Monthly Archives: January 2014

healthcare, policy, politics

PHI GP cover threatens budget and universality

“Aside from equity issues and potential distortions in the allocation and delivery of health services*, critics warn Medibank-style arrangements could drive a surge in the Government’s Medicare bill and the cost of its private health insurance rebate while forcing down the extent of GP bulk billing and raising doctor fees.

In addition, because the initiative would likely boost private health insurance membership, the Government would also be liable for a $400 million increase in the private health insurance rebate, and GPs would likely reduce the extent to which they bulk billed patients.”

*HAH!!!

https://ama.com.au/ausmed/medibanks-gp-cover-threatens-universal-health

Medibank’s GP cover threatens universal health

21/01/2014

A Medibank Private scheme to give members privileged access to a range of GP services threatens to create a two-tier health system and could fracture the relationship patients have with their family doctor, the AMA has warned.

As the Federal Government proceeds with preparations for the sale of Medibank Private, it has been revealed by The Australian that in November the insurer commenced a trial with medical centre operator IPN in which its members are bulk-billed for GP consultations and get access to several service “enhancements”, including guaranteed appointments within 24 hours and after-hours home visits.

The arrangement is so far being trialled at six IPN clinics in south-east Queensland (including one at which AMA President Dr Steve Hambleton practises), and it circumvents a Private Health Insurance Act prohibition on insurers paying for services that are eligible for Medicare rebates by limiting Medibank Private funding to assistance with covering the administrative and management costs of the trial.

But AMA Council of General Practice Chair Dr Brian Morton said the scheme violated the spirit of the law, and corroded basic principles regarding equity of access to care.

Dr Morton said that although the AMA wanted to see health insurers more involved in primary health care, the approach being trialled by Medibank Private was flawed.

“We do want to involve private health insurers in general practice, but we don’t really see this as the best way of doing it,” Dr Morton told The Australian, adding that any provision to allowed funds to cover primary health services should be open to all patients and GPs.

Anticipating that private funds might seek to give their members privileged access to GP services, the AMA in 2006 released a Private Health Insurance and Primary Care Services Position Statement(https://ama.com.au/position-statement/private-health-insurance-and-primary-care-services-2006) setting out the parameters for the expansion of health fund into primary health care and the dangers that needed to be avoided.

In its Statement, the AMA said that a “limited” expansion of private insurers into primary care may be of some benefit, but only where it provides or pays for services not covered by Medicare.

“There are inherent risks in supporting an expansion of health insurance fund services into primary care,” the Position Statement said, noting especially that “limiting certain services to those who can afford private health insurance, particularly those related to preventive health measures, represents the establishment of a two-tiered system.”

Other concerns identified by the AMA included the potential for the focus of health services to shift from quality and continuity to cost cutting; for insurers to develop models for rationing care; for the development of imprecise patient selection techniques; for a shift away from the provision to patients of information and education “related to their health needs”; and for patients being encouraged to visit participating GPs, who may or may not be their regular family doctor.

In its Position Statement, the AMA warned that any scheme or arrangement that created such risks or undermined the universality and equity of Medicare “will be rejected by the medical profession”.

But so far the Federal Government has adopted a hands-off approach to the Medibank trial.

Health Minister Peter Dutton told The Age that he saw no evidence that the arrangement contravened the legislation, and appeared to give some encouragement to the initiative in a statement to The Australian Financial Review.

“I want every Australian to have a good relationship with their GP, so I wouldn’t rule out any changes,” Mr Dutton said. “Like the Australian Medical Association, I am open to greater involvement of the insurers, who cover 11 million Australians, to keep those people healthy and getting more regular access to primary care.”

Aside from equity issues and potential distortions in the allocation and delivery of health services, critics warn Medibank-style arrangements could drive a surge in the Government’s Medicare bill and the cost of its private health insurance rebate while forcing down the extent of GP bulk billing and raising doctor fees.

In a note obtained by The Australian Financial Review, the Health Department in 2008 estimated the scheme would spur a 5 per cent increase in demand for GP services and GPs would increase their fees, adding a massive $3.4 billion to the Government’s Medicare rebate bill over five years.

In addition, because the initiative would likely boost private health insurance membership, the Government would also be liable for a $400 million increase in the private health insurance rebate, and GPs would likely reduce the extent to which they bulk billed patients.

The nation’s second largest health fund, Bupa, has joined the criticism, warning that although insurance cover for GPs charges would likely be a boon for providers, it would drive up the Government’s health bill.

The trial arrangement, and a suggestion that Medibank could assume responsibility for helping to administer the National Disability Insurance Scheme, has prompted speculation the Government is trying to boost the interest of investors in the purchase of the health fund, whose possible privatisation is currently the subject of a scoping study.

The pilot of private health cover for GP services has also come as the National Commission of Audit ponders a proposal for a $6 charge for GP visits [see also, $6 co-payment an illusory health saving].

Adrian Rollins

healthcare, healthy habits, meaning, musings, nutrition, policy, storytelling

Eternal youth for just $43K per day – or just exercise and eat well????

This is funny, only because for the super rich, this seems like a feasible way forward… instead of eating well and exercising. A really interesting insight into how broken our thinking on health truly is.

https://ama.com.au/ausmed/eternal-youth-may-be-yours-just-43000-day

Eternal youth may be yours, for just $43,000 a day

21/01/2014

Like a bad fairy tale, scientists believe they have developed a way to stop people getting older, but at a cost that puts it out of the reach of all but the super-rich.

A team of researchers at the University of New South Wales, working in collaboration with geneticists at Harvard Medical School, claim to have unlocked the secret to eternal youth, and to have developed a compound they say not only halts the ageing process, but can turn back the years.

The catch is, the treatment is prohibitively expensive, with estimates it would cost the average 86 kilogram man $43,000 a day, and the average 71 kilo woman $35,500 a day.

The compound was developed based on an understanding of how and why human cells age.

A series of molecular events enable communication inside cells between the mitochondria – the energy source for cells, enabling them to carry out key biological functions – and the nucleus. The researchers found that when there is a communication breakdown between the mitochondria and the nucleus of the cell, the ageing process accelerates.

As humans age, levels of the chemical NAD (which initiates communication between the mitochondria and the nucleus), decline. Until now, the only way to arrest this process has been through calorie-restricted diets and intensive exercise.

But the researchers, led by University of New South Wales and Harvard University molecular biologist Professor David Sinclair, have developed a compound – nicotinamide mononucleotide – that, when injected, transforms into NAD, repairing broken communication networks and rapidly restoring communication and mitochondria function.

In effect, it mimics the results achieved by eating well and exercising.

“The ageing process we discovered is like a married couple. When they are young, they communicate well but, over time, living in close quarters for many years, communication breaks down,” Professor Sinclair said. “And just like a couple, restoring communication solved the problem.”

In the study, the researchers used mice considered equivalent to a 60-year-old human and found that, within a week of receiving the compound, the mice resembled a 20-year-old in some aspects including the degree of muscle wastage, insulin resistance and inflammation.

Professor Sinclair said that, if the results stand, then ageing may be a reversible condition if it is caught early.

“It may be in the future that your age in years isn’t going to matter as much as your biological age,” Professor Sinclair said.

“What we’ve shown here is that you can turn back your biological age or, at least, we think we have found a way to do that.”

The problem is, the compound is prohibitively expensive, at least at the moment.

It costs $1000 per gram to produce, and in tests so far it has been applied at a rate equivalent to 500 milligrams for every kilogram of body weight, each day.

Professor Sinclair admitted the cost was major consideration, and said the team was looking at was to produce the compound more cheaply.

As part of their research, the scientists investigated HIF-1, an intrusive molecule that foils communication but also has a role in cancer.

It has been known for some time that HIF-1 is switched on in many cancers, but the researchers found it also switches on during ageing.

“We become cancer-like in our ageing process,” Professor Sinclair said. “Nobody has linked cancer and ageing like this before, and it may explain why the greatest risk of cancer is age.”

Researchers are now looking at longer-term outcomes the NAD-producing compound has on mice, and suggest human trials may begin as early as next year.

They are exploring whether, in addition to halting ageing, the compound can be used to safely treat a range of rare mitochondrial diseases and other conditions, such as cancer, type 1 and type 2 diabetes, muscular dystrophy, other muscle-wasting conditions and inflammatory diseases.

The research was published in the journal Cell.

Kirsty Waterford

healthcare, policy

US doctors not happy or satisfied with career

 

 

http://www.cbsnews.com/news/1-million-mistake-becoming-a-doctor/

$1 million mistake: Becoming a doctor
ByKATHY KRISTOF  MONEYWATCH September 10, 2013, 1: 43 PM

 

ISTOCKPHOTO

(MoneyWatch) If you are brilliant, ambitious and gifted in science, you may consider becoming a doctor. If so, think twice. According to a new survey by personal finance site NerdWallet, most doctors are dissatisfied with the job, and less than half would choose a career in medicine if they were able to do it all over again.

There are many reasons for the dissatisfaction, said Christina Lamontagne, vice president of health at NerdWallet. Most doctors enter the field thinking they’ll be able to spend most of their time healing the sick. Yet the paperwork burden on doctors has become crushing, and could become even more complicated under the Affordable Care Act.

“Administrative tasks account for nearly one-quarter of a doctor’s day,” Lamontagne said. “With additional liability concerns and more layers in health care, we can understand the drain this takes.”

Play VIDEO

Doctor: Patients should take active role in care

Worse, the cost of becoming a doctor has soared, with higher education expenses leaving the average newly minted physician with $166,750 in medical school debt, while average salaries are declining. Nearly one-third of doctors — 28 percent – saw a cut in pay last year, according to NerdWallet’s research.

To be sure, pay is still high, with of six-figure positions in the country, according to government data. But it also takes between 11 and 14 years of higher education to become a physician. That means the typical doctor doesn’t earn a full-time salary until 10 years after the typical college graduate starts making money.

That lost decade of work costs a cool half-million dollars, if you assume this individual could have earned just $50,000 annually, and the typical medical school candidate is smart and successful enough to earn considerably more. Add in the time and cost it takes to pay off medical school debt and a dissatisfied physician may well consider pursuing medicine a $1 million mistake. (This assumes the average $166,750 medical school debt  takes 30 years to repay at 7.5 percent interest — a total cost of $419,738.)

Moreover, primary care physicians — those who go into pediatrics, family and internal medicine — earn barely more than the amount they accumulated in medical school debt, between $173,000 and $185,000, according to the study that looked at data from George Washington University’s School of Public Health, the American Association of Medical Colleges and Medscape.

The least satisfied physicians are those who go into internal medicine, according to the study. On average, these doctors see two patients every hour while spending 23 percent of their time on paperwork. They work an average of 54 hours per week, take home about $185,000 annually, and a fifth have seen a decrease in pay. Just 19 percent would choose the same specialty, and only one-third would choose a medical career if they had to do it over.

“The frustrations that patients have about not getting enough time with their doctor is mirrored by the frustration their doctors have with not having enough time to spend with their patients,” LaMontagne said.

The best paid doctors are orthopedic surgeons, who take home an average of $405,000 annually. The most satisfied appear to be neurologists, who earn an average of $216,000, while working an average of 55 hours per week. Sixty-percent would choose the same specialty, and 53 percent would go into medicine again. Oncologists — the doctors who treat cancer patients — are also generally satisfied with medicine and their jobs, with 62 percent saying that they would go into medicine and 57 percent reporting that they would choose oncology as a specialty.

Radiologists are the physicians most likely to have suffered a pay cut in the past year, with 42 percent reporting a decline in salary. However, they’re also among the best-paid doctors, earning an average of $349,000. More than half would both choose to be doctors again and choose the same specialty.

The doctors who work the longest hours are cardiologists, who report being on the job 60 hours per week. Some 54 percent would choose the same medical specialty, but only 44 percent would go into medicine again if they did it over. The average cardiologist earns $357,000 annually, though 39 percent have seen a cut in pay in the past year.

Those least likely to have suffered a pay cut are emergency doctors, who earn an average of $270,000 and work an average of 46 hours per week. Just 19 percent of emergency doctors suffered a cut last year, but only 41 percent would go into medicine or emergency medical care again.

Across all specialties, physicians see roughly 13 patients per day, work 52 hours per week and earn an average of $270,000. However, family and emergency doctors see nearly 75 percent more patients than anesthesiologists.

© 2013 CBS Interactive Inc.. All Rights Reserved.
facts & data points, healthy habits, nutrition

Diabetes and the brain

  • Good summary on the state of understanding the strengthening relationship between glucose metabolism and dementia
  • Type 2 diabetes is a very strong risk factor for dementia – Alzheimer’s disease is sometimes referred to as “Type 3 diabetes”
  • It also results in brain atrophy
  • Metabolic syndrome is also implicated in dementia
  • High insulin in the body means lower insulin in the brain due to a reduction in BBB insulin receptors, and insulin helps clear toxic beta-amyloid from the brain
  • The key to lowering blood sugar and insulin is lose excess weight and exercise more
  • a diet high in high GI carbs and saturated fat is associated with higher unbound beta-amyloid fragments in their CSF. Subjects on lower GI carbs and low saturated fat had less

http://www.nutritionaction.com/daily/diabetes-and-diet-cat/the-effect-of-diabetes-on-the-brain/

The Effect of Diabetes on the Brain

Can high blood sugar lead to brain atrophy?

 • January 16, 2014
“Type 2 diabetes is a very strong risk factor for dementia,” says Jae Hee Kang, assistant professor of medicine at Harvard Medical School and the Brigham and Women’s Hospital in Boston. “Some people call Alzheimer’s disease type 3 diabetes.”

(In type 1 diabetes, blood sugar soars because the body makes no insulin, the hormone that acts like a key to allow sugar into cells. In the more common type 2 diabetes, blood sugar soars because insulin no longer works properly—that is, people are insulin resistant.)

Act now to download your FREE copy of Diabetes and Diet: Decoding Diabeteswithout cost or obligation.

“There’s no question that diabetes damages small blood vessels,” says David Knopman, professor of neurology at the Mayo Clinic in Minnesota.

It may also shrink parts of the brain. A recent study found more brain atrophy in 350 people with diabetes than in 363 people without the disease.

It’s not just those with diabetes who are at risk. People who have what doctors call “metabolic syndrome” also have a higher risk of cognitive decline. That’s roughly one out of three U.S. adults.

Their blood sugar levels are higher than normal, but not high enough to be diabetes. That gives them an increased risk of dementia.

And they may have high blood insulin levels because obesity—especially an oversized waist—has made them insulin resistant. (When insulin doesn’t work well, the pancreas responds by pumping out more.)

That may also spell trouble for the brain. Men with high blood insulin levels declined more on cognitive tests over three years than those with lower levels.

Why would high levels of insulin in the blood matter?

“High insulin in the body means lower insulin in the brain,” says Angela Hanson, a physician and senior fellow at the University of Washington School of Medicine.

That’s because, over time, high levels of insulin in the blood may shrink the number of receptors for insulin in the blood-brain barrier, allowing less to enter the brain, says Hanson. And insulin may help keep the brain healthy.

“Insulin helps clear toxic beta-amyloid out of the brain,” Hanson explains. “So if you put someone on a diet that increases brain insulin, you might have less of the toxic amyloid around.”

The key to lowering sugar and insulin in the blood—and presumably raising insulin in the brain—is to lose excess weight and exercise more.

But one pilot study suggests that it’s not just how much, but what you eat that matters.

Hanson and her colleagues assigned 20 older adults without mild cognitive impairment and 27 older adults with MCI to eat one of two diets. The LOW diet was low in saturated fat, and its carbs had a low glycemic index—that is, they didn’t cause a bump in blood sugar. The HIGH diet was high in saturated fat, and its carbs had a high glycemic index.

The HIGH diet was unusually high in saturated fat and sugar, but it wasn’t off the charts. “If you look at a fast-food combo meal, it’s got a sugary soda and a high-fat burger,” notes Hanson.

After four weeks, people who got the HIGH diet had higher levels of unbound beta-amyloid fragments in their cerebrospinal fluid (which bathes the brain and spinal cord), while people who ate the LOW diet had lower levels.

“The theory is that the beta-amyloid that’s not bound to fats or other lipids is free, and it’s free to wreak havoc, if you will,” says Hanson. “We believe it’s a more toxic form of beta-amyloid because it’s less likely to be cleared. But that’s hard to test in humans.”

The results seemed to fit with a finding from a similar, earlier study: the LOW diet raised insulin levels in cerebrospinal fluid (and presumably the brain), while the HIGH diet lowered insulin levels.

“A Western diet or obesity or other things that cause high blood insulin may decrease brain insulin,” says Hanson. “If you make someone less insulin resistant with weight loss or a diet, they may have more brain insulin.”

Until more studies are done, it’s too early to know if a diet lower in saturated fat and sugars can protect the brain. But the research is encouraging.

“The most striking finding from these studies was that you could change the brain chemistry of people who have mild cognitive impairment,” says Hanson.

“When I’m in my clinic, I can tell patients with MCI that if they eat a healthier diet and exercise, things might get better. That’s the message that keeps me going.”

Sources: J. Am. Geriatr. Soc. 56: 1028, 2008; Exp. Gerontol. 47: 858, 2012; Diab. Care 36: 4036, 2013; JAMA 292: 2237, 2004; N. Engl. J. Med. 369: 540, 2013; Eur. J. Pharmacol. 719: 170, 2013; Neuroepidemiol. 34: 200, 2010; JAMA Neurol. 70: 967, 972, 2013; Arch. Neurol. 68: 743, 2011.

healthy habits, nutrition, policy, politics

Tobacco, Firearms and Food

“But the job of government is not to encourage profitable businesses at the cost of public health; it’s to regulate them so that the public is served. Who is this country for, anyway?”

http://www.nytimes.com/2014/01/15/opinion/bittman-tobacco-firearms-and-food.html

The Opinion Pages
Tobacco, Firearms and Food

Mark Bittman Jan 14, 2014

Let’s say your beliefs include the notion that hard work will bring good things to you, that the golden rule is a nice idea though it may occasionally have limits, and that it’s more or less every person for him or herself. Your overall guiding force is not altruism, but you’re not immoral; you’re a good citizen, and you don’t break any major laws. This could describe many of us; most, maybe.

Now suppose you’re in the business of producing, marketing or selling tobacco or firearms — products known to sometimes kill others. You need not be a corporate executive or a criminal arms dealer; you might be a retailer of cigarettes, a person who sells them along with magazines, a marketer, a gun shop owner. In any case, your conscience is clear: you’re selling regulated legal products and, as long as you’re obeying the regulations, you’re doing nothing illegal. (“Wrong” is a judgment call.)

You sleep well, believing that the government would further regulate your product if it were necessary. And if regulations were to change, you’d change with them. But to act otherwise — to hold back your energy from production or sales just because of moral or social pressure — would be foolish, and put you at a competitive disadvantage.

For many years after knowing about the lethal nature of tobacco, our government did little or nothing to limit its consumption. That’s changed gradually in the last 50 years, and more dramatically since 1998, because of successful lawsuits and because the Food and Drug Administration often tries to pursue its mission. (For a variety of reasons not worth going into, firearms are more challenging to regulate. Let’s leave it at that for now.)

O.K., so suppose we pass legislation that discourages you from producing or selling tobacco or firearms while at the same time actively encouraging you — supporting you — to change to producing apples or cotton or washing machines or screwdrivers; as long as you could see a way to increase profit, you’d probably look at the new opportunity. After all, it’s not as if you wantto produce agents of death. You want to make the best living you can selling stuff that’s legal and that people want. Markets change, and flexibility is important, and the government can and does affect your business, even if it’s by inaction.

Now let’s apply this same way of thinking to the major food categories — and for the purposes of this discussion there are only three — and what it’s like to be a farmer or producer, or a manufacturer, processor, distributor, retailer of this stuff. Again, you’re agnostic about what you sell, but you’re profit-conscious. And the government can and does affect your business; it can help your business (“you didn’t build it yourself”) or hurt it, as it should if your business is harming others.

Let’s call the first food group industrially produced animal products. Producing and selling as much as possible is the way to go here, since the penalties for damage your product does to human and animal health and to the environment (including climate) are virtually nonexistent. You can treat the animals as you like and damn the consequences, from salmonella contamination to antibiotic resistance to water contamination to, of course, cruelty. There are even incentives, in the form of subsidized prices for animal feed.

The next group is most easily labeled junk food; you might call it “hyperprocessed.” This comprises aisles and aisles of “edibles” sold in supermarkets and restaurants, and is often “food” that’s unrecognizable as such, ranging from soda and other sugar-sweetened beverages to things like chicken nuggets and Pringles and tens of thousands of other examples. These are mostly made from commodity crops, especially corn, soybeans and wheat. Federal subsidies abound in many forms here, from direct payments (in theory, these are ending, to be replaced by a bizarre form of crop insurance) to the ethanol mandate to virtually unregulated land use that permits toxic overapplication of fertilizers and other chemicals. There is also that same failure to recognize the public health and environmental costs of what is probably the least healthy diet a wealthy nation could devise. You could even say that the Supplemental Nutrition Assistance Program (SNAP, usually called food stamps) acts as a subsidy to junk food, since nothing limits using food stamps for food that promotes disease. It’s worth noting that for the past century the bulk of university research, much of it paid for with tax dollars, has gone into figuring out how to increase the yield of the crops and processes that turn out this junk that sickens.

Then, in the third group, there’s everything else, from fruits and vegetables — absurdly called “specialty crops” by the Department of Agriculture — to animals raised in sustainable and even humane ways. But here, disincentives abound: farmers may be encouraged to allow some land to go fallow, but not to be planted in specialty crops, and research money, subsidies, insurance, market promotion and access to credit are directed toward industrial food production, distribution and sales. These inefficiencies make most of this real food, which is health-promoting and closer to environmentally neutral, appear to be more expensive. (Only “appear,” though. If you account for the costs of environmental and public health damage, industrially produced junk food and animal products actually cost more.)

One could imagine a government that encourages more life-giving (and less disease-causing) agriculture just as one can acknowledge that sanity prevails when government steeply taxes tobacco and encourages its farmers to move on to something else. (I’m not saying, by the way, that tobacco farmers have been treated fairly; much more could have been done — and still could be done — to help them transition to other profitable crops.)

Of course this is disruptive; change the status quo, and someone is hurt. But the public health disaster created by our commodity-pushing agricultural policies is only getting worse, and calls for the same kind of action in industrial agriculture that we’ve seen in tobacco and, to a lesser extent, in guns. That kind of action will happen only when we have political representatives who care about food, health and the environment.

We can pressure corporations all we want, and what we’ll get, mostly, is healthier junk food. Really, though, as long as sugar is profitable and 100 percent unrestricted (and subsidized and protected!), marketers will try to get 2-year-olds hooked on soda and Gatorade.

But the job of government is not to encourage profitable businesses at the cost of public health; it’s to regulate them so that the public is served. Who is this country for, anyway?

healthcare, policy, rapid learning health systems

Commonwealth Fund 2013 Annual Report

Blumenthal is a top shelf operator and its terrific to see him leading the Fund on new work which includes constructive disruption of the US health system. His opening lines carry a finely crafted, powerful and persuasive message:

“Like every American, like every person on this globe, I treasure the access I have to health care. I know I’m privileged, but every time my family members or I are sick, we are taking risks, that we are entering a system that doesn’t function as well as it should. As a primary care provider, as a scholar, as a professor, I’ve been interested in the same things the Commonwealth Fund is interested in. A high performing health system and vulnerable populations.

We have a system that’s excessively costly, inadequate in quality. Poor results with many other countries on quality metrics. We spend far too much on health care – $2.7 trillion when no other country comes close to that.

It’s important that the most vulnerable access care, because in some ways, they are the canary in the mine. Their vulnerability highlights a general vulnerability.

The Commonwealth fund is dedicated to producing the right information at the right time to make decisions better and make our health care system better.

A high performing health system will be a health system in which the providers of care, the clinicians, doctors and nurses, enjoy their work. It matters to me not just as a policy maker, and a scholar, but as a father, as both my children are physicians in training, and I hope we can leave them a system they can truly enjoy working in.

[….]

The last area, and somewhat new, is what we’re calling breakthrough innovations, which are opportunities to fundamentally transform the system through innovative approaches to health care delivery”

 

http://www.commonwealthfund.org/Annual-Reports/2013-Annual-Report.aspx?omnicid=20

cool, silly

Fight Club easter eggs…

One of my favourite movies…

http://bangbangattack.com/2014/01/18/25-didnt-movie-fight-club/

25 Things You Didn’t Know About The Movie “Fight Club”

1. At the beginning of the movie, after the traditional copyright warning, there is a second warning that flashes for a second.

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2. Director David Fincher has claimed in interviews that there is at least one Starbucks cup visible in every scene in the movie.

enhanced-buzz-32617-1389333655-7

3. Tyler Durden flashes on screen four times before we actually meet him as a character.

grid-cell-11559-1389381550-10

 

4. And, in an early scene of the narrator, there is an ad for Bridgeworth Suites playing on a TV in front of him…

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25 Things You Didn't Know About The Movie "Fight Club"

…Featuring Brad Pitt.

25 Things You Didn't Know About The Movie "Fight Club"

5. The breath in the cave scene is actually Leonardo Di Caprio’s breath from Titanic, composited into the shot.

6. Brad Pitt didn’t want his parents to watch the movie but they insisted. They changed their minds when they saw this scene:

25 Things You Didn't Know About The Movie "Fight Club"

7. Before shooting, Brad Pitt and Edward Norton actually took boxing and soap-making classes.

25 Things You Didn't Know About The Movie "Fight Club"

8. And, according to IMDb, Brad Pitt actually went to a dentist to have his front tooth chipped for the role.

9. Helena Bonham Carter, who is 5’2”, wore huge platform shoes to be closer in height to 5-foot-11-inch Brad Pitt and 6-foot Edward Norton.

25 Things You Didn't Know About The Movie "Fight Club"

10. And she insisted that her makeup artist do all her makeup left-handed, because she thought the character of Marla wouldn’t care about, or be good at, that kind of thing.

11. During this scene, when a Fight Club member sprays a priest, the camera shakes slightly because the cameraman couldn’t keep from laughing.

25 Things You Didn't Know About The Movie "Fight Club"

12. Before deciding on Brad Pitt, the producers initially wanted Russell Crowe to play Tyler Durden.

Before deciding on Brad Pitt, the producers initially wanted Russell Crowe to play Tyler Durden.

13. And both Sean Penn and Matt Damon were considered for the role of the narrator, which Edward Norton eventually played.

14. Reese Witherspoon and Sarah Michelle Gellar were both offered Helena Bonham Carter’s role of Marla Singer.

Jason Merritt

Frederick M. Brown

Getty

Witherspoon turned it down because it was “too dark,” and Gellar’s contract with Buffy didn’t let her accept the role.

And Courtney Love and Winona Ryder were also considered for the role.

Andrew H. Walker

Valerie Macon

Getty

15. The font used for the title and credits is called “Fight This.”

The font used for the title and credits is called "Fight This."

16. When the narrator is sitting at work writing haikus, the names on the document on his screen are of the film’s production assistants and crew members.

When the narrator is sitting at work writing haikus, the names on the document on his screen are of the film's production assistants and crew members.

17. Brad Pitt and Helena Bonham Carter spent three days recording orgasm sounds for their unseen sex scenes.

18. This line of pillow talk was originally supposed to be “I want to have your abortion,” but Laura Ziskin, a producer at Fox 2000, found that too offensive.

25 Things You Didn't Know About The Movie "Fight Club"

The director agreed to change the line, on the condition that the new line wouldn’t be up for negotiation. When Ziskin saw the new line (“I haven’t been fucked like that since grade school”) she found it to be even more offensive, but couldn’t do anything about it because of their agreement.

19. In the scene where the narrator first punches Tyler Durden, Edward Norton was supposed to fake-hit Brad Pitt…

25 Things You Didn't Know About The Movie "Fight Club"

But at the last minute, director David Fincher told Edward Norton to actually punch Brad Pitt. Pitt’s wince of pain is real, and you can see Norton laughing about it.

25 Things You Didn't Know About The Movie "Fight Club"

20. Marla Singer’s phone number is the same as Teddy’s number in the movie Memento.

It is also the same as the Hong Kong Restaurant’s phone number in Harriet the Spy, Eddie Alden’s phone number in the movie Someone Like You, and the number for a mental institution in an episode of the show Millennium.

21. While filming this scene, Edward Norton was actually completely nude from the waist down.

While filming this scene, Edward Norton was actually completely nude from the waist down.

On the DVD commentary, he tells director Fincher this and then jokes, “Did you notice I never had to go to the bathroom that day?”

22. To look convincingly like sagging flesh, Bob’s fat suit was filled with birdseed. It weighed more than 100 pounds.

23. When Tyler is giving a speech to the Fight Club, he looks directly at Jared Leto’s character when he mentions rockstars.

25 Things You Didn't Know About The Movie "Fight Club"

The year before the film’s release, Jared Leto formed the now platinum-selling band 30 Seconds To Mars.

24. The movie contains several subtle hints about the special “relationship” between Tyler Durden and the narrator.

The movie contains several subtle hints about the special "relationship" between Tyler Durden and the narrator.

For instance, when they both get on a bus together, the narrator only pays the fare for one person. Later in the movie, when they are together in a car that Tyler is driving, the narrator also gets out on the driver’s side.

25. And, finally, in the last scene of the film, there is a single frame flash of male genitalia, just like Tyler Durden would insert into films at his projectionist job.

25 Things You Didn't Know About The Movie "Fight Club"

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healthcare, policy

Google backing telemedicine via Helpouts…

  • aligned with US DHHS
  • doesn’t support third party payments
  • asynchronous comms allows more convenience
  • pricing is pitched at co-pay levels
  • various other services discussed

http://www.fastcompany.com/3022450/the-doctor-veterinarian-and-lactation-specialist-will-see-you-now-on-video-chat

THE DOCTOR, VETERINARIAN, AND LACTATION SPECIALIST WILL SEE YOU NOW–ON VIDEO CHAT

WITH SERVICES LIKE GOOGLE HELPOUTS, HOUSE CALLS ARE BACK IN A BIG, MODERN WAY.

When Google launched Helpouts in November, it opened a marketplace for experts–from scrappy entrepreneurs to big-name brands such as makeup retailer Sephora–to share their skills over video chat.

Now, while some clueless consumers are simply looking for mascara tips, the search giant sees a vastly different industry that can benefit from the service: health care.

That’s right, in addition to the many musicians, yogis, and IT pros chatting on the Helpouts platform, there are also doctors, counselors, veterinarians, and lactation specialists, among other medical professionals. By melding parts of its infrastructure–namely Google Wallet and Hangouts–the company gives consumers a single destination, either through a computer or Android phone, to book sessions with experts and to pay for them. Doctors can even prescribe medicine, as Helpouts is aligned with the U.S. Department of Health and Human Services.

“We believe telehealth, and Helpouts, can complement in-person office appointments and play an important part in the overall continuum of care,” Google’s director of business operations, Christina Wire, tells Fast Company. “We look forward to learning how users find Helpouts to be most helpful in their continuum of care.”

Telemedicine isn’t exactly a new concept. Defined very broadly, the term can be applied to, say, African villagers who used smoke signals to warn others of disease outbreaks. More contemporary forms of telemedicine include the use of Xbox to care for patients with chronic illnesses and telepresence robots, such as the human-sizedRP-VITA from iRobot that lets doctors interact with patients from afar. But with the advent of mobile technologies, telemedicine has the potential to go mainstream.

Using Helpouts, San Francisco resident Justine Lam, 34, consulted One Medical Groupabout getting a flu shot while traveling in Austin early November. The first time she connected, the picture was fuzzy and the call dropped, but the second time, she got a hold of a nurse practitioner, who coincidentally happened to be the one she usually interacts with.

“I travel a lot for work, so it’s difficult for me to get to the doctor’s office,” says Lam, who formerly worked in marketing and recruiting for a tech company. “It was super easy. I just log in, find the time available, and within an hour I was seeing a medical professional.”

One Medical provides its services over Hangouts at no cost to its members; it charges non-members $40 to $60 per session. Dr. Kevin Fell is one of the staff members who now works a weekly shift where he’s on Helpouts duty. “Surprisingly, it feels very personal,” he says. “It feels like being a country doctor and making a really personal house call with the help of modern technology.”

Technology, Fell notes, may not quite replace humans just yet: “I still think the one-on-one physical meeting with a patient is still very important–always has been, always will be.”

Patients like Lam are turning to online platforms for less severe illnesses. And some providers are keen on servicing Telecure, a company focused on providing virtual urgent care. It joined Helpouts in November and only sees patients if they meet certain criteria. For example, they can’t have a fever exceeding 103 degrees or be sick for more than two weeks.

But there are also online platforms that aim to provide medical help beyond the common cold. Grand Rounds was cofounded by a blood clot specialist focused on cutting-edge advances in medicine, the type of treatment that on average takes 17 years to trickle into medical practices. “That’s been the bane of my existence,” cofounder Rusty Hofmann says. “I felt ethically compelled to start this company to fix this problem. The work that I do on blood clots was developed at Stanford in 1992, and 15 years later there were still hospitals 10 minutes away from Stanford not offering this treatment.”

Using the web, patients are able to consult with specialists, who review their medical history, imaging, lab tests, and other information before writing a four-page opinion describing the best course of action. Grand Rounds’ efficiency, Hofmann says, is dependent on asynchronous communication, allowing patients and doctors to use the platform without having to coordinate schedules while also giving doctors the time to research patients’ conditions.

One of the biggest obstacles standing in the way of broader telemedicine adoption is a familiar force: insurance companies. While President Obama hopes telemedicine can help reduce health care costs, the Affordable Care Act doesn’t go so far as to require insurers to pay for remote consultations. “Helpouts does not have a system in place to submit sessions to health insurance plans for reimbursement,” says Google’s Wire. “Reimbursement for Helpouts sessions is at the discretion of the health provider and the health plans they work with.”

Pearl.com, a 10-year-old online marketplace that started with a health care vertical, has tried to involve insurance providers for years. “We would love it if insurance companies would cover online doctors and telehealth,” says CEO and founder Andy Kurtzig, noting the site hit a major milestone in November with experts earning $100 million to date. “We would touch base once in a while, and the answer’s always no.”

Virtual health care companies try to make up for the lack of insurance coverage by pricing their services comparable to copays. Across the board, Pearl.com sessions begin at $15 and average about $30. Telecure prices its 15-minute sessions at a flat $25, and most consultations don’t exceed that, says CEO Garick Hismatullin. The company, in part because it doesn’t have an advertising budget, also added a way for patients to pay for their services with tweets–“social currency,” Hismatullin says. “We were looking for a way to make people more aware of our service,” he says, mentioning the pay-by-tweet option is available only on its site, not Helpouts. “This was a direct result of us watching thousands of incredibly satisfied patients, to let them do the talking for our company instead of paying for advertising.”

Helpouts is playing a role in hastening telemedicine’s adoption, but changes take time. “Services like Helpouts have the power to bring back doctor house visits after 50 years,” says Google’s Wire.

There will always be reason to physically go to a doctor’s office, but One Medical’s Fell is amazed at technology’s potential to transform health care. He recalls being at Mayo Medical School in the early ’90s and first hearing about telemedicine. “There was a doctor who said, ‘When you guys are older and in practice, you’re going to be able to see and meet with patients wherever they are, wherever you are,'” Fell remembers. “Most of us at the time, we didn’t even have an email address.”

[Base Images: Flickr users Phalinn Ooi & Official U.S. Navy]

management and leadership

Specilising in being a generalist

Totally agree with this assessment… you do have to work really hard to be a generalist. Am relieved to hear I have a future…

If someone says to you “I specialize in being a generalist,” it’s not actually a crazy claim. Most people cannot be a generalist, and you have to work really hard at a bunch of particular things to be good at it. You’re specializing in doing that. These are people who integrate and understand the contributions of others — that’s a lot like managing. So what you call generalists — I would not oppose them to specialists — there’s a big and growing role for them.

http://blogs.hbr.org/2013/12/algorithms-wont-replace-managers-but-will-change-everything-about-what-they-do/

Algorithms Won’t Replace Managers, But Will Change Everything About What They Do

by Walter Frick  |   12:00 PM December 20, 2013

Workers more and more will come to be classified into two categories. The key questions will be: Are you good at working with intelligent machines or not? Are your skills a complement to the skills of the computer, or is the computer doing better without you? … If you and your skills are a complement to the computer, your wage and labor market prospects are likely to be cheery. If your skills do not complement the computer, you may want to address that mismatch. Ever more people are starting to fall on one side of the divide or the other. That’s why average is over.

But what about management? I interviewed Cowen last month about his vision of the future, and where he sees managers fitting into it. An edited version of our conversation follows.

WF: What do you see as the main career lessons of the book?

TC: One thing the book suggests is that only being technically skilled may not be that useful, because those jobs can be outsourced or even turned over to smart machines. But people who can bridge that gap between technical skills and knowing some sector in a way that’s more creative or more intuitive, that’s where the large payoffs will come.

A classic example is Mark Zuckerberg with Facebook. Obviously a great programmer, but had he just gone out to be paid as a programmer he wouldn’t be that well off. He was a psychology major — he understood how to appeal to users, to get them to come back to the site. So he had that integrative knowledge.

For people who are not technically skilled, marketing, persuasion, cooperation, management, and setting expectations are all things that computers are very far from being good at. It comes down to just communicating with other human beings.

WF: Where does management fit into this?

TC: In any company, you need someone to manage the others, and management is a very hard skill. Relative returns to managers have been rising steadily; good managers are hard to find. And, again, computers are not close to being able to do that. So I think the age of the marketer, the age of the manager are actually our immediate future.

WF: I was talking recently with Andrew McAfee of MIT, whom you reference the book, and he mentioned the way software might even replace some pieces of management, though not managers themselves. Do you see algorithms and software encroaching majorly into that area?

TC: If it’s just measuring how hard people work, how long they’re at their desks, how good a job they do, how good a doctor or a salesman is adjusting for quality of customer, there’s a huge role there for software. But to actually replace managers, for the most part I don’t see that. At least not for the time horizon I’m writing about, 10 to 20 years out.

WF: One thing that McAfee talks about is the idea that people want to get their information from a human; they can be very distrustful of a computer just spitting out a recommendation.

Do you see that being true in a management context as well? That part of my job, if I’m running a company or division, is being able to understand machine intelligence and deliver it personally?

TC: That’s right. You will translate what the machine says and try to motivate people to do it. Professors and teachers will be more like coaches or tutors, rather than carriers of information. They’ll steer you to the program, tell you which classes to take, and be a kind of role model to get you excited about doing the work.

It’s a very important skill, and hard to learn. But I think you’ll see this kind of pattern again and again.

WF: How else do you see management changing?

TC: Management — for all the change we like to talk about — has actually been pretty static for a while. But smart machines and smart software are going to change management drastically, and in general we’re not ready for this. We will need truly new managerial thinking, not just new in the cliched sense of repackaging with new rhetoric and new categories.

WF: I wanted to ask you a little more about the machine-human teams. Freestyle chess — where human and computer teams play together, and outperform either on their own – is the example throughout the book.

What skills does the freestyle chess master have that the grandmaster doesn’t?

TC: The program, of course, does most of the calculations. The one skill the human needs when playing freestyle is how to ask the program good questions. Knowing what questions to ask is how you beat a solo program playing against you, and you don’t even have to be very good at chess. You need to understand chess at some core level, and you need to understand what different programs can and cannot understand.

It’s a kind of meta rationality. Knowing not to overrule the programs very much, but also knowing they’re not perfect, and knowing when to probe. And I think that, in management, those will be the important human skills.

WF: How do you determine where the line is between when the employee is able to add value above and beyond what computer intelligence is giving them, and when the software itself can replace them?

For example, I’m imagining some analytics software. Someone is very skilled at using it, they’re drawing some conclusions, they’re presenting them to people. But the next version of software may have built-in the ability to make those inferences. What skills keep that human from being replaced?

TC: People who can judge that there’s more to the matter than the software can grab; people who can judge the fact that there’s a need for a different kind of software for the problem; people who know when to leave the software alone and get out of its way.

Those are difficult to acquire and often quite intangible skills, but I think they’re increasingly valuable. You can think of other professional areas, like law or medicine, where you let the software do a lot of the work but you can’t uncritically defer to it. Software is bad at common sense in a lot of ways and it misses a lot of context. It’s people who can provide context.

WF: You have an interesting section in the book with respect to specialization in science. Do you see the path towards greater specialization as the path to career security? Or is there still a role for generalists?

TC: There’s a role for both, but you need to ask whether these terms lose some of their meaning. If someone says to you “I specialize in being a generalist,” it’s not actually a crazy claim. Most people cannot be a generalist, and you have to work really hard at a bunch of particular things to be good at it. You’re specializing in doing that. These are people who integrate and understand the contributions of others — that’s a lot like managing. So what you call generalists — I would not oppose them to specialists — there’s a big and growing role for them.

WF: You can’t go a day without seeing a story about who should learn to code or not learn to code. The same thing with respect to statistics. Given the way you see the labor market breaking out, are there specific things you advise people go out and learn?

TC: Statistics will be an increasingly big area. And even knowing a little can have a pretty high return. Coding’s tricky. If you can learn it, great. But if you can’t do it right, you really shouldn’t bother. There’s no half way.

But if you’re a manager or you work in health care, you might not ever be doing statistics, but if you can grasp some basic stuff that you can teach yourself, there’s a very high return. And it’s really quite feasible, unlike coding where it’s a major undertaking. If you’re a doctor trying to figure out which parts of the hospital are bringing in the money and someone hands you statistics — if you’re helpless, that’s really bad.

WF: One area that strikes me as one of the more difficult for machine intelligence is strategy. Where to position your business in a marketplace seems like on the far end of what machines can tell us.

TC: Yeah, that’s all humans, though you might consult machines for background information. But in no sense are machines close to being able to do that. That’s a very long way away.

All of our sectors are all on different paths, and the differential timing actually will be useful because we won’t have to figure it out all at once. We’ll get lessons from different areas sequentially and adjust. Humans will switch into the sectors they’re still good at in a rolling way. And that will make this socially more stable and better for most people.

If you woke up one morning and the machines were better than you at everything, that would be pretty disconcerting. That’s the science fiction scenario but it’s not that realistic.