I never understand why doctors are not blamed for prescribing these. Are doctors not supposed to be responsible for prescriptions? If they are not, should we stop allowing them to prescribe? Why don’t doctors unions throw out members who would claim to have been hoodwinked by pharmaceutical companies?
It's because doctors and hospitals are increasingly evaluated based on patient satisfaction instead of patient outcomes.
It's why you'll walk into a medical plaza lobby that looks like a 4-star hotel, with fountains and art on the wall, and why the doctor will write you a prescription for an absurd dose of narcotics after surgery. After you've been cut open, it's normal to be in some pain for a while, but if the doctor drugs you into such a daze that you feel nothing, you'll rate him or her more highly. Even if 9/10 people end up being fine and stop taking the drug when they're supposed to, 1/10 people have a new addition.
This is bizarre the end-result of the privatization of our medical system. We're just one step away from rating doctors with stars like Uber, where they offer you drugs instead of a free water bottle when you walk in.
As an MD, I strongly agree. However, you forgot to mention the other side of this: a rating lower than two stars is combined with an immediate threat to sue.
Blame the doctors is part of the campaign to influence public opinion to save the Sacklers from the consequences of their actions. Find a different enemy to blame for everything. Just pay attention to the way the argument percolates through social media.
The field isn’t called patient satisfaction anymore. It’s called patient experience and it is pretty much ubiquitous to ensuring high quality patient care.
I see these as a consequence to having no real way to remove bad doctors through the legal system. They all protect each other. There's some idiots looking for narcotics, but that isn't all of it.
The more you'll sue doctors, the more MDs will practice defensive medicine and you'll end up with shit quality overly invasive care. The way to go is to sue the institutions, but not the practitioners themselves. Then the institution punishes the doc if warranted.
In opposition to what you think, doctors are highly egoistical individuals and absolutely do not cover for one another.
We already have defensively practiced, shit quality medicine. I was diagnosed late with ADHD, had to leave that doctor's practice, and finding another doctor who agrees with that diagnosis has been impossible.
The tendency I observed when competency was questioned was to not punish in any way that had strong ramifications. They might badmouth them, but the desire to strip of their license or award large punitive damages isn't there because they are worried about it happening to them, real or imagined.
That is bad also, but does not remove the blame on doctors for defensive-doctoring as opposed to actually trying to figure out what is best for their patient.
> Why don’t doctors unions throw out members who would claim to have been hoodwinked by pharmaceutical companies?
If the companies are lying about safety, how are the doctors supposed to know? The only ones with the data necessary to know the dangers of these drugs are the manufacturers and the manufacturers were lying and covering up the dangers.
I think a casual understanding of history has numerous examples of opioids that were prescribed as being safe, and that people then got addicted to, and then we all moved on to the next one. Heroin was one, after all. I find it hard to imagine too many doctors who are unaware of the history. How they have chosen to view that history (psychiatry's triumphant "this time we got it right!" or perhaps simply shrinking away from the issue) is what informs their decisions.
Is it an opioid? Then it is probably addictive for some people.
I know that there is some experimentation involving kappa opioid receptors, trying to essentially neutralize any euphoria or uplift with the k-receptor's dysphoria "bummer," but until that has been ironed out, they're habit-forming for many. Not all, but many.
Asking doctors to decide which research they should and should not trust based on their understanding of history seems like a more dangerous situation.
I dunno, "The history of all opioids we have ever encountered has always been associated with addiction" is not a particularly difficult concept to grasp, nor can I see it taking an inordinate amount of time to cram into their education.
A huge part of most doctors' jobs is balancing the risk of bad things with the benefits of procedures, medications, etc. One of the main reasons we have doctors is so that we can trust their educated judgment. For example, mine noted that guidance had changed on when we should test for some cancers (not as early), because the risk of false positive is higher than the risk of actually having the cancer.
In the case of opioids, doctors know they are addictive. They also unfortunately happen to be _extremely effective_ (for most people) at treating severe pains, and have to balance the benefits of pain relief (both in terms of patient happiness and the healing process) versus the risk of harm. I've definitely seen a shift in doctors' prescribing habits in the past fifteen years, in favor of starting with Ibuprofen or other NSAIDs, with the option to ask for a stronger prescription if pain is too much.
Oh, I am well-aware, as I have been on a somewhat niche Schedule II prescription for over a decade now. It can be quite a hassle.
I am merely pointing out that the idea that medical doctors being unaware of a basic correlation between opioids and addiction, one which has progressed from one medicine to another over the decades, seems ... disingenuous? Preciously naive? Remember, I am replying to "If the companies are lying about safety, how are the doctors supposed to know?"
Here, I think the doctors are supposed to know in the case of opioids because this is an ongoing historical trend. A random new class of medicine? No, they will probably trust the safety sheet, as well they should. The umpteenth opioid? I would be viewing with a gimlet eye anything saying "Nah, no addictive potential."
If doctors only prescribed opioids it would be simple, but they deal in all sorts of constantly evolving drugs where new research may overturn previous assumptions. Trusting the research and heavily punishing those who falsify data seems a lot more sane.
I will counter this one with a hypothetical for you. Monsanto, or Bayer now I guess, trots out a totally safe guys we pinky-swear pesticide. Would you add a little to your drinking water every day? Safety sheets say it can't hurt.
You would probably not do this because you have a historical association with pesticides turning out to be rather broader in impact than was originally let on. You understand that history.
I only suggest that this historical wariness sounds completely reasonable for opioids, whereas a brand new drug class has no history associated with it.
Let me amend your hypothetical. The pesticide presentation is the twentyth such presentation on various topics you've seen today. You see this many every year, and the safety sheets have always been accurate. And, if this pesticide is not used, it is known that the people of your community will suffer and/or die.
Does your understanding of the companies history outweigh your experience of the formats history?
I am not suggesting that they didn't know or would suddenly not prescribe any opioids at all. I have been very careful to say that some, and only some, get addicted.
And I would still not add that pesticide to my drinking water. So I will ask ... would you?
Given that I know people will suffer and die if I don't, yes.
It's a dumb hypothetical though, as my point has repeatedly been that doctors have far too many areas to be concerned about to selectively decide that this one pain killer needs more investigation before I prescribe it regularly.
Exactly, there is a chain of trust involved, and when that trust is broken it makes sense to first look as far up the chain as possible.
Holding doctors responsible for their actions only starts making sense once we are talking about doctors who keep prescribing this long after the risks have become known, which I am sure has happened too. But it's not the root problem.
They are supposed to have learned about it in medical school. If not, that's fine, maybe doctors shouldn't be allowed to prescribe and maybe only pharmacists should be allowed. My point is that it's a very valuable professional quality and we should put the responsibility where the quality is.
This is (well, was) a new drug. Doctors cannot have learned about a drug in medical school when that drug did not exist when they were studying.
My parents are retired Dutch GPs who also ran a small pharmacy[0], so I know a little about how this works, at least in the Netherlands (I admit that this is a pretty big caveat, because (aside from the obvious biases that this introduces) the opioid crisis doesn't exist here - it seems to be a US-only thing. On the other hand, that only gives me more reason to suspect that the problem is systemic, not something to be blamed on individual doctors).
Every year doctors (or any other medical professional as well) have to attend a mandatory amount of lessons to update their knowledge of recent developments in their medical field. In my parents case this also was true for pharmaceutical knowledge. This is where they learn about new medications and their usage. So yeah, they do in fact learn which drug is supposedly safe to prescribe under which circumstances. But you know what is required for all of that to work? An authoritative source of trustworthy information on drug use.
Doctors only start prescribing a drug after it has been approved by the relevant governmental bodies for their usage. So if OxyContin got through the FDA, and was marked as safe for the usage it was advertised for, then I do not understand why you suggest that it's the fault of doctors that they prescribed it in those cases.
Sure, there might have been some stories going around that this drug might not be quite as safe as claimed, but keep in mind that at any given moment hundreds of quack medicine scaremongering stories are making the rounds. When given a choice between believing those, or the official body that is supposed to verify which drugs are safe or not, doctors will usually pick the latter, and in most cases rightly so.
[0] in the Netherlands this is relatively common in small countryside villages that are too small to sustain a pharmacist, who typically needs at least 5000 clients to be sustainable
> Doctors only start prescribing a drug after it has been approved by the relevant governmental bodies for their usage. So if OxyContin got through the FDA, and was marked as safe for the usage it was advertised for, then I do not understand why you suggest that it's the fault of doctors that they prescribed it in those cases.
The caveat is that once a drug is approved for XYZ, doctors can, and do, prescribe it for anything else in their judgement.
Oxycontin wasn’t approved for chronic non-cancer pain, because it’s a poor choice for that, but that’s where the recurring revenue is and somehow accounted for most of its usage.
Short-term post-operative pain and cancer pain just isn’t that big of a market.
> The caveat is that once a drug is approved for XYZ, doctors can, and do, prescribe it for anything else in their judgement. The caveat is that once a drug is approved for XYZ, doctors can, and do, prescribe it for anything else in their judgement.
Yes, but pharmaceutical companies cannot market the drug for non-approved uses or discuss off-label use when promoting or selling the drug. That is illegal.
That illegal activity is exactly what the courts determined Purdue did - bribery, fraudulent marketing, and more. The issue is that Purdue broke the law (and that their sentences for breaking the law were way too light).
Oxycodone was first formulated in 1917, so it's not really "new".
There are lots of FDA-approved drugs that are highly inappropriate for most patients. One of the reasons we tolerate the professional status of physicians is because of their purported expertise in prescribing these drugs safely. If they don't know the function and habit-forming potential of opioids, one might well question that expertise. They aren't regulated in any sense by FDA, and they can't blame FDA for their ignorance.
I agree, go after the deep pockets. I sympathize with patients who became addicted to oxy, while at the same time I'm convinced that opioids should be available to those who need them. I'm glad I got some Demerol when I needed it. I even sympathize with physicians who weighed their patients' needs against the risks of addiction, carefully followed up on their oxy prescriptions, and still had some patients succumb to addiction. I don't sympathize with blanket statements like "doctors just trusted Purdue". Any physician who refilled an opioid prescription without asking the patient some blunt questions and being satisfied with the answers is a piss-poor physician.
>Doctors only start prescribing a drug after it has been approved by the relevant governmental bodies for their usage. So if OxyContin got through the FDA, and was marked as safe for the usage it was advertised for, then I do not understand why you suggest that it's the fault of doctors that they prescribed it in those cases.
Given that the same opioids are approved in the US and Netherlands, with the same warnings and information, why do you think the outcomes are so different between countries?
Before a doctor gets a new drug it should’ve been approved by a government agency and gone through trails. The company selling it trains doctors on its use and side affects. The problem is the company was lying and telling half truths. Not only that they pushed use cases where something as strong as Oxy was not needed.
Pill mill doctors are a different story and they are prosecuted for it.
Purdue kept a database of doctors willing to prescribe their products "for pain relief" and have now switched sides to push a drug that treats opioid addiction under a new marketing campaign and a new industry front.
Doctors who were prescribing medicine at the time that OxyContin hit the market were not in medical school, they had graduated already. If pharma lies about safety there is no way for a doctor to know unless they conduct their own study, which would require lots of extra time and massive funding. Pharmacists didn't know that the safety data was fudged either. Everyone got their oxycontin from a pharmacist after a doctor prescribed it, so having a pharmacist be the only one allowed to prescribe it wouldn't have changed anything.
That does change the interpretation of your earlier statement quite a lot, thank you for clarifying. Together with
Scoundreller's observation it does seem that there are a number of systemic issues working together in the US to create this problem. And one of these seems to be how doctors prescribe medication.
>They are supposed to have learned about it in medical school.
People need to realize that medical school isn't some all-knowing institution where everything knowable about human physiology is imparted unto students.
Consider OxyContin, which the makers claimed worked for 12 hours. 2 things should be red flags here: firstly, I haven't seen an extended release formulation of anything that would work over that period; I'm not even sure if it's physically possible given the human digestion system. Secondly, the many, many patients who complained that it only worked for 6-8 hours.
Any doctor with a basic understanding of pharmacology, and basic bedside manner, should have known something was up there.
"doctors should have known the manufacturers' claims were bogus" is shifting the blame. The real blame should be focused on the manufacturers making false claims in the first place.
It wasn't my intention to shift the blame - clearly the manufacturers should be strung up for making the false claims they did. Absolutely no argument there.
My point is though, that doctors shouldn't blindly trust whatever a manufacturer tells them, if the evidence right in front of their eyes says different.
> My point is though, that doctors shouldn't blindly trust whatever a manufacturer tells them, if the evidence right in front of their eyes says different.
Just to be clear, you're advocating doctors eschewing published clinical data (including data from published trials and the FDA approval) on the basis of nonrandomized anecdotal data?
The issue here is that the manufacturers committed fraud - falsifying and/or misrepresenting clinical data. The courts confirmed this, finding them guilty of fraud, bribery, and more.
Unlike courts, a doctor is in no better position to such sophisticated identify fraud at that scale than a patient is. The pharmaceutical companies and manufacturers absolutely should be held accountable for that, but doctors by and large are not to blame for the fraud committed by pharmaceutical companies.
> The issue here is that the manufacturers committed fraud - falsifying and/or misrepresenting clinical data
This is my point - the claims were BS. A number of doctors should have been raising a number of red flags, because their knowledge contradicted those claims, as did patient evidence right in front of their very eyes.
I'm obviously not saying they should ignore or distrust all clinical data, but if they see such massive discrepancies then they should be speaking up.
> A number of doctors should have been raising a number of red flags, because their knowledge contradicted those claims
Purdue committed fraud, but they never made claims that were so outrageous that they would be prima facie false. (If that had been the case, Oxycontin would never have been approved in the first place). The problem wasn't that the claims were outrageously impossible; it's that the claims were wrong, and Purdue either falsified or misrepresented clinical data in order to convince doctors that Oxycontin was safer than it actually was.
> Patient evidence right in front of their eyes
Encouraging people to rely overly on anecdotal observations is incredibly dangerous, especially when most doctors who prescribe opioids don't prescribe them in such numbers that these issues would be readily visible to them in the first place.
Yes, there were a small number of doctors who did aggressively overprescribe and misprescribe Oxycontin. That was the result of a direct and explicit campaign by Purdue to identify and enable those doctors. Some of those doctors were prosecuted and/or did lose their licenses, but those doctors still only amounted to a small part of the opioid crisis.
> I'm obviously not saying they should ignore or distrust all clinical data, but if they see such massive discrepancies then they should be speaking up.
Most doctors weren't seeing massive discrepancies. We know the discrepancies exist now because there were lawsuits and prosecutions which revealed the specific fraudulent behavior that Purdue and others were engaged in. But without the benefit of hindsight, these issues simply weren't reasonably visible to a typical doctor - they were only visible at large scale to Purdue, who went out of their way to mislead everyone else about it.
There's plenty of blame to go around, both can be at fault. My family doctor, for example, warned me to be very careful of the Oxytocin I was given by the hospital (without any warnings) after my wisdom teeth were removed.
This is the kind of thing I mean - giving someone oxycontin without any warnings is just plain irresponsible.
Furthermore, opioids shouldn't even be used as first line after wisdom teeth removal - across Europe you'd be sent home and told to take paracetamol or ibuprofen, because those medications generally work very well for inflammation-type pain.
Why blame doctors when the makers of OxyContin told Congress for years that it was safe and non-addictive. It's a systemic issue with various actors/stakeholders whom all are partially to blame in various capacities.
While doctors do share some blame, they were actively targetted by Purdue with brochures, slick salesmen etc.How is was allowed is the real issue for me.
Congress chooses which experts it listens to. Too often it chooses those "experts" based on notoriety and the conclusion they hope to reach.
Now they are "shocked" to find out they people they've been accepting money from were leading them astray -- not that they knew where that money was ever coming from.
1. Physicians in the US don't have a union. Some conservatives call the AMA a physicians' union, and while it shares some union functions it simply is not one. Physicians are licensed to practice by individual states.
2. Physicians are responsible for writing prescriptions, pharmacists dispense them, and patients self-administer in most cases. The opioid epidemic was caused by failures at each of these levels, not just when writing the rx.
Some doctors are blamed for over-prescribing, which is why some doctors were jailed and some doctors struck off.
That doesn't take away from the fact that the manufacturers led a campaign to deliberately mislead people for years about the addictiveness and efficacy of opioid medication to treat pain.
Not typically in money, but in gifts, lunches, and attention paid by young, attractive pharmaceutical sales people. For opioids, specifically, there is also the factor that doctors prescribing opioids will have higher customer satisfaction in the short term because opioids are better than almost anything for pain relief. Higher customer satisfaction (not necessarily the same as better patient outcomes) usually means more recommendations and more money. If some of your patients get addicted it just means they'll come in more frequently for more prescriptions. Plus, they can't actually be addicted, since your sales rep with a bachelor's in biology said that Oxycontin is not addictive.
Saying Oxycontin isn't addictive is false but from talking to doctors they tend to not consider it addiction if you are receiving the medication for an actively treated issue.
Gifts from pharma hasn’t been true for a couple decades. They don’t even give pens now. Sure they can get a free lunch, but it’s usually brought to their office and it’s fast food.
Customer satisfaction is relevant, but only because hospitals have put so much emphasis on it.
But regardless, nobody can get these drugs without a doctor writing a script, so there is plenty of blame to go around.
Huh. I'd love to know where you're getting that idea from.
Through a strange series of events (extreme sports hobbies) I became friends with a group of doctors, none of them participating in anything very special or that could be seen as a career height. Most really just starting out after the hell that is med school.
They spoke of pretty regular outreach of gifts from pharma. Mainly in the form of fancy retreats (like to Hawaii - note, we were based in SoCal at the time) with pretty extravagant dinners and fancy boating stuff. These were, according to them, always filled with the brim with others like them to the point it got to be quite frankly boring, annoying, and a nuisance. No matter how hard they tried to ignore the unsolicited outreach, it wouldn't stop coming.
The guidelines also reiterate the group’s 2002 code, which prohibited more expensive goods and services like tickets to professional sports games and junkets to resorts. And it asks companies that finance medical courses, conferences or scholarships to leave the selection of study material and scholarship recipients to outside program coordinators.
Huh. Call me crazy, but it almost seems as if guidelines and codes haven't meant much for a while. Like, real life "air quotes" oh yes, we won't send them to resorts.
Well, if I had to make an educated guess, they really did cross their fingers and nobody seems to be investigating/enforcing otherwise and they're getting away with it - because I'm telling you, first hand... it's happening, quite frequently, at least on the West Coast.
I used to work in the industry when all this changed. Could there be a one-off company doing it? Sure. They are risking being brought up on Federal charges for it. The gov't has gone after drug companies for much less.
I think there are rules against payment but as we all know, there are ways around rules when it concerns money. Looks like there is a correlation between doctors being buttered up, and them prescribing opiods.
the pharmacutical companies have developed many ways of rewarding doctors for being compliant, such as by being paid 'consultants' presenting at conferences in exotic locations. For everyday practitioners, social primping (wining, dining, rounds of golf in prestigious locations and/or company) works as well as for just about everyone.
Most organizations are not good at throwing out members that do bad things. Usually they are set up to be defensive no matter what. Looked at police unions who protect bad cops, judges (there was something on Reuter’s about judge misconduct) and doctors (it takes forever and many injured people to get bad surgeons banned). It would be grwat these organizations had higher standards for their members but they don’t.
I never understand why doctors are not blamed for prescribing these
Because doctors are human beings and in particular they’re people who are motivated by the desire to alleviate suffering. When faced with patients who repeatedly return to their office, complaining of severe pain, what can they do?
There are no miracle painkillers. We have anti-inflammatories for minor aches and pains. We have opioids for severe, temporary pain (such as recovery from surgery and end-of-life care). We do not have a painkiller suitable for chronic pain.
Purdue pharma offered doctors a way out. The institutional structure of healthcare, into which doctors and pharma companies fit, permits diffusion of responsibility [1]. Doctors escape blame because the determination of the safety and efficacy of medication is outside their area of responsibility.
Shifting the blame to the doctors is/was one of the major strategies pursued by influencers working for the Sacklers. You're simply playing their game here (either knowingly or unknowingly).
Because medical boards are staffed with doctors who let other doctors off the hook. Doctors are held to account about as well as police (in the US), i.e. not at all.
In Florida, opioid prescriptions were recently as easy to get as a medical marijuana card in California before full legalization.[1] The drugs could then be smuggled by car to states with restrictive prescription tracing. The smugglers had legal protection because the prescription was in their name.
Doctors? Let's talk about bankers, accountants, and real estate agents. They must get paid a lot of money to turn off the part of the brain that's screaming about how dishonest this whole chain of transactions is, how much it looks like a pack of guilty people trying to put their ill-gotten wealth out of harm's way.
Because doctors are supposed to provide it to people in pain who approved it and it would rapidly turn arbitrary and Kafkaesque if they started punishing doctors for doing their job while obligating them to do so at the same time. If you punish a surgeon for having a patient die good luck ensuring access to surgeons.
they should be. One of my parents was a primary care physician. When I was growing up she had on-call duties once a month, and fielded lots of after-hours requests for opioid prescriptions or renewals. These were patients of other doctors at her clinic calling in. She always told them that she wouldn't prescribe those drugs over the phone and they'd need to go into urgent care because she was aware of the abuse and addictive potential. This happened in the mid 90s.
Doctors as a group are not that dissimilar to police unions in that their primary function is to actually shield doctors from responsibility or accountability. Both are extremely hostile to criticism of any kind. This focus on their own outcomes results in zero virtuous feedback and being dysfunctional and failing to serve their customers consistently, with frequent gross failures.
You run threadpool of JDBC workers and pretend like it's non-blocking now.
Though there are some experimental non-JDBC drivers using non-blocking I/O to move your blocking code from backend into database. In the end you're still blocking.
I want to resume business logic when the result is available, but I don't want tens of thousands of kernel threads blocked on results until java finally gets fibers. People who write synchronous drivers also tend to make big poorly-used connection pools which defeat TCP flow control.
> I don't want tens of thousands of kernel threads blocked on results
If that is because of the memory consumption of kernel threads, be aware you are trading less memory consumption for increased cognitive complexity (if you agree that asynchronicity is more complex than synchronicity).
True, if hardware cost nothing we might still be on python. Chaining futures with f1.thenApply(arg -> f2) hasn't been that bad, but kotlin's coroutine DSL does look better.
I've not yet done any non blocking DB stuff. JDBC is blocking but there's R2DBC in the spring world that you can use. There are probably a few other options.
I agree. It’s a golden age to be a developer. We can be truly agile with system architecture. The last big system I wrote went through at least three complete architecture overhauls, but all that means is a fun few afternoons on the AWS console. Earlier systems I worked on had to have architecture locked down three months into the project.
I don't think I've ever seen "fun" and "aws console" used in the same sentence before.
The value to me personally is the reliability. Amazon continues to deliver on highly reliable services, which is IMO the main reason they can charge such a premium.
> I don't think I've ever seen "fun" and "aws console" used in the same sentence before.
In my opinion AWS Console is one of the best designed from all cloud providers out there. GCP is years behind, even with $100k credits I just can force myself to use that pice of unusable crap. Probably Material Design is here to blame, as it's terrible on web.
DigitalOcean does a great job with their interface but they don't even have 1/20 of features offered by AWS, at the end it will share the fate of GCP. Being extremely bloated. :)
My cloud spend is in the millions, soon to be tens of millions, every year and I'm a heavy user of AWS, Google Cloud and Azure and I agree with you wholeheartedly. It's not even just the console but the underlying APIs. I do everything via Terraform anyway but GCP is buggy and inconsistent in areas where it absolutely shouldn't be.
Azure is 5 years ahead of Google Cloud. AWS is 5 years ahead of Azure. The differences are that extreme.
I'm spending literally a fraction of your budget and that is my amateurish assessment as well. AWS Console can be better but the Azure dashboard could've been from the 90s. I had a hard time navigating it.
"In my opinion AWS Console is one of the best designed from all cloud providers out there. GCP is years behind, even with $100k credits I just can force myself to use that pice of unusable crap. Probably Material Design is here to blame, as it's terrible on web."
I hear this for the first time; to me all the Amazon related interfaces I've used have resulted in poor user experience at best. This goes from the store to AWS and sellerscentral should really get a special mention. In AWS, I always felt that everything was super cluttered and important things hard to find, nowhere near intuitive. This goes for high level concepts as much as component behaviors like lists in s3... So, I'd be super curious to hear what you found that was so good. Care to share?
> I don't think I've ever seen "fun" and "aws console" used in the same sentence before.
To each their own, but the ability to deploy seemingly endless amounts of computing power to do whatever I want, with the click of my mouse, is something I could only dream of as a kid.
I had that kid-like wonder at a recent project where I had to re-architect an Amazon-hosted website for a customer.
It took me back to that childhood experience of playing with Lego. Everything just "snaps together", and a lot of things that ought to be difficult were shockingly easy.
Mid-way through the project the customer apologised because they forgot to mention that they needed geo-redundancy for every layer, including the database.
It was a checkbox on AWS Aurora. A literal checkbox. I pressed it. There was a progress notification and then it was done. Just like that. A distributed cluster.
I know what's involved, it's not like I haven't built SQL Server clusters dozens of times before, I've even scripted the process before. But it's kind of magic to see it condensed down to a the absolutely most trivial true/false button that it could possibly be.
We might have a different concept of "architecture", but for me it looks like all cloud apps share the very same one. A bunch of (hopefully) cpu bound workers connected to one huge, intransparent persistence service. Not that this is not a viable architecture, but there exist different ones.
You’re not looking beyond the most trivial services. Most complex applications are best designed and scaled through multiple services.
For example, how do you handle long running asynchronous processing, distributed pub sub, or services that have widely different performance and scaling characteristics?
If you haven’t seen this, it might be time to start looking for a more interesting job.
I did not say that you usually need multiple services for scaling. I just noticed that the end architecture looks roughly the same to me once you go into the cloud.
For a truly distributed system just look at a distributed hashtable. You can do it with a cloud provider, but it somehow contradicts the point of a DHT to control the nodes, does it not?
I don’t understand, you acknowledge that vanilla web apps wrapping CRUD aren’t the only architectures but are the only ones suited to cloud? The entire point of the post you’re responding to is that cloud makes many architectures easy, including that one. I can personally vouch for having done wildly different use cases on cloud involving analytics and data processing.
This is the only use case you see for what I described? Most data processing I saw works exactly like that, too: some compute cluster using a shared persistence layer (either object store or a network filesystem).
Edge computing, otoh, explicitly exists because not everything can be handled well in that way.
I looked briefly and, correct me if you know better, but I believe The Law Store is a business partner of Walmart rather than being owned by it. So when you pay them you are not paying Walmart shareholders but its owners (who are lawyers)
In Poland, lawyers got deunionized to a large degree around 10 years ago, and the result is that most lawyers with private practices are no longer making great money, or are plain struggling. The only ones who make a very good living are those in niche specialisations, handling corporate interests.
Can you imagine how much more software developers would earn if we were unionized as lawyers are? If you couldn't practice without a license? If you needed to go school for $$$ before being licensed?
The problem is people treating women worse than they treat men. There's sexism at play when people consider which approaches are appropriate when they are attracted to someone.
Men are currently taken seriously when they complain about sexual assault and as a man there's no way I would voluntarily give this up. Why would I? What could possibly be in it for me?
It's like saying there are no secrets to computing and to just imagine a computer as a Turing machine, forget about stuff like pipelining and caches and whatever. On the other hand, I do believe the supposed "secrets" have actually been known for a long time. Here's my favorite article about it: http://www.grubstreet.com/2018/03/ultimate-conversation-on-h...
I get that it can seem unreasonable that people expect police to behave legally even in the presence of difficult or rude people. After all, very few of us enjoy dealing with difficult or rude people. Maybe very few of us are qualified to be police officers.
Yeah I'm calling this badge-equivalence. The camera (with active indicator light) is the badge. If you don't have a badge you're not a police officer. If you don't have a camera you're not a police officer. The only thing that curbs my enthusiasm for this is the privacy rights of other parties. Not sure how to deal with that but I don't think it should derail the whole thing.
The problem with Brexit is that "leave the European Union" is not a policy, it's an outcome. All of the thinking about how to do it should have taken place before the vote, and then we could have voted on that (this is actually the way legislation is typically developed in the UK, and the job of our sometime venerated civil service). Compare it to the recent Irish referendum on abortion, where there was a clear plan for what would actually happen following a vote for change.
Agreed. This is also the reason why just because a group of rebels can retain enough cohesion to overthrow a government doesn't mean they can govern effectively.
When a vote is for 'status quo' or 'not status quo' then there'll be a lot of people voting for 'not status quo' that want radically different and incompatible things.
I think you're kind of splitting hairs, all policies can be viewed as outcomes. "Bring back grammar schools" is both a policy and an outcome. "Improve education" is only an outcome because it doesn't discuss how to achieve it. "Leave the EU" is 100% achievable and has an obvious way to achieve it, it's policy just not detailed policy.
Realistically they should have planned more, but planning is limited when you're going into negotiations with an unpredictable third party. If other countries had voted to leave the EU, or the German or French elections had been different then the negotiation would be very different. Even the UK election after the vote could have wildly changed our brexit policy.
Fortunately we're something like (top of my head) ten times as important to the EU as either of those, and so even the most hardened remainer would privately admit that we should have more leverage in negotiations.
Presumably Norway isn't in the ECHR, which would be significant. Neither is it obligated to join the Eurozone. It's more complicated than you're painting it.
Norway is part of the ECHR. In fact, just like the UK it was a founding member of the Council of Europe which agreed to create the ECHR at the Congress of Europe at which Winston Churchill was a delegate from the UK.
The ECHR is a separate institution to the EU anyway so I'm not sure why it would be relevant. Leaving the EU does not leave the ECHR, and there has been no referendum to suggest that the UK should do that.
There is no direct connection. But a respect for human rights is required to belong to the EU. Leaving the ECHR would cast the UKs commitment to human rights into question (at the very least it would be an indication that the UK has a different conception of human rights to the rest of the EU) and would mean that the EU would have to scrutinise whatever legislation took its place to ensure that the UK did still intend to retain a conception of human rights close enough to the other member states.
None of this means that the recent referendum gave any mandate for leaving the ECHR.
Cameron did the 'either / or' thing three times, once on House of Lords reform, once on Scots independence and latterly on Brexit. Won the first two, came a-cropper on the third.
