Unnecessary medical care is harming patients physically and financially (2015) - <AUTHOR> https://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande <comment><USER2> I live in a 3rd world country (Sri Lanka). Healthcare is not as advanced as it is in the US, but it is decent for all except the most complicated cases. The vast majority of people use the free services at state hospitals. If you want slightly better care, you can go to a private hospital and still come out with most of your wealth intact.

I recently had a minor surgery to remove a conjunctival granuloma from my left upper eyelid. It was a private hospital, and it cost all of $50. Compared to US standards, the facilities were spartan, but adequate and hygienic. Also, doctors and hospitals do not live in constant fear of malpractice suites. I suspect these factors have a lot to do with the costs (in addition to the obvious cost-of-living adjustment for the third world).

<comment><USER3> Interesting. There are hundreds of other cost issues in the US in addition to malpractice. Perhaps foremost is the obesity epidemic and the chronic diseases that result from it.

</comment></comment><comment><AUTHOR> This article came to mind this morning when I made my second visit to the orthopaedics department at a local hospital. The department schedules all patients for pre-appointment x-rays. That is, before the patient is even seen, before the doctor can determine if an x-ray would even be useful. On my first visit, I missed my x-ray appointment. The doctor I saw that day later said that was no problem. According to him, an x-ray wasn't necessary given my symptoms. I was scheduled for an expensive, unnecessary x-ray for no reason, basically. On today's visit I simply declined the x-ray, and the doctor I saw today was fine with that because he also did not recommend that any imaging be done.

<comment><USER4> You were scheduled for an expensive, unnecessary dose of radiation that would be billed to your insurer and that's how the provider makes a ton of money out of you.

The _only_ priority of any sane health system should be to make people's health better.

<comment><USER5> Bundled payments are slowly gaining traction and help align incentives a little better.

[https://en.wikipedia.org/wiki/Bundled_payment](https://en.wikipedia.org/wiki/Bundled_payment)

</comment></comment></comment><comment><USER6> In the book Antifragile Nassim Taleb cautions against medical care unless it's truly necessary. He argues that since so many things can go wrong in a hospital (you could get sick from someone else, mistakes could be made, etc), only go if the benefits outweigh the risks.

And so if you have cancer, it's probably worth the risk. But if you have something that could just go away naturally, that's got a higher expected value of positive outcome.

He is in favor of subtractive medicine - many harms are caused by adding such things as smoking, sugar, preservatives, etc, and instead of adding medicine or surgery, remove the elements that the body isn't evolved to tolerate and see if it heals itself.

He gives the example of how he hurt his back weight lifting. The doctor proposed surgery. He just waited and his back healed itself, and in a way that is now more robust than if he had had surgery.

As with all things, it's not a black and white kind of decision, but this mindset has worked well for me as a heuristic for health.

<comment><USER7> Nassim Taleb is great at providing backward looking advice. My back got better, therefore I was right to ignore the expert advice. He has predicted about ten of the last two financial crises. I wouldn't take medical advice from a financial pundit who can't seem to go more than a day without picking a fight on twitter.

<comment><USER8> My blog making fun of Taleb used to have higher page rank than his personal website. However, Taleb is totally correct about this, and his Antifragile book is very good (though he still needs an editor).

Most of modern medical science is quackery and pharma companies trying to milk the populace for profit. Trauma surgery is quite good, and antibiotics and vaccines are important. Other than that, I'm pretty sure going to the gym and the salad section of the grocery is much more important than going to the doctor.

<comment><USER7> He may be right in this case, I am not a doctor and don't know the details of his anecdote. My point is that if I'm looking for medical advice from a pop science author I'd much prefer Dr. Gawande's evidence and experience based account to some half baked story about convexity.

I'm not even sure whether Taleb's style of writing is meant to communicate much at all, what's the point of all this phony formalism? [http://www.fooledbyrandomness.com/medconvex](http://www.fooledbyrandomness.com/medconvex)

I'd like to see Taleb acknowledge at least that medical and financial estimation risks have a different character. Financial mispricing is adversarial, whereas you'd have to be more cynical than me to think doctors are always trying to get you to take the maximum care they can sell you.

</comment></comment></comment></comment><comment><USER9> I was preparing to make a long post asking for ideas/help (been saying that for weeks but it's ready and I was waiting to Monday since weekends are slower) This sort of thing ruined my life, cost me everything, and has finally brought me to the precipice. I was convinced 15 years ago to have surgery to "prevent later disability" and it ironically left me disabled and in severe pain. I later found out abroad from several doctors that I never needed the surgery but the catastrophic damage was done, but they did improve things slightly and Ive been trying to get back to live there but cannot.

A few years later in some nightmare the "repair" surgeon messed it up far worse and changed the procedure we had agreed on, but I signed the vague forms hurridly shoved in front of me as I was being prepped and legally he as allowed to. I never would have agreed to that procedure he did had I been clearly informed. They got paid...my life got ruined...and things slid downhill from there as systems and people failed me. Now I am facing seemingly insurmountable needs and costs and more surgery which terrifies me and I would never trust having in this country if at all.

It's long story that has no TLDR. I am at my wits end and don't know if a comment here is the right place to share whole thing, or if I should make my own post now or Monday...I need as many eyes on it as possible if there is any hope.

<comment><USER10> >> vague forms hurridly shoved in front of me as I was being prepped and legally he as allowed to

One of the many problems when the legal system has just become "formalities" that only get used by the powerful against everybody else. Last time we had a baby the hospital was so prepared they were able to bill us for the entire pregnancy when we arrived for our first prenatal check-up. But somehow they couldn't show my wife the forms that waived her right to sue the hospital, her agreement to pay whatever they billed her regardless of correctness of timeliness until she was dilated to an 8.

<comment><USER11> > they billed her regardless of correctness of timeliness until she was > dilated to an 8.

This has to be contestable in court

<comment><USER9> I had faith in the legal system to a degree as well before my experiences started. The doctors have more expensive lawyers and theirs and the hospital's insurance and business lobbies have succeeded in getting legal conditions set in their favor. Low award caps making contingency unavailable to clients, short statutes of limitations etc. It's why surgery centers often cluster in certain counties etc. Those places have more amenable courts and juries. It's a LOT harder than people think from TV etc to win at a malpractice case. There are doctors who have negligently killed people still doing surgeries etc and in one case I read the hospital isn't legally allowed to inform patients of his censure and past.

</comment></comment></comment></comment><comment><USER12> Sounds like another one of those "this is what happens when money (as opposed to patient wellbeing) becomes a driving factor in health care."

I remember I tried to find a PCP once and I showed up for my intake appointment and the young, rushed doctor said they wouldn't enroll me as an official member unless I had two intake visits. They were gaming the insurance system.

<comment><USER13> More like, "what happens when the patient does not directly feel the financial bill and the doctor tries to charge/do unnecessary things to make more money".

This is a direct result of the laws and regulations distorting the market.

<comment><USER14> Have you heard of the high-complexity drug testing scam? It works like this: at the intake visit the physician has the patient piss in a cup and it gets sent off to a drug testing company somewhere. They run a GC/MS, and then a very substantial bill (~5 kUSD) shows up a few weeks later. It's a stroke of genius, no one is responsible. The physician says "you peed in the cup", the drug testing company says "services were rendered", and the insurance says "out of network".

How is such behaviour _encouraged_ by laws and regulations? It's encouraged by the _absence_ of laws and ethics.

I said to all three "send it to collection, so I can dispute the debt, I'm not going to pay"; eventually the insurance paid at their negotiated rate (~USD 250), which is closer to the cost it takes to provide the unneeded service. It took several hours on the phone to put that matter to sleep.

There need to be some laws, but in the present situation neither the Medical Board nor the Attorney General is interested, consequently it continues.

<comment><USER15> >How is such behaviour encouraged by laws and regulations?

Because the laws and regulations create an environment where there is so tons of complexity and little transparency.

A piss test is routine. The cost does not vary and can be forecast wit 100% accuracy.

You wouldn't agree to let a mechanic charge $500 for a $25 oil change. Only a very careless person would fall for that. The current situation in medical is such that the proportion of the population who would/wouldn't fall for that scam is flipped.

</comment></comment></comment></comment><comment><USER16> For the physical harming, Nassim N. Taleb wrote a book called "Anti-Fragile" desribing the concept of iatrogenic illness.

[https://en.wiktionary.org/wiki/iatrogenic](https://en.wiktionary.org/wiki/iatrogenic)

An alarming fact was less dying patients when an hospital workers were in a strike action (during 2 weeks).

<comment><USER17> Johns Hopkins study suggests medical errors are third-leading cause of death in U.S.

[https://hub.jhu.edu/2016/05/03/medical-errors-third- leading-...](https://hub.jhu.edu/2016/05/03/medical-errors-third-leading- cause-of-death/)

<comment><USER18> I was on a multi-corporate task force on medical errors in the late 1990s and the working number was about 80,000 deaths per year. I remember GM saying that statistically it worked out to something like one GM worker or retiree like every week, and that if they had that kind of mayhem on the assembly line there'd be outrage... but the inept health care system just quietly kills people.

</comment></comment></comment><comment><USER19> It's a question of fundamental incentives. Doctors and hospitals are paid for procedures, treatments, and appointments. Is it any surprise that there's incentive to undertake these activities? You don't even need to believe that your doctor is greedy to understand that if there's a borderline case, they might order the test or treatment "to be safe", or "because there's no downside", or because "we have the available capacity". Even if they aren't explicitly considering payment as part of the equation, it's not unreasonable to think that subconsciously the monetary incentive will tip some of these cases in the direction of overtreatment.

IMO, the only way this is going to change is a movement away from the "pay for services" model that is dominant in US healthcare today.

<comment><USER20> I slightly disagree - what's missing is price transparency inviting competition. Through competition the payment and cost side of things will be added to the equation and shift incentives to cut waste and increase quality of service. That includes all aspects of the healthcare services.

<comment><USER21> It is probably both. The primary reason for healthcare cost growth is price not utilization (refer to work from IHME, others), but there also have to be appropriate incentives in place such as exist in ACOs to ensure quality care is delivered cost effectively. Agree that value based care by itself may not be the answer, just look at the way drug companies claim to price medications based on value such as Gilead's Sovaldi curing Hepatitis C.

</comment></comment></comment><comment><USER22> Growing up with a mom who was a non-working registered nurse, every time I or my siblings came down with symptoms like fever, nausea, vomiting, etc she almost never took us to the doctor. Instead it was rest and liquids, maybe an aspirin. I would always plead with her that we needed to seek professional medical advice. Now as an adult I realize that she knew too well the limitations of that advice when it comes to most minor maladies people suffer.

And yet today I still see friends and colleagues go to the Dr or call the "teledoc" when they have these symptoms. They usually get an antibiotic (which has its own issues) or told they simply need to rest.

<comment><USER23> Same exact story except my mom is and still is a working R.N. There was no running to the doctor or emergency room if I got sick or banged up an knee or elbow. To this day as a grown adult I still work this way. It's a completely foreign concept to me to automatically run to the doctor like so many people around me seem to do.

You're other point about knowing the limitations of doctors is completely valid. Every night at the dinner table I heard one horror story after another about the crazy shit doctors would do at her hospital. Maybe its why today I don't run to the doctor for every little thing. I got the understanding that just because someone went to medical school and got an M.D. doesn't mean they're a miracle worker. There's just as many screw ups in that industry as any other.

On the upside though if something does happen where I(or someone in my family) need a doctor I can go to her(and my R.N. sister) to tell me who the good ones are and who to avoid like the plague.

</comment></comment><comment><USER24> After recently getting a cancer diagnosis and going through surgery and chemotherapy, the best advice I can give is: ask lots of questions and you are your own best advocate.

As with any profession, there are some great doctors who are truly looking out for your best interests and will pursue any direction you want. There are others who simply want to "follow the standard practice", even if what they know as "standard" is 35 years old. There are others who just want to get through as many procedures as possible and "see what sticks" when it comes to a diagnosis.

Asking questions helps you better understand which of these you're working with, and what actions you need to take on your own.

Finally, EMR sounds great, but in my experience it just doesn't work. Find a PCP who is part of a hospital system with specialists using the same computer system. This means they can all see each other's notes & test results. A lot of the time, even doctors in the same building are basically "private practice", or part of some other partnership that is not part of the hospital you are at.

<comment><USER25> > Find a PCP who is part of a hospital system with specialists using the same > computer system.

I really can't comprehend how these people don't feel a critical need for compatible open formats, and think they are fine using incompatible proprietary ones. How is sharing information seen as a negative in this scenario?

</comment></comment><comment><USER26> Everyone has a story like this.

I went in for a physical and even though they said to my face my insurance would fully cover a heart electrocardiogram (my family has a history of heart problems) I wound up with a huge bill, month long fight with insurance, and ended up just having to foot it.

Maybe if medical care was driven by some other force besides capitalism this wouldn't be such an issue.

<comment><USER27> Essentially identical story in my family. And to address the sibling comment's question in my case : the hospital has a _recording_ of the insurance company rep on a phone call stating that the procedure was covered. However it appears this achieves nothing because the insurance company can use their magic powers of "pound sand suckers" and we had to pay anyway. Hospital denies any responsibility because they called insurance and were told they had coverage, and they kept a recording of said call. The fact that providers routinely record their calls to insurance companies tells you something in itself.

</comment></comment><comment><USER28> The article pins part of its argument on the claim that advances in diagnostics have not changed the death rate for (e.g.) breast cancer during the past quarter century, but a superficial search immediately suggests this to be grossly false.

"Death rates from female breast cancer dropped 39% from 1989 to 2015." \- all other things being equal, it _ought_ to have increased: age is a risk factor for cancers, and we have an older population. Instead, it has greatly decreased.

So I dispute the veracity of several of the article's claims, but also: what is considered unnecessary changes with the benefit of hindsight.

I would argue that it's expected that a majority of diagnostic tests deliver a negative result (i.e. turn out to be "unnecessary"), and this is actually a mark of a healthy healthcare system.

<comment><USER29> There are other likely explanations for that data. If more women are getting screened more frequently then their cancers will be detected earlier and improve survival rate. That doesn't mean the diagnostics tools themselves have improved the survival rate, only that the diagnostic tools are now used more frequently.

<comment><USER28> There may be other explanations, but the article denies the truth of the data to claim this point.

</comment></comment></comment><comment><USER30> There issue is two folds here.

1\. Medical liability. Doctors must cover their basics or will get sue.

2\. There is no cost relationship between doctors and patients. Doctors and patients work with 3rd party call health insurers. Worst, a lot of people (medicaid recipients) have no skin in the game.

Obama could have fixed item #2 with a universal health care that require (1) doctors to list the price of their services and (2) cover major catastrophic health expenses, such heart issue, cancer, long term care, etc. Prevention care should physical, cold should be out of pocket for the first 5 or 10 visits of the year, then it is covered.

I know some may called foul because poor cannot pay. Paying $20 per visit, at 10 visit, it is $200 out of pocket. They have have skin in the game. This will cut down a lot of abuse.

<comment><USER31> >Paying 20$ per visit...

Such experiments have been made with Medicaid demo projects in the US. They've failed every time. People can't distinguish needed care from unneeded care; they end up foregoing needed care, deteriorate, and end up costing the system much more in the form of hospitalizations, disability, etc.

<comment><USER32> Its because poor people overusing free medical care is the problem with the health care system like people buying doritos with food stamps is the problem with SNAP.

</comment></comment></comment><comment><USER33> This article makes it sound like medical costs in the US could be halved if everyone understood this problem, and did their own research on proposed procedures.

<comment><USER34> Nice idea, but how realistic is it? Most patients are not scientifically- literate, some are flat out incapacitated.

For all the stories about heartless insurance companies denying to pay for things, perhaps they should actually be _more_ strict. As in, refuse to pay for anything unless there is 1) rock-solid (i.e. double-blind, placebo- controlled) evidence that it helps 2) for a specific, objectively verifiable indication 3) when provided by a doctor whose track record is demonstrably non-inferior to that of other practitioners. But for all three of those things, no $.

I would be interested in buying insurance like that.

<comment><USER35> In the US system you agree to pay any bills the insurance will not cover prior to receiving treatment.

Which is an obvious opportunity for improvement. When a giant hospital and a giant insurance company get in a knife fight over whether a procedure is covered, the patient shouldn't be the loser.

(Maybe some sort of system where if the provider states that something is medically necessary then they are on the hook if insurance denies the claim)

<comment><USER34> >Maybe some sort of system where if the provider states that something is medically necessary then they are on the hook if insurance denies the claim

Not only should a provider be legally prohibited from trying to collect payment for unnecessary treatment, they should be held responsible for complications. Even unnecessary x-rays can cause cancer.

</comment></comment></comment></comment><comment><USER36> "or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem"

A hospital system in California _should_ have done one of these on me, but instead didn't and I went with a herniated disc for 10 years longer than I needed to. Finally a hospital in Texas did an MRI and discovered it and I had surgery to address the issue. Previously it had been brushed off as a muscle strain or sciatica and i was constantly given pain medication that only masked the symptoms of a bigger problem. My life may be a completely different place right now had someone just done an MRI years ago. unfortunately I didn't know to ask for one. :/

"I am far more concerned about doing too little than doing too much"

this is exactly why so many "unnecessary" tests and procedures happen too, unfortunately.

There's also a lot of "I want you to DO something" that causes physicians to overprescribe antibiotics/etc because otherwise, they know that the patients are going to give them a lower survey score, which directly affects reimbursements. Tying reimbursements to patient satisfaction scores is an awful idea that needs to go away yesterday.

[http://kunr.org/post/patient-satisfaction-surveys-make- docto...](http://kunr.org/post/patient-satisfaction-surveys-make-doctors-feel- pressured-prescribe-antibiotics)

</comment><comment><USER37> A small example is my girlfriend getting charged for a pregnancy test in the emergency room even after she told them she doesn't have a uterus.

</comment><comment><USER38> > A third patient had undergone surgery for a lump that was bothering him, but > whatever the surgeon removed it wasn't the lump—the patient still had it > after the operation.

One wonders how the constantly trotted out panacea of making patients pay more out of pocket would help with a case like this.

</comment><comment><USER39> Nassim Taleb explains this in "Skin in the Game" rather well. If you are sick a little bit, don't take drugs prescribed by your doctor. If you come to the doctor with a little coughing, the doctor knows you're likely fine and there is a high chance you won't need any meds BUT if you happen to die the next day, the family of the former patient will find something and might sue you because you - as a doctor - didn't prescribe the needed drugs. Some drugs are known to cause problems 10 years down the line, but this is not the doctors problem because he fixed your primary problem but doesn't really care about second-order/side-effects of the prescribed drugs.

</comment><comment><USER40> Rationing medical care because the underlining system is broken makes no sense. People in the US already don't use enough medical services.

"For example, Americans average 4 doctor visits a year compared to 7 in France and Canada, countries with better health outcomes than ours." [http://www.pnhp.org/news/2014/january/americans-underuse- hea...](http://www.pnhp.org/news/2014/january/americans-underuse-health-care)

</comment><comment><USER41> I would share this article but I've been living on a resident/fellow salary for way too long and need at least a few years to milk that cash cow first.

</comment><comment><USER42> The article's author, Atul Gawande, has written four books. So far I've only read _The Checklist Manifesto: How to Get Things Right_ and have been applying it to various aspects of work and life (travel packing checklist, Engineering team runbooks, etc). I would strongly recommend it.

All his other books are on my "to read" list...

</comment><comment><USER43> Medical care in the US seems... unhealthy.

I'm glad to live in belgium, where i won't go broke if something happens.

</comment><comment><USER44> Iatrogenics / Iatrogenesis

[https://en.wikipedia.org/wiki/Iatrogenesis](https://en.wikipedia.org/wiki/Iatrogenesis)

</comment><comment><USER45> "some seven hundred and fifty BILLION dollars a year"

</comment><comment><USER31> I worked in health insurance, and had a graduate degree in health policy, before I second-careered into medicine. I helped implement some of the programs that Guwande promotes in this article; I was and am a true believer in some of these programs, and have built my medical career around implementing them properly.

I say all that to provide an important caveat: Guwande's a Harvard-associated surgeon largely insulated from what any of this looks like on the ground, and basically collects anecdotes that match his views until he can tell a nice just-so story. The reality is far more complicated than he relates, and shared savings programs are far from some sort of medical panacea that addresses all the imbalanced and chaotic incentives in medicine.

A few big nitpicks:

(1) The ACA Shared Savings program is and was bullshit for providers. Because it was built on top of "traditional Medicare", meaning a non-HMO arrangement that did not infringe on pt's right to seek as much care as they wanted, from whomever they wanted, there was no actual __assignment of responsibility __. If Doctor X is to share in the profits of saving the system D dollars, you have to be able to measure the savings he generates. However, no patients are "his" \- we just measure which PCP patients go to the most in a year and give the doc a benchmark based on those. This was based on an assumption that most people saw their PCP at least once/yr. Turns out that not only do people not see their PCP once/yr, but plenty are snowbirds, or have a rotating list of multiple PCPs. Medicare has not fixed the attribution issue.

(2) The most effective way to create savings remains to deny care. There's a reason there was an HMO backlash. Creating _that_ incentive reduces costs/spending, but ...

(3) The vast majority of physicians do not work in pure capitated programs. They work in a mixture of shared downside, shared upside, and FFS. You can't manage patients with a mix of payors like this, because you still have to build your daily operations around the largest volume - the FFS folks. This is what I saw the most of in the rollout of the ACA: docs were "enrolled," sure, but ACO's still pay out on top of FFS, and the rest of the patients are normal FFS + shared risk, the result is daily operations built around volume, not around "spending 45 minutes to review how to take insulin."

4) Docs over-test and overprescribe for medicolegal issues that no amount of incentive-shifting can fix. Hell, my hospital antibiogram doesn't even _have_ pseudomonas sensitivity to pip, just pip/tazo, despite the fact that pseudomonas pretty much never needs pip/tazo (the /tazo is a spectrum extender). But prescribing pip/tazo over pip is something akin to "no one ever got fired for buying IBM." Hell, we do baseline kidney function tests before giving contrast in _emergency_ radiology, despite the fact that the biggest studies to date show that baseline kidney function doesn't have any predictive value for contrast-induced nephropathy-related outcomes 6 mos out. It's a pointless delay that actually hurts patients _and_ costs money. But you know what? No one sues a doc for getting worse in an ED while awaiting a lab result - that " just happens". They _do_ sue a doc for contrast-induced nephropathy, because that looks like something a doc actively caused (well, it is) - and a malpractice attorney will slam your balls to the wall for "why didn't you look at his kidney function before throwing kidney toxins at him?"

The malpractice thing is honestly more insidious than that, even. It gets docs out of the mindset of thoughtfully asking "well, WHY would I order that test? How does it advance the diagnosis or management meaningfully?" to a "might as well order it to be on the safe side" mindset that infects the rest of their practice. The latter creates sloppy, over-broad testing regimens.

Heck, we can't even utilize the latest research unless we can convince _multiple departments worth of docs_ to agree on it. Because the standard for malpractice is what your peers would do, "I did X as part of our department standard, as agreed upon by all the docs in X and related specialty Y" is a very strong malpractice defense. If you can't convince all of those people to get on board and change department policy and just try to practice based on the most up to date data yourself, a malpractice attorney's question becomes: "Where did you get your PhD in statistics and clinical trial design? Oh, you don't have one? So what made you qualified to take in this study and overrule a panel of national experts on the topic that decided what the standard practice is?"

We really need an iatrogenesis compensation fund built at the national level, and to get rid of malpractice suits. That will bring down bullshit spending by a fair degree right off the bat.

A related issue that people overlook is that about 70% of the growth in HC costs is attributable to technological advance: new drugs, or hiked up drugs, new tech, etc. We want all these things, but refuse to take into account that they demand a premium (even when they're not actually more effective.)

I could rant for ages.

<comment><USER46> _> iatrogenesis compensation fund built at the national level_

An FDIC for malpractice suits is an interesting idea. Is there anything comparable to this in universal healthcare systems like the NHS?

<comment><USER31> Yes, France has this as the national scale, and we have something similar for certain federally-qualified facilities aimed at low-income communities. In our case, they need to maintain an ongoing, federally audited QA/QI program, but as long as they meet those requirements any malpractice suits get redirected to a federal malpractice policy.

</comment></comment></comment><comment><USER47> Nothing gets HN more riled up these days than a good story about healthcare in America.

</comment><comment><USER48> Cue 'unnecessary surgery land' in 4, 3, 2...

</comment><comment><USER49> [2015]

<comment><USER50> Thanks! Updated.

</comment></comment><comment><USER51> Ivory tower elite have usually all the time to pontificate. Tell that to this girl who did not see the light of the day. [https://nypost.com/2018/02/26/girl-dies-hours-after- doctor-t...](https://nypost.com/2018/02/26/girl-dies-hours-after-doctor- turned-her-away-for-being-a-few-minutes-late/)

<comment><USER11> What a tragedy.

But lets not forget that this is what we see not what it is. It could have happened the other way: "patient died after not receiving attention even though they arrived on time. Doctor was busy providing care to previously late patients".

</comment></comment><comment><USER52> It sounds like in the "free market healthcare" system hospitals are incentivized to get the patient to spend as much as possible. That's aside from other bad incentives of such a system such as hospitals not wanting to be transparent with their prices, insurance companies not wanting to take patients with pre-existing conditions, also wanting to cover as few conditions as possible, Big Pharma being incentivized to ask for as high drug prices as possible (while lobbying for a ban on generics and imports), and so on.

<comment><USER53> You have the wrong idea. A better example of what you're calling "free market" would be dentistry or something like Lasik surgery. You can shop around and figure out the prices because they are very much apparent since you pay out of pocket for the majority of the former and completely for the later.

Would Medicaid/Medicare be "free market"? Why bother shopping around when someone else picks up the tab?

Insurance companies mostly reflect the costs of the hospital. If the hospital charges you $50 for a bottle of Asprin, so be it. ICD10 and Meaningful Use were designed for billing not really for health care. Those were federal mandates not "free market"

Pre-existing conditions is a lot more tricky than you think. The political ploy is to think of a poor person with a serious illness being turned away by insurance because they don't want to deal with them. When in reality it can be you're obease or someone who just did not take care of themselves period. You can imagine a group pre-existing conditions patients could bankrupt a insurance company. What if to be "fair" you were charged the same as a person with a pre-exiting condition. Say someone that smoked 2 packs a day for 30 years?

ACA was just a big initiative to add more insurance companies to the mix. Now it is mandatory you pay insurance companies.

<comment><USER54> The underlying philosophy of mandating coverage for pre-existing conditions is the idea that everyone should be able to have basic medical care. With that idea it's really not that tricky to say pre-existing conditions should be covered.

<comment><USER53> I don't disagree with the philosophical purpose. Of course by simplifying the facts. You're leaving out the logistics of insurance companies that have to now take that responsibility on. Last I checked they dont work of the sake of goodness.

Better option would be single-payer. I digress...</comment></comment></comment></comment>


Erl2 - A New Dialect of Erlang - <AUTHOR> https://github.com/joearms/erl2

<comment><AUTHOR> Joe's main motivation of this, it seems, is to unify the shell and the modules. Whereas you could not define a module in the shell, and whereas you could not define multiple modules in a single file, with Erl2, both are possible.

And the fact that it won't generate .beam file without passing the unit tests first, is just icing on the cake :)

I find this rather interesting, and I'm curious what kind of traction this might get, or if any of the paradigms introduced here might be mimicked in Erlang.</comment>


Show HN: Vision – Check your Sight online - <AUTHOR> http://vision.vega9.com <comment><USER2> Sigh. Completely blank without enabling JavaScript. I don't necessarily expect the online sight check to function, but I _do_ expect _something_ to appear on the web page.

With all the crap and malware out there, and all the random security flaws in browsers, I always use NoScript when visiting new sites. Then it's up to the site to convince me to enable JavaScript.

But a blank page will rarely be very convincing.

Yes, I know I'm an outlier when compared to the general public. But, after all, this is a nerd site. I'm sure quite a number of HNers browse w/o JavaScript.

Throw us a bone. Give us _something_ to read. Perhaps a general explanation of what you're doing?

<comment><AUTHOR> I know, but it is a realtime webapp.. without javascript it is pretty useless.

Vision, will allow to test your sight interacting with the screen via smartphone.. is better than you try it by yourself, it is also NO Registration required.

</comment></comment><comment><USER3> the german translation is quite off

Ihr Sehvermögen ist wichtig. Mit Vision können Sie ihre Augen überprüfen und trainieren.

Scannen Sie >>den<< QRCode mit dem Smartphone

>>Entfernen Sie sich << 4 Meter vom Bildschirm und schon sind Sie bereit, Ihren Sehtest zu starten.

(not quite sure about the last one, as the english translation is hard to understand as well)

Kontakt & Feedback

Save Punktezahl --> Punkte speichern

...

<comment><USER3> Passen Sie die Anzahl den Schieberegler unten, sollte nur der schwarze Rand außerhalb der Karte sichtbar sein

\--> Passen Sie den Schiebregler so an, dass nur mehr der schwarze Rand der Karte sichtbar ist.

Sie haben noch nichts auf dem Bildschirm ein Standard-Karte oder Kreditkarte

\--> Halten Sie hier eine Visitenkarte oder Kreditkarte an den Bildschirm

(Replaced Standardkarte with Visitenkarte=Businesscard)

Scannen Sie den QRcode, um den Sehtest durchzuführen und entfernen Sie sich 4 Meter vom Bildschirm. Sie können dafür den App Barcode Scanner (Android) oder Qrafter (iOS) verwenden.

Als Alternative kann eine andere Person mit Hilfe dieses Links, die Fragen für Sie beantworten.

\----- It's not perfect, but better than what you have atm ;)

<comment><AUTHOR> Thanks a lot for the translation review :)

I've updated the german translation, where the strings aren't hardcoded

</comment></comment></comment><comment><USER4> I love the way this app works. what other goals can be achieved using this same technique?

1\. Remote control ( like youtube)

2\. Check your sight. ( this app)

3\. Game controler

4\. ???

????

<comment><AUTHOR> You can transform yor smartphone in a custom remote control, which can also be shared among different devices

</comment></comment><comment><AUTHOR> It's beta, and you need a credit card size card to calibrate your screen.

NO Registration is needed

<comment><USER3> maybe it's better to use "business card" in this context. I thought I have to pay for it, when I first read the instructions.

<comment><AUTHOR> I don't know where you live, but here nowdays all the business cards have different sizes :)

No, it's just for calibration. Maybe I could add also "ATM card"</comment></comment></comment>


Your Next Uber Ride May Have a Mini-Fridge Stocked with Snacks - <AUTHOR> https://www.bloomberg.com/news/articles/2018-11-15/cargo-deal-with-venmo-puts-hangover-cures-in-uber <comment><USER2> Seems like a great idea to me. I mean the drivers sometimes have free snacks or something minor as of now.

I always tip more if I use/take something. This just gives the opportunity for the driver to offer more and get paid more. Everybody wins.</comment>


Lessons of the Chewbacca Incident - <AUTHOR> http://binarybonsai.com/2010/09/27/chewie-stats/

<comment><USER2> Wouldn't this have something to do with people opening HN items up in tabs and reading + commenting before moving on to the next one?

<comment><USER3> Many Reddit readers use the same reading technique and their time per page was still low.

<comment><USER4> I recently deleted my reddit account due to an addiction problem, but while I was on I would open lots of tabs to come back to later, and I don't do that on HN. I'm not sure how similar my experience is.

</comment></comment></comment><comment><USER5> So, with that graph floating in the middle of the columns, I'd expect to read the 4 chunks of text top-left, bottom-left, top-right, bottom-right. Did anyone else find it surprising that it actually reads top-left, top-right, bottom-left, bottom-right?

Also, if I offered you a javascript library that could lay out columns properly, on existing browsers, with two-column width floats, would you use it?

<comment><USER6> I've been wanting to see proper support of combinations of column-height, column-width and column-span for a long time. I would definitely be a user of a library if it could give me these features.

<comment><USER5> Looking at <http://www.w3.org/TR/css3-multicol/#spanning-columns> it seems to me column-span is implemented exactly like the site in question, i.e. _wrong_ from the point of view of existing behaviour (that behaviour being all the printed magazines and newspapers since we worked out how to mix text and images.)

</comment></comment></comment><comment><USER7> I don't think the average is an appropriate metric. The author assumes that everyone found the article interesting, but some people were more lazy than others. In reality many people could have just followed a link (perhaps because of a catchy title), found the article uninteresting and never even started reading it (myself included).

</comment><comment><USER8> Given the length of the article I guess that it's not only the most engaged, but actually the only ones who read it. I don't believe that article can be read in less than 5-10 minutes.

<comment><USER9> This is the average though so you can assume people read the article from the other sources to, just the majority of them didn't where it would appear the majority of those from hacker news did.

</comment></comment><comment><USER10> It's not surprising that DF readers are so engaged; if you're a regular DF reader, you implicitly trust Gruber to promote stories that are going to end up interesting. There are vast amounts of new stuff put up on the Internet every day, and Gruber posts only a miniscule fraction of them to his site; it's heavily curated, more carefully groomed than any other referer on the list.

IIRC, Gruber specifically called out this article as an interesting read, which means that if you clicked through to the article, chances are you were doing it with the expectation of reading a good long-form article.

</comment><comment><USER11> Link directly to the article: <http://binarybonsai.com/2010/09/27/chewie- stats/>

<comment><USER12> From the original, the darker bar is the average time spent on the site, while the lighter one is the average number of pages viewed.

Shame on boingboing for using a key-less graph.

</comment></comment><comment><USER13> Does anyone have a link to the article that people were visiting?

<comment><USER14> It's the author's first link, here is the HN page for it: <http://news.ycombinator.com/item?id=1714989>

</comment></comment><comment><USER15> This is the worst kind of pseudo-science, using a single example to make sweeping generalizations far beyond what the data even shows.

</comment><comment><USER16> Can anyone give a quick overview of how viewing time on a page is estimated?

</comment><comment><USER17> wonder if tools like instapaper are brought into the mix. I used to worry when folks would only visit my blog for 10 seconds. Now I just hope they're saving it for an enjoyable read later

</comment><comment><USER18> i wonder if this implies that hn readers are looking to kill more time. procrastinating on the next big startup? :)

</comment><comment><USER19> tl;dr</comment>


Automattic open-sources Wordpress - <AUTHOR> https://github.com/Automattic/wp-calypso <comment><USER2> Can a mod change the title of this submission? It's completely inaccurate.

Here's a post with more info: [https://poststatus.com/wordpress-com-mac- app/](https://poststatus.com/wordpress-com-mac-app/)

</comment><comment><USER3> I got really disappointed when I figured out it was just for managing wordpress-hosted sites and not a new way to manage self-hostd WP installs</comment>


3 Day Startup - Austin, TX - <AUTHOR> http://3daystartup.com

<comment><AUTHOR> I'm an organizer of the 3 Day Startup here at UT Austin. We concentrate on bringing together students from a variety of disciplines here at UT, but we are open to students and (especially strong) non-students from anywhere. The event is totally free, and please apply now if you are interested!</comment>


Ask HN: Is TDD still a thing in 2018? - <AUTHOR> I'm prepping to go job hunting again (sigh...), and wondering whether or not TDD is in vogue.
A few years ago, it was the in-thing and everyone was preaching it like it was some type of technological savior, but I don't see many articles about it anymore.
So is TDD/BDD still cool, or has it been added to the IT scrap pile?
NOTE: I am not asking about Unit Tests - just about TDD/BDD as a development practice for a mid-level developer. <comment><USER2> I find it useful for new projects. It allows me to define acceptance of core functionality and features.

For established projects, not so much. This is especially true for people new to the project as they typically don't yet know the full system and it may push them to recreate some functionality that already exists.

</comment><comment><USER3> There are times where TDD makes a lot of sense, I find it to be quite useful in situations where you have some sort of known interface you need to implement exactly. In that case writing the tests first tends to save a lot of time overall.

</comment><comment><USER4> TL;DR yes, it still works well.

Ignore any hype. TDD/BDD is great for anyone who has seen some shit hitting the fan in his/her professional life.

In fact, jobs not asking for TDD/BDD will probably be throwing shit at you.

<comment><USER5> TDD usually means tests-first development. It's possible to have tests- required without TDD or tests-first.</comment></comment>


If you're doing a startup, you have to read Papillon. - <AUTHOR> http://stephenwalters.posterous.com/what-i-thought-about-a-book-papillon-henri-ch/

<comment><USER2> It's also a classic Steve McQueen movie: <http://www.imdb.com/title/tt0070511/>

As a side note, Papillon is French for "Butterfly" probably signifying his desire to be free.

<comment><USER3> He had a butterfly tattooed on his chest (predated his imprisonment as I remember). A South American Indian with whom he stayed on one of his escapes was so impressed that he had him do him a tiger's head using only a bone needle and alchohol for sterilization.

Papillon is the first book I think of whenever anyone asks for a book recommendation.

</comment></comment><comment><USER4> I laughed out loud at this line:

 _risks that make quitting the day job seem like choosing between the urinal and the toilet_

In my time in the corporate world, I spent hours upon hours in meetings over decisions just as vain.

</comment><comment><USER5> It's worth noting that Papillon is a novel composed of the real life stories of several people, rather than a true memoir.

Great book.

</comment><comment><USER6> The (excellent Steve McQueen/Dustin Hoffman) film is available legally & free to watch online until Saturday 10th April 2010 if you're in the UK:

<http://www.bbc.co.uk/iplayer/episode/b007bw8d/Papillon/></comment>


Transcendent Man Wows At Tribeca Film Festival Premier - <AUTHOR> http://singularityhub.com/2009/04/29/transcendent-man-wows-at-tribeca-film-festival-premier/

<comment><USER4> The most intresting mistake with the signularity concept is the idea that you can get a liner return on intelegence. While a computer with x processing power might be able to compute 10 moves deep in a game and a system with 10x the power might get there in 1/10th changing the goal to 11 moves might not be reasonable.

Another mistake is the assumption that the universe can support "unlimited" intelegence. Their might be a lot of room at the bottom but nothings says computing power can't hit a fundimental limits at some point in the not to distant future.

PS: When people assume exponential growth continues indefinatly they tend to ignore the growth limiters that only apply as you increase the scale.

<comment><USER5> "Another mistake is the assumption that the universe can support "unlimited" intelegence."

One thinker who seeks to address this point is Frank J. Tipler with his notion of the 'Omega Point' - a theoretical point where-after the contraction of the universe means that the available computational power, while still point- finite, will be increasing faster than the time remaining can decrease.

I don't know how much stock I put in the concept, myself, but at least somebody's thinking about it!

Read a little up on it - the guy may very well be bonkers, but it's certainly worth a look if you're into mind-bending metaphysics:

<http://en.wikipedia.org/wiki/Omega_Point_(Tipler)>

<comment><USER6> The original hypothesis made specific predictions (regarding the Higgs, if I remember correctly) which have turned out not to be true. Tipler revised accordingly, rather than doing something new, which seems like a bad sign, scientific-method-wise. :)

</comment></comment></comment><comment><USER7> There was a time when a person could have the entirety of human knowledge on their bookshelf, but then Gutenberg came along and screwed that all up. Since then, even the most ambitious person has had to settle for less than complete knowledge. We rely on experts in their respective fields to make their knowledge palatable and useful for everyone else.

Is the singularity the point where this ceases to become possible, or the point where we rely on the expertise of machines? The latter seems possible, at least, but I don't understand how the former is supposed to come about. People place a pretty high value on remaining naive, and there will probably always be a market for that.

<comment><USER8> The Great Library was bigger than a single bookshelf, and pre-Gutenberg.

<comment><USER7> Fair point. I was referring to the canonical works (i.e. everything by Plato, but not everything about Plato), and was thinking about the period just before Gutenberg. The available body of knowledge was pretty irregular before Gutenberg (the burning of the Great Library, etc.), but monotonically increased afterwards.

My question stands, though: haven't we already hit our individual saturation point for knowledge? What is the Singularity, if not that?

<comment><USER6> One answer is that it's when we can increase the saturation point itself. To use your terms.

<comment><USER7> That seems like an inversion of how I've always seen it described. As far as I understand it, the Singularity is when the rate of advancement outstrips our ability to keep up. If we already can't keep up, but technology fixes that sometime in the future, I don't know if that's the same thing.

<comment><USER6> For decades now, the way to keep up has been to focus on an ever-narrowing field of knowledge. I don't think that's controversial. One description of the singularity is that it's when the maximum intelligence of an agent (human, computer, whatever) begins to significantly increase due to increasing computing power. If we're using that definition, then it fits with your "saturation point" description, since we'd be increasing the amount of information that an agent can handle. The "singularity" aspect is from the perspective of an unmodified human, not the upgraded agents themselves.

But there are other definitions. :)

</comment></comment></comment></comment></comment></comment><comment><USER9> I find the ideas of the Singularity movement greatly lacking in imagination. I think when we discover the true nature of consciousness, life, and evolution (which seem to be related), we'll be in for quite a fundamental philosophical surprise.

<comment><USER10> The field of cognitive science (lingistics + philosophy + computer science + neuroscience + biology etc.) has actually discovered the underpinnings more or less. Consciousness is based on our bodily interaction with the world. Thought uses experiential metaphors from basic physical interactions with the world such as light/dark, up/down, etc. Read "Philosophy in the Flesh" by George Lakoff.

AI will never come from digital machines.

<comment><USER11> a computer can simulate interaction with world just as well as it can simulate your brain.

"actually discovered the underpinnings" is a vast overstatement anyway.

<comment><USER10> Yes but simulating the brain will never be the same as the actual "wetware" in operation. To my understanding, the simplistic reason that hard AI has failed and always will - while it uses digital computation as a platform - is that its a HARDWARE deficiency. I'm generalizing but AI people all seem to be algorithm gurus who feel that the next algorithmic breakthrough will be "the one" to create an AI. I think what they miss is that the physical manifestation of brain and body are in fact required to be conscious. Disembodied consciousness cannot exist since conscious beings (animals) have complex biological systems known as bodies that enable what we view as intelligence.

Yes, computers are infinitely better at rule-based computation than animals. No, they cannot pass simple tests of consciousness that a mouse can, and theres really no prospect of it happening because a better algorithm is created; fact is, animals and even insects don't think based on algorithms. Algorithms are models of the real world, not the real thing.

Being conscious means using ones eyes/ears/mouth/nose/skin to feel, hear, smell, speak to interact with the world around you. It means having agency and not just checking a set of pre-written rules in order to decide what to do next. Its a biological system that enables that.

<comment><USER12> >Yes but simulating the brain will never be the same as the actual "wetware" in operation. To my understanding, the simplistic reason that hard AI has failed and always will - while it uses digital computation as a platform - <USER2> that its a HARDWARE deficiency.

Are you saying that hardware deficiencies are never resolved over time?

>I'm generalizing but AI people all seem to be algorithm gurus who feel that the next algorithmic breakthrough will be "the one" to create an AI.

I study AI at Stanford and I've never met anyone who thinks that.

>I think what they miss is that the physical manifestation of brain and body are in fact required to be conscious. Disembodied consciousness cannot exist since conscious beings (animals) have complex biological systems known as bodies that enable what we view as intelligence.

You need to justify that. The reasonable argument closest to what you are saying is that sensory stimuli are required for intelligence. This isn't hard for a computer to simulate.

>Yes, computers are infinitely better at rule-based computation than animals. No, they cannot pass simple tests of consciousness that a mouse can,

Like what?

>and theres really no prospect of it happening because a better algorithm is created; fact is, animals and even insects don't think based on algorithms.

This needs justification. If they aren't computing, then what are they doing? You're looking down into the dualism abyss...

>Algorithms are models of the real world, not the real thing.

No, algorithms are neither. Algorithms are sequences (trees, if you prefer) of instructions.

>Being conscious means using ones eyes/ears/mouth/nose/skin to feel, hear, smell, speak to interact with the world around you.

So are blind people less conscious? What about those with no sense of smell?

>It means having agency and not just checking a set of pre-written rules in order to decide what to do next.

What makes those two things mutually exclusive? When I make a decision I consult my values and my goals and attempt to make the decision that gets me closest to my goals without compromising my values. Where do my values come from? Some of them are based on instinct (i.e. genes, i.e. hard coded) and some come from parents/society. My goals? I'd say most of them are just milestones on the path to other goals, and then that there are a few fundamental goals that come from biology (e.g. I fundamentally want to reproduce, this means that I need to attract a mate and earn enough to support a family, this is made much easier by an good education, etc.).

>Its a biological system that enables that.

Why? And what makes you think we couldn't build a biological computer (other than by the traditional method ;-) )?

<comment><USER9> _> Computers [...] cannot pass simple tests of consciousness that a mouse can

Like what?_

Vision, for one. Also, running.

 _If they aren't computing, then what are they doing? You're looking down into the dualism abyss..._

I don't think dualism is what he was thinking of, but rather Searle's Chinese Room argument. Coming from a CS-heavy Philosophy-light background, it took me a long time to wrap my mind around what Searle was saying there, but it's a pretty solid point nonetheless. The best way I've found to explain it in CS terms is that while theoretically, intelligence could be modeled using Turing machines, in practice, we will never have a machine fast enough to do so.

 _When I make a decision I consult my values and my goals and attempt to make the decision that gets me closest to my goals without compromising my values_

We have no idea how you or I make decisions, and the notion that we can intuit how decisions are made is a huge road block in even beginning to think about decision-making. Lakoff, among others, does a great job explaining why "values", "goals", and "morals" are simply justifications we create after we've made a decision.

> And what makes you think we couldn't build a biological computer

We can, and we should - but let's agree that it won't be a Turing machine.

<comment><USER12> >>> Computers [...] cannot pass simple tests of consciousness that a mouse can

>>Like what?

>Vision, for one. Also, running.

Um, ever heard of a digital camera? Or if you mean interpreting images, guessing what, they can do that too. Computer vision is a subfield of AI (arguably; I believe some say it's signal processing). Also, blind people are still conscious, so...

And running? Sorry, I hate to take this tone, but WTF are you talking about? Robots can run, and running has nothing to do with consciousness.

>>If they aren't computing, then what are they doing? You're looking down into the dualism abyss...

>I don't think dualism is what he was thinking of, but rather Searle's Chinese Room argument. Coming from a CS-heavy Philosophy-light background, it took me a long time to wrap my mind around what Searle was saying there, but it's a pretty solid point nonetheless. The best way I've found to explain it in CS terms is that while theoretically, intelligence could be modeled using Turing machines, in practice, we will never have a machine fast enough to do so.

You've totally missed the point of the Chinese Room. The point is that something can appear to understand without actually doing anything we'd call understanding. In other words, ~Ax(OutwardlyIntelligent(x) -> ActuallyIntelligent(x)). It's an argument against the sufficiency of the Turing Test, that's it.

And saying we'll never have a machine fast enough? The only limit on the speed of computation is the speed of light (and the physical size of the universe limits parallelization). But these values also bound our brains. In fact, iirc neurons are actually pretty slow relative to transistors.

>>When I make a decision I consult my values and my goals and attempt to make the decision that gets me closest to my goals without compromising my values

>We have no idea how you or I make decisions, and the notion that we can intuit how decisions are made is a huge road block in even beginning to think about decision-making. Lakoff, among others, does a great job explaining why "values", "goals", and "morals" are simply justifications we create after we've made a decision.

Okay, maybe my deconstruction is correct and maybe it isn't. Whatever. Unless you can explain to me why no such deconstruction is possible, I have no reason to accept that deciding is not computation. In other words, if it's not computation, then what _is_ it?

>> And what makes you think we couldn't build a biological computer

>We can, and we should - but let's agree that it won't be a Turing machine.

Of course it won't. It will be less powerful, because Turing machines have infinite memory and the universe is finite. It'll be a DFA, just like all current computers.

<comment><USER9> > Computer vision is a subfield of AI...

One that isn't close to being to process images the way rats can.

> Robots can run, and running has nothing to do with consciousness.

An animal can learn a new gait if it loses a leg. As far as I'm aware, no robot can do that. I was giving examples of what mice can do, not of consciousness.

> You've totally missed the point of the Chinese Room [...]

Good point. Good things I dropped the philosophy major :)

> The only limit on the speed of computation is the speed of light (and the > physical size of the universe limits parallelization).

Also, our architecture. The point I've heard Searle argue (not the Chinese Room, I guess) is that the computers we build now don't have an architecture are as likely to simulate consciousness, given the constraints of the universe, as a convoluted system of telegraphs.

 _Unless you can explain to me why no such deconstruction is possible, I have no reason to accept that deciding is not computation. In other words, if it's not computation, then what is it?_

Let me give my point another shot - deconstruction of consciousness _is_ possible, but not in a way which can be simulated by our current machine architecture.

 _It'll be a DFA, just like all current computers._

Do you suppose a brain is a DFA? Which do you suppose has more states - all of the computers in the world, or a single mouse brain?

<comment><USER12> >One that isn't close to being to process images the way rats can.

Can you justify that? CV systems can track motion, detect objects, do OCR, etc. I don't know much about rats, but I'd imagine that modern CV systems are more powerful than rats.

>An animal can learn a new gait if it loses a leg. As far as I'm aware, no robot can do that. I was giving examples of what mice can do, not of consciousness.

Uh, okay. If you want to see organic-looking gait, look up Big Dog. Here's a video, deep linked to a part where it stumbles on ice and regains its balance: <http://www.youtube.com/watch?v=cHJJQ0zNNOM#t=1m25s>. In general, neural nets often exhibit organic-seeming behavior. In any case, I don't think that mammalian joint structure (which, and I'm just guessing here, is probably what creates the kind of motion we think of as organic) has anything to do with consciousness.

>Also, our architecture. The point I've heard Searle argue (not the Chinese Room, I guess) is that the computers we build now don't have an architecture are as likely to simulate consciousness, given the constraints of the universe, as a convoluted system of telegraphs.

Well, we could build different hardware, but it seems much more interesting to simulate a mind in software, in which case architecture doesn't matter.

>Let me give my point another shot - deconstruction of consciousness is possible, but not in a way which can be simulated by our current machine architecture.

Why not? Sure, our processors are a bit slow, but that's not really an argument for fundamental impossibility.

>Do you suppose a brain is a DFA? Which do you suppose has more states - <USER3> of the computers in the world, or a single mouse brain?

Not that it's especially meaningful, but I'd imagine all the computers in the world do. To try and give you a better answer, I googled "number of neurons in a mouse brain" and the first result was "IBM's BlueGene L supercomputer simulates half a mouse brain" from 2007: [http://www.engadget.com/2007/04/29/ibms-bluegene-l- supercomp...](http://www.engadget.com/2007/04/29/ibms-bluegene-l- supercomputer-simulates-half-a-mouse-brain/)

</comment></comment></comment></comment></comment></comment></comment></comment></comment><comment><USER13> For those who like Kurzweil's ides, might I recommend books written by the author Greg Egan.

His books, in particular "Diaspora", discusses the story line of ai-humans that live to invent, create, and discover. Their journey takes them through 10^10 universes just to solve one problem: the destruction of the Earth.

<comment><USER14> Along the same lines, I'd recommend Accelerando by Charles Strauss. (<http://www.accelerando.org/>) It's another well written piece of post- singularity fiction that's fascinating in the ideas and implications that it presents.

Yes, this is the second topic today I've recommended it in. No, I am not a shill, it just came up twice.</comment></comment>


Do you want SIP and XMPP to work well together? Join SIXPAC - <AUTHOR> http://blogs.voxeo.com/speakingofstandards/2010/11/11/do-you-want-sip-and-xmpp-to-work-well-together-join-sixpac/

<comment><USER2> It would be interesting to use IAX2 instead of SIP. Unlike SIP, IAX(2) is transparent to NAT.

NAT was one of the problems that Skype had to face, resorting to using routable clients to funnel traffic to clients behind NAT. Yes, IPv6 is right around the corner, but VoIP should not have to wait for its implementation.

When you want to have a mass product, you need to work with the reality that many possible clients will not have a directly routable IP.</comment>


Ask HN: Resources to cover an Electrical Engineering degree curriculum? - <AUTHOR> I recently developed interest in Electrical/Computer Engineering, but since I have a full-time job now, I can't sacrifice the time to pursue a full-time bachelor's degree. I have a background in mathematics and Software Engineering. What online courses/books/blogs/kits would you recommend to match an Engineering bachelor's degree curriculum? <comment><USER2> You've neglected to mention which engineering discipline you're interested in. Civil? Electric? Mechanical?

<comment><AUTHOR> My bad - electrical / computer engineering. Updating the description.</comment></comment>


Deis: Open Source PaaS based on Docker, Chef, and Heroku Buildpacks - <AUTHOR> http://deis.io/ <comment><USER2> Gabriel Monroy here, creator of the Deis project. I'll be answering questions here and on Twitter (@gabrtv). I want to give a big shout out to the Docker crew for their support.

I should also mention the release notes (which explain what's next) can be found here: [http://deis.io/deis-0-0-5-public- beta/](http://deis.io/deis-0-0-5-public-beta/)

<comment><USER3> Hi Gabriel, how will this compare to the other Docker-PaaS projects going on? (Flynn, Dokku). I see the inclusion of Chef as a major feature?

<comment><USER2> Well firstly, I believe we're the first distributed Docker-based PaaS to be released. We are using Buildstep for Heroku Buildpack integration, which is part of Dokku. And we've been talking with the Flynn crew about how we can create more reusable components for the Docker PaaS community.

Our use of Chef is reflective of a larger design decision to work with DevOps tools that are already in widespread use.

<comment><USER4> Speaking on behalf of the Docker project, I am very glad that the two first PaaS projects built on Docker happen to be led by Jeff, Daniel and Jonathan (for Flynn) and Gabriel's crew (for Deis). They are all active and helpful Docker contributor who "get" the importance of interoperability between Docker projects. They have pledged to play nice with each other by focusing on reusable components which will benefit the entire Docker community.

So for that, thank you! I hope more people follow your example and remember open-source is not a zero-sum game.

</comment></comment></comment></comment><comment><USER5> This is really exciting, I've been waiting for someone to combine all of the various deployment technologies like this for a while.

However... If I set up my servers manually, or even through chef, I have pretty intimate knowledge of how my apps are being deployed. I know the various pipes data goes through, software versions, what services are running, etc. In other words, I have a pretty reasonable mental model of my deployment architecture. This is especially helpful when troubleshooting. However while the magic of Deis looks like a godsend, I am very caution about upgrading my technical debt from "managing my app servers, load balancer, and db servers" to "managing a PaaS that I happen to run my app on". I'm not trying to do ops for a Heroku clone, I'm just looking for an easier way to streamline my deployment process. What happens when I run "git push deis master" on a new release and everything breaks? The last thing I want to be doing is searching through the Deis github repo for error strings while my site is down.

Can anyone from the project assuage my fears? I realize this is kind of an open ended question, but a little assurance can go a long way.

Related: What are the planned price ranges for support on this?

<comment><USER2> I understand the concern about potential black box on the deployment side. Few points 1) this is an open-source project with a relatively small code-base and few moving parts 2) Chef does most of the heavy lifting on the deployment side using Databags and traditional Chef runs and 3) the build/release/run workflow is described here: [http://docs.deis.io/en/latest/gettingstarted/concepts/#build...](http://docs.deis.io/en/latest/gettingstarted/concepts/#build- release-run)

With regard to support, OpDemand (creator/maintainer of Deis) will be launching paid support and professional services once the project stabilizes. Price points are not set yet. How would you like to see it priced?

<comment><USER5> Cheaply :)

Thanks for the response, I'll delve into the docs more. What would be really cool would be a snapshot/description of a sample deployment I could look through. A fake ssh session demo in the browser that I can poke around in would be pretty awesome. Reverse engineering chef cookbooks from github isn't exactly an easy way to learn about what a product does.

More specifically as per support pricing, I'd love site licensing as opposed to a per-deployment or per-server setup.

Just a thought: what would fit my needs almost perfectly is some sort of tiered email/forum/ticket based support option, which is upgradeable to phone/dedicated support when I'm doing deployments

</comment></comment></comment><comment><USER6> shameless plug:

Open-source Heroku-esque PaaS which uses Go, Git, LXC, and HAProxy.

ShipBuilder is a freely available open-source project which aims to make it fast and easy to deploy arbitrary web-applications.

Get total control over all aspects of your staging and production environments.

More info:

[http://shipbuilder.io/](http://shipbuilder.io/)

[https://github.com/sendhub/shipbuilder](https://github.com/sendhub/shipbuilder)

<comment><USER7> Why not docker? and do u use cgroups etc? in any case, would be great to here about it..

</comment></comment><comment><USER8> is there a public paas deis server where i can deploy some test apps? or do u or does anyone plan a commercial heroku or dotcloud clone?

<comment><USER2> Deis is designed for running your own PaaS. You can use public or private clouds, but we still require you run your own controller.

If you're looking for a public PaaS solution, we recommend you take a look at dotCloud or Heroku.

With regard to a commercial offering, OpDemand (the company behind Deis) plans on offering paid support and professional services for Deis deployments once the project reaches stability.

<comment><USER9> ProTip: If you are building anything that you expect users to run themselves, copy/steal FoundationDB's AWS CloudFormation setup. One click and a couple form fields to setup, one click to tear down.

Edit: [http://foundationdb.com/documentation/beta1/getting- started-...](http://foundationdb.com/documentation/beta1/getting-started- ec2.html)

<comment><USER2> Many of the companies interested in using Deis want a private cloud deployment, so we have intentionally avoided tying ourselves exclusively to AWS/EC2. That said, we can certainly make the installation process a bit easier in future releases. CloudFormation could be part of that.

</comment></comment></comment></comment><comment><USER10> So how does this compare to flynn.io?

<comment><USER11> I'm not involved in Flynn nor Deis, but since Flynn is not available yet (and no source is visible at this point), I would be surprised if anyone could tell :-)

</comment></comment><comment><USER12> i like this is more "private cloud" oriented and "not a whole os" i think thats a better move than attempting to "capture market" like quite a few other projects.

Now for unshare() to become more secure... ;-)

</comment><comment><USER13> operate PaaS and use a PaaS is very different...

</comment><comment><USER14> I wouldn't use Deis because of its tight integration with Chef. (I abandoned Chef in favor of Ansible) But for Chef users, it looks like a great project, and am glad to see an expanding community of Docker-based tools.

<comment><USER15> Yes, I was very sad when I read that I needed a running Chef Server to begin using Deis.</comment></comment>


How to Write Unmaintainable Code - <AUTHOR> https://github.com/Droogans/unmaintainable-code#how-to-write-unmaintainable-code <comment><USER2> From [http://mindprod.com/jgloss/unmain.html](http://mindprod.com/jgloss/unmain.html):

> I would like to remind you this essay is copyrighted material. It is illegal > to repost it without permission. I will usually give you that permission if > you translate the essay into another language and if you provide a link back > to the English-language original. I do this for three reasons.

        1. That way any change I make to the essay is instantly reflected in any English-language copy anyone reads.
        2. That way the formatting and images are preserved. Pirated copies usually screw up the formatting.
        3. Google ad revenue from this essay is the main source of income from the website. It pays to keep me on the air.

I don't understand how the creator of this GitHub repo could miss this, it's the first thing in the original article...

<comment><USER3> You know, at first I figured I'd use the original site, but I'm on mobile and the formatting is atrocious.

<comment><USER4> Same thing happened to me on desktop. They want me to click to another page for every 3-line paragraph? Gah!

<comment><USER5> My first though when checked out the source. That thing is so messy it's hard to navigate not to mention having to click so much.

If this truly is a source of income he should put more effort into making it usable. This is a predictable outcome of anyone neglecting their content.

<comment><USER6> I would have been disappointed if the source for that page wasn't a mess.

</comment></comment></comment></comment></comment><comment><USER7> "Hungarian Notation is the tactical nuclear weapon of source code obfuscation techniques"

...never a truer word was said.

([http://www.joelonsoftware.com/articles/Wrong.html](http://www.joelonsoftware.com/articles/Wrong.html))

</comment><comment><USER8> I had the pleasure of dealing with C++ classes with a dozen or more gratuitously overloaded operators, including overloaded cast operators. You'd cast an object to a certain type in order to access a member of that type, instead of accessing that member in a normal way. I never doubted for a second that it was all done for job security, this stuff is real.

</comment><comment><USER9> I swear... I have worked with coworkers who have taken a lot of these principles to heart.

<comment><USER10> The paragraph on wrapping all of your global variables in a single static array nearly killed me. I've seen a global Dictionary<string,object> for that exact purpose, followed by the proud exclamation "I'm down to a single global variable".

This was in a brand new tool, the programmer was responding to increasing pressure from peers to remove global variables in code. Magic.

</comment></comment><comment><USER11> no, he missed one obfuscation trick that should be quite natural in java land - just create deep nested class hierarchies that serve no apparent purpose - AbstractSingletonProxyFactoryBean for everybody; no hope to understand what is going on here.

<comment><USER12> Even better, call it: IAbstractSingletonProxyFactoryBeanImpl

<comment><USER13> Or take a class name from: [http://www.classnamer.com/](http://www.classnamer.com/)

</comment></comment></comment><comment><USER14> Dear god! I'm an awful programmer.

<comment><USER15> Don't sweat it, majority of the planet doesn't write amazing code. The whole world still runs on it, and it works.

<comment><USER16> I am never going outside again.

<comment><USER17> The code is coming from INSIDE THE HOUSE!!!!

</comment></comment></comment></comment><comment><USER18> Best way to keep a job is to just be a good engineer. When people are motivated they will deobfuscare the code base.

</comment><comment><USER19> Write it in R?

<comment><USER20> Yes, mixing languages is a pro's version of this. Earn 10 points for every language and 20 points extra for every interface between them. Macro languages like XML do count.

Additionally do some build system breakage with automatically partially generated code for extra credit.

Of course if you create some DSL or XML, never include schema or any kind of documentation that is not the parser.

And absolute worst: include optimizrd binary only code - no documentation and sources. Reverse engineering is fun!

</comment></comment><comment><USER21> wDiabloical.</comment>


Berkeley scientists' climate data review puts them at center of national debate - <AUTHOR> http://www.latimes.com/news/local/la-me-berkeley-climate-20110331,0,2472031.story

<comment><USER2> He claims no polar bears have died because of GW. At least Wikipedia seems to cite otherwise: "The effects of global warming are most profound in the southern part of the polar bear's range, and this is indeed where significant degradation of local populations has been observed."

<comment><USER3> Interesting. Seems there are multiple views on this.

According to this article Dr Mitchell Taylor, a leading expert on polar bears, is persona non grata at climate change conferences where there are no other polar bear experts because he reports that polar bear numbers are not decreasing, contrary to their reports:

[http://www.telegraph.co.uk/comment/columnists/christopherboo...](http://www.telegraph.co.uk/comment/columnists/christopherbooker/5664069/Polar- bear-expert-barred-by-global-warmists.html)

</comment></comment><comment><USER4> That article is a real mess, full of bits that are "not even wrong". How can you _simultaneously_ claim that some alternate way of looking at the data (a) won't reach any different conclusions, AND (b) must have had its science corrupted (to reach different intended conclusions) due to a dubious funding source? Aren't those mutually exclusive?

And then there's simultaneously (a) publicizing early claims (outside the scientific literature) that "mainstream" climate researchers are sure the results will be X, while (b) saying that publicizing early claims outside the scientific literature is unethical?

Not to mention the ridiculous confusion over Climategate...

</comment><comment><USER5> How come people can accept that oil money taints climate research, but if you propose that climate research is affected by another agenda, they laugh at you and give you a lecture about the scientific method.</comment>


Hans Island – A most civilized land dispute - <AUTHOR> https://en.wikipedia.org/wiki/Hans_Island <comment><AUTHOR> Hans Island ... is claimed by Canada, and by Denmark:

        The two countries maintain a sense of humour in the
        dispute. Peter Taksøe-Jensen has stated "when Danish
        military go there, they leave a bottle of schnapps.
        And when [Canadian] military forces come there, they
        leave a bottle of Canadian Club and a sign saying,
        'Welcome to Canada.'"

I freely admit that this might not be HN material, but I found it engaging and wanted to share it.</comment>


REPL-Driven Development in Node.js, Ruby, Python, PHP, C# and Java - <AUTHOR> https://medium.com/square-corner-blog/getting-started-exploring-sdks-with-repl-driven-development-in-node-js-49e6316dc6a0 <comment><USER2> Great read, I had someone do reply driven coding the other day in a screen share except they didn't mention or speak about what they were doing 30 min into a problem and they had yet to open an editor!</comment>


The Video Wars of 2027 - <AUTHOR> https://hacks.mozilla.org/2018/08/the-video-wars-of-2027/ <comment><USER2> This post imagines a future where patented video codecs drive up costs for web video streaming -- and Netflix costs $4,500 a month.</comment>