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Apr 3, 2023Edited
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I would guess that people who have significant difficulty going to the doctor in person, whether due to mobility issues, not being able to get time off work/childcare, living in a rural area, agoraphobia, etc are quite a large category.

Specifically needing to drive a hundred miles, I'll admit is fairly small, but also probably larger than you'd think when you factor in people wanting to see niche specialists and not just any random doctor.

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Apr 4, 2023
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Here are some:

"A large secondary analysis of National Health Interview Survey (NHIS) data, Medical Expenditure Panel Survey (MEPS) data, and Bureau of Transportation Statistics (BTS) data, by Wallace et al., estimated that 3.6 million people do not obtain medical care due to transportation barriers."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/

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Apr 3, 2023Edited
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I definitely detect this in my family, who I’d call more right-wing than specifically religious. Maybe it’s just that we’ve gotten so careful about how we talk about every other group that casual trashing of Christians is starting to stand out more? The idea that there’s a double standard for sensitivity is harder to ignore.

The school shooting in Tennessee has their hackles up because as they see it liberals are tying themselves in ideological knots to avoid applying the rhetoric they’ve used for other cases to this one. I tend to dislike any partisan analysis of a tragedy, since each case really is unique and this flattens important details.

On the other hand, a few weeks ago a very liberal friend posted a popular meme “The only thing children have to fear at a drag show is that a Christian will show up with a gun.” I am a Christian, and attend a pretty woke church (but still one within a major denomination) with gay and trans members in regular attendance, so I called my friend out. In the aftermath of the Nashville shooting, that meme looks even more terrible.

In my liberal and unusually atheist bubble, I see that sort of thing a lot and just let it slide. It wouldn’t have occurred to me to stand up for myself if it didn’t *also* seem like a slap to the LGBTQ Christians I’ve met! My friend would never post a similar meme singling out any other religion, much less an ethnic group. At the very least, there’s some unhealthy internal inconsistency there. That’s something you ought to resolve unless you want people to start thinking you really do hate them and their religion, which is what my right-wing cousins already believed about their political opponents.

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"I definitely detect this in my family, who I’d call more right-wing than specifically religious"

I think this is relevant to the trend we're noticing. As Christianity declines in the US and many who would formerly identify as nominal Chreaster Christians now identify as Nones, some on the right who previously weren't particularly religious have adopted an aggressive, politicized Christianity as a culture war symbol. I suspect those are more likely to engage in what I'm describing.

To be clear, I'm definitely not some lefty either. I simply don't care much about anyone's sacred cows.

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"some on the right who previously weren't particularly religious have adopted an aggressive, politicized Christianity as a culture war symbol"

While I agree this has happened, I think for most of us it's the "Christian = Nazi" association that is irritating.

On the other hand, maybe I should just shrug and go "Okay, I'm a Nazi now". Sacred cows and all that, Wendigo? 😁 Since "fascist" and "racist" and "homophobe/transphobe" and "TERF" have now become meaningless terms apart from indicating "I don't like you", why not?

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"In my liberal and unusually atheist bubble, I see that sort of thing a lot and just let it slide. It wouldn’t have occurred to me to stand up for myself if it didn’t *also* seem like a slap to the LGBTQ Christians I’ve met!"

My impression is, for such bubbles, that they don't even contemplate that LGBT+ people would be Christians. They don't have much knowledge about liberal versus conservative Christian churches, and I think they tend to think places like the Episcopalians and other liturgical churches who dress in similar vestments are Catholics and we all know what the Catholics are about. 😁

The idea is "why would you be a Christian when they hate you?" so the notion that "hey, you're including LGBT Christians in that statement!" never occurs to them, and then once pointed out it's "Well of course I don't mean *you*, it's the *other* Christians".

I'd be inclined to ask your liberal friend why they want to teach kids that gay people are the same as clowns, that is, figures of fun not to be taken seriously. Why bring them to drag shows other than to teach them that "gay people are those people who dress up in funny clothes for you to laugh at"? If I were feeling spiky about that comment, I mean.

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The anti-christian bias I think is due to personal experience, as people in muslim majority countries will have anti-islam bias instead. Of the "lgbt" people I personally know (self-included), all have spent some time homeless and several have died either because their christian parents kicked them out or because christian employers fired them.

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I think it's because of (1) stereotyping and (2) conscience exemptions.

(1) is because Not All Christians. Or if you prefer, Chinese Cardiologists as someone or other once did an entire post about somewhere online 😁

I get the impression that the type of "Christian counsellor" is mostly to do with Evangelical denominations which would be geographically limited in the USA. So while I'm sure some patients did have experiences with "you don't need drugs, just accept the Lord into your heart", that wouldn't be every patient.

Nor would it be every denomination and every doctor who is Christian. I know Scott worked in a Mercy order affiliated hospital when he was having his adventures in the Mid-West but I would be highly surprised to hear that the recommendation there to their staff was "tell your patients all they need is a decade of the Rosary".

Imagine if I took Scott's admission as to mild face-blindness and extrapolated that into shrugging, waggling my eyebrows meaningfully, and going "Jewish doctors, amirite?" I kind of imagine I would get some "what do you mean by that?" from someplace. Even if I then pulled out "well studies show people of Jewish heritage have high verbal intelligence but low spatial processing ability, is all I meant" I think I would still get told "knock that off".

(2) is the conflict about conscience exemptions/religious protection, usually around contraception and abortion provision services. I'm very sensitive to this because right now, as I expected, there's murmurings around how our abortion law in Ireland is too restrictive and should be further liberalised. And of course, the pro-abortion supporters are very down on permitting conscience exemptions to doctors: provide the service, bigot, or else!

I say I expected this because it's what always happens: the camel gets its nose inside the tent, then after a while it pushes its head in, then....

And so despite all the "no no, we only are going to permit limited abortion in certain circumstances" (and those circumstances being the ones *always* trotted out when abortion is mentioned, the life-saving ones about rape, incest, threat to life of mother) and "nobody will be forced to perform abortions or provide referrals against their conscience", we are now in the phase of "but these circumstances are too restrictive and a doctor should never be able to refuse to provide legal medical services when requested".

So reflexive knee-jerk "those dumb Christians" is the kind of thing I expect to see when this debate arises, and not really what I expect to see on here. Ah, well.

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I'm not going to give you a specific percent warning, but I think this comment is bad and likely makes the reading experience worse for a lot of people here.

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Apr 3, 2023Edited
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Which makes me wonder if the pharmacist in the first case was refusing to fill the prescription because they weren't sure who was taking it, and if the person taking it was a pregnant woman who then miscarried, they might be on the hook for "why didn't you check that the patient was the same person on the prescription?" in a law case.

All kinds of reasons for all kinds of refusals.

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Apr 3, 2023
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Apr 4, 2023
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No, once we get our participants we need to find a gangster with cancer and have them compete to save his life.

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>(And before someone says “cops are objectively worse than doctors” I suggest looking up the annual number of deaths from medical errors and comparing it to the number of deaths caused by police.)

I don't have any inclination to jump in and claim that cops are worse than doctors, but I don't think this kind of data actually lets us disambiguate.

The question of who is better at their job isn't answerable by the data of who has more people die under their charge. The data we'd need to answer it is something more like "Where do people's outcomes fall on the scale from having the job done as perfectly as possible to having it done as perversely as possible?"

A lot more people die due to doctors' medical errors than would if our medical system were run by hypothetical perfect doctors who never make mistakes. But a lot fewer people die from medical errors than probably would if doctors were hired based on basic job interviews with no particular qualifications. And based on modern vs. historical death rates, we can be pretty sure that fewer people die due to disease, injury, etc. under the care of doctors than without the care of doctors.

Essentially everyone dies of medical problems eventually. In a meaningful sense, it's the only thing people ever die from. So the professionals who manage people's medical problems are automatically in a position of responsibility over more life and death than most other professions. Physician error causes way more deaths than cashier error, but if all doctors swapped jobs with cashiers, we wouldn't expect deaths to do down.

So, the question of which group of professionals do a better job is probably not best resolved by answering something like "who has responsibility for more deaths?" but "who would be easier to replace with a cohort of different workers who'd do a better job?"

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You make a pretty good point, but I disagree about the target for public ire. I don't think it's directed at individual physicians. I think it's directed at some (poorly defined) "public health establishment." So in this case, it could be the DEA is feeling some heat from some people in the Administration who are sensing that hostility, and being told "you should Do Something about this opioid crisis about which we keep being asked in news conferences, so we can say we're Doing Something." I'm skeptical that the origin here is individual patients telling their individual physicians "I dunno if I trust you to diagnose my 9-year-old's sore throat and fever as long as you aren't doing enough to stop opiod overdoses" and the physician then getting on the phone to Washington to say "help me out here, guys."

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Apr 4, 2023
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Sure. That's *what* I'm saying: the pressure comes from the top down. Normal people are neither suddenly distrusting their doc nor the beat cop. So any rising level of distrust is I would guess directed at some hazy "establishment" in both cases.

And I would guess the origin is fairly similar: in both cases you have a profession to which people turn only when things are going shitty. Nobody *wants* to use the services of either a physician or a policeman -- you only turn to those professions when something has gone seriously wrong. So you're already unhappy. You rather hope that the doc/cop can help your situation, but all too often they can't. The cancer has spread too far, the thief/rapist has gotten away and can't be found, the ability to speak or saved money is gone and no power on Earth can get it back now. So there's already a considerable reason to be dissatisfied with what physicians and policemen who are mortal and not demigods can achieve.

Throw in also the fact that both classes are staffed with human beings, who occasionally display all the limitations and character weaknesses of human beings -- arrogance, prejudice, impatience, errors in judgment, dishonesty -- and it's not hard to see why people will *at best* be ambivalent about how they feel about such important people who so often disappoint them, sometimes inevitably, sometimes evitably.

And then we add a soupçon of asshole social parasites, who will stimulate vague dissatisfaction with whispered conspiracy theories that appeal to our tendencies to self-pity and rationalization ("the cops are all secret racists! That's why your cousin got shot!"/"the MDs are in cahoots with Big Pharma to boost profits! That's why your cousin got hooked on Vicodin and lost his job!") -- and we can readily have at any time a wave of public outcry against the existential mistery that no physician is Apollo personified, and no policeman channels Christ the King, still less Solomon. Politicians truckle, as they do, to the cry that Something Must Be Done, and we're off to the circus.

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for what it's worth, i absolutely distrust my local beat cop. my ex used to watch youtube clickbaity videos about horrible civil rights violations performed by cops, so i might be anchoring on some incredibly biased evidence. but as far as I can tell, the incentive is for cops to simply break the law, repeatedly and egregiously, ignoring all civil rights and behaving in ways that would be considered warcrimes if they happened on a battlefield instead of a lower income residential neighborhood. Then, if their illegal search turns up nothing, they just move on. If their illegal search does turn up something, or if they decide your frustration is too disrespectful, you get arrested. If you have any cash or valuable possessions, they seize it via asset seizure laws. if you're wealthy and competent, you successfully defend yourself at trial by getting the illegal evidence thrown out, otherwise you just get convicted. But in no circumstance does the cop ever actually suffer any kind of consequence for violating the law. Their only punishment is spending time pursuing a case where they might fail to get a conviction. Also, even if you get found innocent, they still get to keep the assets seized from you, even if it was your life savings.

knowing about all these examples of people victimized by cops taking blatantly illegal actions and then suffering no consequences, while also seeing intellectually how the law enforcement incentive gradient slopes gradually but unmistakably towards ignoring all civil rights... i feel like the appropriate response is to actively distrust your local beat cop. not some nebulous 'law enforcement institution', but the actual cop actually showing up at your door over the neighbor's noise complaint, or the actual cop actually pulling you over for a broken tail light, or what-have-you. definitely keep your valuables hidden from them, at least, because they have zero incentive not to just rob you on the spot. at least the inquisition had to actually declare someone guilty of heresy to steal all their possessions; in america, the cops get to keep your stuff even if they never even charge you with a crime.

so it surprised me to see you use the local beat cop as an example! it seems like the perfect counterexample to me

heck, west virginia is currently going through a scandal where it turns out the entire state police force, from top to bottom and in practically every unit, had been wielding their power like corrupt feudal lords, basically acting like an organized crime ring. apparently they tolerated cops who did not, themselves, partake in the crimes, so long as they explicitly and emphatically declared that they would never snitch. At least according to the whistleblower. Who, by the way, was set up for a 'violence against a female' charge and arrested the day before he was due to testify against Cahill, the state police superintendent (witness testimony is that he told his colleagues not to worry about the snitch, he would 'take care of him'). And even all of that probably would have been quietly brushed under the rug, if one of the crimes hadn't been one cop setting up hidden cameras in the women's locker room at the police academy, and then his superiors destroying the evidence when a cadet tried to report it. That was eye-grabby enough for some reporters to actually run the story.

or heck, look at the current scandal around afroman, the performing artist of "because I got high" fame. Cops raided his house on obvious nonsense evidence, flagrantly broke several laws, stole a bunch of his cash, 'miscounted' the cash in a way that frankly looks deeply suspicious, then left. afroman tried to find some way to punish them through official channels, and there just wasn't one. so he wrote some songs about the event, trying to embarrass the cops, and used the footage from his security cameras as part of the music video. now the cops in question are suing him for the revenue he earned from the songs. it seems pretty clear their motivation is to punish him for being disrespectful towards law enforcement, and they were surprised to find that some considered this unreasonable! and what will victory look like for afroman? the best case scenario is that he successfully defends himself and doesn't have to give the cops any of his royalties for the songs. but there's no outcome where the government has to return the 'miscounted' money, and there's definitely no outcome where the cops get disincentivized from just raiding his house again next week. much less the outcome i'd prefer, where they get arrested and convicted for breaking and entering, burglary, grand larceny, issuing credible death threats, and maybe some kind of fine for filing a frivolous lawsuit.

and that's just like, the last month or so of news in the 'police misconduct scandals', it's been an above average month but by no means is it an outlier, stuff like this is just constant background noise of law enforcement trustworthiness

idk, sorry for long comment, i just feel like the kind of distrust the public feels towards cops right now is *exactly* the sort that cashes out as a specific distrust of the local beat cop, and rightfully so, and i was very surprised to see you casually say otherwise

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Your comment made me reflect on why I'm pro-regulation for cops, and pro-regulation for civil engineers (my profession), but anti-regulation for this telehealth situation as described in Scott's post. I think it's important to talk about outcomes and what our values are. I'll choose between possible bad outcomes only for each:

Bureaucratic inefficient police lets a criminal go unpunished, or ruthless Wild West police harass/kill an innocent man? I think that the criminal going free is a better option, and the American constitution/American philosophy dating back to 1776 would agree with me, but there's nuance here (what if the criminal does more violence a month from now?).

Bureaucratic inefficient engineering means bridges have 3x higher design costs, or ruthless Wild West engineers cause a bridge to collapse, killing 50? Obviously the higher design costs are better.

Bureaucracy restricts telehealth medicine, and patients stay unmedicated, or ruthless Wild West pill mills give pills to everybody, causing more addiction? Open for debate but I think that the ruthless Wild West situation would be better. (If availability of the drug leads to addiction, then shouldn't we ban alcohol/tobacco/weed/gambling/etc? But nobody is seriously proposing that. I tend to lean towards individual liberty here)

Disclaimer: This is an oversimplification, sometimes we aim for a happy medium, some policies are obviously all good or all bad, etc.

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Apr 4, 2023
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> Addiction kills 100k people every year just in terms of fentanyl,

You mean contaminated, unregulated, and illicit sources of fentanyl kill 100k people per year. If sources for drugs weren't illicit, then you would be able to obtain uncontaminated drugs from regulated sources, and that number would be *significantly* lower. That's my reading of the wild west point.

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Apr 5, 2023
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Nobody actually wants fentanyl. They want heroin, which is more euphoric, but all the "heroin" is now fentanyl because it's easier to smuggle. Also, the big danger with fentanyl is that it's difficult to cut / dilute evenly because it's so potent - you end up with occasional "hot spots" that kill people. So if drugs were legalized, the fentanyl available would presumably be pharmaceutical grade (which already exists and is sold medically) and diluted properly, and no one would buy it anyway, they would buy heroin. I'm not wanting to necessarily come down on one side of the question here, but the current fentanyl situation is a pretty strong argument for legalization for me at any rate.

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If a cop or civil engineer fuck up, other people die.

If a fentanyl user fucks up, they die.

It's about externalities.

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Apr 5, 2023
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I don't, and those negative externalities are more attributable to SF (and my own Seattle) abandoning any pretense of law enforcement than to the drug use per se.

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I think the interesting thing about assessing it like this is it comes down to "what's your frame of reference".

In your frame of reference medication that helps the mentally ill is a good thing (maybe you've seen it in the life of someone close to you), and drug addiction is less of a bad thing (maybe you haven't seen it in the life of someone close to you, or where it was it wasn't as bad as the life struggles of an unmedicated person).

Whereas someone who is suspicious that psychiatric pills even do anything (especially when seeing how many different tries they have to make to find one that works, and maybe the only person in their life gave up on that before they found the right one, or was taking something on the side and blamed it on the legit Rx), but has seen people overdose, or waste away, or have addiction-fueled violence, or go in and out of prison might prefer the bureacracy.

I'm definitely not the other person, but I've known people who are. (And they probably are also more pro-wild-west engineering when complaining about the regulations it takes to move a light switch in their home.) And I wonder how to convince either you or them that what they see as the less bad outcome might actually be the more bad outcome other than it just being a personal thing.

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I don't have much sympathy for cops having to sit through implicit bias training given that every vaguely woke office job includes that these days as well.

But point taken that it probably doesn't achieve much of anything.

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An interesting thing to consider is if rather than doing nothing, it actually makes things even worse. Being forced to sit through a corporate presentation where you're lectured and chided is likely to make you more hostile to any idea being forced on you in such a way. It's quite possible that, either consciously or unconsciously, a desire to act out against the obnoxious preaching you were subjected to might make cops act even more racist in response.

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But then the bias is no longer implicit, so the training still succeeds!

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Typo in the first sentence: "Isn't drug addiction is very bad?"

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Thanks, fixed.

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The first two bullet points are grammatically incorrect

"1: Isn’t drug addiction is very bad?

2: Is telemedicine is worse than regular medicine?"

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Aren’t they based on some old bad video game translation meme sentence

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based based...aren't they based, on some old translation?

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>Since everything about ADHD diagnosis and treatment is already security theater, it’s hard to say what pill mills are doing except kind of smirking under their breath while going through the rituals - as opposed to real doctors, who go through the rituals with sincere faith. Don’t get me wrong, I do think there’s a difference here. But the regulatory state isn’t set up to say “And you have to sincerely believe in the rituals or they don’t count”. So instead they punish unrelated groups, like telepsychiatrists.

This is very on-point. So often, people defend a status quo system by reference to what it is ostensibly intended to do, without regard to the completely bullshit way it actually behaves. It's a kind of magical thinking. There is some worry (overprescription, addiction, whatever), and the rituals are intended to address that worry, therefore the rituals must be respected.

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To me, it sounds like he is saying the system is completely broken so it does not matter if it breaks some more. It sounds very odd to an outsider.

Imagine if he were a plastic surgeon who does operations on transgender adolescents and he said, the diagnostic criteria are meaningless, the interviews are rituals and security theater, etc.

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A plastic surgeon isn’t the one deciding people are trans, but isn’t the process basically rituals and security theatre? The diagnostic criteria for being trans are basically “the patient claims to be trans”, and I don’t think it’s common for cis people to convince themselves of that.

You could imagine a process where they check that someone isn’t actually just gay but isn’t aware that being gay is an option, or hates their body for non-trans-related reasons, and any other things that can make people think they’re trans, but I’m not clear to what extent and how consistently that actually happens. Certainly in the UK simplifying the process to get through the waiting lists seems like a good idea.

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But what could in principle be reliable criteria for psychiatric conditions, given that we can't simply read minds as of yet? Sure, a seizure or something equally unambiguous and involuntary would count as strong evidence, but most conditions don't come with such convenient symptoms. Like Scott says, injecting inconvenience and vague fear of lying to authority somewhere into the pipeline are probably the only feasible improvements on the margin.

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If you just think in terms of the system being "broken" or not in some coarse-grained way, I can understand why it would seem confusing.

If you think in a more fine-grained way about the particular policies not achieving their ostensible objectives but only causing collateral harms, then it makes perfect sense to not want those collateral harms to be caused.

The key is, you need to stop being transfixed by the thought, "But it was supposed to do X!"

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I don’t really understand your comment. What objectives? What harms? What thought do you think I am transfixed by?

The point of psychiatrists is that they are supposed to have the expertise necessary to diagnose and treat psychiatric disorders. If the diagnostic criteria for ADHD are meaningless, then there isn’t any way one can have expertise about it and the conclusion could range from either that no one should be prescribed amphetamines for it or everyone should have access to these drugs for perceived concentration difficulties. Someone who agrees with the latter of these positions might think the ”breaking” of the current system by pill mills is a good thing, just as someone who favors legalization of drugs might think the breaking of the legal enforcement system is good.

The only thing that confuses me is whether Scott actually accepts this latter position. Maybe he says somewhere.

The reason I said it sounds odd to an outsider is that the story told to the public at large is that psychiatrists prescribe drugs to treat actual conditions, not for lifestyle doping. Of course most people are aware there is some abuse of the system. But that is different from admitting that the system itself is just a ritual.

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You're last two sentences point to the core issue well enough. Scott, who is an insider, is pointing out that parts of the system that are presented as load-bearing are in fact just ritual. Furthermore, many other smart MDs who are willing to break from the guild's party line and speak frankly (though this is a minority!) say the same thing.

This should not be particularly surprising or puzzling –– just unfortunate.

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Yes, I agree. Although now that I have gone and read them, I think Scott significantly exaggerates the ”fuzziness” of the criteria for ADHD in the DSM 5.

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Part of what religion does is define the purpose of human life, which includes the purpose of the human body. That, in turn, determines what counts as health and what counts as harm, which has a huge effect on what constitutes correct medical care. In addition to this, there's a competitor called medical science, which isn't a religion, and tries to define health and harm without much of a strong idea of the purpose of the human life, and so it wobbles a good deal; see Canada and MAID for an example of contemporary political trouble stemming from this confusion.

I think a good number of these stories of poor medical care coming from ideologically-motivated doctors are symptoms of patients of one religion seeing a doctor of another. I don't have any recommendation other than that we should recognize that health and harm (and thus, any judgment of good vs bad medical care) aren't actually separable from religion, or some other purpose-granting worldview filling the role of a religion.

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Most doctors are Christian, because most Americans are Christian. People shouldn't have to dig into their doctor's religious affiliation to be sure they won't get a lecture about Jesus when they broach the subject of PrEP or SSRIs or end-of-life care or what have you. Thankfully, the vast majority of doctors do not do this, but clearly some do or these anecdotes would not exist in the quantity that they do. Of course, if they advertise themselves as an explicitly Christian practice (or whatever other religion), nothing wrong with that! But generally speaking, medical professionals have certain professional duties, and putting personal religious beliefs before providing the highest quality of care contravenes those duties.

Not to mention that Christianity itself is incredibly diverse, and many believing Christians are not looking for this sort of experience when they see their doctor.

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Man, if you're the kind of person who wigs out if his doctor (or lawyer, or professor, or banker) mentions Jesus in some friendly way, then maybe you're too much of a precious little snowflake to be allowed to wander the adult world without a nanny.

I mean, Great Ghu, how often does any of us have to hear some well-meant but ignorant "advice" that conflicts with our own convictions? All the freaking time. If I'm expected not to smack around the next sententious clod who wants to lecture me about "implicit bias" or "misgendering" with my pronouns or any other random social fad, then I'll expect other people to exercise a similar degree of grin-and-bear-it civility when I happen to drop mention of something they find is crashingly boring, stupid, outmoded, or just inappropriate to their situation.

We all need to come down off our high horses a bit and focus on the positive intentions, and remember sometime in our turn we'll all say something someone else finds weird or inappropriate, and will need someone to graciously ignore what we actually said and focus on our wish to help.

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"A lecture about Jesus" is very different from the sort of friendly casual aside you are talking about. That's not remotely what I was discussing, and you and I both know that.

I'm talking about the sort of thing where you ask a doctor to prescribe you PrEP and they either outright refuse or try to guilt you out of it, and tell you about how Jesus wouldn't approve of being gay; or, the scenario Scott alluded to, where someone is mentally ill and needs SSRIs and the doc insists that no, they actually need Jesus instead, and tells them they should simply pray more and trust in God.

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No, I don't know that, and if you meant anything in particular you should have said so explicitly. I can't be bothered to attempt to read your mind. And are you giving personal testimony here, or is this just something you heard about somewhere?

In any event, I'm still unmoved. You're not obliged to use the services of any particular professional, and they're not obliged to service you. It's a free country, and any professional relationship is at the choice of both parties. If you don't want your doctor to give you advice on your lifestyle, whether based on the Book of Mormon, the writings of Chairman Mao, Confucius, or Ibram X. Kendi, then choose one that doesn't as a matter of principle. If you have to endure a lecture about Jesus or L. Ron Hubbard or the Dalai Lama to find out, well oh well, sticks 'n' stones you know, if it ruins even the rest of your day I think you're kind of a squish or narcissist and wouldn't really want to trust you with a driver's license, firearm, or the franchise.

I will agree that the mentally ill are in another category entirely, though, because I wouldn't expect the mentally compromised to have the normal adult ego strength to be always able to cope with a collision with someone else's values. (Children are another category, also.) For people who treat psychiatric illness I would agree there should be an extra special level of care, one can reasonably insist that such a person not do damage to a vulnerable person.

But unfortunately whether a given conversation or type of advice would do damage or not is a matter of judgment, and unfortunately even the professionals will not fully agree themselves about what is the correct judgment in each case. Maybe so-and-so needs SSRIs. Maybe someone else would benefit more from church. I don't see any obvious reason to prefer one over the other a priori, since both have a long empirical history of doing some people good. I don't know how the professional makes the call in each case, and I don't have any good solution for any method by which it can be ensured that every call is correct (even assuming we can ever agree on a standard of "correct").

I am confident, though, that if you choose to tar an entire double-digit percentage demographic of your countrymen with some generic contempt, there is probably something more wrong with you than with them. It's not a bit different from concluding transsexuals are potentially murderous monsters that need close watching because of what happened in Nashville (which we would rightly condemn as bigotry).

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I speak my mind as I please. I don't care about offending sacred cows whether they be on the left or the right. I also happen to think there deserves a lot more scrutiny on the insane rhetoric coming out of the trans-activist community in the wake of Nashville, especially if upon release of the manifesto it turns out to be what many of us have been expecting. I don't fit your preconceptions - crazy!

And yeah, it's not like anyone has ever spent months navigating our nightmarish worst-of-both-worlds medical bureaucracy to finally get a much-needed doctors' appointment, after juggling referrals, copays, prior authorizations and the like. And then if they happen to get one of the sorts of doctors Scott points out, who insist on putting their religion before their duties of care, sucks to suck, back to square one, I guess?

If people obliquely criticizing some of your coreligionists hurts your feelings this badly, I think that's your problem, not mine, quite frankly. I will continue to call shots as I see them regardless of frivolous offense-taking.

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You are also apparently making assumptions, when you speak of my "coreligionists." I'm not defending my personal belief system, or tribe, I just despise reflexive bigotry and "poor me!" narcissism. I would have the same reaction if someone slagged Jews or gays or atheists. Put your big boy or big girl pants on and deal coolly and civilly with people who hold different views. If you can't do business with them, don't do business with them, but respect their right to speak their mind -- the same right you are claiming here (and which I agree you have) -- and avoid making snarky unjustified complaints about their entire tribe.

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"if it ruins even the rest of your day I think you're kind of a squish or narcissist and wouldn't really want to trust you with a driver's license, firearm, or the franchise."

It would ruin the rest of my day, yes. Maybe even the rest of the month. After

working up the courage to seek therapy, after spending exorbitant time and money getting the appointment, all I get is a lecture about Jesus? Not only is whatever problem I had not treated, I'm now out the exorbitant cost of the therapy session, and I have to spend the rest of the day or week finding another therapist?

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This is a great example of what I'm trying to say, although maybe I didn't explain myself very clearly. Wendigo has very strong, clear ideas of what constitutes harm and health. A lot of people who practice traditional religions (not just Christianity but Islam or Buddhism or Hinduism) have very different ideas about harm and health, which stem from their religious doctrines on the purpose of human life and the human body. Of course there's going to be conflict over medical care!

I don't know what to do about it, except to echo Scott and say that it cuts all ways: it's just as likely for a traditional Muslim to get frustrated visiting the kind of doctor Wendigo would prefer as it would be for Wendigo visiting a doctor who's a traditional Buddhist, or a Zoroastrian visiting a Christian doctor. Are you going to get mad if a traditional Jewish doctor tells you pork is bad for you?

We should try to be understanding about these things. Everybody believes that their own religious system, or non-religious system that asserts what the human body is for, is the One True Doctrine, and that all the doctors who believe in one of the other systems are going around harming people.

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Yes, the thing about pork from a Jewish doctor would be equally inappropriate.

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No one was talking about "wigging out" on a Doctor, for one. Not every conversation fits within the culture war about "misgendering" you are dragging into this conversation. There is a difference between someone casually bringing up Christian perspectives about your problems and someone who needs medical help having a Doctor gatekeeping access to medicine behind their religious beliefs.

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People who are "too much of a precious little snowflake to be allowed to wander the adult world without a nanny" still deserve medical care.

In fact, often that kind of behavior derives from mental illness, and if you can't get treatment for your mental illness because all the doctors are too insensitive to notice they are hurting you, sounds like you're shit out of luck.

It follows that providers of psychiatric care ought to be above-averagely good at staying within the bounds of appropriateness.

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Yes, I agree with your last sentence 100%. But since I'm not in the business, I don't have any well-founded opinions on what is "appropriate." I wouldn't be very inclined to credit the complaints of patients per se, since patients will always complain about a provider based on outcomes. Every surgeon who appears to save a life is brilliant, if you listen only to the patients with strong opinions. Every public defender who loses a case is a clown or corrupt, if you listen to only his clients with strong opinions. People aren't very objective when it comes to stuff that touches them personally.

But if the shrinks and the psychologists themselves are all in general agreement about what is "appropriate," that's fine with me, and it seems reasonable that they publish some professional code of ethics, and drum out of their professional society anyone who fails them.

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Yes!

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I used one of the pill mills. She instead prescribed me an anti depressant that worked so well I became manic after five days so I dropped it. In her defense I was definitely depressed but it was the middle of winter in the PNW during the final(ish?) Covid lockdown so if I wasn’t depressed then something would be wrong with me.

I then went to my doctor who tried to prescribe me a different antidepressant.

Finally I went to the super nurse my friend used to get his adderall prescriptions from. She gave me the same test as the others but highlighted the “correct” answers on the criteria sheet she had me fill out. She also asked me to answer sans my coping mechanisms which I don’t think is standard but should be.

I switched to another pill mill when I left the state then to another super nurse via telemedicine when I moved again.

As far as I can tell I actually have ADHD but because I coped well enough in childhood I’m considered sus. My apparently permanent gut issues from the stress I heaped on myself to function for 30 years doesn’t seem to be diagnostically relevant.

Btw it’s a bitch to get adderall regularly if you’re nomadic. But that’s one of a hundred issues with nomadism and modern bureaucracy so it isn’t especially bad.

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My personal metric is. Take a stimulant. If it makes it easier for you to have a nap and/or for you to fall asleep at night, you have ADHD.

There's a lot of people with ADHD this doesn't work for, but boy does it work on a lot of them.

Also not good for initial diagnosis, but a solid thing to point out once you've been prescribed stimulants in the past.

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FWIW I was diagnosed as an adult with one of the "objective" computerized tests, and I would fail your metric... sort of. The problem is, stimulants do make it _mentally_ easier for me to relax, but the _physical_ stimulating effect is stronger and impedes sleeping too much.

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Adderall has a strong mental relaxation effect on me too. Mostly when I haven’t taken it in a while since tolerance seems to be a problem.

I actually do sleep better with adderall too but I think that’s just from the reduced stress from being able to meet my obligations. The physical side effects took a year to manifest and seem to have gone away after I took a month break. It was affecting my sleep at that point.

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Hrm... the few times I was in public school and the entire time I was in college, I didn't really have a problem. Also call center work wasn't terrible, and I really don't have any problems with executive function or focus when I want to, but caffeine in the form of a soda definitely knocks me out. Tea goes both ways depending on type and if it's mixed with anything else.

I don't drink coffee and rarely consume caffeine at all. Not sure what other thing that's correlated with ADHD that this caffeine relationship points at.

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I have ADHD, but caffeine doesn't help me at all.

However nicotine and the common prescription stimulants work just fine.

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I was diagnosed as an adult, via one of the fancy expensive computerized tests that Scott mentioned in the post. (I was looking for confirmation that I was doing the right thing, almost as much as I was looking for a prescription, so I found it reassuring.)

I also coped very well in childhood, in the sense that my grades were excellent (notwithstanding what I went through emotionally in getting them, which of course doesn't count.) My psychiatrist told me that I probably wouldn't have been diagnosable as a kid, due to my excellent academic performance, and how the standards were set at the time.

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I was diagnosed at age 9 despite excellent grades. But because I got excellent grades my parents declined the recommended trial course of Ritalin. Putting kids on psychoactive drugs was *weird* in 1992. It was a new and implicitly extreme thing. It worked magic on the boy in the next class who had been flunking and violently lashing out at everyone, but my parents couldn’t see much resemblance between me and *that kid*. So while I’m thinking about finally trying that Ritalin thirty years later, I don’t blame my parents for balking back then.

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Anecdata, but I used to be roommates with a woman who had a teenage son with severe ADHD. One of the problems was getting him to even take the meds because they made him feel very bad.

I'm like twice his size and taking half the dose of medication. I don't blame him for being reluctant, because I suspect the side effects at that dose are not worth the active effects, especially if the active effects are not primarily for your own benefit (even while bouncing off the walls apparently he wasn't failing, he was just bored because he finished all the schoolwork before everyone else and needed more stimulation than school could provide).

I think whether these meds work depend on the patient's goals. I'm taking it so I can get my thoughts together enough to write a grocery list and make dinner. He's [being forced] to take them so the teacher doesn't have to provide him with more intellectually challenging content. No wonder our attitudes are so different!

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I had a kid in CFS care once where they casually mentioned to me what his dosage was and how he'd self-discontinued because of panic attacks. I checked - he was on like 6x the standard adult dosage, which I mentioned to them.

Fortunately I found reading stimulating in school. Otherwise it might have gone badly.

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Children's health interventions generally offer a concave payoff to treatment - I'm quoting from Nassib Taleb here. E.g. upside is small, downside is large. I think your parents made a sound risk decision.

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I'm pretty sure you are actually supposed to answer these questionnaires sans coping mechanisms, especially if the coping mechanisms have significant downsides.

For example, if you can't focus well enough to pay your bills without drinking 800mg of caffeine, I think that counts, especially if you don't actually like coffee/energy drinks and the massive doses is impacting your quality of life / health.

The psychs aren't really interested in "technically you can do it on a blue moon when all the conditions are right, leaning on a crutch that isn't always going to be there." It would be ridiculous to deny someone a wheelchair because technically, they can limp their way into any building that has a lift.

Also, I'm a renter, which can be a kind of forced nomadism in urban areas that have bad sprawl - moving every year when your lease is up can make it hard to keep the same doctor if you have to move quite far. I'm lucky that my city isn't that big, but I have friends who live in a super sprawled city where it's completely possible to go from 20 mins to an hour away from your psychiatrist.

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Try nicotine patches. They are generally available over the counter.

If anything, nicotine as a stimulant has a better side effect profile for most people than adderal.

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Compete speculation, but I think that per appointment telepsychiatry is likely slightly worse than in person, but the benefits of ease of access are worth it.

I definitely have a sense that the body language etc cues are muted on zoom, which probably ever so slightly changes the likelihood of particular diagnoses being missed. My psychiatrist has also mentioned that it's harder to evaluate patients on long term antipsychotics for movement disorders.

However, I personally have found ease of access and continuity of care to be huge upsides to telepsychiatry. On my work from home days, I can block out exactly half an hour on my calendar for my half hour appointment and it's much more discreet than blocking out an hour and a half to commute to a office. Also, my doctor has added some evening appointment slots because she doesn't need to follow the building hours of her practice. There's much less of a barrier to frequent appointments when needed.

Continuity of care is also a big factor. I moved 2 hours away within the same state as my doctor. I sought out a new local doctor at one point, but found the hassle of finding a good fit and getting to know a new doc was not worth it. I have bipolar 1 and also ADHD/a generally chatty/hyperthymic personality. It was difficult to have a new doc learn what the line is between my normal personality and an unusual mood elevation. My telepsychiatry doc has known me for several years and has seen me through a lot of different mood states and I trust that she has a good feel for what my mood episodes look like vs my normal peppiness.

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Being able to keep your doctor through moves is an enormous benefit of telehealth. Especially for people with conditions "considered sus" as malloc put it above. Not having to switch doctors means not having to repeatedly defend and/or prove yourself.

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Personally I suspect it's often much worse. There's a ton of stuff that people can notice in person that they don't on a Zoom call. That's why business people fly across the country to do really important deals, so they can all be in the same room with each other before they decide to trust each other. That's why the President still flies to summit meetings to look his counterparts in the face, rather than do it all by (since it's the White House incredibly perfect 8K) video chat. That's why ordinary Jane and Joe want to meet in person before they take their love affair to the next level.

Human beings are designed to gather tremendous amount of information through nonverbal and even nonvisual means. Does this person lean towards or away from me? Do I smell the sweat of fear? How do they react to me coming close to their personal space? Are they tapping their fingers in anticipation? And the way we look into another person's eyes is quite different from the way we look at a camera -- that's why acting is a talent, albeit less rare than one might hope.

Personally, I would never see a psychiatrist or psychologist for an initial, or important, evaluation via Zoom, any more than I would see a regular physician that way if I was really concerned about something, or a woman about whom I was serious, or a potential business partner, or any other really important meeting.

Edit: that doesn't mean I approve of the regulation, of course. Different people are different, and there are surely doctor-patient pairings where each think doing it all by video chat -- or e-mail, or phone -- is just fine, and who am I (or the government) to mess with what works for them? I'm just saying my objection to the regulation would be based on a generic "None of your damn business how any particular doctor-patient relationship works!" rather than a (to me very dubious) assertion that there's no real difference between in person and tele.

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Devil’s advocate argument: if you compared the population of controlled substance users who get their prescriptions via in-person visits to people who get them via telemedicine, you’d probably find that the telemedicine users have significantly less compelling justifications for their use. Sure, they all have cleared the bar of “get a doctor to say you need a controlled substance”, but the bar is undoubtedly lower in telemedicine versus in-person medicine for what qualifies as a “need”.

Based on that logic, it’s reasonable to seek to accomplish the policy goal of reducing the amount of controlled substances being prescribed by seeking to convert some amount of telemedicine patients into in-person patients. Those people with strong justifications, and therefore strong incentives, will be more strongly incentivize to jump through the hoop than those people with weak justifications.

I think this entire discussion would be more fruitful if it focused on alternative pathways to achieve a policy goal of reduction in the total number of prescribed controlled substances, rather than just pointing out the flaws in this particular manifestation of that goal - which every plan will have, of course.

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I'm not actually sure that's my goal - see https://slatestarcodex.com/2014/09/17/joint-over-and-underdiagnosis/ and https://slatestarcodex.com/2019/09/16/against-against-pseudoaddiction/ . My guess is that more people being on controlled substances overall, at the same legitimate-patient-to-abuser ratio as today, would be net good.

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the clinician at the aforementioned "very institutional-seeming neuropsychological clinic" ended her session with me by saying "honestly it might be net good if there were Adderall in the water supply, we used to say it did nothing for you if you didn't have ADHD but that was a lie to stop people from abusing it"

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A 2018 Pew survey of Americans listed drug addiction as one of the top concerns, beating out basically every other concern but healthcare affordability. It's a short and clear line between drug addiction and prescription of controlled substances.

I don't necessarily disagree with your stance, but I'm fairly confident your stance is out of step with the majority opinion.

https://www.pewresearch.org/fact-tank/2018/10/22/more-in-u-s-see-drug-addiction-college-affordability-and-sexism-as-very-big-national-problems/

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> A 2018 Pew survey of Americans listed drug addiction as one of the top concerns, beating out basically every other concern but healthcare affordability.

Sure, because over a million people have died from opioids, and addition is a serious problem among the homeless which is itself a growing problem. I doubt very much this is the cohort Scott is talking about here that would be impacted by telemedicine on the substances he's discussing. If anything, these substances would reduce some of the issues causing homelessness.

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I got my ADHD (and autism) diagnosis in probably the most legitimate way - I underwent a full neuropsychological evaluation that took several hours and took place at a very institutional-seeming clinic.

I still came away feeling like the central criterion seemed to be that I was willing to spend the time and money, and that if I hadn't brought up ADHD or autism I might not have ended up with the diagnoses. This despite the fact that my symptoms are pretty textbook. So idk man, unless by "the bar is lower" you just literally mean "it costs less time and money", I'm not very convinced.

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>"...it’s reasonable to seek to accomplish the policy goal of reducing the amount of controlled substances being prescribed..."

Only instrumentally; if the policy goal is itself unreasonable (my opinion), then no actions in support of it are themselves reasonable.

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>>policy goal of reduction in the total number of prescribed controlled substances

This is a horrible goal, but easy to achieve - just make it illegal to prescribe them!

A better goal is for people to have better life outcomes. To be healthier. To be happier in the eudaimonic sense. More narrowly, we should aspire to prescribe fewer drugs to people made worse by them, and more to those people who would benefit from them.

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The telemedicine law referred to is 21 USC § 829(e), https://www.law.cornell.edu/uscode/text/21/829#e

In particular:

(A) The term “valid prescription” means a prescription that is issued for a legitimate medical purpose in the usual course of professional practice by—

(i) a practitioner who has conducted at least 1 in-person medical evaluation of the patient; or

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What's the base rate we should expect for governmental competence in 'emerging' technology + medicine in the US?

Sounds like the new rule is *slightly* better than Australia's, but probably worse than Canada's. But then, it doesn't sound like the government is creating a central database of prescriptions that it then mines for use in a campaign of domestic surveillance so ... it could be worse?

What's worse than government neglect? Government scrutiny.

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"If for some reason that doesn’t work, go to a different psychiatrist and try again. You don’t have to tell them you already tried, and HIPAA bans psychiatrists from communicating about this kind of thing among themselves."

Scott, to the best of my knowledge, this isn't right - as far as I know, only records for substance use-disorder treatment and separately maintained therapy notes have special restrictions on them (the former via another law). Generally, providers can communicate with one another freely for coordination of care without a patient release. See the link below from the HHS website that does a decent job of explaining what the rules are.

https://www.hhs.gov/hipaa/for-professionals/faq/3007/when-does-hipaa-allow-hospital-notify-individuals-family-friends-caregivers-patient-hospitalized-psychiatric-hold-been-admitted-discharged/index.html

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Interesting. I'd definitely heard the opposite, and have a lot of trouble with other providers who won't talk to me without HIPAA releases, but you seem to be right. Thanks!

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Oh yeah, the only reason I am so confident about this is because I got into a very heated fight with another hospital's medical record's department who refused to send me a patient's records despite me providing her with the HHS links that clearly showed that this was not a legal issue, because, "why should we give it to you if the patient doesn't want you to have it?"

I'd say it's about 50/50 in terms of people who dig in their heels and insist that I cannot possibly be correct (and even refuse to look at the HHS website), and those that go "Oh, I didn't know that" and then proceed to tell me whatever I want to know.

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This is a standard issue when it comes to anything HIPAA. The threat of the law has a much wider reach than the actual law / rules. I don't know how many HIPAA consultants I ran into that I saw providing inaccurate advice that coincidentally supported whatever product they were selling (so you paid for the consultancy AND the product! And likely didn't actually get any real HIPAA protection...)

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Interesting, but it does not obligate them to share. I have done what Scott describes (reroll doctor to get desired outcome) several times and specifically avoid signing hippa disclosures and requesting that they not share info with other healthcare providers. I would hope they'd respect my wishes even if not legally bound to do so

Also practically, if a healthcare provider doesn't know that you've been treated elsewhere in the first place, they couldn't really request that info, could they?

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If you got a prescription from another provider, there are patient information broker services that the new provider can use to find out about it, even if you don't mention it yourself.

This happened to me once (with one of those telepsychiatry services, incidentally). I was shocked and spent the rest of the week on the phone with my insurer, the pharmacy where I picked up that prescription, the providers, and the broker trying to figure out what information was shared and by whom.

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I think we are only obliged to share if the patient requests that we do so. For the majority of patients, yeah, if you ask me not to speak with someone else I'll abide by that. If you're a paranoid schizophrenic in the middle of an acute psychosis on my inpatient unit and refusing to let me speak to anyone... sorry, I'm going to try and get those records anyway.

To your second paragraph: Healthcare records systems are more and more interconnected these days, and there are lots of ways that physicians can find out who you see. There are EMRs that communicate with one another, patient information brokers, and prescription databases that have the name of the prescriber and the pharmacy.

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All states but Missouri have a database that tracks controlled substance prescriptions, although they vary somewhat at the margins about which drugs they track. Pretty much all of them track opioids, stimulants, benzos, etc. Some states legally require physicians to check this database each and every time they prescribe a controlled substance, although there is not really a mechanism for enforcement there.

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Isn't the scenario Scott described one of a failed *attempt* at a prescription, such that there'd be nothing captured by the database.

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The specially protected categories, at least at the federal level, are records about treatment for substance-use, records about treatment for HIV/AIDS, and, for some reason, records about sickle cell status.

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I admit my comment was poorly phrased and I apologize for offending with my tone. To clarify my point, I'm not really all that interested in the object level question about telemedicine, I'm asking about what you consider the rules to be about when and what types of evidence are needed. Certainly I may be missing something that's clear to others, but to me the approach you took to, say, Ivermectin is markedly different than what you took toward telemedicine, where evidence either way didn't even get mentioned. (not that I disagree with any of your conclusions on these topics!). So, I could imagine your position being, at least looking at the first post:

1. There is no good evidence about this regulation, so we have to do the best we can without it until it can be had.

2. This regulation is the sort of thing that there can't ever be strong evidence about either way, so we have to find some other way to think about it permanently.

3. Government regulation generally has a high burden of proof, so any regulation can/should be repealed if the evidence in favor of it is weak or ambiguous.

4. Your experience and people's general common sense is so clear and overwhelming on this topic that looking for scientific support would be redundant.

I think any of those are plausible, I'm just surprised, given the rest of your corpus, that none of them got a mention.

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The fundamental difference from the ivermectin situation is that it was at its root a fight about getting the government to approve a medical intervention, whereas in this case it's about restricting access to an intervention. Having different standards of evidence for a proactive vs. a restrictive action seems reasonable.

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> the most severe ADHD patients get distracted and fail to jump through the hoops and then I have to decide if I really want to deny them medication on that basis or not.

This is darly ironic in the actually-ironic sense, at least for the amphetamine case. They want prescriptions written to "legitimate" patients and not "abusers", but the patients that most need the drug are least able to jump through bureaucratic hoops. Hence, not only do the regs fail to disproportionately inconvenience pill pushers over honest doctors, they also disproportionately hurt legit patients over fakers. It might reduce the absolute number of abusers, but it will probably *increase* their relative proportion.

(source: personal experience. It took me years to navigate the system sufficiently to get dexedrine, even once I'd decided to get medicated. Today I keep an emergency reserve for prescription hoop-jumping -- because I need the meds to maintain the executive function required to *get* the meds. Life would feel less precarious if they were available non-prescription from behind the counter, like working decongestants are)

I don't know a good solution for this. There may not be one. It seems like a problem inherent to any condition where the patients are bureaucratically-impaired and the treatment has a secondary recreational use.

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You already know this, but remember that stockpiling medication is considered a sign of abuse: make sure you don't mention you do this.

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Is there some kind of professional who can assist people in navigating bureaucracy. Like a private social worker? Margin probably isn't good enough to support it. But is that even legal? You can have someone fill out your taxes, and have someone prepare your healthcare exchange application, can you have someone who is not your power-of-_____ be the person that handles your Rx and medical hurdles? Is there already a service for this?

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My former employer had a health care advocate service where you could sign a form authorizing them to have access to your records and speak on your behalf to resolve specific problems like billing issues with doctors or insurance. I don’t know if they would have done exactly what you’re describing. My current employer doesn’t really offer this service and I miss it a lot. If your idea doesn’t exist that would be an amazing business, I would def sign up.

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Apparently that's the keyword. Healthcare Advocate. Looks like there's a number of businesses and independent contractors that provide the service. Quick skim sees the ICs coming in at $75-$150/hour but I'm sure there's a way to drive the price down by combining cheap call center labor for tasks like appointment scheduling with a case manager for the planning/strategies.

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This, so much this. I really couldn’t adequately navigate getting or affording in-person psychiatrist visits (I will delay returning a phone call for weeks and traditional offices refuse to use email to book appointments even after I begged them over their voicemail to return my call via email) So I went untreated until telemedicine made it very, very ADHD friendly because I only had to click buttons on an app to schedule.

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I'm a psychotherapist who for years did therapy with people via video, phone, and email before Covid hit, when all of us had to do that.

I can't speak to the prescription drug angle of this, but I can say from lots of clinical experience in person and remote using a variety of technologies, that it's helpful if people add "for whom?" when they ask about whether telehealth is better or worse. The research before Covid already told us that it's better for some people and some situations and perhaps not as good for some others, but that overall outcomes are close enough to in-person that we ought to think of remote, technology-mediated mental healthcare as on par with in-person.

There are 24 states in the US that have passed "parity laws" requiring private insurance companies to cover telehealth just as they do in-person -- and part of that is in recognition of the research showing it's just as effective and accounting for the importance of increasing healthcare access to people who face impediments (geography, mobility, schedule, childcare, etc).

Back when I mostly met with people in-person, the portion of my patient population with ADHD were much more likely to miss appointments. During Covid, that changed because it was much easier for a person to not miss an appointment even if they forgot all the way up until the time of the appointment. To my mind, that's a good thing.

Patients of mine with more social anxiety, introversion, and a variety of other concerns do better meeting using remote technology. That obviously may not apply for extroverts or a whole range of other people. The cool thing about telehealth parity is that patients increasingly have the right to choose the format for meeting that best meets their needs, whatever the mix of factors is for them. And they can change their minds and move from one way of doing it to another as their preferences or circumstances change. This increased flexibility for patients seems a good thing to me.

I don't have trouble reading faces in the way Scott describes and I find the different mix of information that comes through phone, video, and text is differently but equally rich as meeting in-person. There's research showing the online disinhibition effect can enable people to bring more things into the clinical encounter when it's technology-mediated than they would in person. Again, that doesn't mean it's the best option for everybody, but it's really good in my mind that it's more and more an option for those who find it beneficial.

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thank you for this important field report predating covid!

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I think there's a pretty straightforward argument about why telemedicine is more helpful for pill mills than for normal doctors. I don't know if that argument is _true_, but I think it clearly exists. The argument is that telemedicine makes it easier for patients to match with a doctor of their choice, which lets bad patients find bad doctors.

Let's say that without telemedicine, most people only have one or two choices of psychiatrist who are convenient enough to get to in person, covered by their insurance, and moderately qualified to deal with their issue. If you're a patient who 90% of doctors will agree should get an Adderall prescription, the odds that at least one of those doctors will prescribe you Adderall is 90-99%. If you're a patient who 10% of doctors would agree should get an Adderall prescription, the odds that at least one doctor will prescribe you Adderall is only 10-19%.

If you allow telemedicine, maybe that means that each person now has access to 100 doctors or 1000 doctors. Now, even if only 10% of doctors would give you a prescription, the odds of at least one doctor giving you a prescription is basically 100%. And if you allow doctors/mental health startups to advertise on the internet, it's not even going to be hard to find that one doctor who would prescribe you Adderall, because they'll tell you who they are.

Maybe this isn't an issue for hardcore addicts, because those people will go to whatever lengths are necessary to find a pill mill doctor anyway. But it might be a pretty serious issue when it comes to people who want to be able to pull 16 hour days working with spreadsheets and think they might benefit from a little boost. That person might be told about side affects and dissuaded from trying stimulants if they have to talk to their local doctor, who's probably a reasonable person (assuming most doctors are reasonable people), but might go for it if they get a targeted ad online that directs them to a doctor who prescribes everyone Adderall.

Of course, the exact same argument means that telemedicine is really important for people with rare, hard-to-diagnose problems, or people who only work well with a handful of therapists, or anyone else who benefits from having a variety of choices for their doctor. And, likewise, telemedicine is really important for doctors who are ethical, good, people with an approach to medicine that is unusual. But the restriction "you are only allowed to ask one doctor for a diagnosis, and you don't get to pick that doctor" is a lot more obviously restrictive of pill mills than "you have to go to the doctor naked" or "doctors must have first-floor offices" or any other arbitrary bureaucratic restrictions. Restricting telemedicine isn't exactly the same as "you don't get to pick your doctor" but it is reasonably close.

This isn't to say that I think this is a _good_ rule, because I completely accept your account of the harms from this rule. But it is to say that it's a rule that seems like it's plausibly targeted against a real problem to a greater degree than you're giving it credit for.

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"Everyone has a vague sense that if they overprescribe controlled substances, according to some inscrutable criterion, something bad will happen to them."

Pharmacists too. If you overdispense controlled substances as a percentage of total prescriptions dispensed, your WHOLESALER (not the DEA) says "no more controlled substances for you." But they won't tell you how much is too much.

https://mattstoller.substack.com/p/the-monopolies-behind-the-adderall

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I honestly have mixed feelings about pill mills too.

On the one hand, it just feels ... bad. I don't believe in legalizing most drugs (but I'm consistent! if we could beat the lobbies, tobacco would be out) and while I don't know enough to make the call on ADHD type drugs, I lean towards "maybe they should be restricted yeah?"

On the other hand, I've had a friend who was able to get their antidepressants basically from a pill mill and it has had a clear positive effect on her quality of life. So, it also seems like maybe some people who are miserable and don't qualify for an official med, but would otherwise probably deteriorate/kill themselves, now have the easier access that at least 50/50 works and the "bad 50%" isn't going to make things that much worse.

idk. If only things were clear and simple

Also, I just sort of hate technology and especially hate video calls, so I won't deny that that influences my opinion.

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"On the other hand, I've had a friend who was able to get their antidepressants basically from a pill mill and it has had a clear positive effect on her quality of life."

Well, from all the posts and discussions about anti-depressants and which ones work for which patients, I'm glad your friend got lucky there. But it does seem to be something that needs to be monitored and adjusted and if X doesn't work, then try Y, and that needs at least one in-person meeting with a doctor. Especially because of side-effects, interactions with other drugs, and the need to ramp up slowly and taper off slowly.

"Fill out this form, get a phone call, and we'll sling you a script" isn't that kind of care.

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