brentashley

In the same week that the US Government has shut down ostensibly in a squabble about improving the lot of health care to Americans, I’ve had a couple of painful shutdowns of part of my renal system with a large kidney stone intermittently blocking my left ureter.

I thought I would tell you about my experience this week as a patient in the Canadian health care system, in this case at one of Ontario’s busiest emergency rooms, Brampton Civic Hospital. A lot of effort has been spent in the US vilifying the Canadian healthcare system, so I thought a real-world story might be beneficial to counter some of the misinformation.

I am a 52-year old white male, 6 feet tall, 225 pounds, type II diabetic. I am covered by the Province of Ontario’s health plan. My key to all services is my health card, a photo card I show at every visit to any doctor, lab or hospital. You show the card and they serve you, no questions, no stopping to determine whether or how much you’re covered, no payment ever exchanging hands, no bills forthcoming (there are exceptions but this is true for close to everything).

The total amount I had to pay out of my pocket for this care was zero. It was completely covered by the taxes I pay and the contributions I make. There was no expense for co-pay. There was no expense for needles, tongue depressors, lab work, nothing. The sum total of expenses for the entire week for me was a $15 parking charge.

I chose this hospital because it is close to my home. I would have received the same care at any hospital. I did not have to choose one that belonged to some particular plan. At all stages I was treated professionally and promptly (with consideration to other patients whose urgency exceeded mine).

Here is a breakdown of the care I received. It was all provided via the government plan, with no need for extra insurance coverage.

If there were to be a bill, these might be some of the line items:

  Consultation:
    Emergency room visits: 2
    Specialist visit: 1
    Family Doctor visit: 1

  Lab:
    Bloodwork: 2
    Urine: 2
  
  Imaging:
    Ultrasound: 1
    XRay: 2
    CT: 1

  Medications:
    Morphine injection: 1
    Morphine IV: 1
    Saline Solution IV: 1
    Gravol: 1
    IV for nausea: 1

The drugs administered at the hospital were all covered. The prescriptions I got were paid for separately and partially covered (80%) by my private drug and dental plan.

Initial Emergency room visit. At 1am, I had some discomfort in the left of my abdomen and blood in my urine. I was triaged through to Ambulatory Care in about 15 minutes, and was in the waiting room there for about 45 minutes until I was moved to an examination room. Was seen about 25 minutes after that, blood and urine were taken, then 1 hour to wait for results. During the hour my pain increased, becoming unbearable and as soon as they were aware, I was given two Percocets, a Gravol and a shot of Morphine in the arm. Once the results came back I was scheduled for a CT scan at 1pm and sent home with prescriptions for Flomax, Naproxen and Percocet, which I filled at the local 24-hour pharmacy, and a referral to my Urologist. Total time from start to finish, 5 hours.

By noon I had talked to my Urologist and had an appointment for 7 days later.

At 1pm I had my CT scan. For the Doctor to see it, I had to be triaged through a now very busy emergency room, and wait for a while at Ambulatory Care. Diagnosis, two 2-3mm stones on the right, one 2mm on the left and one 9mm on the left, 1/3 of the way down the ureter towards the bladder. Total time, 4 hours, mostly waiting comfortably while others were seen who were in distress.

The next Monday I got an appointment with my family doctor to get an extension on the pain medication prescription. He gave me a once-over and grilled me on some details.

The day before I was to go to my specialist, the pain was excessive despite the Percocet, so concerned that some damage might be happening, I went back to emergency. Within an hour I was taken in, blood was taken and I was and seen by the Doctor. I was given an IV of saline and a morphine pack, and later a pack of something for nausea. They took me for an ultrasound and the doctor saw me about 20 minutes later saying it was not clear enough so they were sending me for Xray, which I went to immediately and was seen in short order. The Xray showed it still in the ureter, if a little bit further along. As the symptoms had by that time subsided, the doctor and I decided together that we wouldn’t involve the on-call Urologist but that I would go to my own as scheduled the next day. Total time, less than 4 hours

When I arrived at the Urologist, they tried to get the XRay from the online hospital system, but there were connection problems, so they sent me upstairs to their local lab for another XRay. I was back in 35 minutes with the CD containing the XRay and the Dr gave me my consultation. We decided that due to the invasiveness of the surgical procedure (full anaesthetic, scope up the urethra and ureter, blasting, extraction) I would continue with painkillers and Flomax and if not passed in three weeks reconsider. Total time: 2 hours

Summary to date:

I was seen quickly and efficiently at one of Canada’s busiest emergency rooms three times in one week.

Imaging – I received a CT scan appointment within 10 hours, ultrasound immediately, XRay immediately (twice).

My specialist saw me within a week.

I could have chosen intervention if I cared to at this time. It will be available to me any time should my condition escalate.

At no time did I have to consider the financial implications of this care as there are none.

I understand that the taxes Americans pay for health care (which goes to medicare, government plans including Congress, generally not back to all who pay it) equal or exceed those that we Canadians pay for the care that we all actually receive.

It’s really a mystery why America remains as the only nation who doesn’t get it.

I really love my Android devices – my Nexus4 phone and my Nexus7 tablet.

With the phone, it’s natural to have one user associated with the device, logged into email, facebook, twitter, linkedin, instagram… need I go on? It’s a one user device.

On the tablet, Android JellyBean has started to give you the ability to have multiple users. I can leave my Nexus7 around the house, and as long as I have set up users for my wife and daughter, they can use it too. I have also created a guest account, however it’s pretty useless without a Google account associated with it, so you might as well not bother.

When the tablet is idle – that is to say sort of “logged off”, which means at the login screen, email (and FB, etc) notifications for the primary user appear in the notification bar. The notification alert sounds when email arrives for the primary user. The sender and subject appear for a short time.

The “password” I currently use is a swipe pattern. Anyone can see me use it and remember it. It is the only thing protecting me from their ability to get into my email etc and mess up my entire online life. Great if you trust them, not so much if you don’t.

I’m not even certain that the multitasking features of Android partition the users from each other.

In short, there is a long way to go before this is really worthy of multiple user operation in practice.

As for Apple/iOS? I no longer use them but as far as I know, they’re even further behind in this respect.

I first noticed a disturbance in the force at the start of the month.

Not a full-on twitterite, I follow less than 100 @handles, however by the aggregation of mentions, retweets and metatweets it makes for a fairly steady stream of commentary. I can watch the flow like one would watch a busy streetcorner from a window above, every so often a face or snippet of conversation registering to my eye or ear as the crowd passes.

Sometimes I would gaze through my twitter window hoping specifically to catch a certain character or other on their way past my vantage point. Happily I could reach out and rewind and fast-forward the stream, scanning it for insights or sometimes just for the assurance that my daughter or a friend was simply still there, still ranting or enthusing.

Just as you might smile and wave at the barber on your way to the office, I made it a habit this summer to check every day to see how my friend @michaelocc was getting on. Stricken with cancer, bedridden and often silenced by medications and procedures, he carried on a daily conversation with his family, friends, and the rest of the twitterverse. Occasionally I would say hello, more often I would quietly observe the heartwarming and uplifting banter he would trade with all comers.

When his feed fell silent last week, I feared the worst, and today I hear from many grieving friends and colleagues that indeed, Michael died last night. He was a giant of an imp of a man and I shared many a hearty laugh with him. We started our blogs one day apart from each other back in 2001 (his was first) and crossed paths many times. I shall miss him greatly.

As I watch the flow of my feed, the grieving and the fond memories of Michael rise above the hubbub. I know that these will become fewer and that they will fade into the daily hustle and bustle. Until then, I will cherish the opportunity I have to rewind the stream just one more time.

My friend and colleague Tim Aiello sends me news that California has passed groundbreaking textbook legislation.

A crucial component of the California legislation is that the textbooks developed will be made available under the Creative Commons Attribution license (CC BY):

The textbooks and other materials are placed under a creative commons attribution license that allows others to use, distribute, and create derivative works based upon the digital material while still allowing the authors or creators to receive credit for their efforts.

The CC BY license allows teachers to tailor textbook content to students’ needs, permits commercial companies to take the resources and build new products with it (such as video tutorials), and opens the doors for collaboration and improvement of the materials.

In related news, Katherine Tyrrell commented on my blog recently about the Higher Education Act of 2008 in the USA:

This REQUIRES all educational establishments to define and COST all text books required for a course whether in print or online so as to allow a student to estimate the real cost of taking a course.

“The act mandates that textbook costs be available as part of any schedule of classes, whether online or in print. The intent of this act is to allow students to shop for the best price on textbooks and thus lower their costs. “

http://www.uwstout.edu/lib/services/irs_heoa.cfm

It seems that excessive prices of textbooks is something that has also been a major issue in the USA and that this has been addressed in part via this Act.

These are both really good things. I would like to know if there are similar plans underway in Canada.

Microsoft confirms that Windows 8 the-interface-formerly-known-as-Metro apps will only be available through the Windows Store.

Add to this the fact that Apple’s OSX Mountain Lion is by default restricting downloads to the App Store, although so far that default can be overridden.

There is ongoing controversy about the implementation of UEFI boot loaders, with Microsoft mandating to hardware vendors that ARM-based machines only boot to their OS.

These are signs that the Two Trajectories of Device Convergence are beginning to collide, the fronts are ever advancing, and the Closed side is preparing its arsenal.

Cory Doctorow has for some time been waxing cogently on the long term implications of the coming war on general-purpose computing, and recent and current trends seem to support his prognostication.

Am I over-analyzing or is that distant choppers I hear over the hill?

Rupert Murdoch finally admits that he needs Google more than they need him.

I’m surprised it took so long!

Atrist and writer Katherine Tyrrell weighs in on my summary of the textbook fracas.

In order to focus efforts towards the short-term goal of resolving the issues with this particular course material, I’ve so far somewhat skirted the issue of the changing nature of publishing and how it is affecting post-secondary educational textbooks, impacting both the cost and efficacy of the education of our future generations.

As Katherine points out, we have Pearson, who is

a publisher who is trying hard to work out how it can create new products out of its existing asset base – in much the same way as many other publishers – in order to create new profit streams within the context of the collapse of the traditional business model for publishing

Unfortunately, it’s woefully apparent that the new profit streams they are creating are almost universally abhorred – witness the waves of angst expressed when you simply search for the word “textbook” on Reddit. If that’s not an industry shunted onto the same siding as a speeding freight train, I don’t know what is.

And before you dump on Redditors for being overly tetchy, remember that this is the cohort of our near future, also representing who we all were not so many years ago.

I can recall myself being peeved at textbook prices back in the early 80s, but at that time there were no courses for which the text changed every single term or changed from a one-time product purchase to essentially an annuity for the publisher.

I entreat upon Pearson and every other player in the space to make it their business to take the initiative to come up with innovative solutions that work with the schools and students to provide affordable and workable course materials without making students feel they are being deceived or fleeced. So far it ain’t working.

There has been quite a bit of discussion about this textbook affair. A lot of people are stuck on the copyright issue. Yesterday I summarized my thoughts about it in a comment on the recent TechDirt article. Today I received a similar summary from a commenter named Vlad posting from Russia. I’ll post them both here.

First, my comment at TechDirt.

It turns out it’s not as simple as it seems at first. For the benefit of all, here are some things that have become clear to me this week.

Copyright isn’t where the expense lies, it’s Licensing.

If you want photos of public domain art works that are of high enough quality for print publication, you have a few choices.

1) You can send a photographer out to take photos of each work. Many will be in museums and will require negotiating a photography session with the museum. One reason is that the light used in high power flashes for this quality of photo has a high UV content and over time will contribute to deterioration of the work, so they limit access.

This is very expensive and time-consuming, but you will get high quality photos.

2) You can find a photographer or organization who has done #1 themselves or has bought the rights to license images from other photographers.

This will get you the quality photos, and save you some money.

3) You can try to source photos that have open and free licenses. While there are some organizations who are collecting such images (e.g. googleartproject.com, art.sy, and others), there is not a deep well of these resources, so your experience will result in a lot of searching and varied quality.

As you can see, #2 is optimal among these (possibly not exhaustive) choices.

When you want to get photos for your book, you pay a license fee to the person who can provide you with the high-quality source material. They calculate it based on a number of factors, one of which is the quality of the final images – i.e. it’s cheaper to license a bunch of images to be presented in thumbnail or screen form than in full resolution.

If you print and sell 10,000 copies of your book, the cost component of the licensing is distributed much more thinly than if you have a limited run of 500 books. You have a choice of whether to present pictures in full, thumbnail, or online, or a combination. The choices made in this case resulted in a product that did not meet the needs of the audience (understated, I know, but that’s the bottom line).

What this all comes down to is that once the logistics of producing a book are considered, it’s apparent that there is no one entity in the chain demanding excessive profits. It’s just the economics of a high quality small print run in play here, and then the design decisions that came out of that.

So far the response of the school and the publisher has been very positive and I’m optimistic that a much better solution will come out of this episode. Open dialogue has been spawned and the wider issues of copyright, licensing and the spiralling cost of a university education have been subjected to very public review and criticism.

Thanks to the students who started the petition, and TechDirt who provided a platform for wide recognition, this story promises to have as happy an ending as one could hope for.

And Vlad’s comment:

Let me explain this story in plain words and by numbers.

1. All pre-1800 visual materials (paintings etc) are copyright free. Reproduce them all you want.

2. Quality digital images of these materials are not free and even not cheap, as producing them is really not cheap (you actually need to travel to dozens or hundreds of museums and pay them for using commercial photo equipment there, they charge for that).

3. A certain publisher has paid for gazillions of these images and printed three different textbooks. Their total retail price is 300 dollars. This value is the cost of printing, the price of images, the price of the text, the profit margin and so on — DIVIDED by the number of printed books.

4. A certain college professor realizes that his students need all three books to take the course. But 300 dollars is a lot, so he and the college look for a better solution.

5. They decide to publish a partial compilation of these three textbooks for a lower price and approach the original publisher. He does not mind and tells them the price of copyrights. It’s a resonable price, but when you DIVIDE it by the very small number of books the college needs, it’s 800 dollars per book. Not good.

6. They compromise: the compilation is printed without pictures, the pictures will be available for students online for free, all three original books with images will be available for students online for free — when they buy the compilation for 180 dollars. Instead of paying 300 dollars for the three books. Everybody is happy, everybody wins.

7. Except a small number of slacktivists. They are not happy, but luckily they don’t win either.

I’m sure you’ll note that I disagree with his assessment since the story continued somewhat beyond the reaction to a conclusion that suits many of the detractors, but that’s his opinion and I’m glad to have him express it.