BillsFanM.D.

http://www.youtube.com/watch?v=qvi_jcy9A1I Just watching his introduction at the beginning of the clip is awesome. I remember watching and thinking....finally! Thankfully his career lived up to my 'internal' hype.

Flexible linguistics are an essential part of keeping the math straight.

I thought that bolded statement (you're an idiot) was copyrighted.... Thanks for the 'welcome' to this part of the board. I've lurked here for a while and it's always a good/interesting read. I'm keenly aware of your hyperbole and find it quite entertaining. To borrow from Churchill: "The best argument against democracy is a five minute conversation with the average voter." Regardless of knowledge base, the debate/conversations here are educating and hotly contested. It's great reading and most folks who seem to linger here seem to at least have individual reasons/knowledge for believing what they believe. Much better than the "You can't vote for (blank) because he's stupid" dialogue that is typical of many political discussions. ...and yes, they have to 'keep seeing me.' If they come in once, twice or twenty times... I get 10 bucks per member per month. OK...and a copay with each visit (sometimes).

I agree with your first statement to the point that I would reword it: Meds ARE overprescribed. One of the first things I do when a patient transfers to me is try to figure out what meds I can stop....and I assure you there is no cost benefit. Polypharmacy has it's own 'defensive' component and sometimes you have to have the gumption to tell a patient that too much is too much. Not to mention, polypharm can be very dangerous. Your premise about PCP's overprescribing meds (to limit referrals) is certainly valid as I'm sure it happens. It really speaks to a bigger issue: docs going beyond their scope of practice and the provider lacking a conscience. In my mind, you have to be dealing with a fairly shady doc to have that occur. I am happy to report that the overwhelming majority of folks I've worked with would never even consider that as a 'decision making factor.' Again, i'm sure it is present as docs are nothing but a cross section of society. SSRI's are widely prescribed as they treat the full spectrum of mood disorders. Historically, depression was treated with antidepressants and anxiety was treated with anxiolytics. In simple terms, SSRI's are 'mood stabilizers' and can treat the full spectrum. Hence, they are very widely prescribed as they are typically the best choice vs older meds. Typcially, 30% of primary care visits are for mental health issues. It is reasonable for PCP's to treat the majority of those but it depends on the patient and the provider's comfort level and expertise. I have referred many to Psych and treated many myself. It just depends. I do not prescribe antipsychotics as PCP, however. There are many who do and, again, they are going to be accountable for their level of care...and it may be excellent. I think the defensive part of prescribing applies more to the specialists. For example, "How can you see a cardiologist and he 'only' put you on a statin, a beta blocker and an ace inhibitor? You had a heart attack in the past and you should also be on x,y and z." The specialists have a bigger burden in terms of having to 'do everything.' Hence, here comes the polypharmacy. Evidence based treatments that will alter life outcomes are welcome but there is a lot of 'voodoo' polypharmacy out there as well. Regardless, we (docs) have to answer to ourselves, our patients, our peers and potentially a jury. This includes answering for what we do (i.e. meds, care etc.) AND for what we don't (in this case the implied nonreferral). Again...there is more than one way to be wrong here. As I mentioned above, if a doc allows money to interfere with his thinking he has bigger issues than his/her bottom line. It's beyond bad medicine....It's bad humanity.

90% is not realistic if the implication is that they do this all the time. More like all doctors do this a small percentage of the time. Certain personalities, family members, circumstances, threats, prior litigation etc. will drive most docs to do an extra test/evaluation periodically out of fear of 'consequences.' I sincerely doubt, however, that 90% of all medical encounters are defensive. It does exist, however, and comes at a huge cost burden which is a whole other discussion. Diagnosing someone with mental illness has huge ramifications for the patient. Ultimately, any person's records are 'recoverable' given the correct life circumstances. The stigma alone, although unfair, is significant. Even if the doc is not taking a true interest in the patient and would rather 'just diagnose them' as you say, they are still putting themselves at risk of being wrong. Plenty of patients have 'taken the meds' and had ill/fatal results. Lastly, the 'added benefit of extra money???' Where do I sign up? What you prescribe for a patient has essentially zero impact on your bottom line. A few managed care entities have incentives (which are hardly noticeable) for providers who limit drug costs. This is more geared towards preferential use of equivalent generics than 'not prescribing.' There are no kickbacks unless someone is doing something blatantly illegal. Free golf? Not happening. Big Pharma self imposed regulations in 2001 that limit encounters and any sort of gifting. Essentially, you can have lunch provided in your office provided there is a presentation on a topic (i.e. their drug) and dinner meetings can still be done provided there are at least two physicians present. No spouses allowed. It is really pretty lame. Unfortunately for me, I got out of residency right as they were killing the golden goose. Again, I am sure there are those that circumvent this but it is nowhere near as widespread as it used to be. And that's all I have to say about that...unless I find out I've been lied to for the last decade.

Wow. Can you imagine being a d-back coming up in run support with that "Buffalo" (literally) coming at you?

That's powerful...and I agree. I kept rubbing my eyes thinking I was seeing something that wasn't real. Yuck.

sort of like reading a horoscope. very vague. very general. I thought that was your cousin??? You're not suppose to say anything until after the season. I think 9-7 is about right. I'd love 10+.

Noooooooooooooooooooooooo! Why not...it's in most other threads.

Awesome.

That's typically the only way insurance will cover the procedure. I.e. medical necessity. Just FYI.

OK. It's not the 'best site' but it is an interesting read and some good info there. NALC also has a site with similar self sufficient data. It is nonsustainable, however, given current state of affairs/obligations. The subtitle of the thread is union/government overkill. Hence, two parts here. As currently designed, it is an unsustainable system and needs to change. I'll agree that there surely are issues from both sides (as expected). The forcing of 'pre-payment' for retirement seems silly. Remove it and move on. Long term bennies relative to non federal/state employed citizens are still way over the top. It's a place where those folks can concede some in my opinion. As I said, I've been on both sides of work (private sector; federal and now private again by my choice). I used to snicker just reading my benefits as a Fed employee. Way too much! Thanks for contributing. I suggested reasonable benefits and perhaps increasing the cost of postage as they provide great service at a very cheap price. Hence....you compared me to a Nazi.

No. That's no good either. Rational negotiations/benefits would be a start though. 80% of expenditures dedicated to labor---> not very realistic. In the case of the post office, however, sending a letter cross country for under 50 cents is 'cheap' in my mind. They have some wiggle room to increase fee charges. Adjust your price and let supply and demand figure it out...and then the post office will accomodate/change/compete or they implode. Giving the post office employees a blank check leaves no choice but to close the entire agency. "We have no revenue and we're broke but we cannot be laid off and our benefits should be better than most other citizens." Good luck bringing that to the table in private industry/real world.

http://www.msnbc.msn.com/id/44396682/ns/business-us_business/#.TmTvn3PFKUA Good thing our government re-upped on that no layoff clause last year...and the 'better benefits' than most federal employees. I was a Federal employee for five years. Can't imagine how they could be any better.

As I said... in their day. However, I'm not going to disagree with any of what you said.

Sure. But I'd make him prove it. It's rare that an untested guy will come in and make 'more good decisions than bad ones.' Not impossible but less likely. I think we're close to being on the same page anyway. As I said, If there are a bunch of guys in the box we are gearing to stop the run regardless. Essentially, daring him to pass. Our base D 'might' be effective at stopping the run. I just think that coming out in the first game, on the road, you need to be a bit more aggressive than playing straight up. As above, I didn't think sending 'at least 5' on every play was necessary but I did want to see a good bit of blitzing (even run blitzes).

Apparantly the Niners thought so too. Big Money.

My wife was just yelling at me a few days ago about the same sort of thing. "You remember the play the Bills ran on 3rd and 10 against the Jets ten years ago........but you can't remember (fill in remote acquaintance)." Remember Linton well. Very good to see he is doing some good things.

Great post. I'm looking for a very aggressive D in terms of blitzing. Not sure if we bring at least '5' on every play but I'd be thrilled if I saw it most of the game. Your point about Palko is spot on. If he's under center, he should be able to smell the breath of about 8 of our guys on every play. Scare the crap out of him.

John Fina was a first round pick and hardly obscure. He played for us for quite a while and, while not stellar, he was a solid starting tackle. Jerry Crafts was a revolving door that probably had a lot to do with Jimbo deciding he had 'had enough.' I imagine Jerry is a nice enough guy but he was a terrible NFL lineman. Edit: Sorry "Mr. Baroo." I just realized you weren't necessarily after just the 'obscure/poor ones.' Fina is A-OK on your list. Mea culpa.

seriously?

yes and Belicheck implemented the same gameplan for the next "15" losses??? You're missing the point. the fact that we killed NE days after we signed Milloy is the point. I.e. gameplan info.

How 'bout it. "Hey Mom...I made the team! Never mind." That has to be a major emotional roller coaster. If it is him we release, I wish him well. Edit: just got text. Pianalto released.

No LOL here. He was signed by Buffalo days before the first game. We SMOKED them on opening day and his info was likely a large part of that victory. That close to the regular season, he was certainly privy to 'that' initial gameplan etc. Given that the victory occurred right after we signed Milloy and the fact that we have not beaten them since only supports the premise.

I agree with you a 100%. A lot of us have an irrational emotional draw to the guy as he is such a good story and seems to have 'limitless' potential. I include myself in that group. Based merely on performance, he has been as expected for a seventh round draft. I've just feared the PS given somebody will likely make an offer for him.