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.

Stop the Madness of Dietary Guidelines

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

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

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

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

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

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

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

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

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

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

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

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

And get the government out of it!

 

 

Timeline of corruption

Dr. Wes has another fantastic post with a timeline of the corruption at the American Board of Internal Medicine (ABIM).

We should keep shining the light of truth and hopefully someday we will get out of this miasma.

This will not get looked into until we have change in Washington. The Obama Department of Justice is in collusion with corruption throughout the government – just look at the IRS, never mind the ATF. It is the Chicago way. Corruption, lies, and more corruption.

There is a great movie out now (it is a foreign language film, but do not let that deter you) about how the German government and people after World War II acted as if nothing had happened. A generation of kids was raised with no knowledge of the holocaust and Nazi atrocities. It is called the Labyrinth of Lies. This is a fantastic film, and it deserves to be seen. It is also directly relevant to our government today and the lies which are destroying medicine.

The American College of Cardiology (ACC) has NOT been our friend in this, but I hope that we can change this. I confronted president-elect Rich Chazal about all of this and he says that it is “complicated”. He claims that the ACC has looked at the ABIMs books and they are “clean”.

He is either in denial about the problems or a liar. The books may look “clean” to trusting eyes, but may look entirely different to a forensic accountant.

We need an Attorney General who is willing to investigate this kind of regulatory capture and deep government corruption. I have no idea which of the candidates up for president can lead to this kind of change, but I can tell you who will not: Hillary, the Queen of Cover-up.

I don’t know where this will go, but the more stuff like this gets covered up, the more good people will be driven out of medicine.

Thank you for allowing the space to rant. The more awareness of this issue we can get, the better.

sacredcowonaspit.com

Regulatory Capture

db makes some good points about the problems in medicine today

My responses:

I would like to find anyone with half a brain in Washington and be able to strip all of this away.

1. Meaningful use – this is just silly now that most people are using EHR. I have been 100% electronic for 7 years but still do not meet “meaningful use” requirements without jumping through hoops. The government spent 40 years developing VISTA/CPRS – they should just say we all have to use that and give it to us. (it is already available in some form for free due to FOI requests)

2. Approval forms – I think I should be paid for everything I fill out. Lawyers bill for all paperwork. We should as well.

3. Prior authorization – You do of course recognize that ‘prior authorization’ is purely devised to save the insurance companies money, right? It is an entirely meaningless hoop to jump through, because the studies prove that adding hoops/regulations means that you get less of that activity. They know that a good percentage of studies will just not be done because it is too much of a hassle.

4. Billing requirements (E&M coding) was put into place to try to compensate appropriately due to complexity but it is a joke. Templates have made the notes meaningless. The only way to do away with this is to have some TRUST in the doctors. How about the old Reagan doctrine of TRUST but VERIFY. Doctors can write whatever they want in their notes to make a meaningful contribution to the care of the patient and to communicate to other doctors, like the old days. Doctors then bill at whatever level they deem fit for their services. Random audits of say 10% of the notes would be performed, and people abusing the system would be drummed out.

5. Performance measures are meaningless. Let good doctors charge more for their services. People will pay if they like their doctor. If you are a crappy doctor, people won’t pay.

6. Admission diagnosis is the dumbest thing that some hospital bean counter ever thought of. I usually admit people to the hospital because I have no idea what their diagnosis is, and I need to do some tests to figure it out.

The bottom line is that doctors have allowed business people to take over medicine. The business people were the C students when we were busting our asses and making As. Why do we let these losers come in and take over the whole show?

We have had pitiful leadership in medicine. People are too busy taking care of patients, or to scared to stick their neck out. Our “leadership” of non-practicing physicians has gotten into bed with the politicians and have gotten fat and happy sucking the teat of the government. The entire system is hopelessly corrupt. The AMA makes its money from the coding system. The ABMS/ABIM make their money making doctors jump through hoops filling out satisfaction surveys and taking tests. And now all of this is being codified by nameless and faceless bureaucrats in Washington under the aegis of MACRA.

The “SGR fix” was a scam and has taken more power away from the doctors.

The doctors have to take back the system if we are to have any hope for American medicine.

We will have to strike or revolt or something – if anyone has ideas of where to start, let me know.

ABMS is Evil Incarnate

The Maintenance of Certification (MOC) program is a money-making scheme concocted by a group of non-practicing physicians who are paying themselves high salaries and living large on the backs of working doctors. This is a corrupt system, and ethically wrong, despite the American Board of Medical Specialties (ABMS) and the American Board of Internal Medicine (ABIM) putting out press releases about the “benefits” of MOC, and the importance of having “quality” physicians.

Unfortunately, this program has now been codified into law as part of the sustainable growth rate “SGR Fix” legislation. This is crony capitalism at its worst. There are major conflicts of interest here, and the ABMS and ABIM are colluding to extort money from practicing physicians to finance their high salaries.

And exactly what are these high salaries for? These doctors do not see patients. They sit in meetings and make themselves feel important by telling other physicians what they are doing wrong.

Most working physicians are too busy to have noticed what has been happening behind their backs, but when they do see the full consequences of the current legislation there will be an uprising. We will have to wait and see the fallout of the alternative National Board of Physicians and Surgeons (NBPAS) and the ongoing Association of American Physicians and Surgeons (AAPS) lawsuit, but I hope that enough physicians wake up to what is happening before it is too late.

The ABIM has failed us, the American Medical Association (AMA) has failed us, and even the American College of Cardiology (ACC) has failed us. Richard Chazal had the gall to tell the Alabama ACC that we should be working with the ABIM/ABMS because trying to get out of their corrupt MOC schemes is “complicated”. He says that the ACC reviewed the ABIM books and they were “clean”. He also defended the ACC support for MACRA, because he said that “we needed to end SGR”. Yes, and we got a poison pill in MACRA to do it. He was too blind to see the truth. MACRA puts in place APMs – the rules have not been written yet, but essentially, the hospital/ACO will get paid, take whatever they want, and give the doctor whatever crumbs are left. If you don’t join an APM you have to demonstrate “quality” – and who gets to define that, under MACRA? the National “Quality” Foundation led by Christine Cassell, who just golden parachuted out of the lead spot at the ABIM. It is time for physicians to reclaim the doctor-patient relationship – including the documentation and payment – from all of the bureaucrats and bean counters out there, be they MDs or not.

Doomsday

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

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

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

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

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

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

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

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

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