Guess that Awkwafina song now needs a partial re-write.
Isn't Bernie Madoff dead? He's dead, right?
Nah, that motherfucker not dead, he in jail getting booty-rammed by the feds, getting tossed by a dude named Big Ed, in a hotbed, eating ramen noodles and crying
Different brands use different formulations, apparently the brand that the dealership puts in at BMW/MINI doesn't play nicely with some of the brands from supermarkers.
More of an issue for newer cars though, I will give you that.
But if you look at the biggest pickups from the 80s they're not really that big. The whole compact and subcompact truck market has vanished. People only want 'em big.
Well, I recently switched from a sedan to an SUV, so let me help:
1. There are rows of SUVs parked at most residential intersections. This way I can actually see what's going on at the intersection, and if I can safely enter it.
2. Less headlight-in-eyes issues.
3. More storage capacity in the trunk. Yay! I don't live in Madrid or London; I can't just stop by the nice little corner store on my way home and get fresh produce. I have to do trips to Costco and haul back a supply. This makes a big difference.
4. More room for fitting the kid's car seat in the back. Since car seats in close proximity to a driver's seat are dangerous (if they should impact during an, uh, impact), this is safer.
5. Better stability in our regional weather.
That's why I switched. Please be so kind as not to eat the serpent's tail: I don't care that if fewer people bought SUVs 1 and 2 would be irrelevant. I care that they -do- buy SUVs and this is my safety-oriented response to that reality.
So as people try to increase their safety in vehicle it becomes a feedback loop until the roads cannot be expanded further.
Meanwhile lower drivers, pedestrians, bicyclists, and everyone living within a few miles of busy roads suffers from blinding headlights, more deadly impacts, and increased pollution; respectively.
I've got an old 4Runner. It was $1400. It does great in snow. It doesn't get hung up on dirt roads like our minivan does (there are dirt roads where I live). I can fit the whole family and all of our ski gear. I can tow a trailer (van can do that but the car can't). It's body on frame construction like a truck and handles tons of abuse. Granted, it's actually more like a car than modern SUVs, which are huge...the 4Runner is narrow and can fit in my tiny driveway. Anyway, there's a lot to love about SUVs, they're practical for a whole lot of things.
> You're sitting significantly higher than most traffic, giving you a much better idea of what is going on around you.
This also comes with a higher center of gravity which makes it more difficult to control the vehicle during emergency situations
> -Mirrors tend to be very large by car standards, further enhancing your awareness.
Larger vehicles tend to have bigger blindspots (even with properly adjusted mirrors)
> While riding tall, they are often both relatively short and narrow, further easing your life in traffic.
But you still have a higher center of gravity and worse vehicle handling as a result. Trying to swerve around something or make an emergency lane change makes it more likely you'll lose control of the vehicle
> Oh, and winters.
This is more a factor of the type of tires used and how many wheels are driven. My all-wheel drive vehicles do very well in the winters when equipped with snow tires.
> Anecdata - my Land Cruiser is shorter and narrower than my wife's VW Passat, has more than twice the trunk space and just over half the turn radius.
How would your Land Cruiser do in the moose test versus the VW Passat?
This is the video[1] of a Toyota Hilux during that test. And this is a video[2] of a VW Passat. Note that the first video was done while the driver was going 37 mph. The second was at 45 mph.
-Do note that the question I was (poorly, as it were...) trying to address was 'what is the appeal of SUV/4x4 type vehicles?', not 'why is a 4x4 the only right choice, for anyone, under any circumstances?'
That being said - yes, the narrower track and somewhat higher CoG does make the LC handle less well than the Passat at speed, however this disadvantage is largely negated by the local conditions - I live in a (very) rural area where the posted limit is mostly 20 or 30mph.
Blind zones are definitely much smaller in the LC - side mirrors are almost three times larger and placed farther from the vehicle body; the rear window is more than 50% larger and, crucially, more than a foot closer to the rearview mirror than in the Passat, greatly improving the view.
I agree tire quality and wheels driven affect handling very much (obviously!) - part of the (local) problem being that when it snows, it really snows, and with very few people living on this island, every snowfall is effectively a DoS attack on the roads. When there are 6-8" deep ruts while waiting for a plough to eventually arrive, 15" ground clearance beats 6" ground clearance every time.
As for moose, luckily we don't have anything larger than deer, but if we did, I'd rather be in the Passat driving under the moose rather than in the LC getting it in the face, no doubt.
Again - I did not intend to leave the impression a Humvee was the only choice which made any sense -rather that 4x4s have properties which make them sensible choices to some people in some locations.
I used to feel this way until I rode around with my roommate a bit in his pickup. clipping a curb in my small hatchback would scrape or even deform the rims. in a big truck you don't have to care. he wouldn't even try to avoid curbs; he would just roll right over them if he felt they were inconvenient.
another (possibly more legitimate) reason is that many speed bumps seem to be calibrated for large vehicles with lots of suspension travel. the speed bumps at the grocery store I go to are incredibly jarring in my car, feels like I am bottoming out the suspension even under 5mph. in a big truck, this is not a problem.
People like big vehicles; people like to sit up higher; small women especially like them because it makes them feel more powerful. Finally, Americans just don't care about fuel economy, or cornering ability, or having a vehicle that doesn't roll over easily.
People like to sit up higher so that they can see over the other people who like to sit up higher, recursively.
People like to have a heavy vehicle so that they feel less at risk in a crash with other people who like to have heavy vehicles for the same reason, recursively.
But does it work with the native keyboard when it sees a password field?
Edit: Nevermind. I see it now. I need to explore this. It just that it can’t be 1Password for the reasons mentioned above. Any good alternative that someone can recommend?
You could try Bitwarden (it’s not as rich as 1Password, but is adequate for web logins, cards, etc.). You can even self host forks of it if you wish. You get a lot for free, but it also has some paid tiers that are quite cheap with additional features.
With how massive the wheels and tires are, maybe hub motors with batteries packed in their centers could work. I don't get the impression that monster trucks strive to minimize unsprung weight, the tires are wrecking balls.
You wouldn't need huge battery life for a 15 minute performance, so shaving off battery weight might just work. What most people go to see is airborne jumps rather than crushing things hence need for low weight.
IIRC the rubber tires weigh 1000+lbs each, I wonder if the tires could be implemented differently using lightweight materials shifting their weight budget into hubmotor+battery.
Tires are consumable so you're unlikely to see monster truck teams adopt anything too exotic for cost reasons unless there's a huge performance improvement to go with it.
On the other hand, I hate the general attitude of "don't question your doctor or do your own medical research; the doctor knows what's best"
Doctors are mortals too and can only have so much time to draw on info they crammed X years ago. Patients can quickly become more expert than GPs with regards to their own diseases, especially if they have months to research it.
Anecdotal example - my sister had a wierd skin condition in high school. My mom researched skin images and symptoms for hours and hours and concluded it was shingles. My Mom then brought her in and discussed her findings with the GP who scoffed and said she was far too young for it to be shingles. He then admonished my mom for doing her own research. Long story short and one embarrassed GP later, it was shingles.
But medical advertising doesn’t inform the patient. Often it misleads. It has no value. Having medical information in public would be good so people can learn themselves but advertising provides no value.
FDA has done research into it and it clearly provides some value.
Other highlights of the surveys include:
Most physicians agreed that because their patient saw a DTC ad, he or she asked thoughtful questions during the visit. About the same percentage of physicians thought the ad made their patients more aware of possible treatments.
Many physicians thought that DTC ads made their patients more involved in their health care.
I would imagine you’d need to draw a correlation between advertisements and quality of care and successful treatment rate; awareness and involvement aren’t positive or negative per se.
Secondly, I see too many damn branded pens in my doctor’s office to be under the illusion that the marketing is only directed at the patients. I can’t count the number of times I’ve been prescribed medication just to have it swapped out at the pharmacy for a generic variety. Doctors are just as susceptible to advertising than the rest of us, except exclusively at harm to the patient.
The demonstrated “value” being provided seems to be mostly in the form of cash in the pockets of providers and pharmaceuticals, not in material benefit to the patients.
Secondly, I see too many damn branded pens in my doctor’s office to be under the illusion that the marketing is only directed at the patients.
I can assure you that drug reps didn't bring in catered lunch to my ex-wife's GP office for the benefit of better informing patients about their choices. We got divorced 30 years ago, but I'd bet money I've still got a sticky note pad lying around the house somewhere with a pharma company's name on it.
There's plenty of drug marketing going on that will never come under the gaze of a patient.
So, the reason they've got branded pens is that the drug reps are allowed to give them pens, so they do. Trivial low value gift. Historically the doctor wouldn't remember HealthyHeart brand beta blockers because of the 40 cent pen but because they paid for his two week safari. Most of the world banned that, but not so very long ago. My nurse friend didn't spend a penny of her own money on big birthday events when she was younger, drug reps paid for everything. (In the NHS system some nurses have full prescribing powers I presume some US nurses likewise but even if not it's the same for doctors)
Drug reps in the US quit giving away pens and coffee mugs in the US in 2008, in accord with PhRMA rules (that's the drug manufacturers' association/lobby). They got to say it was improved ethics, but it was also a mutual disarmament agreement of sorts. "We'll stop giving out sticky pads if you will."
If the true goal is to educate the patient, I'm 100% certain there are more effective and ethical ways to accomplish that goal other than for-profit advertising (which by definition cannot be unbiased).
They can be sued for making false claims. There's no value in doing so, especially in a high profile medication.
Why would you spend a couple billion dollars on research/marketing, years of research, to bring something to market only to shoot yourself in the foot by making false claims?
I'm a trans woman. It's widely acknowledged in the trans community that most of us have to teach our doctors what meds to prescribe, what starting doses are common, and how to interpret lab results to determine how to titrate the dosage. Most of us have read the Encdocrine Society's clinical guidelines for HRT cover to cover, because we have to be the experts. And half the time, it turns into a fight. At one point, I had to print out relevant sections from the Endocrine Society's guidelines and use a highlighter on key parts just to demonstrate that my dose needs to be upped, to a level that's still regarded as safe, because my levels were way too low. I was so happy when I switched to a better doctor a couple of years later.
And a lot of us end up ordering our meds from gray-market online pharmacies anyway and paying for our own blood tests (usually via Private MD Labs).
If you can, I'd encourage you to find the care providers you need.
One friend moved to become a patient of the #2 Lyme disease specialist.
Another moved to become enrolled in a clinical trial. He was proclaimed terminal and went doctor shopping. (Still alive today.)
I've stayed anchored in my house for decades because I won't risk leaving my care providers (SCCA, FHCRC). I've had terrible experiences with noob doctors. As in life threatening.
I now better understand how doctors think. Recurring rounds of 20 questions time boxed to 15 minutes. Hopefully they've seen your condition before. If not, oops, too bad, out of time, take two aspirin and call me in the morning. Next!
> Patients can quickly become more expert than GPs with regards to their own diseases, especially if they have months to research it.
Waking into a 15 minute appointment with months worth of research seems like a bad way to approach collaboration with healthcare professionals. Or do people still have personal relationships with doctors outside the appointment window?
It seems like GPs have become dispensers of medicine rather than care.
It isn't always possible to answer every question in 15 minutes, but I think it's helpful when people have questions to come prepared with those questions. It's literally our job to provide health advice; the "realities" of dealing with high volume can't/shouldn't change that.
Concierge medicine in some areas allow hour long appointments which makes the exchange of complex health concerns effective. I really wish the model would scale up, but primary care doctors are currently slaves to an administration.
So I have a friend with Hashimoto's. Before finally being diagnosed, she had a long history of being misdiagnosed, blown off, and having her symptoms dismissed as nothing. After being diagnosed, she connected with a number of other Hashimoto's patients and sufferers of chronic illness in general and found out that pretty much everyone she's talked to has the same stories. Constant invalidation, ignoring of symptoms, doctors just plain not listening, until they finally find someone who actually knows their stuff.
>Patients can quickly become more expert than GPs with regards to their own diseases, especially if they have months to research it.
A couple of years ago my GI specialist put me on a medicine that had just been approved that was designed for my type of gut issues. We spent a lot of time talking about what we hoped to see, and he spent a lot of time listening to what my experience actually was. This has continued ever since, and he always spends a lot of time listening, because I am one of his few patients that takes that medicine. This patient / doctor feedback loop is incredibly important!
>Doctors are mortals too and can only have so much time to draw on info they crammed X years ago.
First, doctors are expected and generally pursue continuing education. As much as the "golfing at an exotic locale during a medical conference" is a meme, many of those conference also educate doctors on new therapies.
Second, let's not pretend that the drug conpany reps don't get as damn close to bribery as possible to get their medications in front of doctors and in hospitals
I have a lot of serious long term health issues and quickly found out you have to be the champion for your own health and research everything. But that doesn't mean just asking for the latest drug in the market. Its about asking the right questions. Unless you have a common well understood health issues, you will quickly reach a roadblock.
don't forget ED drugs! america: take all the dick pills you want through a shady phone app (sponsored by VCs) but don't expect to have have your life threatening illnesses treated affordably!
edit: i'm getting downvoted. in case you weren't aware the subways in NY are plastered with HIMS and Roman health ads.
I know a couple of doctors overseas and while there isn’t direct to consumer advertising for Rx drugs, the doctors get invited by the pharmas to conferences in the Greek islands or the Adriatic, sometimes they are invited to “talk”. They can bring their spouses too... in addition I think they get kickbacks for Rxs -but I’m not sure.
Is it really such an odd question? Putting advertising outside, it seems to me that it would be a common occurrence that someone dealing with problem X has probably spoken to other people with the same issue, and what the group knows works well would be spread around. In my case, I'm asthmatic, and I know very well what works best for me, simply because I've had decades of experience figuring it out. When I've gone to see a new doctor, I've been specific in my medicine requests, and it has been received well enough.
Sorry that’s not what I meant... it was a joke of course but I was saying if you suggest any course of treatment to a doctor you’re going to get a hairy eyeball in response. I wasn’t saying anything at all about the places where ads are allowed.
That's why we (the Dutch) have pharmacies that take the prescription of the doctor and then determine, based on your current medicine and medical history, alter your new prescription to fit your need (and he will confer with the GP if needed)
In the US, we have something similar (but evil) that people don't know or refuse to acknowledge.
A Doctor writes a script, and then a pharmacist (not on their own, but at the direction of an insurance company) suggests a change typically to benefit the insurer (for example changing a name brand to a generic or changing 30 days to 90 days so the patient doesn't get seen by the doctor again for 90 days for additional testing/monitoring). In the US the pharmacy/pharmacist can not change the script so they send the recommendation to the doctor for approval (and get paid a bonus from the insurer for sending the request), if the doctor approves the pharmacy gets a 2nd bonus, if the doctor does not make the change, there is a very good chance the insurer will drop the doctor from their network for not doing what the insurer asks to lower their costs through the pharmacy proxy.
In most states, the law explicitly requires the pharmacist to fill a prescription with a generic (if available) unless the doctor specifically writes "dispense as written". Not allows - requires.
The purpose of these laws is to protect patients - in the overwhelming majority of cases, the generic and brand name drugs are equivalent for patients, so patients save money by purchasing the generic medication even if the physician prescribed the drug using its more well-known name (the brand name).
Its not the patients that lobbies for these laws...it is the insurers, and its to lower their costs.
Its also why the insurers pay the pharmacists a bonus for these changes, if it was about costs to the patient, the bonuses (money back) would go to the patient.
> Its not the patients that lobbies for these laws...it is the insurers, and its to lower their costs.
I mean, no, patients don't lobby for them because patients don't really lobby en masse for healthcare policy in general, but patients definitely are the ones who benefit from them.
There are some cases where the relationship between insurers and patients is adversarial. This is not one of them.
>There are some cases where the relationship between insurers and patients is adversarial.
Well imagine your doctor gives you a Rx, you go to fill and the insurer tells the pharmacist to ask doctor to change it. If the doctor disagrees (for whatever reason) the insurer may drop your doctor from their network, then you will be stuck going to a doctor who does whatever the insurer asks.
If you feel there is no conflict there or that isn't adversarial that is fine...in my experience both patients who lose their doctor and the doctors themselves disagree.
That's not something similar, and has nothing whatsoever to do with what you replied to.
And there's nothing wrong with switching from brand name to generic, and most patients don't need to see their doctor every 30 days, and if they do, they can still make an appointment.
The length of the drug prescription does not control the appointment - and anyway you can just call and they'll extend the prescription on the phone.
>And there's nothing wrong with switching from brand name to generic, and most patients don't need to see their doctor every 30 days, and if they do, they can still make an appointment.
For patients with chronic conditions if the doctor determines the patient should be seen to evaluate their condition in 30 days before a new script is written, insurers having pharmacists effect a change to 90, is a direct interference with the doctor's practice of medicine. The doctor should make the determination, because they have the relationship with the patient, they know if they are at risk or likely to adhere to the therapies better than an insurer making broad brush strokes based on the cost to insurers. You also skip over the part where doctors get dropped from the insurers network when they don't accept the insurers "recommendations."
>The length of the drug prescription does not control the appointment - and anyway you can just call and they'll extend the prescription on the phone.
Sure, but that is not how it works in practice, the patients won't set up another appointment until they need another script, which is cheaper for the insurer and worse for the patient outcomes. Nevermind the Doctor being in the best position to determine which patients should be seen every 30 or 90 days, the shorter duration and 30 day appointments lead to higher percentages of drug adherence...which is a major issue in the US leading to about 1 million hospitalizations per year.
> For patients with chronic conditions if the doctor determines the patient should be seen to evaluate their condition in 30 days before a new script is written
I'm reasonably cynical about lots of things, but I would be absolutely shocked if a pharmacist can give you 90days of pills when handed a 30day (no refills) prescription.
The don't unilaterally change the Rx and hand it to you...they fax the Dr. a request for change to the therapy (and earn a bonus from the insurer for sending the request for change). If the Doctor authorizes the change, the pharmacy gets a 2nd bonus payment from the insurer.
If the Doctor(s) refuse to make the requested change that data is tracked and eventually the insurer will drop the doctors from their network.
>It doesn't, it has nothing whatsoever to do with that
Yes, the patient could pick up the phone and schedule another appointment, or the doctor could call to try to schedule another appointment in the meantime. You are missing the point...in practice those appointments don't get rescheduled.
The Doctors and insurers know this, which is why the Doctor tries to do 30 day scripts for at risk patients so they can be closely monitored, and its why the insurer attempts to change 30 day therapies to 90 day because they know the patient won't schedule an appointment in the meantime and that saves the insurer money.
Anyway its clear you see nothing wrong with an insurer interfering with a doctor's practice of medicine...or the other part you keep glossing over that is the insurer dropping doctors from their networks (i.e. patients losing their doctor) when the doctors don't follow the insurers requests for changes to therapies.
>Such a patient isn't going to correctly take their medication either, 30 days or not.
Exactly that is why the doctor specifically writes a 30 day so they come back in and can check their numbers.
>Insurance companies do a lot of bad stuff, but you seem to have invented a whole new class of things that they just don't do.
When you hear the term consolidation of the healthcare market this is what they are talking about. There are numerous lawsuits right now by doctors against insurers for dropping them, illegally, from their networks and sending their patients to new providers/practices that are owned by the insurers. You can find any number of those lawsuits, if you cared, but here is an article on the practice of insurers buying providers (to control all aspects of their costs), you have insurance A, odds are you are only able to go to a doctor practice/hospital owned by the insurer.
You are wrong, and it is clear you have never even heard of Medication Therapy Management (MTM) or OutcomesMTM. Walk into any big pharmacy (walmart, cvs, walgreens) and ask the pharmacist about OutcomesMTM and MTM generally. Or use this link to a OutcomesMTM report and learn about it http://www.outcomesmtm.com/wp-content/uploads/2018/02/2016MT...
>"Today, more than half of U.S. pharmacies are active
in OutcomesMTM programs, earning revenue for their clinical services while helping healthcare payors reach their goals."
>Each year, OutcomesMTM recognizes pharmacies and pharmacy chain organizations with exceptional performance in delivering MTM services. Top MTM Center and Top Chain awards are based on the organization’s overall effectiveness in delivering CMRs and resolving drug therapy problems through TIPs
Sure, but neither is the guy who asks for a new drug based on the 30 second ad he just saw.
If I go to my doctor and say "hey, for my condition XYZ I hear there's a new drug ABC, would that offer any benefits over what I'm on now?" that's one thing, but if I go in and say "hey give me that ABC" they'll correctly roll their eyes at me.
That's what I meant - you can use that first phrase and the doc's very likely to say "No." with no explanation. Even if your current drugs aren't working well.
I get it, they're nearly always overworked and tired, and most of their clients are idiots.
But people should be free to try something new without all this gatekeeping that keeps getting worse.
At the same time, place the responsibility on the user if they request something out of the ordinary, of course.
Isn't Bernie Madoff dead? He's dead, right?
Nah, that motherfucker not dead, he in jail getting booty-rammed by the feds, getting tossed by a dude named Big Ed, in a hotbed, eating ramen noodles and crying