Why now?

Why is it necessary to fight the Maintenance of Certification program?

This is a call to all doctors. I implore you. I know you – I am one of you – and I know your nature. You want to soothe, to placate, to moderate pain.

This current MOC fight is anathema to many of you. In many of yoscam5ur minds it is too hard, too dangerous, and too disruptive. What is most disturbing is that some of you think that it is unnecessary or even pointless. Please let me show you why this is not true. Allow me to extemporize, so that I may show you why this is critical to our future.

Many of you may be asking why it is necessary to fight this fight. Why not just go through the MOC modules, earn your points, pay your fees, and be done with it? With every revelation about the tactics of the ABIM/ABMS we get a glimpse of their true intentions. They do not have your best interests at heart but are only after your money. But this is not a money fight (we will discuss this later), it is a fight for principles. You are a professional, and maintaining your status as a professional requires you to be up to date on the key elements of your area of expertise. We already face requirements placed by our medical boards for continuing medical education. I personally could not face my patients if I were not informed of current advances in medicine, particularly in my field. It is part of being a doctor and a professional.

The ABMS and ABIM would have you believe that patients are demanding that their doctors undergo some artificial trials in order to determine that they are competent, because they have no other way of deciding if their doctor is good. I have more faith in the abilities of the average patient. Patients have a sense of the competence of their doctor, and they are able to ask questions to probe your knowledge. They also have the freedom (for now) to go to a different doctor if they are not impressed.

The ABMS and ABIM are playing on your underlying insecurity that you do not know everything. What they are implying is that you need them to help prove to your patients that you know anything. They are using your inner fears to their advantage. I can tell you that with everything you have gone through, you are more than competent, you are very knowledgeable, and you do not need more and more certifications on your wall to prove that fact.

Continuing medical education is a good thing – that we can agree on. But beyond the requirements of the medical boards and your own personal search for knowledge we do not need any new programs.

Why is it necessary to fight MOC now?

This fight is insidious. The people who are thrusting this upon us are financially enmeshed in this system and do not have your best interests in mind. This fight needs to come to a head now, because the majority of the regulations that will hinder us in the future have yet to be written.

The passage of MACRA, which was the ‘SGR fix’ brought in new concepts for physician pay. Now we will be paid in one of two ways, the Alternative Payment Models (APMs), or Merit-Based Incentive Payment System (MIPS).

If you are part of a larger system or in some specialties, you may get paid as part of a lump sum through the APM. God knows what crumbs will be left of the lump sum after the hospital system takes its part.

For others who will be in the MIPS system, your pay will be determined by (straight from the cms web site):

  • Quality
  • Resource use
  • Clinical practice improvement
  • Meaningful use of certified EHR technology

Note that we have the MOC part 4, practice improvement, which was supposedly put to rest, rising like a zombie to stalk us again. And we are also to be judged on ‘quality’, which no one can seem to define. Supreme Court Justice Potter Stewart famously defined obscenity with the phrase ‘I know it when I see it’. This is about the best we can do for defining medical quality. The true obscenity today is the ABMS/ABIM system.

And this goes beyond just the MOC fight. Now we have medical students being taken advantage of through the National Board of Medical Examiners’ Step 2 CS requirement. This is another unproven regulatory hoop that does nothing but enrich the people who are putting this in doctors’ ways.

What about the money?

I said before that it is not about the money, but it is. Certainly to the non-practicing bureaucrats at the ABMS/ABIM it is about the money, because they do not do anything productive on their own. They have to take your money. And it is your hard earned money. To some of you it may seem a pittance, but to others these are large sums. Please take pity on your fellow doctors who may not be in as good of a financial position. The greedy overlords of the certification scam need their seven figure salaries. I wonder how often they take call.


What is all the anger about?

The media and Washington establishment are up-in-arms because the status quo is being disrupted this voting season, and it seems that most pundits are at a loss as to what is driving the masses to the “horrible” figures of Mr. Trump and Mr. Cruz.

The driving narrative is that there is a group of angry voters who are racist, xenophobic, misogynistic, homophobic, and whatever other demeaning term you can come up with who just cannot be brought to their senses.

Now why would a group of voters be angry? Just look at the last paragraph. People get tired of repeatedly being called names. Instead of thoughtful discussion of issues and a recognition that there are valid points on multiple sides, the media stoops to name calling and lambasting a large percentage of the population because they don’t understand them.

This reminds me of the often misquoted statement by Pauline Kael after the 1972 Presidential election, “I live in a rather special world. I only know one person who voted for Nixon. Where they are I don’t know. They’re outside my ken. But sometimes when I’m in a theater I can feel them.”

The media does not understand people like me. But instead of doing real journalism, which might actually require work and travelling outside of their comfortable jobs in Washington, they choose to sit back and take cheap pot-shots with name-calling.

Don’t believe me? Just a sampling of the op-eds today gives loads of evidence, to wit: Americans (a “shocking number” of them) are “petulant, impudent” says Frank Bruini in the aging grey lady. “Obnoxiousness is the new charisma, “he writes. He calls Donald Trump “a jerk” and says that Ted Cruz speaks with “nastiness that’s by turns adolescent and hyperbolic”.  He says that these voters are “so distrustful of the usual etiquette that they think valor lies in viciousness, integrity in insult.”

In his usual Democratic Party spin-meister mode, Dana Milbank, who wouldn’t know journalism if it bit him in the toe, says that Cruz and Trump have “stoked the fires of resentment and xenophobia”. Unabashedly he declares “There is no equivalent on the left these days to such nasty stuff.”

And Dan Balz in the Washington Post says that a growing group of voters has “resentment toward cultural shifts that reflect the diversity and tolerance of a changing country”. Note the terminology used – illegal immigration is a reflection of “diversity” and “tolerance”, but calling for the government to actually follow the law is termed as “resentment”.

This is the consequence of political correctness run amok. Frank discussion is “obnoxious”. Clear talk apparently can no longer go on without clouding everything in a blanket of ‘not-that-I-am-implying-everybody-associated-with-X-thinks-this’ or ‘I-know-he-is-a-mass-murderer-(not-to-imply-that-there-is-anything-wrong-with-that)-but-if-you-can-just-try-to-understand-his-feelings-you-would-be-ok-with-the-fact-that-he-killed-and-ate-your-family’.

The fact is that there used to be a sense of right and wrong in this country. There used to be a sense that we were ruled by laws. Now I am actually a very tolerant person, and what you do in your own living room is no business of mine, be it sex, drugs, or whatever. Just leave me out of it.

But for the past seven years we have been shown that the laws are in fact very political. They are only to be used against the enemies of the state. Oh, and the laws are only for the little people. The IRS scandal? “Nothing to see here” Due process on campus? “You are an oppressive male so you are by nature a rapist”.

And now there is clear proof that Hillary Clinton has committed multiple felonies. But no one in the establishment seems to care! Why doesn’t Jeb Bush use his $50 million war chest to good use and do a campaign about how Hillary Clinton should be in jail, instead of his greasy campaign against Marco Rubio? The New York Times and the Washington Post need look no further than their front pages if they want an explanation of why their readership has suffered – it is a disgrace to this country that this story has not been covered properly.

So yes, there is anger, but it is not without cause. And is not because of latent racism or bigotry. It is because the institutions that we hold so dearly have been blighted with indignities that may have shattered this country to the core beyond repair.

Stop the Madness of Dietary Guidelines

The Federal Government has published new dietary guidelines to try to influence the diets of Americans and improve public health. The is the eighth edition of these guidelines issued by the Agriculture and Health and Human Services Departments, updated every five years since 1980. Overall they have encouraged Americans to consume more fruits and vegetables, whole grains, lean meat, and low-fat foods, while restricting intake of saturated fat, trans fats and dietary cholesterol.

What have we learned from the history of these guidelines? We have learned that the Federal Government is terrible at promoting good health.

First of all, the whole notion of nutrition “science” is highly questionable. Instead of hard science, what we have is pseudo-science, wrapped in opinion, given a political twist, and then presented as something it is not. Unfortunately, most people do not recognize that this hogwash is full of bias and has more to do with feeling good than advancing knowledge.

Last year, a government advisory committee of nutrition “experts” recommended that the dietary guidelines encourage all Americans to consume more plant-based foods and less meat to help promote environmentally sustainable eating habits. This is purely a lobbying effort and is politically rooted.

Environmentally sustainable = what progressives want you to do no matter what the hard science says

The entire obesity epidemic can be traced back to earlier iterations of these guidelines. By eschewing saturated fats and cholesterol many foods which satisfied the palate in small portions were avoided. Instead people overdosed on carbohydrate-heavy but non-satisfying foods, and they have subsequently gained weight. This is the SnackWells effect – you are eating non-fat “healthy” cookies, so why not eat the whole box?

Progressives love this type of touchy-feely nonsense. “I mean well, so what I am doing must be good.” As the old saying goes, the road to hell is paved with good intentions.

It is time for the government to get out of the business of dietary guidelines altogether. What purpose do they serve? This is a waste of tax-payer’s money, and has not been helpful – in fact it has been damaging to the public health.

As a doctor, I will say here what I tell my patients every day. People tend to eat foods that are available and that they like. You can make a resolution or go on a diet, but six months from now, you are likely to be eating what you are eating now. If you want to avoid obesity, moderate your diet. Do not go on fad diets – eat what you like – just less of it. If you can reduce your calorie intake by 5-10% and ideally at the same time increase your caloric output by 5-10% the weight will fall off.

If you want to then be more aggressive about weight loss, change one day at a time. Pick one meal during the week that you want to eat in a more healthy way. You will find healthier foods that you enjoy and you can incorporate them into your diet.

Sustainability is key. It matters less how heavy you are one month from now as one year from now. If you are on a diet and hate it, you won’t stick to it – that is human nature. Same thing goes for exercise – if you are doing an exercise you hate, you won’t stick with it. Find something you like to do and make it a part of your everyday life.

Food, exercise…life. They are all entangled and intermixed, and too much or too little will get you into trouble. Find your own balance.

And get the government out of it!




Time to stop whistling past the graveyard and face the reality that the United States will not be able to meet its credit obligations to its citizens much longer. Politicians continue to spin the truth as most Americans stick their heads in the sand and ignore what is really happening. Fast approaching is the day of insolvency, when the country defaults and the checks stop going out.

Look at the history of man and you will see that periods of stability and prosperity are few and far between. We have been fortunate to have lived in a bubble of relative harmony, but we are deluding ourselves if we believe that our current government will be able to sustain itself ad infinitum. This experiment called the United States of America is nearing an end. Our beginnings were inspired by the noblest ideals of the French revolution – liberté, égalité, fraternité – and we have spent the last two and a half centuries smashing those ideals into bits. As we stand on the shards of our values we must begin to look ahead and ask ourselves what comes next.

We are not likely to have an all-out anarchic civil war, but clues to what will happen here may be found in the remnants of the old Soviet Union, or more recently in Ukraine. It may start as a ripple but it will soon become a tidal wave. The markets will crash. People will be in shock. There will be outbreaks of protests, looting, and mayhem. I don’t think most Americans have even considered the thought of our government crumbling. But everything that is unsustainable must come to an end.

People do not realize that we are hitting the limit fast. We have seen the default of cities and counties. Several states are now at the point of default – California, Illinois. No one is willing to face the truth, so we will continue to lie to ourselves. The only choice is whether the government will delay the checks or just print money, and you can make an argument that printing money is exactly what has been going on with the ‘quantitative easing’ of recent years.

We continue to smile, laugh, and congratulate ourselves for the ‘progress’ we have made as a society, but the system is on tenterhooks. What will it look like when it comes? Hyperinflation? A crash? The trouble with finance is that it is a house of cards and any little thing could bring it down. A bad trade in Malaysia, a judicial decision, a corporate merger. If you went to the ATM tomorrow and it would not give you money, what would you do?

People say I am a doomsayer, that I think all is lost. Nonsense. We will still have sunrise and sunset. You, your families, your neighbors will go on living just as you do today. Hopefully most people will continue doing what they usually do in a sort of societal momentum, but they will find that the paycheck does not come. And so they won’t pay – bills, mortgage, utilities. And then some people decide not to go to work any more because they are not getting paid. The utilities go out. The system shudders to a stop. People will give anything for a gallon of gas. There will be heroes and martyrs. Winners and losers.

We may end up depending on corporations. If the state is gone, who do we turn to trust that the water is drinkable and food is safe?

In the aftermath we have to consider: what next? Do we accept the status quo? Will we accept a strongman who takes control of the military and leads us in the fashion of Putin? We throw around the ideals of ‘democracy’, but when it really matters, most people are not comfortable with ‘majority rules’.

The US is an airplane out of fuel, out of power. My dearest hope is that we can land it gently and walk away, rather than crash and burn.

PC police can go away

SCOAS does not do PC. We do not strive to be gender-neutral or gender-sensitive. In fact, we think that gender is rather important, and men and women are fundamentally different. When in comes to writing, however, using ‘man’ and ‘he’ and other such words is just a convenience.

You may assume ‘man and/or woman’ when the term ‘man’ is used, as it has been used through thousands of years of literature. Don’t throw your mamby-pamby “paternalism” and “heteronormative” crap out around here. If your mind is too small to understand the standard use of language, or your ears are too delicate to hear harsh words, then go home to momma and cry yourself silly.