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Punching Doctors to Reduce Healthcare Spending in the United States Abstract Healthcare costs in the United States are the highest of any country in the world, even when adjusting for relative wealth1 (Figure 1). In spite of this, life expectancy in the United States falls behind that of other OECD countries2, as demonstrated in Figure 2. Considering the disparity in life expectancy by income quintile3―a disparity that is not nearly as pronounced in other countries4―it is presumable that the overall life expectancy in the United States would increase significantly if universal coverage were achieved5, thereby granting the poor, who are disproportionately represented by uninsurance and underinsurance6, access to basic preventative services. Figure 1: Healthcare spending (public + private) per capita in several OECD countries. Source: The Kaiser Family Foundation Figure 2: Life Expectancy at Birth of OECD Countries, 2011. Opinions regarding the manner in which universal coverage can be achieved, or should be achieved, vary widely by partisan affiliation7. However, in consideration of the fact that Medicaid, the United States federal program that seeks to alleviate uninsurance among the poor, yields high returns on investment8, bipartisan support should exist for a proposal in which funds accrued from an agreeable health-related policy change were earmarked to expand coverage under Medicaid. In particular, Republican politicians widely favor tort reform9, whereby legislation is enacted to minimize malpractice lawsuits against doctors. These costly lawsuits, it is reasoned, not only waste time and money where the cause for litigation is often trivial, but also incentivize medical practitioners to order unnecessary and expensive testing. This investigation proposes an alternative to tort reform: Violence against doctors. Theory The phenomenon of violence against doctors and other medical practitioners exists primarily in China, where, accordingly, malpractice lawsuits are less common than in other countries10. As patients find it difficult to successfully sue practitioners who provide inadequate care or order unnecessary tests (often at the expense of the patient in the form of co-pays and deductibles), they instead retaliate by violence against those practitioners. While the patient may make this decision out of personal emotions, this phenomenon theoretically works to the benefit of the healthcare system at large, because this incentivization against malpractice is much less expensive than lawsuits. The conservative think tank American Action Forum estimates that tort reform enacted nation-wide could save $15 billion11. This figure will serve as the minimum amount of savings required for this "Violence Against Doctors" system to be considered successful. (In fact, this system will likely have additional benefits not shared with tort reform; for example, tort reform enacted in Texas simply capped the plaintiff's allowed expenditure of medical malpractice lawsuits12, which does not necessarily disincentivize the doctor from committing malpractice or ordering excessive testing.) In 2008, there were 63,370 medical malpractice lawsuits costing a total $55.6 billion across the system, meaning that the mean lawsuit costs approximately $877,387. In order to save $15 billion, therefore, 17,096 lawsuits (or roughly 27% of all medical malpractice lawsuits) would have to be avoided by violence-induced disincentivization. In order to standardize the amount of violence against doctors, we will use "punches" by the patient against the practitioner as the unit of measurement. Figure 3 demonstrates the theoretical relationship between each punch and the amount of averted medical malpractice lawsuits. Figure 3: Relationship between punches and resultant averted lawsuits. Because 0 punches should result in 0 averted lawsuits, the regression does not have a y-intercept. Therefore, the relationship between the two variables is y = mx, where "m" represents the amount of lawsuits averted per punch. For example, if a patient punching a practitioner results in two fewer lawsuits, then m = (1 punch)/(2 averted lawsuits) = 0.5 punches per averted lawsuit. However, intuitively, it is much more probable that the value of m exceeds 1, meaning that multiple punches are required to avoid a lawsuit. Therefore, to achieve the desired number of averted lawsuits (17,096), it is necessary to estimate the required number of overall punches, p, multiplied by the inverse of the coefficient m. Figure 4: Number of punches required to avert desired number of lawsuits. In the above relationship, the quantity p (punches) × m-1 (averted lawsuits/punch) = averted lawsuits. Randomized control trial(s) will be necessary to yield the values of m and p. Analysis The following factors may contribute to uncertainty: Other units, such as "kicks" and "karate chops" can be utilized in lieu of or in coordination with punches, and separate experiments may need to be conducted in order to measure the coefficient m of these alternative methods. Less discrete methods, such as "rear naked chokes, "kimuras," and "Batista Bombs," may be utilized by the patient in practice but would be difficult to quantify as a function of m. The value of m is subject to variation depending on the medical practitioner's income: An identical number of punches administered to two separate practitioners should result in more averted lawsuits from the better-paid practitioner. This effectively makes the legislation progressive in terms of revenue, which should please Democrats. In many cases, the medical practitioner may retaliate by engaging in combat with the patient; this would result in an increase in the value of m and thus a decrease in the value of p, indicating that more punches will be required to achieve 17,096 averted lawsuits. The above factor is exacerbated by the fact that the constitution of patients, by definition, is usually inferior to that of the medical practitioner. Care centers may enact measures to retaliate against potential violence by patients. In China, for example, hospital staff have been taught kung fu13 and security personnel recruited to minimize violence. This problem could be alleviated by outlawing such defensive measures. Practitioners who receive an excessive amount of punches may end up as patients themselves; subsequently, they may be the victim of malpractice by another practitioner, prompting further violence and possibly resulting in a death spiral. Conclusions Depending on the findings of potential experimentation, public healthcare spending may be significantly decreased by implementing at the federal level laws with the following effects: Patients who perceive malpractice on the part of their medical practitioners may punch those practitioners without personal repercussion. As the effectiveness of alternative methods of violence are revealed by reliable experimentation, those methods will be permitted (and encouraged) alongside punches. Immediate family members of the patients who perceive malpractice on the part of their medical practitioners may punch those practitioners without personal repercussion. Medical practitioners are not allowed to carry weapons within a 2-mile radius of any care center in which they work. Medical practitioners are not allowed to practice martial arts within a 2-mile radius of any care center in which they work. Add an exception to this rule when the medical practitioner is administering outpatient care and a robber invades the patient's home. Improve price transparency. Yearly analyses by the Congressional Budget Office will be performed in order to determine the increased revenue resulting from these provisions, and this revenue will be earmarked to expand Medicaid. References http://kff.org/health-costs/issue-brief/snapshots-health-care-spending-in-the-united-states-selected-oecd-countries/ https://aneconomicsense.org/2013/11/22/us-health-care-high-cost-and-mediocre-results/ https://www.washingtonpost.com/news/wonk/wp/2015/09/18/the-government-is-spending-more-to-help-rich-seniors-than-poor-ones/?utm_term=.b78a869d9c01 https://www.ncbi.nlm.nih.gov/books/NBK62373/ http://keepthemiddleclassalive.com/inequality-and-health/ http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/ http://www.pewresearch.org/fact-tank/2017/01/13/more-americans-say-government-should-ensure-health-care-coverage/ http://ccf.georgetown.edu/2015/07/28/medicaid-provides-excellent-long-term-return-investment/ https://www.washingtonpost.com/news/to-your-health/wp/2016/12/30/top-republicans-say-theres-a-medical-malpractice-crisis-experts-say-there-isnt/?utm_term=.7046065be43e https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4261607/#CR3 https://www.americanactionforum.org/research/tort-reforms-impact-health-care-costs/ http://www.legalmatch.com/law-library/article/texass-cap-for-medical-malpractice-damages.html http://world.time.com/2013/11/06/kung-fu-doctors-shanghai-hospitals-train-medical-staff-for-attacks/

There is a secret language spoken in the darkest corners of the visual novel world, a cant so ancient and intricate that none know its origins. To be initiated in its ways, one must drink from the Dread Chalice and be reborn in fire. Only then will the caul be drawn from your eyes. You shall know onomatopoeia. And you shall know fear. Sploosh 101: What is onomatopoeia? Before we jump in with both feet — *splash!* — let’s do a quick primer on terminology. An onomatopoeia is a word that imitates, resembles, or suggests the source of the sound it describes — i.e, it sounds like what it is. Like clink, yip, kaboom, swish, meow, oink. (That’s the verbatim transcript of my bachelor party, in case anyone’s wondering.) This is different from a word that describes a sound or action, but doesn’t actually imitate it — e.g., sneeze vs. achoo, punch vs. kapow, close vs. slam. The latter are onomatopoeia; the former, I call ononotopoeia. For the sake of brevity, let’s refer to these O and not-O. The Japanese language is rich in O. There’s a sound effect for everything. There’s probably a sound effect for there being a sound effect for everything. (If there isn’t, I’d like to propose one now: darubu.) There are even sound effects for things that don’t actually make sound — e.g., “jii” for staring. While it’s woven into the fabric of the modern Japanese language, O is especially prevalent in manga and, to a somewhat lesser extent, anime. Since visual novels draw heavily from these two worlds, they too feature lots and lots of these words. English is relatively impoverished in O by comparison, and therein lies the challenge for VN translators and editors. Do you leave these essentially untranslatable sound effects as they are? Or do you try to translate them, losing some of their immediacy and, for lack of a better word, oomph? Across the great divide The VN community seems to be fairly split on that question. In one camp, we have the purists. By and large, these are readers who are already comfortable with Japanese O through manga and anime. They consider it part and parcel of the VN experience. Learning and appreciating such terms is simply part of becoming an accomplished reader. It’d be like going to a fine dining restaurant and, instead of the chef presenting you with “the amuse-bouche,” he just came out and said, “Here’s this small appetizer thingy I made. Hope you like it.” The vocabulary is part of the experience. In the other camp, we have the reformists. To them, leaving O untouched isn’t translation; it’s mere transliteration. It denies meaningful content to the uninitiated English reader — e.g., if you don’t know "munyu" means to grope someone, you’ll be clueless when the best girl hauls off and smacks the protagonist in the very next line. To extend the fine dining metaphor, it’d be like going to the same restaurant, being handed a menu that was all in French, and having the waitstaff snootily refuse to tell you what anything meant. Hope you like thymus glands, mon ami, because that’s what you just ordered. When it came to KoiRizo, I was a reformist editor on a purist project. I joined the team after the translation had been completed and a lot of the big up-front decisions had already been made: Will this be a literal translation or liberal? (Literal.) Will we keep all the honorifics? (Yes.) Will we keep all the onomatopoeia? (Yes.) MDZ, the KoiRizo project lead, was very up-front about all this. And that was fine. The job of a VN editor is to facilitate and execute on the project lead’s vision. It’s great if you’re involved early enough to shape that vision, but it’s ultimately his/her show, not yours. (If you’re not okay with that, go start your own TL project.) So with that in mind, I did the best purist editing job I could. But what if I had carte blanche in how I approached O? What would I do differently? As luck would have it, I’ve given that some thought. Onomatopoeia in standard scripts For the majority of scripts, it helps to separate O-words into two groups: content-light ad content-heavy. The content-light group tends to consist of interjections, exclamations, grunts, groans, laughs, etc. These are mostly self-explanatory terms, communicating very little other than the fact that they’re a familiar sound. Some examples include: HoEAHehUuuAt most, I’ll clean these up to make them friendlier to Western eyes — “A! A sea cucumber!” becomes “Ah! A sea cucumber!” (In this case, it’d be too easy to mistake the “A” sound for a stammering repetition of the indefinite article “a.”) Otherwise, I’m happy to leave them be. On the other side, we have the content-heavy O-words. These are either (1) terms that have a very specific meaning you’d never be able to guess at without prior knowledge, or (2) common sounds that are rendered much differently in English than Japanese. These are the words that, if you ignore them, will result in meaningful content being lost in translation. Some examples include: Kakkun = the “sound” of hitting someone in the back of the knees. Based on a kids’ game.Su = the sound of something suddenly appearing (among other meanings)Gusu = the sound of a whimpering sobHakushon = the sound of sneezingChikutaku = the sound a clock makesOur first line of attack is to see if there’s any suitable English onomatopoeia we can swap in. It’s rare that it works out so neatly, but it does happen. So "hakushon" becomes “achoo,” "chikutaku" becomes “tick tock,” etc. If this doesn’t work, we fall back on another common approach: turning not-O English words into O by enclosing them in asterisks. So: “Gusu. Why won’t you return any of my calls?" becomes: *whimper* “Why won’t you return any of my calls?” As your final line of defense, you might consider abandoning O altogether, instead relying on some explanatory text to flesh out the intended meaning. So: Su. “Where do you think you’re going, jerk?” becomes: She appeared out of nowhere. “Where do you think you’re going, jerk?” I’d recommend turning to this as a last resort, however, since you can see a certain staccato elegance gets lost in translation. As for where you can find out what all these untranslated O-words mean, there are all sorts of online resources to be had out there. I tend to use the Japanese > English SFX dictionary over at The JADED Network, but I’m sure there are plenty of others just as good. Onomatopoeia in H-scenes Sex scenes are something of a special case. You’ll find there are large blocks of text that are nothing but wall-to-wall O. (I see what you did there, you sly dog you ...) Here are some sample lines from KoiRizo: Sango: “Nafufu. Fumu, Juru, Zuzuzu." Sango: "Rero, Chu, Chuu ..." Sango: "Hamu, Chuu, Chuu ... Rero, Juupu, Zuzu." Sango: "Jupo, Gupo, Zu." Sango: "Juzuzuzuzu." Sango: "Fumu? Fua ..." During editing, I liked to call these sections “word salad.” They’re an unholy mishmash of content-heavy O, content-light O, and nonsensical fuck-grunts. It’s a tangled mess of syllables that can make even the bravest editor or translator turn tail and run. In my earlier post on editing H-scenes, one of the commenters — smile for the camera, Ittaku! — suggested it might just be better to replace these sections with ellipses and let the VO do all the heavy lifting. It’s a tempting thought. But despite all appearances, there’s content to be had there — content the Japanese reader would have understood, and which the English reader will miss out on ... unless you take action. Let’s see what happens if we (somewhat liberally) run it through the techniques we’ve discussed so far. Sango: "Ummph. Umm." *slurp* *sluuurp* Sango: “Mmm.” *suuuck* Sango: *nibble* *suck* “Mmmm ...” *bob* *sluuurp* Sango: *sucksuck* *slurp* Sango: *slurpslurpslurpsluuurp* Sango: "Mmmph? Ahhh ..." Okay, it ain’t poetry, but at least we’ve transformed our tossed salad it into something with actual meaning. Even without having read the rest of the scene, you can guess that Sango is vigorously polishing the protagonist’s knob. Or is trapped in a vat of ramen and eating her way to freedom. It can be improved upon, of course; all those asterisks start getting visually distracting, so if the VN engine supports it, italics might be a better choice here. But I’d argue it’s much better than what we started with. Feeling more confident? Good. Go forth and sploosh.