reureu's comments

I've been driving an M3 since 2020 and have put 40k miles on it, mostly over road trips throughout California and the western half of the US.

Phantom braking has always been a bit of an issue -- when I first got the car, I just wouldn't use cruise control in heavy traffic, but felt ok using it once out of a city. In the past year or so, it's been so bad I'm scared to use it at all, and I've filed multiple complaints with the NHTSA. I'll be driving on I-80 through Nevada or Utah and every ~10 minutes the car will slam on its brakes. This is dry, consistently lit, consistent colors, minimal bridges casting shadows, etc.

I wish there was a way to make my cruise control "dumb"/non-adaptive just to stop the random abrupt braking in the middle of nowhere.

I think you're totally right, and I think that's the tragedy of apps like grindr. I was on gay websites as a teenager in the late 90s/early 00s, and it was only tech savvy guys. You could chat with someone for weeks without exchanging photos. The horny, shallow guys somewhat weeded themselves out because there wasn't a large enough population to sustain that.

But as the internet became more popular, dating sites became more mainstream, and then the location-based ones matured, it almost became a race to the bottom (so to speak).

If someone is horny right now, why chat with person A (with a text-based profile) when person B has photos? Why chat with person B when person C has shirtless photos? Why chat with person C when person D sends dick pics right away? Why chat with person D when person E sends dick pics and will drive to your house in 10 minutes? So a subset of users start pushing this towards being hyper efficiency, but that comes at the expense of the other subset of users who don't necessarily want that.

My experience has been you can't ever escape that. That mentality has permeated the system, and now we're conditioned to "meet up within 3 messages", "send pics in first message", "no fats, no fems, no flakes", etc. And if you don't like that and want something slower then you get told "it's just grindr, what do you expect?" (which eventually morphs into "it's just tinder what do you expect?", "it's just hinge, what do you expect?"). But even the people saying "it's just grindr" also complain that after they have sex, they just feel lonely again and that they feel trapped or addicted to grindr.

Obviously I'm painting with really broad strokes. Some people do find relationships on grindr. Some people are satisfied with their interactions. But, I think like the original article describes, it feels soul destroying. And by the time you're in your 30s, I think a lot of gay men realize that easy sex doesn't necessarily mean good sex and it often doesn't mean feeling satisfied or content afterwards. But it's difficult when you have a heterogenous population, with a vocal faction of the population that keeps pushing the limits of efficiency, and the rest of the population is just sorta dragged along.

As a gay man, I hate grindr and many of my friends do too. We still may use it because it's ubiquitous, honest to a fault, and it's easy to confuse solutions to horniness with solutions to loneliness. But I know it often takes a toll on self-esteem, particularly in areas where you don't match the dominant "type" (e.g., a nerdy guy living in LA or OC). There aren't better options and many of the guys on hinge or tinder are also on grindr -- so, I think grindr gets used often despite it not really delivering on the users' hopes. So, I wouldn't confuse use with satisfaction, and I'd really love to see data on how many gay men actually are satisfied with grindr.

Their two Glassdoor reviews are a fun juxtaposition...

From "CEO-Founder": "First team in biotech software that actually knows what they are doing when it comes to biotech software", "Advice to Management: Keep doing what you are doing."

From "Contractor": "Rude and overconfident management who make it really undesirable to work there. If they are not successful it will mainly be because Alfredo and Aidan are mean people with a big ego who drive away good people from considering joining the company."

That was what Nuna (nuna.com) was originally trying to do ~10 years ago (put together bundled payments for value-based care models). I think they've since pivoted to more general healthcare data tools.

One of the difficulties is that in many systems medical billing is done by coding specialists based off the provider's note. They may recommend CPT codes, but that may not be what's actually billed. In addition, most providers are too swamped to do things like put together an estimate or drag and drop CPT codes. Hell, many providers will literally count the clicks they have to make in an EHR and will LOUDLY let you know if your proposal will increase their number of clicks by even one.

I don't mean to be a downer on this, and I do think there are solutions... but I think 90% of the problems in healthcare aren't technological ones but are navigating large, entrenched systems that have very little incentive to change.

There's something off about this. I don't want to be pedantic, but one of the images states "32% consume controlled substances to perform better and cope with long work hours and high stress", and then goes on to say 45% use painkillers, 34% use stimulants, 36% use antidepressants, and 35% use sleeping pills.

But antidepressants is defined as benzodiazepines, which aren't antidepressants, they're anxiolytics. Normally when someone talks about "antidepressants", they're referring to SSRIs, SNRIs, NDRIs, and some similar meds. They have a category for SSRIs, but their example medications include non-SSRIs. Regardless, all of the medications they list in the categories other than SSRIs ARE controlled substances. So, it should be at least 45% consume controlled substances.

Anyway, the odd math and misclassification of medications makes me question the results of this study. I don't doubt that tech execs are stressed, drink a lot, use illicit drugs, and prescription drugs... but I'm not sure I'd believe the specific percents given here.

My point in mentioning that all major religions frown on making a show of your giving was more to point out how ubiquitous and culturally cross-cutting that belief is than to say "some ancient books" should dictate our values or beliefs. Regardless of what you believe, hopefully you can acknowledge that there's a meaningful signal in Christianity, Judaism, Hinduism, and Buddhism all agreeing about a particular point.

Mr. Beast doesn't do _philanthropy_, he makes entertainment videos. His niche is giving money away in exchange for challenges or stunts. This gets him views, and has created a profitable business for him. That's not altruistic at all, it's just a business guy who is quite good at knowing his audience and executing his trade. "thousands of people regaining their sight" is a glorified marketing campaign.

Yes, money goes to causes; but the fact that money wouldn't otherwise go there is a policy decision that we've collectively made. We could tax billionaires and use the revenue to fund health, education, housing, infrastructure, research, or whatever. I'd much prefer to see us do that than wait around until we see Mr. Beast's Children's Hospital pop up somewhere.

No, obviously not. I'm unclear how you got to that conclusion, or what your point is. I was responding to someone who was quoting the Bible regarding philanthropy and wanted to point out that it's not just Christianity that makes this point. Further, the fact that it's such a ubiquitous view means that it probably represents a more fundamental value that cuts across cultures and beliefs.

When I went to the Kentucky Derby, I was surprised by how few people were drinking Mint Juleps and how many were drinking cases of Bud Light. It was a particularly hot year, so not sure if this is normal, but I saw at least a dozen people carted off by the EMS golf carts hours before the Kentucky Derby was run.

I've been to a bunch of events, including the Indy 500, Times Square for NYE, and Mardi Gras in New Orleans, and by far people were more sloppy drunk at the Kentucky Derby.

This is what makes me uncomfortable -- if you have to be seen giving something away then you're not really doing it for altruistic purposes.

Also, this isn't strictly a Christian concept, but similar ideas exist in

Judaism: https://www.chabad.org/library/article_cdo/aid/256321/jewish...

Buddhism: https://www.learnreligions.com/perfection-of-giving-449724

Islam: https://www.quranexplorer.com/blog/Education-In-The-Light-Of...

Hinduism: https://www.hindupedia.com/en/Ideals_and_Values/Charity_and_...?

woah, I was with you until you brought chipotle into this. Hopefully we can agree that it's valuable to support your local chipotle over the financial district's chipotle, since it's also keeping people employed in their communities.

You'd enjoy "Urinetown: The Musical"

agreed, that's an unfair statement. Facebook added reactions in 2015.

I'm not sure that prisoners dilemma is the right framing of this problem.

First, there's value in decreasing the viral load of ALL patients regardless of risk, as viral load is likely proportionate to risk of onward transmission. If it decreases onward transmission, then the math would likely favor its use in all cases, since exponential spread gets costly fast.

Second, we continue to focus on hospitalizations and deaths with increasingly poor data and with no focus on disability. Treatment may decrease risk of long covid in non-"high risk" patients, which itself may be beneficial.

Third, while we should expect paxlovid-resistant variants to pop up, the fact that we prescribe it about 4x the rate of molnupiravir and don't see nearly that level mutation should be somewhat comforting. It seems equally plausible that a new "long branch" lineage would pop up with resistance irrespective of evolutionary pressure from paxlovid prescriptions. If that's the case, it'd be a shame to ration its use to only have it go bad anyway (this is basically what we saw happen with all of our monoclonal antibodies).

Fourth, this entire conversation should be less focused on who we deem worthy of one of our last remaining treatments, and more focused on how we're allowing a very quickly mutating virus to spread virtually unchecked and with basically no investment in any further treatment or prevention. None of us need to be prisoners here if we were continuing to invest in new treatments, better vaccines, improved air filtration and ventilation, and paid sick leave.

Yes, there are levels of controlled substances based on, among other things, their abuse potential. That's not what we're talking about here because paxlovid is not a controlled substance.

If you're going to construct a new strawman argument, don't make up quotes that I never wrote. I also have a lot of thoughts about how controlled substance laws create problems and harm patients. But I'll stick to the main point of this thread: paxlovid drug interactions are easily checked and managed for the majority of patients, and should not be a reason for providers to reflexively deny prescription requests for it.

I spent a decade working in a nursing home before becoming an epidemiologist, so definitely have worked with elderly patients. Not to mention my own experiences with elderly family members.

> but it's not like the doctor is in any way responsible for verifying that information.

Yeah, that's the exact point. Everybody does things that the doctor says they shouldn't, but that doesn't mean we withhold care as a result.

People stop antibiotics before the scripts are done. People smoke and drink too much, some even drink and drive. People don't take their blood pressure or cholesterol or even HIV meds as prescribed. Some people take half a pill because the pill they were prescribed is "too big" -- people are weird and do all kinds of things.

Paxlovid is no different. The provider can be checking drug interactions, making adjustments as needed and counseling the patient. That's their job. They can't babysit the patient all of the time. If it's clear the patient doesn't understand and can't care for themselves, then there are larger conversations to be had.

My point is that deciding not to prescribe a medication to a qualifying patient because it generally has too many drug interactions and patients can't be trusted with their health is not ok. Patients don't need to understand that ritonavir is a protease inhibitor that was incidentally found to inhibit cytochrome P450-3A4, which subsequently boosts the levels of many other medications. They just need to know to stop taking their cholesterol pill for the next week. That's all. Some, like your elderly relative, may not be able to follow that direction. But there are millions of high risk people who are able to do that, and shouldn't be denied care based on the assumption they're incompetent.

I dunno, the NIH literally suggests using this website to check for interactions: https://covid19-druginteractions.org/checker

Managing drug interactions for paxlovid isn't much more complicated than inputting meds into a web form and looking at the color of the box that pops up after. I think most providers can handle that if they know these tools exist and get past the reflex of "paxlovid has drug interactions, you don't want to take it."

Managing drug interactions is part of ordering medications, and if it's really taking that much time (i.e., the EHR isn't just doing all the work for you), then it'd result in a higher E&M code when it's billed out. Medication management, in some cases, can also be billed and reimbursed by the pharmacist.

So, totally agree that the US medical system is optimized for billing. I don't think those of us in the US should be ok with that, and I don't think it's an excuse in this case to not prescribe paxlovid to patients who want it and would qualify for it.

I think this is where many providers get mixed up. It's for "mild-to-moderate" COVID-19 (i.e., "you're not sick enough yet" isn't at play, because then you have "mild" covid which is exactly what paxlovid is indicated for) who are at "high risk for progression to severe COVID-19."

According to the CDC, risk factors that make you at "high risk" include being over 50, having a mood disorder (including anxiety and depression), being obese or overweight, being physically inactive, being a current or former smoker, or having asthma: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/...

Most Americans would check one of those boxes, even the healthy and young among us. And some of those (e.g., "physically inactive") are pretty ill-defined that you could argue even more fit in that category. Just saying you're anxious about covid outcomes should qualify you for paxlovid because anxiety is a risk factor.

Many of the infectious disease doctors I work with think that paxlovid should be offered to virtually everybody because it seems to decrease your viral load (this could decrease the chance of onward transmission), there may be a decrease in risk of long covid, it may shorten your symptom duration, and there aren't many other treatment options if you get sicker. So, short of being on one of the medications that's absolutely contraindicated, their opinion is generally if you want paxlovid you should get it.

So if your doctor is saying you don't need it or don't qualify, and you want to take it, I would find a different doctor or use a telemedicine provider.

By the medical professional who is prescribing paxlovid. When I wrote "can be managed", I mean the health care provider tells the patient to either stop taking their other meds for 5-7 days, to reduce the dose, or to look out for symptoms and call them if they have certain issues. Not be hospitalized to watch for side effects. You can look for yourself at the list of common meds, and the ones that are absolutely contraindicated are relatively few: https://www.covid19treatmentguidelines.nih.gov/therapies/ant...

One's ability to "trust" a patient isn't a factor here, and is, frankly, pretty condescending. The patient and provider have aligned interests, it's just a matter of ensuring the provider is making sure the patient understands what's going on. The provider should be doing that in all of their encounters, so that's nothing specific to paxlovid.

There are renal dosing standards for paxlovid. So if you have not-great kidneys, they just give you a different dose. Covid can also cause kidney damage, and kidney issues are associated with worse outcomes from covid. So, it's all a bit of a double edged sword.