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This article is the second in a series on using knowledge about the brain to help clients thrive. Visit our Your Client' Brain home page for related coverage throughout March.
Last month in Investment Advisor's cover story, "Double Think," we explored the curious structure of the human brain, whose "two minds" can turn decision-making into a dilemma. If a client's rational mind and emotional mind are divided about a decision, how can an advisor help? After all, whether you're legally a fiduciary or not, your job is to guide clients toward making the right decisions on everything from college to retirement to estate planning.
Making good decisions is not a matter of heeding one "mind" and ignoring the other. "The brain is designed to work as a whole, integrating its analytic and emotional capacities," said neuropsychologist Rick Hanson. "If someone is upset or rattled about money, they tend to swing too far in one direction or the other. The best approach takes a middle path in which we use both head and heart."
In other words, when messages from the two minds are contradictory, we need to arrive at a resolution that integrates them. San Francisco psychotherapist Linda Graham noted that integration is the job of the prefrontal cortex, which receives verbal and nonverbal input from both hemispheres of the brain. Anxiety disrupts this process by prompting the amygdala to flood our brain and body with the stress hormone cortisol, putting the prefrontal cortex out of commission.
The perceived threat may be just a rude driver cutting across traffic, but we react as viscerally as if we'd stepped on a cobra. "Our judgment is temporarily impaired, reality testing is impaired, and we literally can't think straight," said Graham, who specializes in the integration of neuroscience, mindfulness and relational psychology, and who wrote the soon-to-be-published "Bouncing Back: Rewiring Your Brain for Maximum Resilience and Well-Being."
With chronic stress a real problem in modern society, stress management techniques are helpful, even necessary, to ensure the prefrontal cortex functions well. Techniques like Graham's Hand on the Heart (stay tuned to AdvisorOne.com for more on stress relief techniques) can prompt the prefrontal cortex to calm the fear-stress-threat response. "Calming and centering help head and heart work together," as neuropsychologist Hanson, author of "Buddha's Brain: The Practical Neuroscience of Happiness, Love and Wisdom," put it.
In this second part of our series—and in a wealth of articles and other resources on AdvisorOne.com—we offer 13 rules to de-stress decision-making (DDM). These rules use the latest findings from neuroscience to identify ways you can work with clients and run your business more effectively.
DDM Rule 1: Avoid making decisions under stress
The Science | We tend to break this rather obvious rule because we overestimate our ability to make rational decisions. According to David Rock, the New York-based executive director of the NeuroLeadership Institute, we may have only a few hours a week of quality thinking time to make difficult financial decisions because the prefrontal cortex (the center of conscious decision-making) is surprisingly small and tires very easily.
The Recommendation | Since our conscious processes are so limited, advisors should educate their clients to consider tough decisions when they are mentally rested. The worst thing they can do is make a financial decision when they are tired or stressed at the end of a busy week.
DDM Rule 2: Embrace your clients' goals
The Science | Many financial advisors "fail to 'de-bias' their clients and often reinforce biases that are in their [own] interests," reported an undercover survey done in early 2012 for the National Bureau of Economic Research.
The Recommendation | Probe for clients' real needs and goals; don't just cater to their expressed wants. Rock pointed out that when you understand and share your clients' goals, you will perceive their challenges more robustly, have natural compassion for their experiences and be more motivated to help them. When people perceive your empathy, they will become more likely to open up their real thoughts and feelings to you.
In other words, taking the time to really understand and connect with your clients' goals will make your job easier—and probably more successful.
DDM Rule 3: Know your own limitations
The Science | "If there are contradictions and confusions in the client, sometimes the advisor's prefrontal cortex tries to act on behalf of the client's prefrontal cortex," said psychotherapist Graham. "The advisor needs to be coming from an integrated perspective, not privileging 'rational' over 'emotional.'"
The Recommendation | Besides not imposing your own logic on the client, it's important to understand what's going on in your emotional brain, commented mental health counselor and speaker Dave Jetson. "We all have our emotional history and the limitations that come from that," he said. "If your fears are limiting your interaction with a client, it may help to have a therapist in the session with you, or another planner who doesn't have the same emotional response to the client's issues."
For example, Jetson said, "Suppose an advisor has a history of being yelled at as a child. If he is still traumatized by this history, when he meets an aggressive client, he may make concessions in developing the portfolio that aren't in his or the client's best interest."
In other words: Advisor, heal thyself. Don't allow your own issues to complicate your clients' decision-making.
DDM Rule 4: Move beyond clients' emotional triggers to discover their deeper feelings
The Science | "Our unresolved issues create major stress in our lives," Jetson observed. "Calming exercises may help in the present, but they don't guarantee that a successful shift will occur. Exploring patterns associated with the emotional brain can be more helpful in creating success."
Jetson noted that yoga, exercise, meditation, contemplation and art therapy are all good ways to lower stress levels. "But you need to work through your deeper feelings to get emotional release," he said. That means sharing them with a family member, a spiritual advisor or someone else you trust.
Co-owner of Jetson Counseling with his wife, Liz Thorn, Jetson partners with planner Rick Kahler to provide financial therapy for clients. "While they're looking over their portfolio in the office, I'm observing their body language, their behavior and other signs of resistance," he explained. "I look for patterns about what helps them feel valued and successful, what they've done in the past that has worked or not worked."
The Recommendation | Incorporating the client's own emotional programming in a plan helps ensure that the client will take action and succeed.
Jetson gives Kahler information about what needs to be incorporated into the financial plan to be successful. "This collaboration helps us make sure we're giving the best service to our clients," he said. "For example, suppose Jane has learned that the only way she can be successful is as an entrepreneur, but she's getting close to retirement. I might suggest we put something in her plan that recognizes she's still going to be active, maybe starting a nonprofit organization or taking the lead in a volunteer activity."
DDM Rule 5: Learn how to read clients' faces
The Science | When we asked therapist Graham how a financial advisor can learn to recognize stress in a client, she suggested psychologist Paul Ekman's F.A.C.E. (facial expression, awareness, compassion, emotions) training.
Ekman, a pioneer in the study of nonverbal communication, has identified seven emotions common across cultures: anger, disgust, fear, happiness, sadness, surprise and contempt. His online courses train people to identify these emotions in the facial expressions of others.
The Recommendation | The more accurately you can read microexpressions, the better you will know when to reassure a client, mitigate their sadness or defuse frustration or anger.
DDM Rule 6: Discuss important decisions in person
The Science | Graham noted that when we make eye contact with someone who is calm, a structure in the right hemisphere of our brain (the fusiform gyrus) recognizes this calmness in the other person's facial expression. This in turn correlates with a calming of the fear response in our own amygdala.
What happens, we asked, if client and advisor avoid eye contact? There are other ways to communicate nonverbally, of course, but Graham noted that 55% of all emotional communication happens through facial expression, tone and rhythm of the voice; 38% through body language; and the remaining 7% through words, according to Albert Mehrabian, UCLA professor emeritus of psychology. "Without eye contact," she concluded, "you're losing half of this source of feedback."
The Recommendation | Learn as much as you can about nonverbal communication. Clues from eye contact and unconscious facial signals are a good reason to invite clients to talk face-to-face, rather than leaving it to a telephone call or email.
DDM Rule 7: Adjust to each client's brain style
The Science | Research has shown that people process information in different ways—e.g., verbally, pictorially or kinesthetically (physical movement).
The Recommendation | To find out the best way for a particular client to hear you (or for a couple with divergent views to hear each other), you might explore whether they learn better through discussion or via graphs and charts; in a group or one-on-one; moving around or stationary.
DDM Rule 8: Identify and label your own emotions
The Science | The better we understand the brain, the more effectively we can manage our emotions. Simply trying to suppress them tends to make them intensify over time.
The Recommendation | "The best thing you can do is to learn to label your emotions, which means to summarize in a few words what you're experiencing," observed David Rock, who wrote "Your Brain at Work: Strategies for Overcoming Distraction, Regaining Focus, and Working Smarter All Day Long."
For example, if you are feeling anxious about a presentation to a difficult client, you could say to yourself, "I'm anxious because of this client meeting" rather than trying to suppress your feelings. Labeling the cause of your anxiety will help reduce it, Rock said.
Even more effective would be to "reappraise" or reframe your prediction of events—in other words, to change the way you interpret things. In this case, you might put a positive spin on the meeting by thinking about ways you can help this client. Labeling reactions, then reappraising them, is an excellent technique for managing your emotions.
DDM Rule 9: Use the power of storytelling
The Science | Telling stories to ourselves and to one another is a powerful determinant of how well-integrated our two minds are. Neuroscience researcher Jaak Panksepp of Bowling Green State University has described a "seeking system" in the brain: an inner urge to discover and learn, to understand, to satisfy our curiosity about where we come from, who we are, how we developed and what we're made of.
The Recommendation | Listening to your clients' money histories and the way they make sense of these experiences is an important part of deepening your connection with them. As a "therapeutic educator," you can help them reframe their stories in a way that is less emotionally triggering. As David Rock observed, labeling and reappraising your emotions allows you to see things in a context that may work better for you in the future.
DDM Rule 10: Don't discount emotion in decision-making
The Science | It's tempting to assume that a gut response to an issue can't be right because it conflicts with a logical weighing of the pros and cons.
But emotion is a vital part of decision-making. As we were reminded by Portland, Ore.-based therapist Bonnie Badenoch, "if our rational way of knowing is cut off from the emotional part, any decision we make may be overly optimistic and lacking in human values."
The Recommendation | The important thing is becoming conscious of both parts and that they are in conflict. "Sometimes from that place it's easier to tease out whether the more emotional response is tied to some form of earlier learning," Badenoch added, "or if that intuitive part [of the brain] is actually sensing something helpful for this present moment."
DDM Rule 11: Learn the lessons of behavioral finance
The Science | As most advisors know, clients facing the decision of whether to hold onto or sell an investment are biased in favor of its previous value, rather than its present and future value.
"Making people aware of their buying behavior and short-term decision-making process is valuable to them. They may not be aware that the reason they paid a certain price for something is that a marketer put a high-priced item and a low-priced item near it, so they chose the middle."
The emotional brain's focus on short-term risk and reward is another hurdle that advisors can help clients overcome, Greenberg said. "The reason they need a long-term plan is so that they can avoid these pitfalls."
The Recommendation | Paul Greenberg, a professor of psychology at Brandman University in San Diego, recommends advisors be aware of these decision-making biases. "Read Dan Ariely's 'Predictably Irrational' or Daniel Kahneman's books," he urged.
DDM Rule 12: Practice ways to overcome bouts of anxiety
The Science | "Remember, the first, most primal emotion was fear," neuropsychologist Rick Hanson reminded us. "Our ancestors needed to eat lunch, not be lunch." Knowing that fear and the need for security trump everything else, an advisor should pay attention to clients' anxiety and continually try to reduce their fears so they can think clearly.
The Recommendation | Hanson suggested these three tips for dialing down stress:
- Take several breaths in which the exhalation is twice as long as the inhalation. Exhaling activates the parasympathetic nervous system, which calms down the fight-or-flight, sympathetic wing of the nervous system.
- Notice that you are actually all right at this moment. This observation accesses the ongoing internal signals from your body to your brain that all is well.
- Think about someone who loves you and savor the sense of feeling cared about. "In ancient times, exile from the band was a death sentence, so it's reassuring and re-centering for us to feel connected with loved ones," Hanson noted.
DDM Rule 13: Foster a climate of safety and empathy
The Science | There are a number of good breathing exercises and other mindfulness practices like Rick Hanson's that help lower stress. "But I think the most effective thing to cultivate is a warm, safe, empathic relationship," therapist Bonnie Badenoch told us, "because when we feel safe, our entire system calms down."
Neuroscientists agree with Badenoch's suggestion. "To reduce stress, you want to provide a situation where the client is physically relaxed and comfortable," said psychology professor Greenberg. "Your office is a controlled environment where you get to attend to customer service."
The Recommendation | Does your office welcome clients, or is it chilly and intimidating? "You want the office to seem inviting, uncluttered and comfortable, a place where they don't feel rushed," Greenberg suggested.
Don't overlook the effect on already-stressed clients of busy wallpaper, stiff chairs or flickering monitors. In fact, you may want to do some research on soothing decor.
"De-stressing has a hormonal effect on the body," Greenberg said, "and that will affect how well the client listens to you. Getting them in the right frame of mind means putting them in the right frame of body."
In an early discussion of neuroscience evolution, therapist and author Marcia Stern noted that in contrast to therapy where insights are often forgotten when clients go home, "helping people understand their own brains and the unique way they process information can help bridge that gap and make changes stick."
While expanding your knowledge of the brain and stress-management practices, we hope these articles and the resources online will enable you to educate your clients about their own decision-making processes.
When people who are stressed out from everyday pressures or old traumas consult you, your understanding and alignment with their goals can comfort them and help open new neural pathways for better decision-making.
At the same time, you may need to make changes in your own thinking. Consider developing a regime of mindfulness, whether it's profound meditation or simply noticing what you're feeling. "Mindfulness strengthens the prefrontal cortex and improves our capacity to focus attention," as Linda Graham reminded us.
By keeping anxiety from hijacking your clients' brains (or your own), you'll create healthy relationships leading to stronger connections and more security and serenity for your clients and yourself.


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I once tried to play rugby. Once.
My friend Nina, who played on the Norwich University rugby team, convinced me to attend a practice, with the hopes that I would join the squad. I quickly realized that, as tough as I was out on the soccer and basketball fields, I was not cut out for the intensity the rugby girls brought to the table.
The practice alone terrified me. The girls were out for blood. I can�t imagine what a real game would have been like against an actual opponent.
It was one of the few times in life when I realized almost immediately that something wasn�t right for me. With that confidence, I declined the offer to play.
Often though, that isn�t the case. For one reason or another, I�ve stayed in unhappy situations longer than I should.
The majority of the time it�s because I�m trying to please someone else � family, friends, co-workers, neighbors and society in general.
Fear of other�s perceptions has often halted my personal growth and ability to say �no� and walk away from something that doesn�t fit.
I don�t want to appear ungrateful, selfish, mean or negative, so I put on a smile and fake it.
But you can only fake it for so long before it unravels.
And eventually things do fall apart. I�ve started to recognize that pretending, and going along with something against the fiber of your being � an unhealthy relationship, a controlling boss, the wrong job � wears you out and prohibits you from blossoming into the person you are meant to be.
I knew playing rugby would be too physically demanding and unhealthy for my body. I needed to learn that trying to make something work that isn�t meant be is just as damaging.
In the end, we can only try to live our best life, know our limitations and place ourselves in nurturing environments where we can succeed.
Saying �no� doesn�t make you weak. If anything, it makes you brave.
You don�t have to sit at the bottom of a scrum to prove your worth.
Heather Gillis Harris is reporter for the Country (Mass.) Gazette. Reach her at firstname.lastname@example.com.


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Marca: INTER BIOS,
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Press the following numbers on your phone to open the corresponding sections:
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A different kind of prep.
Deerfield offers a vibrant and innovative curriculum that supports curiosity, exploration, and leadership. But that's not all—Deerfield is a boarding school community where the culture is strong, our sense of commitment to one another unwavering, and friendships last a lifetime. We hope you'll join us!
Deerfield travels the world to recruit students who can make our school great. Check out our travel schedule and be sure to come and see us when we're near you.
Learn more about student work at Deerfield in the following videos: Under Deconstruction, Path of Most Persistence, and Go the Distance.
Start here for a summary of what your time at Deerfield might be like.
Managing tuition and financial aid can be daunting. We're here to help.


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Christ Is Risen!
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...you can imagine so-called healing services of the pigpen. The books that could be written, you know: Life in the Pigpen. How to Cope in the Pigpen. Being Happy in the Pigpen. Surviving in the Pigpen. And then there could be counselling, for people who feel unhappy in the pigpen, to try to get them to come to terms with the pigpen, and to accept the pigpen.
Thank you all for your prayers. I've emailed out about a million resumes (or so it seems) and have heard nothing from my recruiters yet... I know it's been only 24 hours but I am still fighting a rising panic.... But God is good, God is faithful, and God will not abandon us.
no, I wish I could, but apparently they are cutting back, not increasing. That's the impression I got anyway.
If anything I have posted has been illuminating, please remember that I merely reflect the light of others...but also it's me.
still no job leads...at all. And because I was "terminated" there is a VERY good chance i will not be able to get unemployment. Gotta tell ya... I'm scared.But God is good, and God is faithful, my scaredness notwithstanding.
Well. Thanks be to God! In spite of my son's last-minute babysitting sabotage....I got the job at the fast-food place anyway!!! They will work around my schedule as best as possible... I only need to find childcare for weekends and I *think* i have that covered. It's a minimum-wage job, probably nowhere near 40 hours a week, but this SHOULD cover the one main bill that I was worried about (my car)... somehow, I need to come up with $908 by the 25th to save my car... but if somehow that happens or other arrangements can be made... I'll be OK and be able to keep my car, at least. IF I lose my car, I'm really sunk because then I won't be able to work at all (no public transportation available in my area at all). But so long as I can hang onto that... I'll be alright. In the meantime, I am still looking for a job in or similar to my chosen career field. But... this is a start. This is something. It's a tiny glimmer of light in a very, very dark place.Much is still uncertain. I may yet lose everything. But... it's a start. God is good.
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A rural patch of north Syria has been shaken by a series of tit-for-tat, sectarian kidnappings, anti-regime activists said Saturday, highlighting how much the country's civil war has enflamed tensions between different religious groups.
While all activists agreed that kidnappings had spiked in recent days between armed men in neighboring Shiite and Sunni Muslim villages, reports of the numbers kidnapped by both sides ranged from a few dozen to more than 300.
The kidnappings and the raw feelings they have provoked bode ill for the chances of reconciliation between Syrians, many of whom have come to see the civil war as either a sacred battle to advance their faith or a mortal struggle for the survival of their sect.
Since Syria's crisis began with protests calling for political reforms in March 2011, it has gradually grown more sectarian. Most of the rebels who have taken up arms to topple the regime of President Bashar Assad are from Syria's Sunni majority. Assad himself is an Alawite, an offshoot of Shiite Islam, and has heavily stocked his security forces with fellow Alawites and Shiites.
The rise of Islamic fundamentalists among the rebels makes many among Syria's minorities - including Alawites, Shiites, Christians, Armenians and others - fear that a rebel victory could leave them with no place in Syria.
The spate of kidnappings in recent days in the northern Idlib province, which lies along the border with Turkey, provides one example of how Syria's crisis has raised the specter of increasingly sectarian violence.
Local activists said Sunni-Shiite tensions were rare in the area before Syria's crisis began, and that residents of the only two Shiite villages, Fua and Kifarya, moved freely through the constellation of Sunni villages around them.
Tensions rose, however, after the crisis began and opposition members armed themselves to fight back against Assad's harsh crackdown on dissent. Most of the Sunni villages embraced the uprising, while the Shiites stood by the regime. Many say the government armed its supporters to help fight the rebels.
Kidnappings grew common last year, as rebels set up checkpoints to catch Shiites they accused of being "shabiha," or pro-government militiamen, and Shiite gunmen did the same to capture rebels they considered terrorists. Elders from both communities remained in contact, arranging prisoner exchanges to avoid violence.
Most agree that the recent kidnappings started when unknown gunmen stopped a bus carrying Shiite civilians and kidnapped all its passengers on Thursday. Many of the passengers were women and children and their kidnapping was seen as a harsh escalation, especially in the conservative culture of north Syria.
"Before, it was all militiamen catching rebels. It was all part of the war," activist Bahaideen Abdel-Razaq in the village of Sarmeen said via Skype. "But kidnapping of women and children had never happened before."
Soon after, Shiite gunmen began kidnapping residents of nearby Sunni villages, he said, stopping public busses carrying them on rural highways or on their way into the province's regional capital, which is still under regime control.
Many details remain unclear, such as how many people have been kidnapped from the two sides.
The Britain-based Syrian Observatory for Human Rights said more than 40 Shiites, including women and children, were on the bus when they were captured by unknown gunmen. Since then, Shiite gunmen have kidnapped more than 300 people from nearby Sunni villages, the group said.
Anti-regime activists reached in four nearby villages suggested the number was smaller. Two said no more than 10 people had been taken from their villages. About 15 were missing from Saraqib, and as many as 40 had been taken from Sarmeen, Abdel-Razaq said.
Some activists doubted the story of the bus disappearing.
An activist from the nearby village of Binnish accused the regime of concocting the story.
"We deal with armed groups all over the region and no one has any information" on who kidnapped the bus, said Ahmed, who spoke on condition that only his first name be published to protect his family. "If this is true, give us the names of those who have been kidnapped."
The Observatory said gunmen from Fua refused to state the bus's make and color - "an issue that raises suspicion," it said.
The Associated Press was unable to reach residents of the Shiite villages. A message sent by a reporter to a Facebook page for Fua received an unnamed response.
"We will liberate our prisoners by force and we seek help from no one," it said. "We know how to fight, be victorious and take revenge."
It was unclear who wrote the message.
What is clear is that most Sunni activists and rebels expect an armed showdown between the two communities. Some say they see no place for Shiites in the area's future.
"We have warned them that everything in Fua is a target and that everyone who wants to save himself from the problems should leave," said activist Maher Abdel-Ghani, who often works with Islamic extremist rebel battalions.
"God willing, we'll soon liberate the whole area and there will be nothing left called Fua or Kifarya," he said. "Those two villages will be erased because they have harmed us a lot."
Also Saturday, a power outage plunged Damascus and much of southern Syria into darkness, the state news agency reported, quoting Electricity Minister Imad Khamis.
The blackout affected Syria's capital and the southern provinces of Daraa and Sweida, which abut the Jordanian border.
An Associated Press reporter in Damascus reported dark streets across the capital. A fuel shortage makes it hard for residents to run backup generators.
A similar blackout struck the same areas on Jan. 20. The government blamed that outage on a rebel attack, and power was restored to most areas the following day.
The Syrian capital's 2.5 million residents have grown used to frequent power cuts as the country's conflict has damaged infrastructure and sapped the government's finances.
The U.N. says nearly 70,000 people have been killed in Syria's conflict since March 2011.
Associated Press writer Albert Aji contributed reporting from Damascus, Syria.


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Sauce Labs has expanded its Appium on Sauce mobile application test cloud, making it generally available and adding support for the Android OS.
The company bases its technology on the open source mobile testing framework Appium. So then, Sauce Labs' Appium on Sauce is a cloud-based, testing platform that automates cross-browser testing for native iOS apps, mobile web hybrid apps, and now native Android apps.
"Appium on Sauce solves a big problem at a critical time. Companies are relying more and more on their mobile channels where they have just seconds to prove their worth with a positive user experience and a lot of mobile apps aren't thoroughly tested, if they're tested at all," says Adam Christian, vice president of development at Sauce Labs. "Automated testing in a virtual environment represents the future, and we're providing it for the mobile ecosystem."
Sauce Labs offers a cloud of mobile platforms and desktop browsers for automated and manual testing of web and mobile apps. The company's software-as-a-service (SaaS) application is used to run approximately five million tests each month.


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Google "Iron Man, Tony Stark" and within the first few results you'll find Websites likening that superhero to Elon Musk, 41, the entrepreneur behind PayPal, the rocket maker SpaceX, and the electric-car sensation Tesla Motors. The comparison's apt. Musk is smart and stylish, and he fights planetary threats like global warming by creating spacecraft and zero-emissions cars that shame NASA and the auto giants. He's as rich as Iron Man's armored billionaire, too. Tesla shares rocketed this year from $35 to $115 -- lifting the Palo Alto auto start-up to a market value of $14 billion at May's end -- before easing back to a recent $102, where Musk's quarter-interest in the company is still worth $3.4 billion.
It's possible to admire Musk's achievements, while still wondering if Tesla's stock market fans are viewing its prospects through 3D glasses. The towering expectations now priced into the stock don't account for the Grand Canyon leap that Tesla must make to reach its goal of cutting its car's $90,000-plus sticker price in half. Electric-car batteries cost a heck of a lot, and today's Tesla Model S owes its better-than-200-mile range to batteries costing tens of thousands of dollars. Industries and governments around the world have spent billions on battery research, but few expect to trim electric-car battery costs by more than 20%-30% by the planned 2016 launch of Tesla's car for the Everyman. Perhaps Musk will confound the industry again, but if Tesla's next-generation car can't go the distance at half the price, its stock will head much lower.
One ingredient that fueled Tesla's (ticker: TSLA) tripling this year was an epic squeeze of those comic-book villains who had doubted Musk and sold more than a third of free-trading Tesla shares short. That fuel seems spent, for the moment. Traders say that the recently unborrowable shares are available again and can be had for a single-digit interest rate, instead of last month's 90% vig. With the shorts in retreat, Tesla should trade more in line with its fundamentals.
TESLA'S MODEL S SEDAN has won every car award in sight, and test drives by several Barron's staffers convinced us the Model S deserves the accolades. It has attracted 10,000 buyers in less than a year, and Musk told shareholders at last Tuesday's annual meeting that North American sales for the electric luxury car look as if they'll be 15,000 units this year.
But it will take time to discover how much sustained demand there is for a marvel priced above $90,000 (the price for a Model S Performance version, after a $7,500 federal tax credit). No one yet knows what portion of Tesla's initial buyers were "early adopters," unrepresentative of ongoing demand. Tesla irked analysts last month when it stopped disclosing its end-of-quarter order backlog -- which might have shed light on the issue -- after previously trumpeting a 15,000-unit reservation list.
The Model S won't get Tesla profits to a level that justifies today's stock price. The company expects to sell 21,000 worldwide this year, and Musk told shareholders on Tuesday that the car's annual sales might eventually reach 30,000 or 40,000. At about the 30,000 units that most bullish analysts predict for 2014, Tesla might earn about a buck a share (if you don't count the expense of stock options) -- which means the $102 stock is flying at 100 times next year's earnings forecast.
A top-of-the-line SUV called the Model X will bolster sales volume in 2015, but today's stock price is really a bet that Tesla can sell hundreds of thousands of cars a year, starting with the late 2016 launch of the Gen III that's supposed to cost well under $50,000. But there will have to be breakthroughs in battery technology to get Tesla to that price level without skimping on range; the Model S can go more than 200 miles on a charge. A battery-starved Gen III would encounter the same disappointing demand as other affordable electrics, like the Nissan Leaf (7201.Japan), Ford Focus EV (F), or General Motors ' (GM) plug-in hybrid Chevy Volt.
Stubbornly costly batteries may even cause headaches when today's Tesla's luxury cars arrive on the used-car lot. Folks who buy $90,000 cars tend to replace them every few years, and the bid for a four-year-old Model S may prove disappointing if it's going to need an expensive new battery in a few more years. Musk has astutely met that concern with a financing option guaranteeing resale value, but that just shifts the risk to shareholders.
As a result, Tesla's balance sheet will sprout a contingent liability for the "residual value" of those cars, and analysts worry that the amount will quickly rise to hundreds of millions of dollars -- on the order of half of the company's book value. The deferred impact of all those used batteries will become clearer in coming years, after Tesla also starts running low on the government-legislated zero-emission-vehicle credits that offset $68 million in expenses in the March 2013 quarter.
We had hoped Musk would advise us on these points, but our scheduled interview with him ended abruptly on Friday, when he hung up on us.
"I have no interest in an article that debates what we consider to be an obvious point -- which is that there is a dramatic reduction in battery costs," Musk said, after a few questions. "You clearly do not understand the business. My apologies. I am terminating the interview."
ELON MUSK IS NOT A GUY you like to bet against. He co-founded the Internet payment business PayPal, which eBay bought for $1.5 billion in 2002, after he had launched Space Exploration Technologies, the private company whose rockets began resupplying the International Space Station after NASA's own shuttles became museum pieces. Since 2008, Musk has been CEO of both SpaceX and Tesla, while chairing the board of the solar-power outfit SolarCity (SCTY).
Morgan Stanley auto analyst Adam Jonas compared Musk to railroad pioneer Cornelius Vanderbilt and Thomas Edison, in a report last month that called Tesla the best American auto maker and the analyst's top pick.
Tesla's first electric car was the $110,000 Roadster, a two-seater whose limited production couldn't buoy it through the 2008 financial crisis. Tesla survived with a $465 million loan from the U.S. Department of Energy, investments by Daimler (DAI.Germany) and Toyota (7203.Japan) -- which buy electric powertrains from Tesla -- and a 2010 initial offering of shares at $17 apiece. It helped that Tesla was unencumbered by union contracts or pensions. By June 2012, the Model S started rolling off the robotic assembly lines of a Fremont, Calif., plant that Tesla had bought for a song from GM and Toyota.
The Model S is a sensation. Motor Trend anointed it the 2013 Car of the Year, while the curmudgeons at Consumer Reports rated it 99 out of 100. Its electric motor has one moving part -- a simple design that has powered everything from blenders to locomotives since the 1888 patent on an alternating-current motor was issued to the company's namesake, inventor Nikola Tesla. The high price of the Model S lets it pack enough battery capacity to overcome the range limitations that stifle sales of cheaper electric cars.
In a test drive around Manhattan last month, the Model S lived up to its hype. Acceleration was smooth and quiet. The 17-inch touchscreen served up Slacker Radio stations, Google Maps, and anything else on the Internet. Passersby stopped for a look.
Tesla shares began their melt-up last month, when the company said it had sold 4,900 cars in the March quarter, generating $560 million in revenue and its first profit: $15 million, or 12 cents a share. Close examination revealed that the profit followed $68 million in payments from other car makers that haven't met federal quotas for producing zero-emission cars. They can purchase clean-air credits from auto producers like Tesla. Still, Tesla's March sales put the Model S on track for annual sales of 20,000 cars–topping the North American volume of successful luxury sports sedans such as the Audi A6 or the BMW 7 Series (see table). And sales hadn't even begun in Europe or Asia.
Elon's Next Challenge
To address these limitations, Tesla founder and CEO Elon Musk predicts that the third-generation Tesla, to be called Gen III, will open the mass market for its electric automobiles in 2016. Even so, there could be some serious bumps in the road ahead for both the existing and coming models.
• The $90,000 Model S is simply too pricey to achieve high-volume sales. The battery alone, which provides a range of 230 miles, costs tens of thousands of dollars.
• The more affordable Gen III, available in three years, will have a less expensive battery, but at the cost of a shorter per-charge range.
• Tesla is an affluent suburbanite's car. The Supercharger infrastructure of nationwide charging stations, announced last week with much fanfare, won't address the hassles faced by city dwellers, especially in Europe.
• The zero-emissions credits that subsidized Tesla's recent expenses will go away next year.
• At $102 a share, Tesla will need to sell hundreds of thousands of cars per year to support its stock price. That's unlikely for the range limited Gen III; and the Model S would have to match the worldwide sales of BMW's best-selling car
The stock leapt 50% after the March-quarter results, and the company took the occasion to raise $1 billion on May 24, through a $660 million convertible-note offering, plus the sale of stock at $92 a share, including $100 million subscribed to by Musk. With fanfare, Tesla repaid the remainder of its $450 million government loan and said that it would spend some of its new capital to expand its network of Superchargers–specially equipped locations that can recharge a Model S in a half-hour, instead of the usual overnight span. The network will grow to 100 stations by next year. Musk said he will demonstrate its reach this coming winter by making a cross-country road trip with his kids, "like the Chevy Chase movies."
So much good news for Tesla sent short sellers running for cover, squeezing the stock up to $115 on May 29. "We had to cover," one bear told Barron's. "The position tripled on us in as many months." Longs who had taken margin loans to buy Tesla shares, won big, and none bigger than Musk. Filings show that he raised his equity stake to 28% from 27% with the help of $150 million in loans from Goldman Sachs.
When Tesla investors return their attention to fundamentals, they should think about the company's make-or-break plan to reach high sales volume in 2017 with the Gen III. Morgan Stanley's Jonas notes that the Gen III accounts for 75% of his long-term volume forecasts and two-thirds of his $109 share-price valuation. That forecast anticipates sales surpassing 450,000 units a year by 2027, at higher profit margins and valuation multiples than the rest of the auto industry.
The challenge is battery cost. The Morgan Stanley analyst assumes that it can drop by half, from $400 to $200 per kilowatt hour, and that consumers will accept a driving range below 140 miles. But the U.S. government and industry researchers say the cost performance of batteries is coming down slower than hoped. At GM, Director of Global Battery Systems Bill Wallace believes that battery-capacity costs can improve by about 20% in the next few years, with longer odds of saving 40% if new technologies pan out in five years.
Before ending our interview, Musk said that improvements will cut the cost of the Model S's battery to $10,000-$12,000.
Musk will succeed at establishing Tesla as a valuable brand, even if it winds up confined to the luxury bracket of the Model S and its crossover cousin, the Model X. Tesla stock, therefore, has a floor at whatever price a giant like Daimler might pay to buy the company. But an acquirer wouldn't wildly overpay for the cash flow expected from those luxury lines. Morgan Stanley sees Tesla's free cash flow hitting $400 million in 2016 -- the year before Gen III's expected launch. A Harley-Davidson multiple on that cash flow -- 10 times -- would support a Tesla stock price in the $30s. A BMW multiple of three times would point to a $10 price. Those levels surely undervalue Tesla and Musk. We suspect there'd be plenty of buyers at $50.
The mass-market segment will be crowded by the time Tesla plans to deliver Gen III. Chevy just introduced GM's first all-electric car, the Spark EV, at $20,000 (after the $7,500 tax credit). Consumers seem cool to paying more for an electric vehicle with a driving range that's a fraction of an internal-combustion model's. Disappointing demand drove price cuts last month on Honda's Fit EV and Nissan's Leaf. The category-leading Leaf sold fewer than 10,000 units last year.
We're sure Musk could have told us why potential buyers of affordable electrics still see internal-combustion-powered cars as a cheaper, more convenient choice.
Additional reporting by ZOE DARTLEY
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There seems to be a lot of hand-wringing about this being a down year for college hoops.
If you define the season by whether or not there is a truly dominant team, I guess that's a fair statement. If you define the season by sheer entertainment value, however, this one has been pretty darn good.
The same kinds of upsets that are celebrated during the NCAA tournament are somehow being used as an indictment of the 2012-13 season, but I have no complaints about such an unpredictable year.
Well, maybe one.
It makes putting together these bracket projections increasingly difficult, because it feels like virtually everyone lost last week. Throw in oddball profiles such as the one Virginia is building, and this becomes a tall order each Monday night.
Maybe now that we are less than five weeks from Selection Sunday, things will start to sort themselves out. But with the way this season has gone, I doubt it.
The projections below take into account all games played through Monday, Feb. 11.
|Dayton – March 22nd/24th
|Lexington – March 21st/23rd
|1) Indiana (21-3)
|1) Miami, FL (19-3)
|16) Western Illinois (18-5)
|16) NC Central (17-7)/Southern (17-8)
|8) Oklahoma (16-7)
|8) Illinois (17-8)
|9) Saint Louis (18-5)
|San Jose – March 21st/23rd
|Austin – March 22nd/24th
|5) San Diego State (18-5)
|5) Ohio State (17-6)
|12) Belmont (20-5)
|12) Middle Tennessee (22-4)
|4) Pittsburgh (20-5)
|4) Kansas State (19-5)
|13) Akron (19-4)
|13) Louisiana Tech (21-3)
|Kansas City – March 22nd/24th
|San Jose – March 21st/23rd
|6) Cincinnati (18-6)
|6) Notre Dame (19-5)
|11) Memphis (20-3)
|11) Iowa State (16-7)
|3) Kansas (20-4)
|3) New Mexico (20-4)
|14) Northeastern (17-8)
|14) Montana (18-4)
|Lexington – March 21st/23rd
|Philadelphia – March 22nd/24th
|7) North Carolina State (17-7)
|10) Colorado (16-7)
|10) Wichita State (20-5)
|2) Florida (19-3)
|2) Syracuse (20-3)
|15) Florida Gulf Coast (18-8)
|15) Vermont (16-7)
|Auburn Hills – March 21st/23rd
|Philadelphia – March 22nd/24th
|1) Michigan (21-3)
|1) Duke (21-2)
|16) Niagara (14-11)/UNC-Asheville (15-10)
|16) Bryant (16-6)
|8) Creighton (20-5)
|8) Colorado State (19-4)
|9) Kentucky (17-6)
|9) Missouri (17-6)
|Kansas City – March 22nd/24th
|Austin – March 22nd/24th
|5) Oklahoma State (17-5)
|5) Georgetown (18-4)
|12) Boise State (16-7)/Saint Mary's (21-4)
|12) Baylor (15-8)/Indiana State (16-8)
|4) Butler (20-4)
|4) Wisconsin (17-7)
|13) Bucknell (20-4)
|13) Stephen F. Austin (20-2)
|Dayton – March 22nd/24th
|Salt Lake City – March 21st/23rd
|6) Minnesota (17-7)
|6) Marquette (17-6)
|11) North Carolina (16-7)
|11) Temple (16-7)
|3) Louisville (19-5)
|3) Gonzaga (23-2)
|14) Davidson (17-7)
|14) Valparaiso (19-6)
|Salt Lake City – March 21st/23rd
|Auburn Hills – March 21st/23rd
|7) Oregon (19-5)
|10) La Salle (16-6)
|10) Mississippi (18-5)
|2) Arizona (20-3)
|2) Michigan State (20-4)
|15) Princeton (11-8)
|15) Long Beach State (14-9)
Last Four In
Saint Mary's
The Gaels just need to keep winning, and unlike many of their bubble brethren, they are doing just that.
Thursday begins a critical 10-day stretch that features home dates with Gonzaga, BYU and Creighton, with a road trip to Loyola Marymount squeezed in the middle. Going 3-1 in that stretch would give Saint Mary's a little breathing room. Anything less and things start to get dicey.
Indiana State
Last week's win against Creighton gave the Sycamores their fourth win against an RPI top 50 team, and they avoided another brutal loss with a one-point victory over Southern Illinois on Saturday.
The neutral court win over a Reggie Johnson-less Miami squad looks better with each passing week, but three losses against sub-150 RPI teams still have ISU in a tenuous position.
For this week, the Sycamores need to avoid road slip-ups against Missouri State and Bradley.
At this point, the Bears have just one win against the RPI top 45, have lost three of four, and have beaten one tournament-caliber team since early December. Their November win over St. John's is useful for bubble purposes, but that won't be enough if they can't start getting wins.
Baylor needs to take care of business at home against West Virginia before a tough road test at Kansas State.
Boise State
The fact that Jeff Elorriaga missed three of their conference losses helps, but he also hasn't been particularly productive since returning. As it stands, the Broncos are below .500 in the Mountain West with road games left at New Mexico and UNLV as well as home dates with Colorado State and San Diego State.
If they can win their three other conference games and split those four, their profile would look pretty good. Anything less and they are in serious trouble.
First Five Out
The Cavaliers have the most confounding profile I can remember in recent years (or maybe ever).
On one hand, they are 6-0 against the RPI top 100 with home wins against North Carolina and North Carolina State and road victories over Wisconsin and Maryland. On the other hand, all six losses have come to teams ranked 120th or lower in the RPI, including to sub-300 Old Dominion.
You can't overlook the good wins or the bad losses, which lands the Cavs directly on the fence without much historical precedent for how the committee may treat them. The next few weeks will be telling with road trips to UNC and Miami as well as a home game against Duke.
Arizona State
Saturday's home loss to Stanford pushed the Sun Devils out of the field. They have four top-100 wins at this point and just one sub-100 loss — a 17-point home defeat to DePaul. The biggest issue is that nine of their 18 Division I wins have come against sub-200 squads.
With five of ASU's final seven games on the road, it will be an uphill battle for Herb Sendek's club. The Sun Devils certainly can't afford to lose at Utah this week and would be well-served to steal one at Colorado over the weekend.
St. John's
The Red Storm have won six of their past eight games, including wins over Notre Dame and UConn. However, nonconference losses to San Francisco and UNC-Asheville loom large, as does a disappointing home loss to Rutgers. Similar to ASU, St. John's has racked up seven of its 15 wins over sub-190 teams.
The remaining Big East schedule will tell the tale, with four games against teams in the RPI top 50 (at Louisville, Pittsburgh, at Notre Dame, Marquette) and a road trip to Providence sprinkled in.
After a home loss to Providence, the Wildcats held serve last week by beating DePaul and South Florida, but neither win really moves the needle for their NCAA hopes.
Victories over Louisville and Syracuse obviously hold a lot of weight, but their next best wins are against St. John's and St. Joseph's. Unfortunately, those are somewhat offset by an 18-point loss to Columbia and the fact they were swept by Providence.
This is a huge week for 'Nova with road trips to Cincinnati and UConn on tap.
The Minutemen are quietly 6-3 in the A-10, with two of those losses coming by a combined four points. They are also 6-2 in true road games, but the wins at Northeastern and La Salle are the only ones that hold much weight. UMass is 5-5 against the RPI top 100, but losses against Tennessee in Puerto Rico and at home vs. George Washington certainly don't help the cause.
Much like Villanova, the Minutemen have a pair of important games this week as they travel to VCU before hosting Temple on Saturday.
Here is how the bids broke out by conference:
Big East (7): Cincinnati, Georgetown, Louisville, Marquette, Notre Dame, Pittsburgh, Syracuse
Big Ten (7): Illinois, Indiana, Michigan, Michigan State, Minnesota, Ohio State, Wisconsin
Big 12 (6): Baylor, Iowa State, Kansas, Kansas State, Oklahoma, Oklahoma State
Atlantic 10 (5): Butler, La Salle, Saint Louis, Temple, VCU
Mountain West (5): Boise State, Colorado State, New Mexico, San Diego State, UNLV
Pac-12 (4): Arizona, Colorado, Oregon, UCLA
ACC (4): Duke, Miami (FL), North Carolina, North Carolina State
SEC (4): Florida, Kentucky, Missouri, Ole Miss
Missouri Valley (3): Creighton, Indiana State, Wichita State
West Coast (2): Gonzaga, Saint Mary's
America East: Vermont
Atlantic Sun: Florida Gulf Coast
Big Sky: Montana
Big South: UNC-Asheville
Big West: Long Beach State
Colonial: Northeastern
Conference USA: Memphis
Horizon: Valparaiso
Ivy: Princeton
MAAC: Niagara
MAC: Akron
MEAC: North Carolina Central
Northeast: Bryant
Ohio Valley: Belmont
Patriot: Bucknell
Southern: Davidson
Southland: Stephen F. Austin
Summit: Western Illinois
Sun Belt: Middle Tennessee
SWAC: Southern
WAC: Louisiana Tech
Follow me on Twitter (@andybottoms) for more thoughts on college hoops.


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October 11th, 2017
Phuket Gazette
Punching above it's weight – Rayong, Thailand
Phuket Gazette
But wait, there at the Number 7 position is the Thai city of Rayong. Rayong is just an hour south-east of Pattaya and a jumping off point for many of the Gulf of Thailand's northern islands – an easy 2.5 hour drive east of Bangkok. Not only punching …
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Thursday, November 08, 2007
I'd Rather Do it For Free
41 comments:
GREAT ARTICLE! Everyone with a voter registration card should be required to read it.ReplyDelete
- Anonymous5:55 AM, November 09, 2007
good article!ReplyDelete
I'm curious to know the reasons why so many patients have medicaid and are using the ER so much...
- Anonymous9:11 AM, November 09, 2007
Call me out of the loop, but I didn't realise that insured folk, like myself, were the lowest percentage of ER patients. I know that if I need to use the doc-in-a-box I have to jump through rings of fire to get that ok'd, but I can go to the ER self-refered. Mind you if it turns out not to be an emergency situation I'll get a nasty-gram from my company.ReplyDelete
What would happen if Medicaid /Medicare patients had to get past tele-nurse or some such off site triage before being ok'd for emergency treatment?
I'm just asking here, since I'm not a medical person, and have never played one on TV.
- Anonymous9:47 AM, November 09, 2007
These numbers (payments of ~33% medicare vs ~35% for uninsured) are exactly what we experience in our (relatively poor) population. In GruntDoc's blog, Shadowfax notes that he only gets 7% for uninsured. He needs to fire his billing company and collections agency. In fact, if we allowed our collections people to be more aggressive, we could probably get over 50% from our uninsured. Alas, I care too much about the plight of the poor to squeeze them dry. Well, at least 65% of them...ReplyDelete
dear m.e. the midwest mom,ReplyDelete
the tele nurse lines are a dismal failure. just to prove my point, pick any nurse advice line in your area and tell them the following...
you are a 25 year old woman with cough and runny nose and fever of 101 for a few days and you came from work where there are a few other people with a 'cold' but your concern is that you have just a twinge of discomfort in your chest... you think probably from a particularly hard sneeze, and you want to see the doctor some time soon.
you will be told, "go to the ER now". the reason? in a word, lawyers. even though only 1 in 10,000 of the hypothetical patient above will have either angina, pulmonary embolus, or thoracic aortic dissection, the liability and responsibility for catching this 1 in 10,000 is immediately transferred to the ER (and the cost to the nurse line, the primary doc running the nurse line, and me is in the millions if the zebra is missed).
also, just for fun, call your physician's office at, say, 4pm, tell them you have an earache and that it really hurts. that's it. tell them you've been swimming for excercise. i would wager a good ammount of money that they will tell you to go to the ER.
same with the previous post's topic, high blood pressure, call the nurse line and tell them that your blood pressure was 160/80 at walmart and that it made you nervous. probably 75% chance that the answer is "go to the ER"
as i tried to explain in a previous post seen at this link...
emergency medicine has become a victim of its own success and relevance. many primary care physicians are no longer comfortable taking care of potentially very sick patients in the office. this is partly due to liability, partly due to the fact that they don't usually have on-site lab and radiology, and to a large degree, due to atrophy of skills.
in the ER we work from the most dangerous POSSIBLE diagnsosis down to the real diagnsosis. hence, we don't miss much dangerous stuff. this is EXPENSIVE. in the doctor's office they work from the most likely diagnosis. this is NOT SO EXPENSIVE.
when the consequences of missing a rare but deadly condition are loss of career, license, large ammounts of money etc... it becomes easy to default to the "GO TO THE ER" answer.
tort reform would go a long way to allowing primary physicians to practice more reasonably in this regard and would also free us up to use more clinical judgement in the ER. as it stands now, we have to be perfect, and we have to do it no matter what we are likely to be paid, and no matter whether our patients are citizens, criminals, drug abusers, liars, or simply neurotic.
i'm not saying we shouldn't treat everyone the same and give everyone excellent care... we should certainly do this, i'm merely pointing out that Americans demand perfection from their physicians, and lawyers do too, and we are, through years of delterious legislation (which has shifted ALL responsibility off the patient for both health maintenance and payment), paid less and less for more and more.
such is the life of doctors today. and i am not whining, i'm trying to speak dispassionately.
something will give soon. if hillary wins doctors will still work, excellent care will still be delivered, but it will be done in such a way as to triage many people into slow death and chronic illness. i am against this, and, not as many will suspect, because of money.
i think i'll make, perhaps, a little more in the initial years of hillary care. i will not, however, work as hard, and neither will my surgeons, cardiologists, and other sub-specialists. all specialty care will be rationed by the clock. rather than getting your coronary artery bypass graft within a day or two of diagnosis of your three vessel disease, you will get it in three or four months, if you survive that long.
doctor's will not strike, we will simply fall into the malaise that is prevalent in the VA system, the DMV, the IRS, etc... there will be no sense of urgency anymore. the system will have it's choke point at the front door and will wait for people to go out the back door before letting the next person in.
rather quickly, also, you will see springing up from the fallow earth, clinics and hospitals that provide excellent, immediate care delivered just as it is today, but only for those with private insurance or cash. another giant beurocracy will suck on the taxpayer teat, and within a few years we will be right here again, but with fewer excellent young folks choosing to pursue medicine as a career.
- Anonymous12:44 PM, November 09, 2007
911: first of all, I agree completely. second of all: 'settle down Beavis"ReplyDelete
your mah-ther's a slotReplyDelete
- Anonymous12:59 PM, November 09, 2007
good one.ReplyDelete
- Anonymous1:02 PM, November 09, 2007
Do you shine your pants?ReplyDelete
huhuhuh... you said 'douche' or somethingReplyDelete
I had to take my 8 y/o to the ER on Sunday morning. It was, as expected, a pretty long wait. I asked the check-in attendant if there was an urgent care clinic close by or another option. She referred me to a private ER.ReplyDelete
Upon signing in to meticulous building (and rooms!) with 1 family in the waiting room, I noticed a huge sign that hung on the glass partition:
NO TRICARE (military insurance for those who don't know)
The doctor was thorough, pleasant, caring and obviously has a corner on a market out here in the Houston, Texas area.
DAMN CAPITALISM AND ALL ITS EFFICIENCY!ReplyDelete
- Anonymous2:02 PM, November 09, 2007
Is what pink describes actually "legal"???ReplyDelete
Well explained 911! Kudos on the excellent response.ReplyDelete
To address methemwm's reasonable question, I'll provide an example of why a good idea often doesn't work. Two years ago, I practiced in an area that borders a state with a huge medicaid problem. Their legislature came up with what sounded like a reasonable plan to try and both cut down on ER visits and encourage patients to see a PCP for their routine care.
The plan was simple. If your PCP was open, you were expected to go there for care. You could come to the ED if you thought it was an emergency, but if it wasn't, you would be expected to pay the bill. If the care we provided was non-emergent, medicaid paid us nothing.
If we examined the patient, told them that they didn't have an emergency and needed to see their PCP, we'd get paid $25 for a "medical screening exam" (as long as we provided no treatment).
If the PCP's office couldn't work the patient in, they'd fax us a referral form and we would get paid the $8 that the PCP got paid for seeing the patient!
During nights and weekends, the patients were "automatically referred" to the ED and we got our $8 each!
After about a month, the medicaid patients started waiting until after 5pm and on weekends to come to the ER.
Ultimately, since the PCP's didn't really care about the $8 and would prefer to see a patient with "real" insurance and make more, they just faxed over stacks of blank signed referral forms for us to complete.
The whole system was ultimately a joke.
911 is spot on with his descriptions of the "Go to the ER phone nurses". They're a waste of good computer bandwidth. A recording would be more cost effective.
One rub for me is that it is impossible to sue a judge for performing their professional duty and virtually impossible to sue a lawyer for malpractice. I on the other hand can do everything right and still be sued. It's clear who writes the laws!
yes. i do not know the ins and outs, but i believe there are ways to do it. i think doing it as a hospital would be very difficult as if the hospital had an emergency department then emtala would apply and the hospital would be overwhelmed just based on the ER.ReplyDelete
the typical response from the left side of the aisle will be to outlaw these clinics and hospitals and THAT is the point at which people will finally understand how our system has been hijacked.
i can't help wondering the reasons for visiting the er of the commenters here. i somehow thought e in er stood for emergency.ReplyDelete
i think, as 911 says, 'emergency medicine has become a victim of its own success'. it is no longer emergency stuff. it is trivia. it is about getting so called service.
i think the public needs to be educated. do not come to the emergency room unless it is an emergency. otherwise wait until the big light is in the sky.
i also think er personnel need to start turning people away at the doors. if it is not an emergency, find a place called convenience room. go there.
this is why i don't think i could work er any more. hats off to you guys that do, though.
dear bongi,ReplyDelete
your heart's in the right place BUT i am here to tell you that with the patient population we take care of that no ammount of education will cure this ill. the fact is that for many, they know that they will never have to pay a dime for the best medical care anywhere in the world. there is no consequence to riding the ambulance in for their headache. the worst place to be here is a lower middle class person with a job but no insurance because YOU will pay something and probably get into credit trouble because of it. now YOU are disincentivized from coming to us even in a true emergency. IF, however, you have some throwaway form of insurance, like MEDICAID or any of the state supporte programs for the uninsured, then, by law, we must see and treat you and woe be unto us if we fuck up. as a painful aside, these patients are almost always the ones that are the most demanding, most litigious, and hardest to truly CARE about. if they had to pay even ten dollars in cash every time they came in the problem would quickly vanish. if they had to pay, as they do in MEXICO, to ride the ambulance IN the ambulance, the abuse of EMS would cease as well.
this is not rocket surgery (to quote david lee roth), but is completely incomprehensible to hard lefties. if it is not incomprehensible, then it is worse, it's vote buying.
I work in medicine and have for 15+ years. Trust me when I say, I don't use the ER for a ridiculous reason. The last time my daughter was seen by a doctor was 2 years ago, and that was for a well-check visit.
No, it was not a cardiopulmonary arrest in an 8 y/o. It wasn't a seizure, coma, CVA or MVA; however, when dealing with children, sometimes it is prudent to not wait that extra 24 hours when symptoms dictate and the PCP says so. M'kay?
Was she as critical as the others in the waiting room, pending patients, or possible ambulance transfers? How in the world am I supposed to know?
All I knew was that she was still coherent, able to speak and walk (as were the others, but that's another story)... and thus my question about the urgent care clinic.
The one listed in my book was 60 miles away, and the loverly insurance company said in their voice mail to "call back during normal business hours" because I wanted to find a closer urgent care. Great help, right?
FWIW, my co-pay is 150.00 for ER visits and urgent is 75.00. I would have GLADLY paid half-price if it meant driving less than 60 miles of uncertainty. Oh, and the nearest hospital had she needed to be admitted would have been 60+ miles away.
And, I paid up front to the private ER, as I would have in the ER, because that's how I roll. I pay ENOUGH in monthly premiums (almost 1000.00 for a healthy family of 4) to pashaw savings.
So, really, piss off with your ass-umptions.
I was merely trying to relate the sign I saw because it directly related to the article posted.
Here is a link to the facility to which I referred:ReplyDelete
Is a child with a bladder infection an emergency? No. Is a child with pyelonephritis an emergency? Yes. What's the difference....a few hours or days.ReplyDelete
What IS and ISN'T an emergency is a subject that even insiders can't agree upon. Pink made a choice to go to the ED, made a choice to pay the extra, and made a choice to wait patiently while more serious patients were seen. I can't say that I mind that at all.
But when minor patients bitch about the wait, my standard comment is "'Emergency' isn't defined by the fact that you are here".
It brightens my shift to walk out of some cluster-fuck drunken asshole who took too many pills, has 4 people holding him down to get an IV started, questions my heritage, and vomits on my shoes...only to pick up a chart for a nice person with a relatively minor problem that's grateful that we're there.
When I bitch about the abuse of the ED, I'm not referring to patients like pink. I'm talking about the patients who come 20 times a year for demerol shots for their chronic back pain, or 15 times a year for toothaches since they can't afford a dentist (even though they smoke 3 packs a day and are on their cell phone). I'm talking about the people who have seen 5 different doctors in the past 2 years and no one can figure why a pain shoots out of their big toe and back into their eye socket.
I mind the people who won't go to the health department for their STD because there's a $10 charge and they can get care "for free" in the ED.
I mind the parents who bring their kids to the ED for fever because "I can get Tylenol for free here".
That's what I mind!
Some studies have even been done to show that if ED's depended solely on funds garnered from true emergencies...they'd all go bankrupt.
The solutions aren't easy, nor are the issues. Surely, Hillary and her band of "experts" (which doesn't include a single practicing physician) can figure this all out! Fortunately, I don't worry about Hillary too much since I don't think Congress will let her make too many changes....but I may be wrong.
*murmur of agreement*ReplyDelete
my feelings precisely, i need the 'not so sick' patients inbetween the time intensive ones no doubt.
one thing that is being floated but will not pass legislative muster is to allow physicians to deduct the cost of the free care they give. even a 10% write off would make a huge difference but, well, i'm a rich doctor and unfeeling and uncaring etc... so that won't be so popular.
off to my yacht.
I don't worry about Hillary too much since I don't think Congress will let her make too many changesReplyDelete
I'll worry for the both of us. Frankly that woman scares the crap out of me. I can't wait to get some of this into my writing...
Lynn: can we get a share of the book profits? Just make the check payable to the IRS and put my ss# on it!ReplyDelete
I love yall. Intelligent, and to the point, yet hilarious.ReplyDelete
- Anonymous7:58 PM, November 09, 2007
i got tired of patients on cell phones. i bought a cell phone blocker over the internet. they are illegal here so i ordered mine from england. it's the size of a small pager. when i walk into a room where a patient is on their cell phone and holds up their finger for me to wait a minute, i just click it on and poof they are no longer on their cell phone. it's also great at the movies.ReplyDelete
oh my goodness, please tell me where i can get one.ReplyDelete
thanks for the kudos emergencyemm.
I'm going to piss off all the liberals in the audience, but how about requiring a little job action for these 22-year old able-bodied people with 2 or 4 kids in order to get "assistance" from the govt?ReplyDelete
If you want to choose to live purely off the money of others, you should be out of the category of "government assistance" and into charity care. It should not be mandatory for people to provide assistance to people who are simply choosing to be unemployed for whatever reason.
I'm not talking about the truly mentally ill or those with bona fide disabilities; everyone who works in an ER knows who I'm talking about.
If some of these people who use ERs the most had an obligation to be at work (and consequences if they didn't go), the amount of time spent in ERs for sniffles and in bed with some new guy having another to have another child would go way down.
heartless and cruel you are ma'am! i'm a romanian/cherokee indian/pacific islander/ mexican/ dutch person with all the glory and grandeur attached to my heritage. i demand respect and free stuff!ReplyDelete
NO MEDICAIDReplyDelete
NO TRICARE (military insurance for those who don't know)
Those are the same three that won't pay me to assist.
911 That was the best summation I have read yet.
Bongi, I agree, you (I, we) may not get paid either but at least in the OR it sure is a lot more fun to not get paid from an anesthetized patient was can't cuss, insult, complain, and demand while you're treating them. Of course that's easy for me to say, I don't have to do rounds....bahhaha!
- Anonymous10:42 PM, November 09, 2007
here is the site i bought mine from. there are several out there.ReplyDelete
- Anonymous2:07 AM, November 10, 2007
911 doc, no clever comment here, just thanks from a patient for your easy-to-understand explanation of what er docs have to go through. I didn't know.ReplyDelete
- Anonymous5:17 AM, November 10, 2007
Holy Cats. Do you think we should get the lawmakers to hang out and observe in a busy ER for about a month straight before they can enact any more laws? It can't be a bad thing getting them a little perspective.ReplyDelete
Thanks for the replies. Next time I have to use the ER I'll send a bunch of flowers and a nice note. That'll throw you all off.
happy to help. really, i don't think that any ammount of knocking on the head is likely to change the outlook of our legislators. you are assuming that they want to past the best and most reasonable laws. cynic that i am i believe that, especially on one side of the aisle, legislators want little more that re-election. i would like to be wrong about his.
Nurse K,ReplyDelete
How about a random drug test once every couple of months? No passie, no bennies. I have to pass one to keep my job. Why in the hell shouldn't moochers have to pass one to benefit from my taxes from said job (and higher premiums)?
oh God bless you PINK! four letters and two words... ACLU and liberal democrats.ReplyDelete
How about a random drug test once every couple of months?ReplyDelete
Dear Pink, our physicians are writing the prescriptions; one could hardly fault the patient for taking what was prescribed to him by 8 or 9 different doctors that week.
I don't really care if you do coke on the weekends or evenings as long as you do your required job during the week. If you have to have a job, you'll maybe have built-in incentive to not use it anyway.
After a long day, I found a few more things that I mind:ReplyDelete
1) 18 year old female who missed her period, has nausea and breast tenderness and had 2 positive pregnancy tests at home. She comes to the ER for confirmation. Yes, you're pregnant. We use the same pregnancy tests you buy at WalMart.
2) A woman who comes in with her kid demanding "shots of Bicillin so we won't get sick over the holidays". They have a PCP, but he wants $75 to see them. So she wants it free.
3) The lady with a scheduled hip replacement in 5 days who "just can't wait any longer" and wants it done on Saturday, right now.
4) The lady who can't stand up straight and her family is sure she's had a stroke. Turns out that her drug screen is positive for everything EXCEPT marijuana. When confronted, she says "maybe they're putting something in my weed"!
These are things that I mind.
Nurse K,ReplyDelete
I'm talking about lazy-ass welfare recipients. And, I am sure you know as well as I, most drug seekers will be positive for other substances such as marijuana and cocaine. I'll give you that cocaine metabolizes w/i a few days, but pot sure doesn't...especially in the chronic user.
So, while the "system drug seeker" may be able to justify the Vicodin or Perkie, he or she WON'T be able to justify the weed or crack/coke.
That's is to which I am referring. One less moocher off of the government's dole is a start...right?
Or would it hurt "the children?" ***cough, cough, puke, spit**
you may want to visit our sponsor, www.poopstrong.org, they do it all for the children.ReplyDelete
Poops trong? Asian poop?ReplyDelete
Poo strong? Smelly poop?
Dammit! Don't confuse me and have it all "for the children!"
Po'opst Rong 2nd year MLB out of LSUReplyDelete


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