Familiar Strangers

What is this phenomenon that has been happening in our culture leading to outbreaks of violence? Are outbreaks of violence becoming more common and severe or are we just more aware of these events when they happen? Certainly there does seem to have been a coarsening of our culture in recent years, but does this represent a measurable trend or is it only a perception? And are these questions any different from similar ones in previous generations?

StrangerThese are difficult questions without clear answers. I am not a social scientist (and tend to think of the term as an oxymoron, anyway) but certainly some of the studies from social sciences appear to have some interesting insights into the ways in which we interact. The first aspect I would like to explore is the concept of “familiar strangers” as identified by Stanley Milgrim in 1972. These are people who we see on a regular basis and know by sight, but whom we would not call friends or even acquaintances. This is a concept that has been studied in urban settings such as train stations, but I would say that this increasingly is becoming the norm in suburban neighborhoods as well. We may know the names of our neighbors but do not interact with them regularly.

A recent study examined how distrust among Americans is increasing due to spending less time with neighbors, watching more television, spending more time in cars rather than public transportation, and economic and political self-segregation of our communities.

distrust1A separate survey by the Pew Research Center in 2010 showed that while 19% of adults said they knew all and 24% said they knew most of their neighbors, the majority of American adults knew only some (29%) or none (28%) of their neighbors by name.

At the same time we have had the explosion of social media. While some would contend that social media has made us more connected, I would argue that the broadening of our social contacts has also reduced the depth of those contacts. There is a large variation in the number of acquaintances and friends that any given individual may have, but the total network interactions do not change that much over time. Due to the larger number of interactions we are not able develop them as deeply and prolonged interactions. This is to some extent simply a function of time available, but likely also heavily influenced by personal preference. While people change over a lifetime, and personal networks grow and shrink, the amount of time available in a day for human-human interactions stays relatively constant between major life events such as school or job change or retirement. So one would suspect that within any major phase of life the total amount of human-human interaction is relatively constant. The increasing number of contacts leads to shallower interactions, and as these interpersonal interactions become more superficial it becomes easier to depersonalize the ones we are interacting with. We treat each other as less human than we used to.

Another disturbing and likely related phenomenon has been seen in our politics. For a number of different reasons including our party primary process, the sound-bite-driven twenty-four hour news cycle, and increasingly data-driven campaigns our politics have become more polarized. The two major political parties have increasingly built advantages for themselves into the law with the effect of largely keeping third parties out, and this has accelerated polarization into a strict two-sided, us-vs-them system. Within these parties we also see divisions.polarization On the left the division is driven by grievance politics. Groups are identified and divided and encouraged to separate themselves and demand apologies and reparations from others: black vs. white, gay vs. straight, union worker vs. business owner. On the right personal choices are derided, disparaged, and repressed due to a suffocating religious conservatism. Individuals are demeaned as being socially unacceptable by people who are often blatantly hypocritical. Again, all of these political forces lead us to dehumanize each other.

There is a way out of this cycle, although I am not very optimistic about this happening, and that is to start treating each other like human beings again. Just as the old saying ‘you cannot legislate morality’ you also cannot legislate humanity. Humanity requires connections – actually talking to people instead of demanding government correct our grievances. This means taking direct action yourself rather than asking someone else to do your dirty work for you. From a policy standpoint this means less government and less regulation. But from a social standpoint it means more personal responsibility, and in some areas our personal responsibilities have fallen apart. Those that are blessed with skills and opportunities that lead to financial success should give back to their employees and fellow citizens and share their wealth. (Note that I did say give and not have wealth be taken by force.) But for those people who do not give back there should be more of a public shaming and ostracizing. This is our tradition, the American way, but somehow we have lost this sense.

There is a grand philosophical argument to be made between the forces of collectivism and the forces of individualism. The collectivists have had the last eight years in power and the results have been predictable – dehumanization, lack of opportunity, demotivation, and even terrorism. It is time for a return to personal responsibility and rugged individualism.

Dallas Shootings

This is Obama’s legacy. The sickness starts from the top. We need a leader and what we have instead is a vacant fop, A sinister figure who doesn’t even know what power he is playing with. I see the devil in that man and he is laughing at all of us now. He is delighted with all the carnage around him and revels in the pain of his people. He has been trying to pull the whole thing down and he is succeeding. Only sheep, ripe for the slaughter, would vote for Hillary now. This country hungers for a leader who can take us through a change.

These grievance politics do not do anyone any good. It is the measly whining that is promulgated by the left that has led us to this. We need to put a stop to all of this garbage. All of the political correctness and dancing around issues. Mamby-pamby pussyfooting is Obama’s style, and it is leading us into destruction.

Black lives matter? Get your ass out of that recliner and do some work! And don’t let some bureaucrat tell you that you are not doing things properly. This means getting rid of governmental intrusions into your lives. Rake down the barricades that prevent you from living your life the way you should! Permits, licenses, charters, concessions and any other obstacles need to be shed like a dead snakeskin.. We need to shake loose this crust that has formed over our society.

The United States of America is aging badly. We have allowed the Baby Boomers to pull us into their senescence. Our society is a languid hulk hurtling into destruction due to its sheer momentum. The cracks are starting to show. We need a new vision to get us out of this morass.

And that vision is what we were founded on. Freedom. Freedom from the shackles of burdensome government. Freedom from our old racial and bigoted ways. Freedom from the sins of our forefathers and a chance to start anew. Freedom.

A Change Is Gonna Come

keep-calm-and-join-the-revolution-8We are in the middle of a revolution, and some people are only starting to become aware of it. I am not sure exactly how long it has been going on but the most obvious changes started occurring after 9/11. There has been a subtle but real change in the perception of our institutions – governmental, financial, educational, and now in medicine.

There has been a cheapening of the value of our institutions, and it comes from within. Throughout these systems employees and civil servants have stopped taking their roles as seriously as in years past. The primary motivation has shifted from doing a good job to ‘whats in it for me?’. It has affected our politicians, our police, our teachers, our bankers, and our doctors.

We have allowed our institutions to run out of control, and now, due to sheer momentum, we cannot stop them as they barrel ahead and destroy our society. This is not falling along traditional left-right lines – while the roots go long back it came to life with George Bush’s ‘Compassionate Conservatism’ and took shape under the guise of anti-terror activities with the Patriot Act. This sickness has now run rampant under Obama’s non-leadership and inaction from the Department of Justice.

What am I talking about? I will give you a few examples for starters, but if you look around you will find many more. Our civilization has passed its freshness date and is rotting before us. Anyone who wants to know why Donald Trump is the Republican nominee should read on. The same phenomenon is happening in Europe but with a different flavor, and the Brexit vote is the proof of the pudding.

Education:

http://www.dailyinfographic.com/student-loan-debt-americas-next-bubble-to-burst
Click on image for full details. Source: http://www.dailyinfographic.com/student-loan-debt-americas-next-bubble-to-burst

The most obvious problem is in the college system, which has become an absurdity, although it has started trickling through elementary and high school education as well. Students used to live in modest accommodations and be happy about it. Professors ran the colleges and a few administrators were around to help sort out the details of payment, scheduling, housing and other such things that supported the primary goal of the college which was education.

But over the past thirty years or so things have changed a lot. A few administrators hired a few more administrators and the bureaucracy has built itself into a monstrosity along the way. Now college dorms model four star hotels with all the amenities included, and administrators outnumber professors. The Waldorf-Astoria is being made into condos, but they will have to compete with the new dorm at Columbia, which will be bought by a Saudi prince. The old phys-ed building has become a glittering ‘recreational facility’ complete with indoor running tracks, pools, hot tubs, and day spas. Colleges offer ‘extended learning’ courses which are essentially business workshops, all with the goal of bringing more money to the institution. I wonder if I should go through the local university concierge to score front row seats to see Ariana Grande? Tuition has gone through the roof and is beyond the ability of the vast majority of people to pay – but that is not a problem because the government will happily give students loans to help the money rain, through a thoroughly corrupt student loan system run by the ‘representatives’ who set it all up. At the end of the day when the loans go into default, who will end up paying for it all? The American taxpayer.

And we haven’t even gotten into what is being taught at these ‘schools’ today. Garbage non-sciences (social science is an oxymoron) like gender studies, African-American studies, and purple-New-Guinean-ethno-cocksucking-studies are treated as real majors instead of being recognized as grievance politics. Anyone outside the progressive narrative is derided and outcast. Instead of real debate we have ‘safe spaces’. I want to know when the book burnings begin, or in this modern age will it be an NSA led mass deletion of PDFs?

And nobody cares. The professors don’t care because they are too busy trying to keep their jobs, and they mostly agree with the leftist agenda. The administrators don’t care because they don’t even see a problem. And the regulators don’t care because they are getting rich off it all.

Police/Law Enforcement:
downloadLocal law enforcement has gone from protecting and serving to taking a slice of the pie. Federal grants have allowed even small towns to develop SWAT teams which go on drug raids killing ninety-year-old grandmas. Why the hell does East Podunkville, Alabama need an armored personnel carrier? The police seize money and cars under the ‘suspicion’ of illegal activity and it all goes into their own coffers. Try to get it back and it’ll cost you ten times more than it is worth in lawyer’s fees. Prosecutors try to make a name for themselves by being ‘tough on crime’ and end up labelling teenage hookups as ‘sex-offences’ which carry lifelong consequences. The ‘War on Drugs’ is a failed forty year experiment that has made felons of the majority of the young black population that hasn’t been killed in the firefight, and has created an epidemic of prescription opiate addiction.

And nobody cares. The police don’t care because they are having fun ‘playing army’ in their SWAT gear, and the money from the raids is too good. The judges and prosecutors don’t care because if it is their kid who gets picked up, a few handshakes and winks and nods over coffee will make sure the case gets dropped. And even the liberal politicians don’t care because they get their grievance politics: Black Lives Matter.

Banking/Mortgages:

Do you need a loan? You can’t have one. Oh, you have plenty of money? Then here is some more…and why don’t I give you a special deal on it, too? Just make sure you short XYZ Pharmaceutical because my friend on the inside says that the FDA is going to block them from selling their direct-to-consumer blockbuster drug next month because the Phase III studies were faked.

20160530_selfhelp_0
source: http://www.zerohedge.com/news/2016-05-30/here-we-go-again-wells-fargo-trying-give-mortgages-low-income-debt-heavy-millennials

Actually, I lied, I will give you a loan. A great big one. I know you won’t ever be able to pay this back, given your salary, but I get a big commission off this, and if I can finalize twenty more this month I’ll get a bonus to help pay off my boat. Gotta keep my buddy in construction busy, too. Where is your McMansion? East Podunkville? That’s OK because the governor is getting a kickback for approving a new eighteen lane highway out that way. He told me that directly from his office over the phone while he was getting his Johnson serviced by his secretary. Her cousin made a fortune from the illegal casino he was running to help pay for the campaign expenses.

And nobody cares. Nobody cares because I’ve got mine – don’t you have yours?

Medicine:

bbgwaldorfastoria03

The hospital just built a new wing where the patient suites have hardwood floors, microwaves, and wide screen TVs. The contractor who built it had a delay because he got tied up installing gold faucets into the Columbia dorm room for a Saudi prince. The hospitals are now run by administrators whose main task is to protect the system from liability. Doctors have been turned into data entry clerks to ensure that the hospital gets paid appropriately by the government and ‘insurance’ companies. That twenty-year-old computer on the ward is good enough to put data into the forms because the administration has put blocking software on it to make sure that you can’t get to Google or some other nefarious unsafe site on the interwebs. Outdated technology is OK because…HIPPA, even though nobody has actually read the law. And by the way, doctor, you are out of compliance because you haven’t paid your annual maintenance of certification fees. Here is your pile of mail for the day which includes twenty offers for ‘educational programs’ to help you get your MOC compliance points, and if you’ll just send your specialty society $2500 we’ll even give you a FREE iPad to review the material on. But make sure you are up to date on your dues, because the rates are higher for non-members.

And nobody cares. Well actually some people care. And that is why we are about to undergo a revolution. Will it be bloody or messy? I hope not. But Baby, pack your clothes with mine

I feel a change comin’ on…

 

Muslim reform

In a recent editorial in the Washington Post, Glenn Greenwald says that the FBI was right not to arrest Omar Mateen before the shooting. I agree with his point of view in general, because I believe that our freedoms are more important than absolute security, which cannot ever truly be achieved. I also believe that we have long ago passed the point of diminishing returns, where increasing authoritarianism – and simultaneous loss of freedom – leads to increased security. We are giving up far more than we are gaining.

That being said, I would like to return to the analogy that Greenwald uses in his article, that of fatal car accidents. As he rightfully states, a large number of people die each year in fatal car accidents, and we recognize that this is “the worthwhile cost paid in exchange for the benefits of efficient auto travel and affordable cars”. We do a deadly calculation to decide that it would not be desirable to put in place severely restrictive speed limits (worse than they are now), excess traffic lights and stop signs (more than the excess we already have), and insane amounts of padding inside our cars. As he states, “we accept that some deaths are inevitable” and try to find a balance between convenience and accessibility versus fatal accidents.

car accident

However, if in doing this calculation we discovered that the large majority of fatal accidents were caused by one particular make of car, and that particular car maker was at best ambivalent and at worst deliberately making cars that would cause fatal accidents, we would not stand by and let that car maker continue to put more cars on the road. We would demand that car maker to have a recall to fix their defective cars and to put in place design changes to assure that defective cars would not continue to be put on the market.

mohammedThis is the situation we are in with Islam. While most Muslims are law-abiding and peace loving, Muslims are carrying out the vast majority of terrorist actions. And because the Islamic faith has not undergone a reformation, most Muslims living in the West are in a state of cognitive dissonance, where the demands of their faith’s sharia law conflict with the human laws and society in which they live.

Therefore, while the vast majority of Muslims are shocked and horrified by the actions of a small number of people of their faith, the demands of sharia and their cognitive dissonance prevent them from actively speaking out against these actions and demanding change within the religion. There is likely a proportion of these Muslims that are secretly pleased by the radical actions of their brethren, because this subtle backing, whether conscious or unconscious, helps to relieve the cognitive dissonance.

So what is to be done? Leaders in the West, and people in general, must push Muslims to demand a reform within their religion. The outdated and outmoded parts of their religion that push for the suppression, diminishing, and even death of women, homosexuals, and unbelievers must be condemned and declared no longer essential parts of the religion. If we are going to live and thrive together, we must find common agreement on these basic tenets.

Empty rhetoric

AP_obama_ml_160518_12x5_1600

As the fallout of the most recent mass shooting continues I have to say that I was disappointed with the president’s response to the event. Once again he went into containment mode and set up straw man arguments instead of facing the truth.

The truth is that radical Islam is destructive. And I will take it further to say that Islam in general is destructive because Muslims have not had a reformation.

The bloody histories of the major religions basically boil down to the fact that some people want to tell other people how they should live. I am not interested in debating whether or not there is a god or which one is the right god in this discussion. Despite its bloody history, Christianity has undergone reformation, and, leaving aside fringe sects, the mainstream of the religion today –  whether Protestant or Catholic – can agree that the message of Jesus is that we should love and respect each other. The average Christian in the west can live peacefully because the laws of the state do not conflict with the rules set by the religion. Spreading the word in modern Christianity is a message of inclusion and welcoming, and as for unbelievers, we will pray for them, not kill them.

This is not the main message of Islam today. starandcrescentThere is no modernity in Islam. The problem is sharia. This is the religious law that supersedes human law. The average Muslim in the West is caught in a dilemma because their religious laws often conflict with the norms of society. These norms include women going to school and driving cars – dangerous things indeed.

So what is an average Muslim to do in the West? Succumb to the norms – send their daughters to school and let the infidels live the way they want? This is what many peace-loving and law-abiding Muslims do, but because Islam has not had a reformation they are being ‘bad Muslims’ by doing this.

No, a ‘good Muslim’, following sharia, would instead be trying to change the norms of the society that they live in. A good Muslim would be working to bring sharia law to the whole world. This is the stated goal of ISIS (or ISIL, as Obama stubbornly continues to call it).

So we in the modern western world have a choice. Do we want to agree to live under sharia law or do we insist that Islam reform itself to the modern world? Of course we must choose the side of reform, unless we want to throw away all of modern science and humanity. Unfortunately, this cannot be done from outside – it must come from Muslim leaders. They must stand up themselves and denounce the outdated and outmoded standards of the seventh century. There must be a full reformation in which the average Muslim living in the modern west can live in complete harmony with the human laws.

How likely is this to happen? Doubtful, given the power and ego that drives the Islamic hierarchy. We need a modern day equivalent of Jesus’ take down of the self-righteous rule-following Pharisees. But this will never happen with the current glad-handing attitude of “can we all get along?”

This is precisely why we have the rise of a man like Donald Trump, who for all his faults at least tries to speak his mind. He is hitting a nerve when he says that we need to figure out what is going on with Muslims, and despite the hysteria in the media it is not about race, it is about sharia.

What Obama does not get is that you can be right and still lose the argument. It is a frustrating position to be in, as I know from personal the_amateur2experience. It is not enough to be right with the facts. You have to be persuasive enough to sell your version of the world and events.

Obama came into office puffed up by the media as the great savior for our country, but he had an old school ideology that just does not work. Now after filling vast balloons with his rhetoric we find that his entire presidency is hollow and the promises – and threats – are empty.

High Noon

I recently watched the classic Western movie High_Noon_posterHigh Noon (1952). Despite my love for movies and an extensive collection, this was the first time that I had seen this particular film. It is amazing, and sometimes creepy, how the same themes repeat themselves throughout history, and how well old stories relate to current events.

For anyone who does not know the story, in the movie we have our protagonist, Will Kane, portrayed by Gary Cooper, who is the retiring marshal in the small town of Hadleyville in the New Mexico territory. He has just married Amy (Grace Kelly) a pacifist Quaker and is on his way out of town with his new bride when he gets word that a criminal he worked hard to put away, Frank Miller, has been freed on a technicality and is on his way back to town. Kane knows that Miller will terrorize the town and will likely come after him, as he had previously threatened to do. Feeling the duty of his position despite just retiring, Kane returns to the town to face Miller.

Kane seeks to put together a posse to stop Miller and his gang, but it quickly becomes apparent that this will not be easy. He apparently has been a tough marshal and has made as many enemies as friends in the town. His old deputy Pell (Lloyd Bridges) who Kane did not think was ready to be the new marshal tries to bribe Kane into giving him the marshal position, and when Kane refuses he quits in anger. The people in the saloon want nothing to do with him. The innkeeper is cheering against him. His previous allies are scared of Miller and fear for their lives. His friend Sam Fuller (Harry Morgan) pretends that he is not home and sends his wife to the door to lie to Kane, saying he is not there. The previous marshal says he is too old to fight and has arthritis. The people in the church think that if Kane will just leave town the problem may simmer down and somehow go away. The pastor claims piety and sets himself above the fray, saying he condemns all violence, although it is clear he knows that Kane is right.

All this time the clock is ticking towards noon. The train-whistle blows as Miller arrives and comes with his gang into town. Kane is left to fight by himself. He kills several gang members before being wounded himself. His new wife, who had been planning to leave on the train, runs back to find him and despite her pacifism, shoots another gang member. Miller takes her hostage, but she distracts him long enough for Kane to shoot him dead.

Finally the townspeople come out to find the gang and Miller dead. Kane throws his badge in the dirt and leaves with Amy as the credits roll.

So what does all of this have to do with our situation today? The parallels are obvious, if you choose to see them. Doctors are the townspeople. The ABIM/ABMS represent Frank Miller and the gang who have taken advantage of the townspeople (MOC). There are a few ‘Will Kanes’ out there like Wes Fisher who have taken a stand against the criminal wrong.

The question is who are you? Are you one of the people in the saloon who are siding with Miller’s gang? Are you a churchgoer who just wants Kane to go away and is hoping that Miller won’t continue to take advantage of the town? Are you the pastor who views himself above the fight and wants to pretend that he can go on doing his job while ignoring the wrong he sees? You can be Sam Fuller, Harvey Pell, or any of the others who run from the fight.

gary_cooper_high_noonOr are you Gary Cooper, who despite all of the odds and the forces against him, knows right from wrong and is willing to face the bad guys?

Your choice.

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.

 

Why fight this MOC fight?

Doctors everywhere, I implore you. I know you – I am one of you – and I know your nature. We want to soothe, to placate, to moderate pain.

This current MOC fight is anathema to many of you. In many of your 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. Indulge my extemporation, so that I may show you why this is critical to our future.

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

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? This is not a money fight (we will discuss this later). This 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 you as their doctor, and they are able to ask questions to proscam-alert-1024x788be 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, but what they are implying is that you need their help to prove that you know anything. They are using your inner fears to their advantage. I can tell you with certainty, 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 it is 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 only 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 old 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 real obscenity today is the ABMS/ABIM system.

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 to pay for their own salaries. 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 are filleting us to obtain their seven figure salaries. I wonder how often they take call.

ACT on MOC

Physicians everywhere: You are good people, but you are doing evil by your complacency.

I am writing this to every physician who is frustrated with the certification system that we have in place and that is becoming increasingly encoded into our laws. We have reached a crossroads in the evolution of health care in America. We, as physicians, have been under assault literally for decades.

We have suffered degradations and loss of prestige as an army of administrators has constructed a fortress of policy around the hospitals and issued ‘guidelines’ which now are treated as treatment mandates for our patients. And, I am very sorry to say, many of us have been complicit in this tragedy.

Some physicians have been overtly complicit by taking non-practicing administrative positions and dictating not only how we should care for our patients, but also implying that we are not competent to do so. Many others have been silently complicit, as we have sat by and let the rot set in. As the great theologian and anti-Nazi dissident Dietrich Bonhoeffer said “Silence in the face of evil is itself evil: God will not hold us guiltless. Not to speak is to speak. Not to act is to act.”

We are now subjected to MOC in order to somehow prove ourselves, when by the very act of treating our patients and looking up information to do so shows that we are dedicated to maintaining our profession. Our profession: that is what is being called into doubt and what many bureaucrats would like to do away with. Instead of dedicated professionals seeking out the best treatments for our patients, they would prefer us to be interchangeable widgets.

Enough! It is time for ACTION.

Our leaders have abandoned us, and it is not enough to moan and complain to your colleagues. I have faith that you will continue to keep your knowledge up to date, but it is time to STOP ALL MOC ACTIVITY. DO NOT PAY ANOTHER PENNY TO THE ABMS, ABIM, or whatever specialty board you fall under.

CALL the hospital executives. ASK about the bylaws. PROPOSE changes to any language regarding maintenance of certification, and make sure the NBPAS is included as an acceptable alternative. DEMAND that these things be discussed at the hospital board meetings.

To anyone who is grandfathered in, or beyond the last needed certification, you are HURTING MEDICINE if you do not act. You need to help the people behind you who may be taking care of you when you are sick and dying.

Nelson Mandela said “We fought injustice wherever we found it, no matter how large, or how small, and we fought injustice to preserve our own humanity.” This is precisely how we need to shape our fight.

We must take action. Signing petitions is not enough. You should call your hospital administrators on a regular basis and let them know that the physicians are not happy.

Burnout is at an all-time high, and good men and women are leaving the field of medicine in record numbers. The surveys show that it is bureaucracy and maintenance of certification that is driving good people away. We must put a stop to this. Do not hang your head and say that the fight is lost, because the very future of American medicine is at stake.

The administrators of every hospital should be harassed until every single hospital in this country accepts alternate board certification rather than the ABMS monopoly.

Be brave and act boldly. I will leave you with a last quote to remember when you have doubts. “You should never let your fears prevent you from doing what you know is right.” – Aung San Suu Kyi

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.