Anyone concerned about bathrooms is an idiot

I honestly cannot understand what all the fuss about transgender people and bathrooms is all about. It seems to me that common sense should prevail. Tonight on the Tucker Carlson show, Zac Petkanas, a democratic pundit, was interviewed and stated repeatedly that gender is determined by how people self-identify. This is absolutely absurd on it’s face. Tucker then asked him the entirely reasonable question whether race is determined in the same way, but Mr. Petkanas said no. This is clearly incongruous. If we are going to put aside biology and use self-identification to determine gender, then the same logic should be applied to race. And therefore logically any white man should be able to claim to be a black woman for the purposes of, say, getting into a University. This is insanity.

Biology is biology, despite people wanting to deny that. Men are men, and women are women, but I believe that gender biology as well as gender identity exist on a spectrum, and for a very small portion of the population in the middle of this spectrum gender is ambiguous. Still, other than a very tiny fraction of people who are hermaphrodites or have mixed gonads, the biology is clear. The majority of people in the world are men who identify as men or women who identify as women. There are a small number of people for whom this does not apply, but this still does not change biology. A man who identifies as a woman is not a woman, but a man who identifies as a woman, and vice versa. Anyone who says otherwise is a nitwit and a biology denier.

That being said, what any one person wants to call himself or herself makes no difference to me. If a man wants to go around saying he is a woman, or a woman wants to say that she is a man, that is fine with me. All I ask is that if I am going to be accepting of you and be sensitive towards you that you do the same for me. If you appear to be a man and I address you as a man, please do not take offense if you want to be addressed as a woman. I will try to be sensitive, but please do not go out of your way to take offense.

As far as bathrooms are concerned, what I want to know is where are the bathroom police who are checking? If you identify as a woman, use the women’s bathroom. If you identify as a man, use the men’s room. I certainly am not going to check whether you are what you say you are.

People who want to be divisive are ginning this entire issue up, and it serves no one any good. People who are ignorant or bigoted about transgender people may have irrational fears about these people being ‘dangerous’. I think this is a personal problem for the people who are afraid, and education and kindness can overcome this problem. But I believe that there are more people on the left who are just looking for ways to take offense in order to push their agenda.

If everyone would just mind their own business and stop trying to tell other people how to live the world would be a better place.

Climate Shame

Once again we have revelations of data manipulation and false information in the ‘settled’ science of the global climate. This reveals what I have long argued: ‘climate change’ is a scam.

Now before you dismiss me as a ‘climate denier’, please, hear me out. I am an environmentalist and hope that we continue to work to manage our pollution better. But this entire issue really has nothing to do with the environment.

I have a few points to share that may upset the sensibilities of people who are convinced of the coming climate catastrophe:

1) Climate changes, life goes on

The climate of this planet has changed over the eons and will continue to do so in the future. Wishful (magical) thinking on the part of activists will not cause the climate to suddenly stop changing to suit their tastes. Human activity likely is contributing to that change, but how much and what to do about it remain topics of hot debate.

I hate to break it to you bleeding-hearts, but the planet will continue to do just fine for the foreseeable future. One hundred, five hundred, one thousand, or one million years from now there will be life in abundance on this planet, whether human or not. Whether we blow ourselves up with nuclear bombs or trash the planet with poly-cyclo-benzo-whatevers, life will find a way.

2) Species go extinct

Look at the fossil record and you will see countless species that have developed and then gone extinct over the ages. But now all of a sudden because some econutballs have ‘awareness’ of the environment, everything is supposed to remain static. If I understand the green fringe elements, any species that roams the earth at this moment is sacred and it would be a tragedy if we let any of them die out. This not only goes for the large mammals, but also for the left-handed-green-spotted-wharf-snail in Kalamazoo. I am all for preserving areas where wildlife can live, but I think the way to go about it should be for the environmental groups to buy land and then keep it natural. Bringing government into the equation is only a power play by the weak – they can’t get their way through persuasion so they must hire (elect) people with guns to enforce their way of view. And expecting all living species today to continue on in perpetuity is a pipe dream.

3) Science is messy

Science is never ‘settled’. In fact, the majority of scientific advancement is achieved by disproving previously known ‘truths’. Trying to predict the future is a fool’s errand. Just look at your local weather: models have gotten quite good at predicting the next few hours or even days of weather, but is it going to rain where you are one month from now? Who knows? There are just too many variables for us to be able to comprehend this system entirely.

I know what science is like – I have published a number of papers myself – and anyone else who has published a peer-reviewed scientific paper will know the magic of statistics. You can take raw data and analyze it by many various methods, you can fill in gaps in the data in many different ways, and you can drive the outcome of a study towards a desired goal in the process, if one were so inclined. Every scientist makes personal justifications for these manipulations, and every one will find their position on the spectrum of what is and is not allowable. The more manipulation of the data that takes place, the further from ‘pure’ science we go. And this brings us directly to the next point:

4) Many climate scientists have an agenda clouding their judgment

What are these agendas? They are different for each individual, whether it is a desire for tenure, status, and respect among peers; righteous indignation towards polluters; disdain for American capitalism; or some combination of these, the agendas of the individual may drive them away from ‘pure’ science and allow them to justify data manipulation to the point of a reversal of the true findings of the study.

So deeply ingrained is the ‘global warming’…err ‘climate change’ paradigm that many scientists cannot see their data objectively. They resist change fiercely, and will go to great lengths to defend their theory. As Thomas Kuhn puts it:

The source of resistance is the assurance that the older paradigm will ultimately solve all its problems, that nature can be shoved into the box the paradigm provides. Inevitably, at times of revolution, that assurance seems stubborn and pigheaded as indeed it sometimes becomes.

Kuhn goes on to say that the ‘assurance’ of scientists allows science to proceed, but the resistance to change is often so strong that it takes the dying out of an entire generation for new ideas to take the place of the old way of thinking.

5) It is all about money and power

Most of the powerful players in this game couldn’t care less what the temperature of the planet will be in fifty or one hundred years. What they do care about is money and power and how to manipulate people, governments, and corporations. The only proof you need: were climate activists and government officials so concerned about carbon they would set up internet tele-conferences instead of flying on their private jets to conferences in Paris, Geneva, and Davos. Everyone wants clean air and clean water, so this serves as a useful front for their bait-and-switch game.

that, ladies and gentlemen, is the Inconvenient Truth.

Leeches!

 

In ancient Greece an imbalance in the proportions of the human body’s four “humors” — blood, phlegm, black bile, and yellow bile — was believed to be the cause of ill health. Bloodletting using leeches was one method used by physicians to balance the humors, and this practice continued through the ages.

 

Modern medicine continues to use the leech in a few ways, mostly through the use of hirudin, lepirudin, and bivalirudin, but for most people the lowly leech (Hirudo medicinalis) is viewed with horror and disgust for the blood-sucking parasite that it is.

 

And this brings us to the American Board of Medical Specialties (ABMS) and its ‘Member Boards’ and the Maintenance of Certification (MOC). In ancient times the ABMS had its place, and hopefully we can take the best parts of MOC and use it in new and different ways. But it is time for all doctors to see the ABMS for the blood-sucking parasite that it has become.

 

And it is with horror and disgust that we see all that Westby Fisher and Charles Kroll have uncovered.

•  It is time to pull off the leeches that are sucking us dry!

•  I call for all Board positions to be held by practicing physicians – no ‘professional class’.

•  I call for a federal law to mirror the Oklahoma Law to free all physicians to practice without the dark shadow of MOC looming over them.

Trump Derangement Syndrome

We have once again preserved our tradition of a peaceful transition of power and a new president has been sworn in, but the Washington bubble has not even begun to comprehend what has actually occurred. It has been with some amusement that I have watched the machinations of the media trying to put together complete sentences without betraying either their utter contempt for middle America or their stunning obliviousness.

 

My personal thoughts on Trump are as yet not fully formed, but on day 1 it seems sporting to give him a chance. We still haven’t quite hit on the right term for the collection of people who have been so dismayed by the election results that they are still sputtering sneering sophistries two months on; bubble inhabitants, coastal elites, and Washington insiders each leave something to be desired.

 

Of course we all knew this group would include most of the liberal ‘mainstream media’, but what a disappointment to see how many of the more conservative pundits have seemed to have lost their lucidity in their rush to judge the new man at the helm. This serves as another reminder of just how far the chattering classes have gone off into their collective delusion.

 

Trump said:

For too long, a small group in our nation's Capital has reaped the rewards of government while the people have borne the cost. Washington flourished, but the people did not share in its wealth. Politicians prospered, but the jobs left, and the factories closed.

The establishment protected itself, but not the citizens of our country. Their victories have not been your victories; their triumphs have not been your triumphs; and while they celebrated in our nation's capital, there was little to celebrate for struggling families all across our land.

And…the media blathered, froth foaming from the mouth, not even realizing that they themselves had just been called out for their part in the damage that has been done.

 

So what is this damage? It has been repeatedly reported over the past few days that unemployment is low, the markets are up, and the Donald’s poll numbers are so low that there ‘clearly’ must be ‘no problem’. But anyone outside of the bubble knows what is wrong, and anyone who knows something about statistics knows that there are ways of cooking the books.

 

I know many people don’t want to think about math and statistics and there is a little danger of getting lost in the weeds here, but let us delve into the numbers just a bit to see what exactly I mean when I say “cooking the books”.

Unemployment

First of all we have unemployment. Here is the graph all of the media want us to see:

 

 

 

At the left side we see the effects of the 2007-2008 financial and housing crash with a huge jump in unemployment. Then from about 2010 forward we see a slow steady decline in the unemployment rate back to under 5% today. Looks great, doesn’t it?

 

But what about this graph depicting the labor force participation rate?

 

 

There has been a major drop in the percentage of the population that is working since a high in the late 1990s. Here is a closer look at just the past ten years of that graph:

 

 

There has been a slow and steady fall of the percentage of the population that is working. Well, you may say, this must be due to the aging population and all of the retiring Baby Boomers, right? Well…maybe…but if that were so would we not also expect to see these effects consistent across multiple data sets?

 

Take a look at the next few graphs – first, here is the US population:

 

 

…then we have the raw number of employed people in the US:

 

Now let us look at the upper right corner of these two graphs. I have taken the curves and scaled them in order to plot them together, but the raw numbers have not been changed. Feel free to try this yourself with the data available from the US Bureau of Labor Statistics.

We see that something really funny happened around the time of the Great Recession. All of a sudden, the graph of employed people took a big stutter step down and it has not returned to the historical average line. The ‘renormalization’ of the data explains much of the funny business in the unemployment numbers, and when the BLS says it is all due to population shifts you can just drop the L from their acronym: BS.

Markets

Now we go to the markets. Here is a quick snapshot of the Dow Jones Industrial Average over the past thirty years or so:

Looks great, doesn’t it? Fantastic growth! Wow! And big growth during the Clinton and Obama years! How can you dispute that? Well, if you are someone like Paul Krugman, you don’t, you simply pass on the lies and get applauded by the clueless for ‘astute observations’.

 

But disputing the graph is simple, if you dig below the raw numbers. Let’s take a look at the components of the DJIA towards the end of the Reagan era:

1987

Allied-Signal Incorporated Eastman Kodak Company Navistar International Corporation
Aluminum Company of America Exxon Corporation Philip Morris Companies Inc.
American Can Company General Electric Company The Procter & Gamble Company
American Express Company General Motors Corporation Sears Roebuck & Company
American Telephone and Telegraph Company Goodyear Tire and Rubber Company Texaco Incorporated
Bethlehem Steel Corporation International Business Machines Corporation Union Carbide Corporation
The Boeing Company International Paper Company United Technologies Corporation
Chevron Corporation McDonald’s Corporation USX Corporation
(fmr US Steel Corporation)
The Coca-Cola Company Merck & Co., Inc. Westinghouse Electric Corporation
E.I. du Pont de Nemours & Company Minnesota Mining & Manufacturing Company F. W. Woolworth Company

 

Some big companies there…lots of manufacturing…aluminum, steel, cars, tires, airplanes, paper, utilities…companies that make things.

 

But that is quite different from the list of companies which make up the DJIA today:

2017

3M Company General Electric Company Nike, Inc.
American Express Company The Goldman Sachs Group, Inc. Pfizer Inc.
Apple Inc. The Home Depot, Inc. The Procter & Gamble Company
The Boeing Company Intel Corporation The Travelers Companies, Inc.
Caterpillar Inc. International Business Machines Corporation UnitedHealth Group Incorporated
Chevron Corporation Johnson & Johnson United Technologies Corporation
Cisco Systems, Inc. JPMorgan Chase & Co. Verizon Communications Inc.
The Coca-Cola Company McDonald’s Corporation Visa Inc.
E.I. du Pont de Nemours & Company Merck & Co., Inc. Wal-Mart Stores, Inc.
Exxon Mobil Corporation Microsoft Corporation The Walt Disney Company

 

So when viewing the DJIA graph, you have to take into account that the data points over time do not measure the same things. We are comparing apples to oranges. But what has changed? you may ask and the DJIA would argue that it has normalized company stock values (i.e. fudged the numbers) to try to keep the measure historically consistent and stable. In reality the entire universe might well have changed!

 

We see some things that you would expect. Some of the giants have remained (e.g. GE, du Pont, 3M with a new name, Proctor & Gamble, and IBM), and Coke and McDonalds still make the list. Old merchants such as Sears Roebuck and F.W. Woolworth have been replaced by competitors that helped take them down: Wal-Mart and Home Depot. Some technologies (e.g. Kodak) and habits (e.g. Phillip Morris) have fallen by the wayside and have been replaced by new ones (e.g. Apple, Intel, Pfizer).

 

But what is stunning is that the DJIA is now filled with a bunch of companies that really don’t make anything! American Express, Goldman Sachs, JPMorgan Chase, Travelers, Visa. We could also argue that Walt Disney doesn’t really make much that is tangible, and what about UnitedHealth?

 

Gone are Allied-Signal (aerospace, automotive and engineering, now part of Honeywell and off the DJIA), Navistar International (trucks, buses, harvesters, defense contractor), ALCOA (aluminum), Union Carbide (part of Dow Chemical), Bethlehem Steel, USX (US Steel), International Paper…

 

Yes, yes, I hear you: it’s the ‘service economy’. But most of the so-called ‘service’ of these companies is being done in a call center in Bangolore! And even the companies that build things like Apple and Intel don’t do their manufacturing in the US.

 

So the DJIA is a sham! Nothing more than shells remain where there used to be strong American assets, and these companies are owned and controlled by a tiny fraction of a percentage of our population. Let me be clear: this is the American carnage that Trump spoke about.

 

All of this became stunningly apparent to me after some of the uproar caused by the inaugural remarks. In his speech Trump stated:

“We will seek friendship and good will with the nations of the world. But we do so with the understanding that it is the right of all nations to put their own interests first.” (emphasis mine)

 

This statement seems self-evident to me – of course this is true. No country could survive long if it did not place its own interests first. But it is high time to bring back Spiro Agnew’s alliteration for the media because this statement was met by a bewildering barrage of buffoonery by the nattering nabobs of negativity.

 

The frenetic fisticuffs included words like ‘racist’ and ‘Hitlerian’ and paltering pundits had the United States withdrawing from NATO, shuttering bases in Korea, and sooner or later nuking Canada.

 

That a statement this plain and simple can ring true to untold millions of real-life Americans yet draw the scorn of the media ‘elite’ lays bare the truth of the disconnect: someone has moved. And I dare say that it was not the American people who moved, but the bubble inhabitants – off into ‘La La’ land.

 

And don’t tell me about the Marshall plan, and the Cold War, and the intentions of the late twentieth century deep state, because I grew up with knowledge of that world and know what it meant. What we are being told today about that the path the country was put on after World War II is a great lie brought to us by the worst generation this country has ever seen – the Baby Boomers, the ‘me me me’ generation that never grew out of its Woodstock dreams and still does not have this country’s best interests at heart.

 

While we are at it can we finally put to and end of the use of the term ‘elites’, whether they be political elites, corporate elites, media elites, or coastal elites? That is to say if we are to take traditional definitions of the term meaning choice, or best, or highest class, there is nothing elite about them.

 

One last thing (and this will really get their goat): Trump has essentially overturned the tables of the moneychangers…I wonder will they kill him for it?

The Deepening Problem of Truck Violence

With the news of the latest truck attack in Jerusalem it is fair to say that a pattern has developed and it is high time that we have a serious discussion about truck control laws. We need Congress and our new president to work together to develop a plan for keeping trucks out of the hands of terrorists. Too many people have been killed already for us to sit around and do nothing about this major problem.

I know that there are many people who think that trucks are not a serious problem, and many arguments will be put forth for the continued widespread availability of trucks in our society, so before the debate begins I would like to comment on some of the more common points that are brought up in the defense of trucks:

There are legitimate peaceful uses for trucks

This is one of the most common arguments for trucks today. But are there not alternate means for transportation of goods? We could expand the use of shipping, trains, and airplanes. New technologies such as drones will be used in the future for the sending of parcels. Why do we need to use such an outmoded method of transportation? Some people will insist on bitterly clinging to their trucks, along with their Bibles and hunting gear, but it is time to bring these people into a more modern age. A more progressive enlightened world view can herald a new era for such backwards folk.

Existing trucking licenses are enough to restrict the use of trucks to responsible owners

If this were true we would not be seeing the rash of truck violence that we are today. Just because someone carries a Commercial Drivers License does not mean that they are not violent or a terrorist. The existing requirements for health exams and driving tests are not enough. At a minimum the programs need to be expanded to include background checks for all drivers, and we need to prevent people with a history of felonies or violent crime from owning a truck. But recent terrorism cases have shown that even trucks under the possession of licensed truck owners/operators may be hijacked and used by terrorists for violent acts. Therefore the only way to meaningfully prevent more truck violence is to stop the sales of all trucks and take measures to get existing trucks off the streets.

People in a free society should be free to own trucks without government intervention

There are many precedents for the outlaw of general use of trucks. Do we not prohibit people from carrying automatic weapons or nuclear bombs? Should trucks get a pass because they are considered less dangerous? How many more people need to die before we do something about this terrible problem?

Trucks don’t kill people, people kill people

This is a silly argument put forward by people who want to continue to allow the free availability of trucks. Of course trucks, by themselves, are just physical objects and do not have minds of their own. However, just because a truck sitting by itself is not necessarily dangerous does not mean that a truck, in the wrong hands, is not a threat to society. People would not be able to kill other people with trucks if they didn’t have them in the first place.

People who didn’t have access to trucks could still hurt people

This is another of the foolish arguments given by the pro-truck lobbyists. Yes, people intent on hurting other people could still use knives or other weapons to hurt them, but that does not mean that we should go on allowing people to freely own such dangerous items as trucks that can be used to harm so many people so quickly. This goes back to the above mentioned limitations on the free ownership of automatic weapons and nuclear bombs.

Let us take the opportunity in this year of great political change to take a stand: let 2017 be the year we finally pass sensible anti-truck legislation. Do not let the demagogues in the pro-truck lobby sway you with foolish arguments.

That was easy…

I sent an email…

To Whom It May Concern:

I recently paid my dues for 2017 but on reflection I would actually like for you to refund my dues. I no longer wish to be associated with an organization that repeatedly undermines its members interests in order to enrich itself. The horrible way in which you have handled the MOC issue only reveals you to be part of the corruption. I hope that with our new president the Attorney General will investigate the ABMS, the ABIM, and the ACC and tear you all apart. Many of you need to go to jail.

Please issue my refund for my 2017 dues of $935. If you refuse to do so, I will get claim fraud with MasterCard. I will then file suit against the ACC for fraud.

Thank you

 

and it was granted…

Good morning, As requested, we have issued a refund in the amount of $935 to your MasterCard account, and will forward your resignation request to our member services department.

 
Kind regards,
 
Marcy Gregory
Resource Center
American College of Cardiology
2400 N St NW
Washington, DC 20037
202.375.6000 x5603
mgregory@acc.org
www.acc.org

Now if more people would do this it would turn some heads!

 

 

Bureaucracy is Killing Medicine

I received a phone call the other evening from a colleague who was asking for my advice about how to deal with hospital credentialing. He wanted to hire an intelligent, gifted, and well experienced interventional cardiologist for his practice, but he was not able to extend a job offer because he was not able to make things work out at his hospital. Because I had been in similar circumstances he wanted my help in finding a way to make this work.

The man he wanted to hire has worked as an interventional cardiologist for over twenty years. He has been in the trenches through many of the advances in interventional cardiology and understands the ins-and-outs of stents, how to place them, potential problems that may arise in during cases, and how to handle all sorts of emergencies when dealing with a patient whose life literally is in his hands. He is the kind of person who I want to take care of me should I ever have a heart attack.

So what is the problem? Why can this man not go to work at this new hospital? Has he had a stroke? Has he suffered some sort of mental breakdown that has made him unable to practice? No. The only reason he is not able to do his job is because he decided to do something else for a while and has not been in the cath lab for two years. Now the hospital is not willing to credential him unless he first performs seventy-five cases. But he is not allowed to do the cases in the hospital, unless he is first credentialed. So he has to find another hospital in which to do the cases, but then he will likely find the same problem there. The only easy way for him to get the cases needed would be for him to do fellowship training over again, which is ridiculous.

He has found himself in the modern day version of Catch-22. Insane bureaucracy. Why do hospitals require these cases? Well, a group of people at some time sat in a room and said that someone who was working as an interventional cardiologist should have done at least seventy five cases over the past two years.

Where did that number come from? There may be an actuary that at one time may have calculated the actual risk of a bad outcome based upon the numbers of procedures that an interventional cardiologist had performed in the previous two years. Thus a threshold can be found. But does that number actually mean anything? These numbers often appear arbitrarily based on some risk assessment and benefit model, but to the physicians involved the numbers used often appear to be pulled out of thin air, and my gut tells me that these numbers just get passed around between hospitals as some sort of a consensus figure, not necessarily derived from any specific empiric knowledge.

That is what the hospital by-laws state. And why do the by-laws state that a person who everyone agrees is fully qualified to practice, and could step into the cath lab with minimal problem, needs to go back to square one? Lawyers.

This is all about lawyers. I live in Alabama. In pretty much any ranking of the states we are near the bottom, but most of the time we can at least say ‘Thank God for Mississippi!’ for keeping us out of last place. If you were to assemble a ranking of the most vile and disgusting members of our society, the most repugnant reprobates, sociopaths, and pedophiles would at least be able to say ‘Thank God for lawyers!’.

Why have lawyers ruined medicine? Because of their own incompetence. Lawyers generally do not want tort reform because they want to be able to make a quick buck by suing doctors because they were able to find something that went wrong during granny’s boat ride down the river Styx. Ambulance chasing lawyers and their better domesticated and fumigated compatriots have kept a horrendous medical malpractice system in place in this country in order to make money. And the lawyers do make out like bandits in this system while any victims of real malpractice hardly get any compensation. With the explosion in hospital administration and insurance company bureaucracy, lawyers have come to have even more say in the way that medicine is practiced in this country.

The measure that all doctors must now conform to is the ‘I cannot defend that’ standard. If a doctor wants to do something that a hospital lawyer somehow thinks that he cannot defend in court, then that thing is not allowed. Given the incompetence of many of our lawyers, this sets the bar quite low. And because doctors are now considered interchangeable widgets in the system, the same low standards must be set for everyone.

So due to the incompetence, or at least lack of confidence, of the lawyers who might have to defend someone, somewhere, in some theoretical case we have actually debased medicine, and made the total care delivered by the health care system decline. Because some unqualified idiot somewhere might screw up while putting in a coronary stent, we now have to say that all doctors must have at least have done seventy-five cases in the past two years and not screwed those up, so that in the case that something ever does goes wrong, some hospital and their lawyers will feel more comfortable defending that doctor by being able to say that he or she fit the ‘standard of practice’.

These same lawyers have also made it impossible for a doctor to go to another hospital and act as an ‘observer’ or a ‘trainee’ in order to get cases for credentialing. Lawyers have convinced everyone that ‘observers’ are not allowed due to the Health Information Portability and Accountability Act (HIPAA) – which most lawyers (and doctors) have not even read because it is another stinking pile of unreadable garbage which comes out of Congress disguised as ‘law’. The only way to get into the cath lab of a hospital and do cases is to be an employee of that hospital or be in a fellowship program with that hospital.

Never mind individual skill. Never mind competence. Never mind that someone may be an expert. What drives fear into the hearts of lawyers everywhere is the thought that they may have to defend someone against an ambulance chaser who asks the doctor on the stand “You mean to tell me, doctor (with all sarcasm and derision said lawyer can bring into his voice), that you had not done the requisite number of cases leading up to your hospital credentialing that we ask of the lowest of new trainees?”

So common sense flies out the window. Forget doctors policing their own. Forget about the old practice of ‘proctoring’ where the doctor can come and do some cases under supervision to make sure that his or her skills have not degraded. Now we have to listen to hospital and insurance company bean-counters who wouldn’t know their left anterior descending coronary artery from their inferior rectal artery how to practice medicine. This is the fall-out of Obamacare, and more generally the fall-out of an out-of-control bureaucracy put in place by both political parties over the past twenty five years.

Who watches the watchers? We must be vigilant in determining the best way to protect patients from potential fraudsters, but at the same time we must protect ourselves from the same menace. In exactly the same way as the credentialing system has been tainted, the Maintenance of Certification (MOC) system had been corrupted. MOC should ideally be a place where doctors can obtain knowledge without the threat of losing hospital privileges or insurance company compensation. But where the corruption of the credentialing system has been to reduce risk for the hospitals and insurance companies, the corruption of MOC has been for the financial benefit of the people who are running the system.

Unfortunately, our masters at the American Board of Medical Specialties (ABMS) and all of their counterparts, which in my case includes the American Board of Internal Medicine (ABIM) and the American College of Cardiology (ACC), just do not get it. Like the sea change in presidential politics we are undergoing a transformation of the willingness of fellow physicians to blithely follow along with the MOC program.

Yes, there are valuable bits of knowledge in the program, and this type of learning can be an important part of medicine. But the current establishment in place is deeply corrupt. Just as the poisoned well taints all of the fruits of the orchard, just as water contaminated with bacteria can result in entire batches or product lines being recalled, the valuable parts of the MOC program have been spoilt. These products are polluted, infected, rotten, and diseased, and we must be done with them completely to rid ourselves of their putrid stench.

We may build some new system in place of MOC, but until we have a full house-cleaning at the ABMS and the ABIM we will not be rid of the smell. It is time to fumigate and eject this redolent fetor which fills the ranks of our ‘leadership’. End MOC now. End MOC today. And end the silly requirements for credentialing and use common sense in deciding who can practice medicine. Rid medicine of this fraud, this embarrassment, this menace of bureaucracy!

 

The American political system is broken

The process of putting forth opinion pieces into the public space for debate is an important part of journalism, but typically the selected essays are within a certain bound of what we may call the ‘main stream’. From time to time, and more frequently of late, we find major publications putting into the public space opinion pieces that are so far from the center of normal discussion that they foster emotions of objection, or even anger, and foment arguments amongst the readers. We have today just such a piece presented in the New York Times, an article entitled “The American political system is broken” by Mehdi Hasan.

This article is so misguided in its thinking that it demands a response in an attempt to set things right. What makes it so interesting is that I happen to share the writers’ opinion as far as the premise: I do believe that the American political system is broken, but the reasoning behind the remainder of the article is fundamentally flawed.

We will start from the top:

Mehdi Hasan is a British broadcaster and author based in Washington. He is the host of “UpFront” on Al Jazeera English.

First we recognize that the writer is not American, but an outsider, which is all well and good, but does give us an understanding of his perspective. I am happy to have outsiders discuss our political system, but hopefully they too will understand that they are on the outside, and we all know where we stand. Next we see that the writer is based in Washington, which means that the writer is in the bubble. Finally, we see that the writer is a host on Al Jazeera, not exactly the most objective source of information in the world today. So three strikes already, and we have not even started on the opinion piece, but in the interest of fairness, we might as well let him get up to bat.

So we go to the piece:

Consider the following scenarios: What if Venezuela held a presidential election and President Nicolás Maduro claimed victory with fewer votes than his main rival? Or if Russian liberals won the most votes in the country’s legislative elections but failed to secure the most seats in the Duma? Or if Iranian authorities tried to prevent members of the country’s largest minority group from voting?

Can you imagine the howls of outrage from the White House press secretary? The pious calls from the State Department spokesman to respect the will of the people and protect minorities? Yet all of these undemocratic travesties occurred. Here in the United States, in front of our noses.

Much has been written since Election Day about the need to resist the “normalization” of racism and misogyny. Less has been said about the “normalization” of democratic dysfunction, the signs of which are all around us.

The main point of the article is that his side lost and he now wants to gripe about it. So he sets up the article with a few straw men that he can attack. This is all standard debating tactic. Let us proceed on to his arguments:

 Take the popular vote. Sorry, Americans, it’s just not “normal” for the candidate who came in second to be declared the winner of the race for the second time in the space of a mere 16 years. In 2000, George W. Bush was elected the 43rd president of the United States despite winning about 540,000 fewer votes than his Democratic opponent; in 2016, Donald Trump has been elected 45th president despite trailing Hillary Clinton by 2 million votes.

The writer clearly is still rubbing his wounds from the Bush v Gore loss in 2000, but that was sixteen years ago, so one would think that those scars would be grizzled and thickened by now. Not so, apparently, as the writer bewails that this is ‘just not “normal”’. Actually, we have a system: the electoral college. This system has been in place for well over two hundred years and has served us well. It is only after losing the game that he now wants to complain about the rules. We could go into a long discussion about the benefits and potential downfalls of this system, but the heart of the reasoning for this system is that we are a set of united states with different interests, resources, population, etc.

None of the other Western democracies have anything comparable to the archaic U.S. electoral college — which Trump himself once dismissed as a “disaster for a democracy” and which Americans across the political spectrum have been consistently in favor of abolishing — and therefore have not experienced anything similar over the same period. In the United Kingdom, for example, the last time a political party won the most seats in parliament while losing the popular vote was in 1974. Before that? 1951.

Here I will simply paraphrase: ‘It’s not fair! That’s not how things work at my house! Mommy?’

Take campaign spending. The United States continues to spend more on elections than any other country on Earth, with the 2016 race for control of the White House and Congress costing a record $6.8 billion. For comparison, consider India: With a population almost four times that of the United States, the price tag for the 2014 Indian parliamentary elections was almost $2 billion less.

Consider also the 2016 Senate race in tiny New Hampshire (population: 1.4 million), where an astonishing $120 million was spent by the two main candidates and their supporters. By contrast, in the U.K. (population: 64 million), where the 2015 general election has been described as the most expensive British election on record, the combined spending of all U.K. political parties reached … $60 million.

Every time the ‘progressives’ lose they start complaining about money. George Soros’ pockets apparently do not run deep enough. For comparison, the money spent making the Marvel Comics movies has been about $5.6 billion dollars. Ask yourself which is more important. Actually this campaign was remarkable for how little money mattered. We are starting to move beyond standard campaign spending on television advertising. The technological innovations which have connected us to ‘social media’ have created an entirely new phenomenon. Information, like water, is being spread as if it were a tidal wave crashing across the country and now we do not need to rely on a few spigots to obtain our supply. The ‘mainstream media’ who have controlled the water supply to date are in a tizzy after the deluge and do not know what to say. Forget it, Jake, its Chinatown.

Only in the United States is money considered “speech” and corporations classed as “people.” Most other democracies recognize the latter position in particular, to quote former U.S. Supreme Court justice John Paul Stevens, as undermining “the integrity of elected institutions” and the “cause of self-government.”

This is a canard. Money is money and speech is speech but to get speech disseminated to the people takes microphones, cameras, and transmitters, and those cost money. The two are intertwined. Whoever said it was a problem to have more speech? I mean if you have amplifiers drowning out my speech like Bill Clinton and Janet Reno did to people in Waco, Texas, then we might have a problem, but for the most part the more speech that is out there the better. The problem is that all of the ‘progressives’ political power is not based on intellect but on emotion, and the more we talk about things the more likely we will diffuse all the emotional drama and then the ‘progressive’ agenda will fall apart.

 Take turnout. The United States falls far behind most other developed democracies, coming 31st out of the 35 member states of the Organization for Economic Cooperation and Development (OECD). How many Americans are aware that more of them stayed at home on Nov. 8 than voted for either Trump or Clinton? Or that, despite the closeness of the race, turnout fell from 58.6 percent in 2012 to 58.1 in 2016?

Compare and contrast U.S. voter turnout with recent rates in OECD member states where voting is compulsory, such as Australia (91 percent), Belgium (87 percent) and Turkey (84 percent). “Of the five highest-turnout OECD countries in recent elections,” noted a recent Pew study, “three have laws requiring their citizens to go to the polls.” Few Americans are aware that the state of Georgia, in its pre-independence 1777 Constitution, made voting compulsory and “subject to a penalty.” Is it time for the United States to invoke the Georgia precedent?

People who are engaged in the politics of this country will vote. People who are not may choose not to vote. Again we come back to a question of personal choice. I would prefer that people who know nothing about the candidates nor their positions not vote, but everyone has a right to vote in our system.

Take voter suppression. It looks like U.S. politicians across the country have mastered the dark art of denying certain citizens their right to vote. According to the Brennan Center for Justice at the New York University School of Law, 15 states had new voting restrictions in place for the presidential election as “part of a broader movement to curtail voting rights, which began after the 2010 election.”

Consider the swing state of North Carolina. On the eve of the election, a federal judge said she was “horrified” by the “insane” process by which people were “being purged” from the voter rolls. In July, a three-judge panel ruled that the state’s 2013 voting law could only be explained by “discriminatory intent” and “hinged” on a concern that “African Americans … had too much access to the franchise.”

To be clear: Republican politicians have spent years trying to prevent black people from voting. To quote one longtime North Carolina Republican strategist: “Of course it’s political. Why else would you do it?” 

Now that we have finished the appetizers, we can get to the meat. What in fact we are finding is that politicians have long kept ineligible voters on the rolls. Dead people, people who have moved, and people who have multiple residences fill up the voter rolls with ineligible or duplicate entries. Is this intentional or fraud? Well, no – for the most part. If you have ever performed an internet search on yourself, you will likely have found a plethora of partial information with old addresses and phone numbers long forgotten. The ‘Motor Voter’ laws have put millions of people onto the voting rolls. Keeping voter rolls clean can be tedious work, but there are also advantages to keeping extra numbers on the voter rolls if you want to pad a vote count. Just stack up an extra set of ballots there, they are real voters I swear.

So we have now started to push back with some reasonable thinking. Why not just have people identify themselves when they come to vote? Then you will not have a problem with fraud anymore (cough). But joking aside, voter identification is very reasonable and a way to try to reduce the likelihood of shenanigans. At my polling place voters lined up very orderly and everyone showed their ID. Not a big deal. But supposedly there is this large population of oppressed African-Americans who do not have IDs. I guess they can’t buy beer. Would somebody, please, show me one of these poor lost souls? I would be willing to drive them personally to the DMV to get their free identification card.

We do not have a national ID card and I certainly would not advocate having one, but if you would like to vote it is very reasonable to ask that you have some sort of picture identification. The argument that asking for identification is suppression does not hold water. Anyone who cares to vote can. If there are problems with any individuals who have been ‘purged’ from the rolls for some reason, they may cast a provisional ballot and we can sort it out for each case. We do not have voter suppression, but in the real world there are people who think that they can mark a few extra ballots in somebody else’s name and get away with it.

To be clear: there are no black people that a Republican politician has stopped from voting.

Take gerrymandering. The practice of redrawing the boundaries of electoral districts to secure party-political advantage is neither new nor exclusive to the United States. Yet the difference is that gerrymandering in the United States is actively encouraged, to quote Harvard political scientist Pippa Norris, by “leaving the processes of redistricting in the hands of state politicians, rather than more impartial judicial bodies.”

Democratic systems that show little evidence of gerrymandering tend to be those that recognize the blindingly obvious connection between an impartial election management body and an impartial election process — Australia, for example, has the Australian Electoral Commission, Canada has Elections Canadaand the U.K. has four boundary commissions, all of which are either independent or operate at arms-length from the various executives and legislatures.

In the United States, however, the Republicans, who currently dominate state legislatures, have perfected the practice of gerrymandering, pulling off, in the words of investigative journalist David Daley, “the most audacious political heist of modern times.” Republican dominance in states such as Michigan, Wisconsin and Ohio, notes Daley, are a result of “maps that were drawn after the 2010 redistricting.”

I don’t like gerrymandering either, but it is the system that Democrats mastered for years to control the system. The problem is that Democrat policies have failed so badly that people have stopped voting for that side. Now the Republicans are in power, and the writer does not like the tables being turned. I am not opposed to some form of commission for redistricting, or even coming up with another way of selecting our representatives. Politicians will be politicians, and we have the Lord’s grace to comfort us.

Oh, my, my I have forgotten my manners. By name and affiliation I am to assume that the writer is of the Islamic faith, and may not understand grace. And here we come to one of the rifts that our multicultural world demands attention. We are a secular nation because we have given people the freedom to choose what religion, if any, that they want to follow. I suspect that most people don’t even put that much thought into it. But our Western societies share some Judeo-Christian values that are not necessarily, (although I believe them to be) universal. The values of fairness and justice should be held dearly, and despite all the chatter and alarm that is filling the ‘info-space’ I believe that they are.

Is this really what we define as democracy? Or is this, to quote the president-elect, a “rigged” system? Rigged not against Trump and the Republicans but against the poor, against ethnic minorities, against Democrats but, above all else, against basic democratic norms and principles and pretty simple notions of equality and fairness?

This isn’t a time for denial or deflection. The American political system is broken. Far from being the “world’s greatest democracy,” to quote President Obama, representative democracy in the United States seems further hollowed out with every election cycle.

And here we find the fundamental flaw in our writer’s essay. This is the core of the problem. No, I say, this is not what we define as democracy: this country is a representative republic. I am very sorry if you do not like our system, but to use a trite phrase that goes back to John Locke and An Essay Concerning Human Understanding, it is what it is. And a democracy it is not, despite Barack Obamas’ amateurish attempts at philosophy. The writer moans about the state of the system, and there definitely has been a rank stench emitting from the cesspool that is Washington, but the results of the recent election are not the problem; more hopefully, they will be the cure.

The real divide

So this debate has brought us to the political axis which has split America, and which, in the twenty-first century, is probably the most important political axis for us to consider. This axis splits across party lines as we have seen it during this election cycle shatter the traditional Republican coalition but also divide the Democrats as well. Arguments along this axis were also some of the strongest driving factors of the wars throughout the twentieth century. Where you stand ideologically along this axis largely determines how you feel about taxation, freedom, health care, and even immigration and globalism.

What is this all-important axis? It is the line that runs from communitarianism to individualism. The traditional Nolan chart of political preferences has labeled this axis as ‘authoritarian’ ↔ ‘libertarian’, which could be reasonable labels, although due to past abuse of these terms they have become contaminated with all sorts of confounding ideologies that give these labels certain liabilities in any pure philosophical discussion. In an attempt to be more precise in my language, which is a requirement when trying to make points clear, rather than ‘muddy-the-waters’ as so many pundits would prefer, I will stick to the ‘communitarian’ ↔ ‘individualist’ (C↔I) labels.

All of the major government systems can be placed along this axis, including communism at one end, socialism (Scandinavia) a bit further along the spectrum, other Western style liberal democracies (excluding Scandinavia and the United States) coming next, and finally the furthest along on the spectrum (at least among large nations) would be the American ‘experiment’ as defined by the founding fathers, if not as much the reality into what we have transmogrified the US system today. We could place anarchism at the far right of this axis.

Now we have added into this mix ‘Trumpism’, which I would argue we will not really understand for years to come as the president-elect appears to have not made up his mind about many things and has yet to implement any policy, but for the sake of argument I will use ‘Trumpism’ as we have come to know it during the election cycle. Unfortunately for those of us who tend to be of a libertarian mindset, this ‘Trumpism’ does not appear to be anything close to our traditional libertarian or individualist philosophy but rather seems a mishmash of populism, authoritarianism, moderate social liberalism, and free market ideology. What I can say is that this system is likely much closer to the original American ideal along the C↔I axis than anything that Hillary Clinton advocated, and certainly light years away from Obama’s politics of the past eight years, which has seemed hell-bent on transfiguring our society into some utopian progressive fantasy land way down on the left hand side of the axis.

As simplistic as the Nolan Chart is, and as hackneyed as it has become, it is still quite informative to examine this layout in order to cut through some of the propaganda that has been populated by all manner of unreliable sources, not the least of which has been the ‘mainstream media’.

You can take the quiz for yourself to see where you lie:

worlds-smallest-political-quiz

Here are a few variations I found with a quick search. Some I include only for their humor value. If you are not already very familiar with this chart, you will quickly get the idea. Political ideologies may also be mapped in many other ways, with just about any shape you can imagine having been used. The point of all of this is that a simplistic left/right, Democrat/Republican view of the world does all of us a disservice in these discussions.

Standard Nolan chart:

nolanchart

This is a very reasonable split-up of the chart including many of the views in modern American politics:

nolan-chart-majorphilosophiesAnother view of the chart with historical world philosophies:
nolan_chart

A more complex view of the chart (also rotated) with more views:

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Where the 2016 candidates + Obama stand:

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How most libertarians see the chart:

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One of my personal favorites with relevance to this current discussion:nolan-chart-subdivisions

 

One of my usual foils came at me with his opinion that individualism is really the attitude of the haves versus the have nots. To quote:

And I don't think your country of origin has changed its mind about how it provides for the group. Those provisions are not created from voluntary contribution, but by mutually agreed desire to have the system available for all. This momentary blip due to the foolish failure to recognize that generosity to the world, outside of people of like mind, is wide open to abuse by people whose countries have failed to provide decent standards of living. That blip must and will be dealt with and the social group will settle down and recreate the circumstances needed. 

That quality has not been achieved by personal voluntary contributions as you appear to believe is the way it should be, but by the social group imposing its collective will on individuals. IMO that is the biggest single error that the US has made in promoting its original statutes of liberty. Were your views to be implemented across the board, you would be unable to ensure that everyone, or anyone, paid their due share to the whole process of social conformity; no ability to impose taxes to pay for any services that are required, no right to call on people to help defend the nation in event of attack, no means of establishing some form of law and order or anything else that is needed to make the social group viable. That is the horror of personal rights and freedoms. In any good society, all rights and freedoms must be for the benefit of the group, in order that they may benefit the individual. Freedom of any form is dependent on the conditions pertaining, never something for the individual to take on for themselves, unless they are prepared to be made a pariah in their own group.

This is a straw-man argument. He has chosen not to recognize what I have said all along: that this axis is a spectrum, that where we stand along this spectrum at any given point in time is a subject of debate, and that this is precisely what we have our political system set up to debate in a civil manner. Instead, he insults me by saying that if I happen to think that we have strayed too far down in the communitarian direction that must mean that I am an anarchist, want NO government, NO taxation, and NO national defense.

Of course that is not my position, nor was it the position of our founding fathers, who very carefully set aside in our Constitution what they felt was the rightful place of government. And please do not also try to smear me with the common leftist canards that the founding fathers had slaves so we cannot appreciate anything they did or that slavery was enshrined in the Constitution so the document no longer applies. I do not condone what was done in the past regarding slaves in any way – we have moved beyond that way of thinking, from the African slave merchants who sold their enemies into slavery to the Western world which took advantage of the situation.

But what was done by the founding of the United States was that a government with limited powers, checks and balances, and all conceivable (at the time) design limitations was established and allowed to be tested as a system in the real world. And the result, which you can clearly see, is that the country flourished and has become very powerful.

On the other hand, communitarian government systems have been tried repeatedly over the past few centuries and have overwhelmingly failed. Not only have these governments typically had to kill large percentages of their populations to be put into practice, but they have required brutal totalitarian regimes with secret police to maintain. If the failures of the twentieth century are not clear enough evidence, just look at Venezuela, once a thriving country, abundant in natural resources, which has been now driven down to third-world status with large numbers of people unable to obtain food or medical care in that ‘progressive paradise’. As Margaret Thatcher famously said, “The problem with socialism is that you eventually run out of other people’s money.”

How many pogroms are needed, how many ‘cultural revolutions’, how many hundreds of millions of more people need to die before people can see the dangers of collectivism?

My arguments have always centered on a few things: 1) The American experiment established one of the few places on earth that people were free to generally do as they please, with a limited government and system of laws put into place to try to maintain that system; 2) All governments tend to grow, based on the self-interest of the people running the governments. If clear obstacles, laws, and checks-and balances are not put into place, all governments will tend to grow and slide down the axis towards more and more communitarianism, because government ‘experts’ always believe that they are smarter and better at making decisions than ‘common-folk’; 3) It is the place of the political system to help the people argue and decide just where on the axis between pure communism and anarchy that they wish to live; and finally 4) The science and economies of countries further towards the individual side of the axis will thrive, because they unleash the power of the people to create, explore, and build through the inherent incentives in the system (you keep what you earn, create, or build, and share it how you like), while the countries further towards the communist side will sink into excessive bureaucracy, corruption, and laziness due to disincentives to work (all property is to be equally shared, no matter how much effort each individual put into obtaining or creating said property).

Now, all of that being said I will grant that there are exceptions to the rule. Countries across the world differ in vast ways in their geography, natural resources, and most importantly in the beliefs, value systems, work ethic, and the intellectual and creative abilities of their populations. These differences will lead to different levels of achievement that can be reached by each country and their individual citizens. A serious problem in trying to measure various countries against each other, and even individuals within any given society against their compatriots or among people in the world at large is that ‘achievement’ itself is very subjective. I always laugh at rankings of, say, the United States’ position in the world on a measurement such as health care. ‘Health care’ itself is such a complex subject that any such ranking would be severely problematic unless it can be broken down into smaller subjects which are all encompassed under the blanket term. These rankings never measure what they purport to measure, but instead reveal the agenda of the people who have produced the report. We can, however, attempt to produce a ranking in objective measures, such as, say life expectancy or infant mortality, but if you read my recent essay on statistics you can see how even such ‘objective’ measures can still be highly subjective and be used to try to advance an agenda.

There are also plenty of examples of problems within the United States system, including all forms of corruption – fraud, graft, nepotism, breach of trust, exploitation of workers, (and on and on ad neuseum) – which occur in both the governmental and private sectors. I would argue that the smaller the government, the less opportunity for corruption. I do think that in a system with a healthy rule of law (something the Obama DOJ has apparently forgotten about) it is important to have enough power and ability to monitor corporations and punish misdoings. I also think that we tend to jail way too many people in the United States, but again my argument is that the underlying problem is that we have strayed from our founding ideals and favored safety and security over freedom.

One of the biggest problems in modern politics from my perspective has been the mixing of the ideas of globalism and free trade into the argument. The left wants globalism to help spread the wealth of the more advanced nations to all the people of the globe. The right wants free trade to be able to expand their markets. Both sides want immigration in order to advance their goals. This is all well and good in theory: I actually think that open borders and free trade are important concepts –  given that the people on both sides of the bargain share similar ideals, beliefs, and ethics. What has been lost on many of the coastal elites of all political stripes (the people I call the bubble inhabitants) is that the world is populated by people of vastly differing fundamental ideologies.

We currently have a large percentage of the world population whose fundamental religious texts call for all unbelievers to be killed, converted, or enslaved. These are the fundamental ideas behind the cult that is called Islam, and though the majority of the people who profess this faith may not believe what their leaders and religious texts call for, the fact that these tenets remain unchanged and ensconced in their ‘religion’ is problematic. If we are to accept these people into modern Western society, it is not unreasonable to ask them to reform their statements of faith.

We also have many large and powerful nations (i.e. China, Russia, Iran) who openly flaunt the deals which we make with them, knowing that the will of most of the Western democracies is weak and they can get away with it. This power differential does not lead to fair bargaining when considering trade agreements, nuclear deals, or immigration policy.

But who ever decided that ‘globalism’ has to be the way of the world anyway? I never got to vote on this topic. What we have is a group of oligarchs, i.e. the bubble inhabitants, who have taken control of the US government and used their power for self-enrichment, all the while telling the regular people in flyover country that what they are doing is inevitable, the wave of the future, and for the ‘common good’.

Enough of this rant. It is Thanksgiving. Time to focus on the many blessings in our lives that we can be thankful for.

Health Care

stethoscopeA subject which has been a focus of intense debate over the past decades has been health care. Part of the reason for the debate is that there has been a fundamental misunderstanding about what health care really is. Many people feel that health care is a ‘right’, but health care can never be a ‘right’ as we have historically understood rights. Our founding fathers properly described the rights that we have as human beings – the rights to life, liberty, and the pursuit of happiness. These are what may also be termed negative rights, meaning that they demand inaction. We fundamentally have life, liberty, and an opportunity to pursue happiness as long as no one (especially government) impedes upon those rights.

Other purported rights – the ‘right’ to education, the ‘right’ to health care, and the ‘right’ to a job being the most common that are debated – are positive rights, meaning that they require action on the part of other people to be fulfilled. I propose that a different term be used in our discussion of positive rights, in order to prevent confusion between the two. I would say that these are ‘expectations’. I believe that positive rights can never be considered true rights, because in order to honor those expectations, other people must be obligated and forced to work on your behalf. Therefore, while we can discuss whether or not to honor any of these ‘rights’, we can and should recognize that these are only ‘expectations’, and any effort made to honor those expectations should be considered a privilege.

So as long as we can agree that you do not have a fundamental right to health care, we can discuss what obligations a modern society should have towards its citizens. While I strongly believe that your own health care is your personal responsibility, I also recognize that through circumstances often out of your control you may not be able to pay for health care services. This is especially true for people who have been born with congenital diseases which may be very expensive to care for, and which may prevent those individuals from being able to work and provide for themselves.

Taking a pure libertarian position on this entails no government part in providing health care for its citizens, and making people rely on family and charity to provide for them. This, I believe is not only possible in theory, and desirable, but given government mismanagement of this issue for decades, and the amount of ignorance and misinformation that is present among our citizenry, this is not likely obtainable any time in the near future. People will need to weaned off the government teat, a process which will take many years, if it will ever be obtainable honoring our political system. People will always vote their pocketbook, and given the option to require others to provide for them, most people will select that option. Unless we are able to return to a system where everyone is required to pay some taxes, the people who pay few if any taxes will prevent true reform.

ppacaThe recent changes in the health care system, the Patient Protection and Affordable Care Act of 2010 (PPACA, or Obamacare) and Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), are in my opinion, the exact wrong way to go about reforming the healthcare system. These laws make some basic assumptions which are deeply embedded in ‘progressive’ thought, but in my opinion make fundamental mistakes in understanding rights and human nature. These basic assumptions are: 1) that positive rights are true rights that all people ‘deserve’ and are entitled to; 2) that all patients and medical problems are essentially the same and can be treated through treatment algorithms decided on by medical ‘experts’; and 3) that physicians, or ‘treatment providers’ are all the same and are interchangeable, including using nurse practitioners and physician assistants in the place of medical doctors (MDs).

I have already addressed the first of these and will now try to explain why the remaining two assumptions are problematic. As for #2, while it is true that people are very similar in many respects, and often the treatment used for one person or medical condition will work in other cases, people are not widgets. There are hundreds if not thousands of factors that differentiate people from one another, and the best way to determine the treatment for any given person is for a qualified expert to examine and talk with that person. Some of the factors that go into deciding the correct treatment for any given patient include: What are the different options for treatment, and which one best fits the patients’ needs and desires? What other medical conditions do they have, and how will the treatment prescribed interact or interfere with other medications the patient is taking? Is the patient likely to follow the treatment course recommended? What are the patient’s expectations for the treatment? Is the patient able to afford the treatment prescribed? What are the side effects of the treatment and will these prevent the patient from finishing the treatment course?

All of these considerations must be taken into account when deciding on the proper course of treatment for any given patient. Trying to come up with guidelines and treatment algorithms has been the wet dream of progressive health administrators because these would eliminate the requirement for a skilled doctor to figure out how best to treat the patient. One of the biggest battles in medicine now is how to handle treatments which diverge from the guidelines which have been formed by ‘experts’. The dirty little secret of guideline based medicine is that the panels which come up with the treatment algorithms often have fierce debates about what is the proper treatment for any given condition. There are large areas of disagreement, and while the treatment guidelines usually are based on areas where consensus could be found, sometimes they are based on ‘majority rules’ and are deeply divisive.

Just as patients are not interchangeable, fundamental mistake #3 above is that medical providers can be treated as widgets in the system. The payment system in medicine already makes this assumption, which is deeply flawed and not reflective of reality. In truth, some physicians are very skilled and able to diagnose and treat patients very efficiently while others order a large number of laboratory tests and imaging studies in order to make a diagnosis. Some physicians are also better at making an emotional connection with their patients, a skill which I believe makes diagnosis and treatment much easier, while other physicians have trouble relating to their patients. Unfortunately, the current medical system we have in this country rewards the wrong things. Doctors are not paid to think, but are paid on the basis of the tests that they order and the procedures that they perform. Therefore, the unskilled doctor who requires a large number of tests in order to make a diagnosis actually gets paid more than the physician who does a complete examination and is able to make a diagnosis based on their very in-depth history and physical. The system forces doctors who know what they are doing to order unneeded tests in order to get a reasonable reimbursement for their time.

“So why do we not go to a capitated system, where doctors are paid a flat fee for each patient?”, the astute reader may ask. This type of system may in fact work, but there will always be bad players who see a lot of patients and order no tests in order to make a lot of money. This type of system also would encourage doctors to only see well patients who do not require much testing. The sickest patients who require a lot of care may be left out.

I do not pretend to have all the answers as to the best payment system which will reward the best doctors and help the sickest patients, but I do believe that doctors should be able to charge different amounts based on their skill. Just about every other profession in this country allows experts to charge more than novices. The time of the best, highly trained and experienced doctor in this country is certainly worth more than the time of the unskilled and unexperienced new graduate. But the current system pays the same for everyone. Therefore, the skilled and experienced doctor, in order to make up for the inability to charge more, must see more patients and spend less time with each individual patient than desirable. While the highly skilled and experienced doctor should be able to do this because they have become more efficient, the combination of less time with patients and increasing paperwork requirements means that mistakes will be made.

And this leads us to another area of discussion in the health care realm: medical mistakes. There has been a trend in recent decades of organizations such as the Institute of Medicine (now the National Academy of Medicine) to come out with studies showing a large number of ‘mistakes’ being made in medicine. If you dig down into the definitions of mistakes in these studies they often include such things as the patient being out of the room when morning medications were given, so the patient got the medicine at lunchtime. Other ‘mistakes’ include known interactions between medications that potentially could be avoidable, but the physician felt that the benefit of the medication outweighed the potential risk.

“So why are all these things labelled as mistakes?” you may ask. That is a very good question and goes to the agenda of the people doing the studies. The more that doctors can be marked and viewed as unreliable, the more oversight they theoretically need. This goes to the heart of the argument of people who want government intervention and control in health care. They believe that if they can label doctors as prone to making mistakes, then they can swoop in as ‘government experts’ to protect the citizenry from the ‘harm’ that doctors are inflicting on them. In truth, the only harm here is to the integrity of the medical system and the overall trust of people in their doctors, and this harm is being inflicted on us by the ‘government experts’.

We have a system in place for suing doctors for malpractice. We do not need another level of government oversight in medicine. However, the malpractice system desperately needs reform. Turn on the television at any given time and you will likely be inundated with commercials from lawyers who want to help people sue their doctors or the drug companies. Sometimes these suits are laughable, but unfortunately they will cause great expense, trouble, and damage to reputations in the meantime. For example, we have been blessed in medicine with a number of new replacements for warfarin for thinning blood. These new blood thinners can prevent potentially lethal blood clots from forming after surgery and can also prevent many strokes. How do they perform this magic? By slowing the coagulation system preventing the formation of clots. So if we prevent the formation of clots, what would be an expected side effect? Bleeding, naturally. The use of these anticoagulants has to be weighed on a scale of risk and benefit – clot prevention versus bleeding – and this calculation has been the basis for hundreds if not thousands of medical studies trying to find the right doses, delivery systems, and potential reversal mechanisms for these medications. This is what doctors do – this is our area of expertise.

Yet the trial lawyers want to sue the drug companies because some of the people who take these medications have suffered bleeding side effects. The lawyers know that they can play on emotion and drum up sympathy for the unfortunate patient who may have had a devastating side effect. The lawyers also know that they can often bully doctors, hospitals, and drug companies into settlements. Who benefits from these lawsuits? The lawyers clearly benefit, the patients less so. There needs to be a system in place for malpractice to be prevented and compensation for malpractice litigated, and we can even argue that there should be some sort of compensation system for the people who suffer known potential side effects of medications, but the current ambulance-chasing and hit-the-jackpot system is not it.

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