$1,250,000. Close enough for arguement's sake.

There are three reasons why this is nonsense (4 if you count my research methods being crap).
First, that might be the cost if you buy your child designer clothes, always eat at fancy restaurants, regularly take the family on 5-star vacations, and pay tuition at an Ivy League college. (We're leaving off paying for medical school and/or law school.) Somehow people on modest budgets manage to raise perfectly fine children without all that.
Second, even if it costs that, or whatever it does cost, you don't have to front the money. It's not like when the baby is born, the doctor says, "1.25 Mil on the table now, or I put the kid back."
Third, although maybe this should be first, is to consider what money is for general. The unstated part of the argument about the cost of rearing a child is that you won't have the money to do something else. (Sometimes it is stated.) Well, d'uh. Really? You mean if I spend money on one thing, I don't have it for something else? News flash. Money is finite. If you are super-rich, it is functionally unlimited in that you really couldn't spend it all, but for the 7-billlion of us who don't have 9- or 10-digit bank balances, any spending of money is a choice. I choose to spend mine on the upbringing of my children rather than something else. It gives me great satisfaction (he said sleepily), more than spending that money on something else would do.

I admit that since I didn't have children until late in life (it was on my to-do list, but it was a really long list), I have the advantage of having already done most everything else I could have wanted to spend the money on. That's irrelevant. The statement that having children cost money is specious.
warriorsavant: (Dr. Injecto)
The Canadian Medicare system, whatever its flaws, does cover all medically-necessary acts & visits. There is no copay. No one has to take part, but for providers, you're either in-or-out: I can't say I'll take it for you, but not you, and I can't take it for you, but charge a little extra also.

There are exceptions. Cosmetic procedures aren't covered (well, d'uh), although some things are a gray area. Anesthesia and medications aren't covered in office visits, so the patient has to pay as "accessory charges." Generally, these are no big sums of money, and if someone truly needs (as opposed to wants) something, and doesn't have the money, then I don't charge them. Initially, I took checks or cash. After awhile, I realized that many people don't carry any cash, even 5$ or 10$ or 20$. Maybe I'm showing my age, but I find that bizarre for a grown adult, but so be it, I started to take charge and debit cards. I had to raise my prices slightly; whether you know it or not, the merchant (me in this case) gets charged every time you use your credit/debit card. A while after that, after a few bounced checks, I stopped taking checks. Didn't happen much, but extremely annoying when it did. For some older patients, whom I've known a long time, and also who are old enough they just don't do 'plastic,' I still take checks, otherwise it's cash, charge, or debit.

Recently the Quebec government (Medicare is organized and run by the provinces, not the feds) and the medical board have been cracking down on these accessory charges if they are "excessive." Part of that is based on complaints; in some cases patients don't understand why they have to pay, and in some cases the fees are indeed excessive. Part is also based on the government wanting to change the Act governing physicians and access to same. Seems that people are having trouble getting to doctors in a timely fashion. Some of that is that when a service is free, it tends to be overused; some is that there aren't enough doctors for the population size. The government feels that the way to improve access, despite not having enough doctors, is to rearrange the deck chairs on the Titanic reorganize how that access happens. They have proposed a Bill about that, which died when the provincial parliament recessed for the summer. I think some of this sudden concern about "accessory fees" is a pressure tactic on the part of the government going into negotiations about that Bill. I've already been inspected by the government to make sure I was charging these fees in a legal fashion. It was actually a rather benign exercise, and surprise! I was doing everything correctly.

I admit some of the problem is that a small number of doctors have been demanding excessive amounts, and as in many things, that small number might ruin it for the rest of us. As my accountant likes to say, "You can be a pig, not a hog; pigs get fat, hogs get slaughtered." For now, will keep on doing what I'm doing, getting most of my money from the public system, and a small percentage from private sources generally paid by credit cards. Or debit cards. Or cash. Except of course, time travelers, who are strictly cash.*

*Points to anyone except [livejournal.com profile] ravensron who gets the reference.

Pharmacies

Sep. 3rd, 2014 09:09 am
warriorsavant: (Sword & Microscope 1)
Just read that CVS, a large pharmacy chain in US, has decided that they will no longer carry tobacco, as being incompatible with being involved in health care. Good. Pharmacies in Quebec collectively stopped carrying tobacco several years ago for the same reason. I'm not a smoker, nor in favor of smoking. I do agree that a grown adult should have the choice, but anyone, any institution involved in health care should be opposed to smoking (and also "recreational" tanning).

Smokers' lobbying groups criticized CVS on the grounds that large pharmacies like them have become mini-department stores, and so sell other things that are not completely health-ful. However nothing else they sell causes as much health damage and premature deaths as does tobacco.

It is true that big chain pharmacies have become mini-department stores. This is a great financial benefit to the chain, not to the pharmacist. The latter is like any franchisee; sounds like a great deal, but you end up working like a dog to pay the huge overhead while the chain skims most of your profits. An individual pharmacist can do just fine with 350-500 square feet (about 35-50 square meters).

Amusing note about pharmacies from today. We're expecting a delivery crom one of the local pharmacies. A man walked in with a pharmacy bag, so Evil Secretary thought it was the delivery. Turned out he was a patient who just happened to be becoming from picking up something at his pharmacy. He thought it was a great office - come in for an applintment, and we give you money.
warriorsavant: (McGill)
I’ve mentioned that I’m faculty at McGill Medical School. I’m part time, which if you’re a clinician, basically means that you don’t get paid for teaching as such.  This past year, McGill started giving a small honorarium for lecturing during the first 2 years of the Medical School. The amusing part is that the Dean’s Office tells Payroll to issue a check for a certain dollar amount, listed as “casual pay” (eg they don’t withhold taxes). Payroll has to make it work with their accounting software, which requires an hourly amount and the number of hours worked. To make their life easier, they just issued me a check stating that I worked 1 (one) hour last academic year, for which I got paid 250$/hr. This would be a great hourly wage, if I’d really only worked 1 hour for it.  If you add up the number of hours actually spent lecturing, and the number of hours spent creating the talks, and the number of hours in committee and the number of hours spent bugging other people to do their talks… yeah, somewhat below minimum wage.

I’m not keeping a copy of that check stub, but I did keep a copy of a similar one from some years ago. There was a screw up with scheduling, and they didn’t have enough Derm rotations for all the students who wanted them, so they asked faculty if we would allow 4th year students to come to our private offices. The amount of the honorarium was based on how many students we had rotate through our offices. Since they needed rotations, I like teaching, and Evil Secretary likes teasing the students, it was a win-win-win situation, and I had a lot of students rotate through. Total pay/hour was well below minimum wage, but the pay stub read “2000$/hr for 1 hour’s work.” Too bad I don’t actually make that, I’d be retired already, but I did keep a copy as a souvenir.
warriorsavant: (Sword & Microscope 1)
I'm unusual in modern developed world mindset in that I really hate having any debt. Maybe it's my highly organized nature, maybe it's having been raised by Depression era parents. Regardless, debt is anathema to me, and I try not to have any.

I'm not in the income bracket where I can buy a house for cash, but even there I've always paid off any mortgage as quickly as possible. Can't see any reason to be paying interest to a bank instead of pocketing the money, or spending it on wine, women, and song - make that iTunes, woman (singular, who has her own money), and baby milk.

Until now. We're looking at buying a house. Since we're picky, and have different tastes, it's taken quite a while to find something we both want. Some of the possible candidates are pricier than we were initially thinking (like everything in life), and I'm actually looking at a long term mortgage. Long term. Possibly about as many years as I have left on this globe. Of course one never knows, but statistically, it could be close. It's a very eerie feeling. It won't stop me from buying such a house if all else works out in fagor of buying it, but still sends a small shiver down my back thinking in those terms.

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