Monday, July 28, 2008

Scientists Report 30% of U.S. Adults are Disabled; Other 70% Exhausted

This is a perfect example of the reason I view "Evidence-based medicine" with a suspicious eye. The first reaction is one of interested surprise - "What? 3 out of 10? Amazing! I never would have thought..."

For me at least, there is a second thought process that begins to form when I hear these seemingly unbelievable reports: I begin to assess whether that information is consistent with common sense. Those who preach the religion of Evidence would call that inappropriate, unscientific, or even "allegorical" (that is the new term for idolatry in the Church of Evidence).

Think about it. How many people do you know? How many people are you in contact with? Would you say that 30% of them are "disabled" in some way? I know literally hundreds of people as a result of my work as a doctor. There is no way that 3 out of 10 of them are disabled.

So, then, what does this mean? Am I horribly mistaken? Is there a vast unknown number of Americans with disabilities out there? Have I simply missed them somehow? Or has some sort of error been made in this study?

Errors occur from time to time, and are dealt with by the scientific method itself. Unless of course, the study does not lend itself to scientific methodology. Errors can be of basically two types - (a) errors in data collection and (b) errors in conclusions regarding the data. At the very least, I believe the author of this study is guilty of scientific error. Fortunately for her, her study can not be subjected to scientific scrutiny. Her interpretations of the data indicate that there is something missing - some piece of the puzzle undefined. So much so that a dedicated physician, diligently attempting to find how this study might impact his practice feels left out of the inside joke. So I continue digging...

The author is Barbara M. Altman, Ph.D. A former employee of the CDC's National Center for Health Statistics, Dr. Altman, a psychologist by training, has a long history of research dealing with the disabled. She seems especially interested in the relationship between disability and occupations. In fact, she seems to be a bit of a revolutionary in this field. She supports a new and controversial definition for disability that, as the review of her textbook puts it, "focuses attention on the dual themes of theory and methodology that must form a basis for studies of impairment and disability". It goes on to describe the general aim of the book:

"Issues discussed include: critiques of current concepts of disability; the fit between sociological role theory and the concept of disability; the operationalization of different definitions of disability; conducting surveys with people with impairments; the reliability and utility of several qualitative research methodologies as applied to impairment and disability. Overall, the papers in this volume represent the beginning of a resurgence of interest in social science theories and methodologies within the study of impairment and disability".

Allow me, if you will, to define this for those of you as-yet untrained in the language of Psychotripe. Dr. Altman and her co-editor wish to redefine disability. No longer is it merely the (they would say seriously inadequate) definition which deals with concrete, objective, verifiable facts of inability to perform a certain task. Now this highly-charged social phenomenon of disability is placed into the nebulous universe of the psychologist, where definitions are impossible because nothing has actual meaning. If you read the methodology for the study, you find that Dr. Altman unilaterally uses the broadest possible sense of the term "disability". In her world, disability includes "feelings that interfere with productive work". Under this ridiculous definition, I and the ever-diminishing number of us who actually get up every morning and go to work and make a living are clearly, perhaps permanently, disabled.

Here is the problem. It is fine if Dr. Altman wishes to destroy any useful meaning for the term "disability". In fact, I support her right to live in a self-made universe without meaningful definitions. That will not be enough for Dr. Altman, however. As evidenced by her much-publicized recent study, this will grease the skids for vast increases in tax monies spent to care for this new onslaught of the "disabled". Those of us who are too busy paying for all those leeching off the system already will once again be harnessed with a new yoke.

If we are going to use "Evidence-Based Medicine" as the new standard for practice, I demand that we at least exercise some controls on what constitutes evidence. I barely scratched the surface of this article and found what appears to be a deep, dark, festering core of liberal social engineering, propaganda, and dishonesty. How many other "studies" could be similarly debunked?

Sunday, July 27, 2008

Well played, Montezuma. Well played.

In the not-so-stunning latest chapter in the Salmonella saintpaul scare, the FDA announced Friday that it appears that food grown in the United States has been given the all-clear. Jalapeno and serrano peppers from Mexico seem to be the culprits. At latest count, over between 1500 and 2000 U.S. citizens had been made ill by the peppers.

Where is the outrage? Is this the price of our new global economy? Are we to get used to the fact that in order to bring greater prosperity to our hostile neighbor to the south, we may all get an entirely preventable illness at some point? Are our children to bear the burden of these slip-ups in food security? And what is the point of the millions of tax dollars we spend annually for the FDA to exercise draconian tactics on our own U.S. food companies if we are allowing in human-waste-contaminated food by the truckload across the Mexican border?

I have almost grown accustomed to our government's apparent lack of motivation to do their Constitutional duty to protect us from the human invasion from the south. Now, it appears we have conclusive proof that their typical sleeping at the switch has cost us even more unnecessary suffering.

Shockingly, the New England Journal of Medicine is silent. They and the rest of their liberal egotist brethren are too consumed with their crusade against legal, responsible gun ownership to pay attention to the very real public health threat posed by this breach in our food security.

Here's the article, if you care to become further enraged...

Friday, July 18, 2008

Beware of Politicians Bearing Gifts

I just read an article on that started my "Spider-sense tingling". I have an almost visceral mistrust of people who try to bribe you, and this seems to fall into that category. See what you think...

The part I like the best is the following:

There are 4.4 billion prescriptions written annually in the United States.

The National ePrescribing Patient Safety Initiative, a coalition of health care and technology companies including Dell, Aetna, Microsoft, Google and WellPoint, has offered to provide e-prescribing software from Allscripts to any doctor for free.

On July 1, the two biggest e-prescribing networks announced that they were merging to form a single, secure, nationwide network for e-prescriptions and exchanging health data.

RxHub, a joint-venture of pharmacy-benefit managers CVS Caremark, Express Scripts and Medco Health Solutions, joined forces with SureScripts, a private company formed by the National Association of Chain Drug Stores and the National Community Pharmacists Association.

"We're really focused on seeing how we can help the market get to the elimination of the paper prescription pad," said Rick Ratliff, co-CEO of the new SureScripts-RxHub.

Uhhh...Why? And don't try to tell me that the largest drug stores, the largest medicine shipping company, and the entire computer industry are in this unholy alliance just for patient advocacy. There are billions to be made if we sheep will just fall in line. And what better way to make that happen than to use everyone's favorite bait - money?

The really hilarious bit, however, is that there is no better demonstration of just how far the medical profession has fallen than to see just how little people are willing to use for attempting to bribe us. I mean, seriously. Why don't you just spit on us while we're down. What are we, 1940s bellhops? "Hey, guys...uh...we'd really like you to buy all this new equipment. Not sure about it, huh? Well...uh...we have a couple of friends that I think might be able to talk some sense into you. Say hello to Abe Lincoln...and this is his friend George Washington."

This reminds me of an old story I heard once. Back in the day, in our recent agrarian past, everyone used mules or draft horses to plow and cultivate their fields. Eventually, someone invented the tractor. It was much more productive...when it worked. As someone who has used tractors, I can tell you first hand that you spend about as much time repairing them as using them. Anyway, the tractor manufacturers realized that they had a problem. If they introduced the tractors slowly and word got around that the tractors weren't the miraculous invention they'd been billed as, then farmers might just go back to using their well-trained and well-seasoned mules. No, that wouldn't have worked. They'd have to master the market in one explosive instant.

So they made the farmers an offer they couldn't refuse. They made even trades. Tractors for the farmers' mules, draft horses, donkeys...pretty much anything that'd pull a plow. Then they killed them. They killed them all. They buried them in mass graves. An entire generation of trained farm animals destroyed - animal genocide. Now there was no going back. They could have given the tractors away for free, for that matter. They would have a hundred generations of tractor-buying rubes to make their money back.

True story? I don't know. But it wouldn't surprise me. Caveat emptor, it's been said. I guess I'm just overly apocalyptic in my thinking, but once there are no more prescription pads, then we'll all be at the mercy of whoever sells the prescription-writing-machine.

As for me, they can have my prescription pad when they pry it from my cold, dead fingers. Or when they whip out "Andrew Jackson" to convince me.

Thursday, July 17, 2008

More dangerous: Guns or Doctors? The debate rages on.

I must be on the right track with this blog. MedPageToday had a survey about whether gun control is a public health issue. Shockingly, the response was overwhelmingly "No". God bless us crazy doctors. We may save the world yet. Other than that bit of good news, the article and survey were so last week.
I had a really interesting talk with a fellow physician last night at dinner. We were discussing the possibility of starting some weekend work at his clinic. I realized well into the conversation, which got really deep and intense about a lot of the things this blog is about, just how nice it is sometimes to have professional colleagues. It sort of made me feel a little better - not so isolated and alone.

Tuesday, July 15, 2008

May God Save Us from the Fury of the...Physicians?

Author Arlene Weintraub, in a June 27, 2008 article in BusinessWeek, made much of what was painted as an inappropriate relationship between some leaders of a smoking cessation clinic in New Jersey and the pharmaceutical giant Pfizer, maker of the immensely popular smoking cessation drug Chantix. In the article, and in the CBS Evening News piece on the same topic, this relationship was used as an example of what was described as the larger problem of "physicians on the take" from drug manufacturers. There are a few problems with the article, and with the assumptions it hand-feeds the reader.

Most consumers and potential consumers of American Medicine are not well-versed on the true nature of pharmaceutical companies, or the nature of the relationship between American clinicians and those companies - a fact that Ms. Weintraub takes full advantage of in her article. If Ms. Weintraub's implications are to be believed, then almost every physician with a pen and a prescription pad is offered a cash reward for writing a particular medication. Let me assure you that this is not the case. I have never been offered, and would never accept, such a kickback. In fact, such things are not only immoral and unethical, but are illegal. That, however, is not what occurred in this case, despite the veiled accusations.

Smoking is a known killer. Cancer is the most feared complication of this practice, but is by no means the most common or the most deadly. Elevated blood pressure, chronic lung diseases, and cardiovascular complications dwarf cancer in terms of poor health and mortality from smoking. Until Chantix, the success rate for stopping was abysmally low - somewhere around 10-15%. Chantix doubled that rate of success. Like all medications, however, Chantix had some side effects. In the vast majority of cases, these side effects were either not present, or were mild enough to be tolerated until the completion of the course of therapy. Each patient and physician had to make a decision about the risk:benefit ratio and whether treatment with Chantix was right for them. This is the way it should be. For example, much less hot-button medications also have side effect profiles that must be considered when thinking about starting treatment. Aspirin has been known, on rare occasions, to cause life-threatening Stevens-Johnson syndrome. It would be incorrect, however, to make the statement that aspirin is an unsafe medication. In fact, it has probably saved more lives (and cured more headaches), both in its modern form and its original one - willow bark - than any other pharmaceutical.

So what about the physicians so viciously attacked in the article? Were they hired guns for Chantix, subjecting hapless patients to life-threatening complications just for their own monetary gain? Many alarmists, like Ms. Weintraub, would like us to think so. In fact, they were not paid for prescribing Chantix. They were paid, like many other physicians, to give lectures about the new pharmaceutical. This is common practice. And who better to be a spokesperson for the wildly successful medication that someone who uses more of it than almost anyone else? This was the case with the UMDNJ physician and psychologist named in the article.

Allow me to give an example a little closer to home for me personally. Almost all physicians have a personal formulary. That is, they have a group of medications that they know very well and trust. In my case, either fortunately or unfortunately, depending on your perspective, my own formulary is made up almost exclusively of medications that are now generic, meaning that no pharmaceutical company is now likely to pay for their active marketing, as they are now sort of in the "public domain" for lack of a better term. If someone approached me, however, and asked me to go on a lecture tour to talk to medical students, potential patients, and other physicians about Bactrim (trimethoprim/sulfamethoxazole), for example, I would be happy and honored to do so. I believe in Bactrim. I've seen it work time and again. I've come to trust it. I also realize that it has side effects, as do all medications, and so I have familiarized myself with these and I know what to watch for and I know when to discontinue the treatment. My time has value, though, and I would expect to be compensated for the time away from my office I had to spend giving those lectures. This is the reality of the situation in which the New Jersey physicians found themselves.

There was nothing remotely inappropriate or unethical about what they did. The only mistake they made - and it is a mistake that most of us are guilty of - is underestimating the lengths to which some will go to demonize physicians and pharmaceutical companies in this new, highly-charged environment. The suggestion that somehow they placed their own avarice ahead of the welfare of their patients is more than simply wrong. It is slanderous. I do not know what agenda is being pushed by the author of this article. I have to assume that in some way, the pot is guilty of calling the kettle black.
It would be interesting if she and the other alarmist journalists were held to the same level of scrutiny concerning any possible conflicts of interest they might have. I would have to assume that Ms. Weintraub benefited in some way by writing it.

There is another, more troubling aspect to this new poorly-founded alarmism. If one single person uses this ridiculous, unscientific, and misleading article as a reason to resist treatment by the best available medication for smoking cessation, and that person subsequently dies from a smoking-related disease that might have been avoided by the use of Chantix, then Ms. Weintraub and her conspirators at CBS News carry the guilt that has traditionally been borne by us physicians alone. When similar articles were written about Celebrex (celecoxib), people discontinued its use out of the fear that ensued, and resumed more traditional anti-inflammatory medications. Those older medications were (and are) felt to be more dangerous than Celebrex ever was. I have often wondered how many people have suffered or died needlessly as a result.

It is the most serious sort of business to be responsible for people's lives. That is why it is difficult to become a doctor. That is why we take an oath. And, it is likely, that is why people like Ms. Weintraub work tirelessly to lay us low - they do not believe in the kind of trust or faith we try so desperately to be worthy of. As a result, the uninformed die or are made ill. Ms. Weintraub will not be to blame - those who shout "Fire!" never are these days. As usual, physicians and the companies that make the medications we all depend on will take the blame, and we will continue to play foolishly into the hands of those who are blind leading the blind.

Thursday, July 10, 2008

Our New England Schoolmarms Strike Again

In one of the few rulings by the Supreme Court that has made sense in recent memory, the self-proclaimed Third Branch of American Government ruled last week that a local ban on the keeping and bearing of firearms by the law-abiding, tax-paying residents of the District of Columbia was, in fact, unconstitutional. Duh. Not surprisingly, the academic medical community, much too busy to work to save American Healthcare from destruction by the insurance industry, and complicit in its destruction by the forces of socialism, came out against the ruling in an editorial in the most recent New England Journal of Medicine.

If the sentiments expressed in the article were not so deeply-felt and so dangerous to our way of life, they would be almost laughable. It betrays the Technocratic mindset of so many in power in today's academic institutions - that somehow it is up to them to save us from ourselves. Epidemiological experiment? Hilarious. Liberty must be so incredibly irritating to these braniacs. It is so...untidy. Their silence was deafening as we the people (apparently their helpless, hapless wards) were subjected to other "epidemiological experiments" at the hands of the Highest Court - "Law enforcement officials can not be held responsible for defending people in their homes"; "Your personal property can be seized through imminent domain not only for the good of a community but also for the good of a more profitable tenant".

Where is the outrage at the New England Journal when people are attacked and out-gunned by criminals in their own homes? Where is their scientific input on the true causes of inner city violence, crime, and illiteracy - namely, the irresponsibility and even participation of those communities in those problems? Where is their backing of Bill Cosby when he addresses matters such as these? There is absolutely no doubt that those problems are at the root of the issue, but still the New England Journal remains silent. Well, silent at least until something occurs that offends them personally. Their fear of law-abiding citizens owning the firearms to protect themselves is legendary. They've always sided with the criminals in that regard. In their world, the law-abiding, ignorant sheep are supposed to look to the increasingly impotent government for everything, and remain victims of circumstance. This ruling was a slap in the face.

Their statement shows how utterly despicable and irresponsible they have become. They care nothing for the residents of Washington D.C., or any other city, town, or rural area in the country. If they did, they would use their power as the leadership of a (previously) highly-respected medical publication to educate our most vulnerable citizens about how to work and fight their way out of illness. They instead use their power to push their ultra-liberal agenda using the mantle of medical expertise to hide their true intentions. Their ridiculous opinion is thus given artificial credibility. What cowards. They know that their beliefs are losing traction, so they must package them as the "advice of the experts".

The New England Journal of Medicine thus continues to lose much of its credibility, hijacked, like so many of the great institutions of our nation by the socialist parentalism of the academic community. They are not welcome to speak for me. They should be ashamed.

Wednesday, July 9, 2008

Delayed Gratification - Numbers Don't Lie

I'm a little bitter. I admit that. It is difficult to be in my mid-thirties and still struggling, still living not unlike a college student. I am tired of Ramen, you know? To make it worse, I am constantly confronted with those who chose other career fields and whose lives seem so much better than mine. I see trips to Europe, new cars, big houses - all for the people that, according to our guidance counselors - "weren't going to be able to make it without a college education". I know how this sounds - jealous. Guilty as charged, I guess, but more than anything - disappointed. I'm disappointed that my work seems like it is never going to pay off. I'm disappointed that the future seems to look more bleak all the time. Most of all, I am disappointed that people are so wrong and bitter toward me for what they apparently imagine my life to be like.

Doctors are all super-wealthy. Isn't that the common notion? I suppose all professions suffer at least to some degree from the false perceptions of those outside the loop. Medicine is no exception. At least once each week, a patient that is either bitter enough or socially clueless enough to be completely honest about his feelings accuses me (usually with veiled sarcasm or in the guise of a jest) of doing extremely well for myself in my chosen career field.

Physicians have traditionally felt uncomfortable addressing this subject. I think there are a few reasons for this. One reason I feel uneasy denying this misconception is that I don't want to be further accused of whining. I guess I feel like "If this guy already thinks I'm a spoiled doctor, it'll just make things worse if he thinks I am also ungrateful for the giant imaginary fortune I am amassing". The second thought that usually creeps into my mind is the thought that if (a) he thinks all good doctors are filthy rich, and (b) I admit to continuing to live very modestly, then (c) I must be a pretty lousy doctor. Suspicion of false riches is bad enough - an accusation of professional failure is downright intolerable. Finally, and most pathetically of all, I continue to hold out hope against all evidence that someday, in the distant future, I may actually begin to reap some of the rewards from the lifetime of study and hard academic work it took to become a doctor. I would hate to jinx that. Almost all doctors are at least a little superstitious.

Eventually I'd like to discuss the loss of prestige, professional pride, respect, and sanity felt by so many of my peers. Today, though, I would like to partially tackle the false rumor that today's family doctors make a fortune.

Insurance is the obvious target, and probably is, in fact, the biggest contributor to the decline. They have made a very comfortable profit for years by frightening people into paying a middle-man for a vital service. Following Medicare's lead, they have worked to prevent physicians from working together to bargain for better rates while doing the exact same thing themselves, creating an uneven playing field. This has had a negative effect on all specialties, but has hit the already-lowest-paid primary care practitioners the hardest.

The increasing medical school debt to income ratio is another element of the decline. During a period in which medical school costs have shot up drastically, physician salaries have remained flat. For a neurosurgeon making $400K/year this is frustrating - for the primary care physician it can be devastating. It is estimated that family physicians pay up to 20% of their post-tax income for medical school loan repayment.

This amounts to a game of catch-up for the primary care doctor, with the deck stacked against him. The average starting salary for a family physician is $120,000. A salary of $120,000 seems like a fortune to a poor kid - it did to me, at least. And perhaps it would be, except for all the hands dipping into it. At a salary of $120K, the doctor is in a fairly high tax bracket, even under today's much lower taxation levels. After taxes, the physician has about $92,300 left. The typical physician owes between $150,000 to $200,000 in school debt. The payment on that debt will be approximately $1500-$2000, even with very low interest rates, and will take the doctor 15-25 years to pay off. Take home pay? Around $71,000. And we mustn't forget about malpractice insurance, which will run at least $10K/year. After all is said and done, the physician takes home about $60,000 a year - about half of what he started with. And considering that most physicians work between 50 and 60 hours a week, that comes out to just over...are you ready?...just over $21 per hour. Just over $21/hour after 11 years of education.

Compare that with a nurse, who goes to school for 2 to 4 years, and can expect to make $50/hour before taxes, a construction laborer who makes about $18-20/hour plus overtime, an get the picture. It will take the family doc in the scenario above about half his career just to catch up with the lifetime earnings of the laborer with a high school education and no school debt, who has been taking home $20-25K each year.

So please forgive me if I'm a little bitter. I had hoped that I would be able to enjoy some of the fruits of my many labors before retirement. But don't dare accuse me of being a "rich doctor". I just may hit you in the face.

Monday, July 7, 2008

Environmentalism - the Art of Compulsory Conservation

The world is a dirty, disgusting place. I become increasingly aware of that daily. My childish naivete yields to an increasing realization that it is more and more difficult to find any honor, any integrity, any transparency. I have become more suspicious and cynical. I feel that I've had to. You can't trust anything. And so, when I read this story from the Wall Street Journal about Richard Sandor, the so-called "Father of Carbon Credits", I felt that my suspicions about the Enviro-Banshees were at least partially confirmed.

Let me explain how it works, for those of you who (like me) didn't really quite get how this shell game operates. With the government's assistance, or better yet at the insistence of foreign powers (See Kyoto Treaty), arbitrary caps are set on how much carbon (in the form of CO2, especially) can be emitted by a particular company. If they fail to meet those standards, then they must buy additional carbon credits to avoid penalty - ultimately from Dr. Sandor and his cronies at the Chicago Climate Exchange. If a company does well and emits less than the standard, then they have some "carbon credits" which they can sell to a needy company to bring them into compliance. Either way, the Chicago Climate Exchange makes lots of money - either through the creation and subsequent direct sale of this new arbitrary and previously worthless currency, or through fees on the carbon trades between companies. It gets better. The caps get progressively lowered so that fewer and fewer companies are able to win, requiring them to go groveling with greater frequency to the economists, politicians, and academics at the Exchange, kissing the ring and begging enviro-indulgences. And it doesn't end in Chicago - the same bunch of mega-rich All Stars have identical trading centers across the world. Quite a racket, eh? They appear to be off to a champion start. The Exchange was opened in 2003. Dr. Richard Sandor made an estimated $260 million last year alone.

Biography of Dr. Richard Sandor:

Dr. Sandor is a recent convert to the worship of Mother Gaia, but appears to have always gravitated toward green of a different sort, at least generally. He was one of the original proponents of applying the futures market concept to interest rates. He was also instrumental in a past environmental "cap and trade" futures trading scheme similar to today's carbon trading, but during the last much over-heralded Apocalypse of the Universe, the Acid Rain scare of the 1980s.
Now I am not claiming to have any sort of special knowledge about the environment. I will tell you that as someone who is trained to read and interpret scientific studies as part of my job, I believe that there appear to be some serious flaws in the methods, results, and conclusions of those studies. The thing that bothers me about the scenario I describe above, however, is that it simply looks bad. Allow me to explain.
If a doctor accepts a pen or a dinner from a pharmaceutical representative, he is increasingly accused of being in the tank, or at least of questionable, if not unethical conduct. This is because people are very suspicious of doctors and drug companies right now. Part of that is medicine's fault for not being more critical and discerning when dealing with our partners in healthcare, the pharmaceutical companies. Part of it is the fault of over-zealous attorneys who exaggerate the problem in order to personally profit. And part of it is simply misinformation and ignorance on the part of those who make the accusations. What is the end result? I have to consider carefully how what I do with respect to pharmaceutical reps will look to the public.

I believe that there are those well-meaning souls who truly believe with every fiber of their being that our planet is perched on the edge of ruin because of man-made pollution. I respect that. I disagree, but I don't condemn them for their beliefs. But in the same way a physician has to be wary of the image he presents to the public, the growing and strengthening environmental movement should use extreme caution before making bedfellows of the kinds of people I now find are at the heart of the movement to mandate cap and trade for all industries. They, along with the ultimate self-servers, Albert Gore, Inc., are causing the environmental "Movement" to appear less of a cause and more of a cash cow for a few wealthy industrialists and Technocrats.

It is clear to me that until assurances can be made that we are not all simply being duped by Sandor's pals into funding their (and their great grandchildrens') retirements in the name of Environmental Protection, it is my duty as a responsible American and taxpayer to be resistant to the idea of making these carbon limits mandatory.

Saturday, July 5, 2008

Independence Day Self-Examination

First, I would like to wish everyone who reads my blog a very happy Independence Day. The fact that I can sit here writing my unvarnished opinion on all these matters is truly a miracle, especially when you consider the series of events that had to occur in order for this to come to be.

Consider, for a moment, what was involved in that statement, the Declaration of Independence. In fact, you don't have to look much further than the title of the document itself. What does it mean to "Declare one's Independence"? One part of it is easy - we Americans have mastered it. It means, in part, to declare that you will no longer answer to authority. The first Americans stated plainly that they would rather suffer grievous loss - even die - rather than to continue to pay homage to a distant, foreign, and almost tyrannical ruler. Amazing. This collection of farmers and merchants (actually only about one third of the total population actually supported the Revolution) declared for the first time since Spartacus that they would no longer bow to the authority of their masters. No doubt many of them assumed that they would soon share Spartacus' fate.

But there is another, often overlooked element to a declaration of one's independence. Independence does not make one free from obligation, responsibility, duty, or toil. A person who is independent is simply not dependent on another. Somehow, over time, we've forgotten this critical element of our Liberty. We are great at refusing to pay homage - we are less great at actually being self-sufficient - independent if you will.

In fact, as a people, we are more dependent than ever. We depend on others for our food, for our fuel, for our security, for our retirement needs, for our health care, and even, in some cases, for our shelter. Our most basic human needs are being assumed by the Collective. I wonder, with shame, if the men who so bravely signed a defiant letter to the most powerful king on the planet at the time could have possibly foreseen a nation so socialistic, so weak, so...well...dependent. Would they be proud of us? Would they be proud of me? Would they be proud of you? Would they even recognize us? Or would they repudiate us in disgust for our failure to keep the Revolution alive?

The Revolution continues. In truth it never really ended. Even when the seeds of our Republic were sown, there were already those who felt that without a strong central government, the sheep could not survive. But that is not what I believe. I believe that there will always be a nucleus - often quiet, as now - who believe that it is the individual's responsibility and right to be truly free and responsible. I literally hope and pray that those people will rise up and reclaim what is rightfully ours - our precious, dearly-bought, God-given Liberty.

I invite each of you to examine yourselves, as I am doing this Independence Day. I beg you to measure yourselves against the bravery, selflessness, and long-sightedness of those original Patriots who first articulated our precious beliefs. And try to make our Fathers proud of you. I pray that you all have a safe, happy, and blessed day. May God Almighty bless our dear Republic, and may we continue the Revolutionary Struggle against tyranny in all its forms. Amen.

Thursday, July 3, 2008

The Hyper-sensitive Beefcake - and Other Children's Moral Tales

I've never really liked Governor Jesse Ventura. Which is odd, because there are several things about him - at least the Cliff's notes version of him - that I should have liked. We are both veterans - he is a former Navy SEAL and I am a former Marine. We are both small-government guys. We both like underdog political candidates because we think they are, in theory, good for the system. Then I heard him on Fox News this morning on the way to work, and it all became a little more clear for me.

"Fox and Friends" is sort of a goofy show. I know that. And the blogosphere is all lit up with complaints about them. But that is just their shtick - they are silly. I can appreciate that. If Iran shot all their nukes at us, I probably wouldn't turn to Steve, Gretchen, and Brian for their reportage. But if I'm looking for something kind of light in the morning on the way to work, and still want to know the headlines, they are a good choice for me. So it is in that context that I heard the wrestler this morning.

I had always assumed that Minnesotans voted for Jesse out of a sense of their own masculine inadequacy - sort of a Stockholm syndrome thing. But it turns out from listening to him this morning that he was actually a good choice, because he may be the biggest liberal, conspiracy-theorist clown in the whole state. I was stunned to hear him suggesting 9-11-01 as an "inside job" wouldn't surprise him, and using his past as an Underwater Demolition Team (UDT) member as some sort of credential for this conclusion. His statement was that his government had lied to him so many times in the past that they'd lost all credibility.

The thing that really gave me a clue into his personality, however, was what he did next. I preface this with a little story. In the Marines, we were all brothers of a sort. And although we were supposed to refer to each other as Rank and Name (example: PFC Smith), in privacy, we would "break the rules" and call each other by our nick names. There were those, however, like a certain Sergeant I remember, who were so empty inside and so dependent on their rank for their self-worth that they required everybody to call them by their rank and name.

He (Jesse) stopped the interview to ask them, in his characteristic "'-roid voice",

"Do you call all former Governors by their first name, or is it just me?"

Are you kidding me??? Ummmm. Aren't you that jack-ass that used to dress up in a fur stole and tights and prance around before your wrestling matches? I'm sure that he would play it off as a joke, but I heard something a little too familiar in that. You might be able to fool a lot of people, JESSE, but you can't fool a fellow Vet. At least not all of us. I know where you were coming from. You are just a scared little boy in that beefy, steroid-laced body. Take away your little titles and you fall apart, don't you?

The morals of this story are (1) that you can't trust your government, no matter what, (2) that former SEALs are experts on how 100-story skyscrapers are supposed to fall, on architecture, on physics, on aerodynamics, on meteorology, and on rules of etiquette, (3) don't ever criticize a main-streamer. Not so much a free-thinker as much as just one more authoritarian schoolmarm who knows what others are supposed to do because he is a know-it-all.

Wednesday, July 2, 2008

Fun With Drug Testing, Volume 2

The call was routine. At least it should have been. You know the old saying about how "no good deed goes unpunished"? It's true. It wasn't even my case. My comrade at our other clinic was out of town, so his drug test reviews fell to me. Just my luck.

The donor had popped positive for methadone. At this point I should make a confession about something. I know less than I probably should about methadone. For example, having never prescribed it myself, I know less than some about its effects on the patient. I have to assume that it has some effect. Otherwise there would seem to be little reason for prescribing it. There are two main reasons for taking methadone - that much I do know - (1) chronic pain that is poorly-treated with more traditional narcotics, and (2) management of opiate addiction.

There are those who believe that methadone is as close to a harmless medication as exists. I have found that these people are generally the doctors who prescribe it and the patients who take it. On the other hand, the Department of Transportation forbids its use in drivers. Somewhere in the middle is the probable truth. If the reaction of the drug testing donors is any indication, however, then it probably needs to be better regulated. They display many of the same denial characteristics as those who take the drugs commonly abused. This brings me to my story.

The donor was very cordial. I went through my routine with him; he acknowledged the use of methadone. He gave me the prescription number and the name and phone number of the pharmacy where it was filled. I thanked him and hung up. Only one little red flag went up - he had a loudmouth wife in the background. She kept interrupting him and I could tell that she was disappointed with the fact that he wasn't giving me the earful that she wanted to. I called the pharmacy to verify the prescription, and it got interesting. The prescription was six months old.

Methadone should not be prescribed for "as needed" use. Whether for pain management or opiate addiction, it should be taken constantly to provide a baseline level. I called him back and asked him about this. It was really a moot point anyway. His job called for him to perform safety-sensitive duties - driving a forklift, working 50 feet or more above ground, etc. His company would not have hired him even if he was taking it appropriately. He tried to explain that he hadn't needed it for a long time, then he began having some acute knee pain so he took a couple. This may have been true - he may have been that boneheaded. Or it may have been a lie. He may have been taking illicit methadone for months. Either way it was not good. I reported the result as "negative" but recommended against his working in safety-sensitive duties.

About 30 minutes later, he called me back. Actually his wife called me back. And she was not happy. I was not able to tell her that I couldn't discuss his test results with her because she wouldn't shut up telling me what a sorry S.O.B. I was. Eventually he got back on the phone. She had apparently done a superb job of spurring him into action. He was very believable as a creep.

"I've gotta work. You are gonna cause me not to get this job. I'd looove to be sitting up there where you are, bein' the doctor, tellin' people whether they can work or not. But I'm just a construction worker, tryin' to make a livin'..." I imagined him - eight feet tall, massive, but with chronic, crippling back pain and tobacco-stained lips and hands. All the while, I could barely hear the harpie in the background.

"You tell him it's your medicine, and you can take it any way you damn well want!"

"You tell him he just cost you a job!"

"You find out where he is!"

Eventually, even I'd had enough.

"I'm not going to listen to any more of this. I didn't make your back hurt. I didn't make your knees hurt. I didn't make you take methadone. I didn't tell you to take it wrong. In fact, I didn't even call you positive, although maybe I should have. I just said it wasn't safe for you to do dangerous things while taking methadone. So I think we're done talking now."

And that was that. I'm sure that in his mind, I do have a pretty great job. If he only knew what it feels like to be in constant fear and real jeopardy of some dead-end loser taking everything my family has for something like that. I have to content myself with knowing that I may have saved his co-workers from injury due to his inattention while taking massive doses of narcotics. They will never know. All they'll think about is what a jerk the "company doctor" is the next time they lie to me and I call them on it. God, I wish I could escape this sometimes. I'd just take back the $250,000, turn in the license so dearly purchased, and stop being everybody's favorite target.

Health Care: Rights and Responsibilities - Part II

Here is a quick recap of yesterday...

The belief held by many that health care is a right is plagued by some inherent difficulties. Among these are the following:

(1) Health care is difficult to adequately define and as such is difficult to promise to anyone.

(2) Freedom from illness has not traditionally been considered a "right", as health is impossible to guarantee, even under ideal circumstances.

(4) Universal health care, like the partially-socialized plan of today, would suffer from serious inequities in the real world, with a small group paying most of the bill and a different minority reaping most of the benefit.

(5) In order to guarantee this benefit, the government would have to crush the objections of the practitioners - through force if necessary.

It is primarily for these reasons that I do not believe health care is a basic human right. Instead, I believe that it is up to each of us individually. Admittedly, my way is not perfect, and I will discuss these weaknesses of my position today.

If health care is not guaranteed, then what are we to do with the uninsured?

I admit that there is no perfect answer to this question. Almost immediately, though, I am reminded that ours is not a perfect world. Historically, though, these less fortunate citizens were cared for by private citizens and their organizations. I believe strongly that they do a better job of dealing with specific issues than the government does. The government requires, by its nature, a large beauracracy for even the smallest task. This causes the work of the government to be particularly wasteful. A church or civic organization, on the other hand, requires almost no additional manpower, is quick to act, and by acting, strengthens its community in ways the government can not hope to.

What about the children?

Children, due to their vulnerability and their inability to completely care for themselves, must be cared for by others when things go wrong. Continuing to care for all children without other resources under the age of 18, even expanding coverage for them, seems to be the right thing to do. I am a capitalist, but I am not heartless.

By requiring all able-bodied adults to care for themselves, it allows them the opportunity to make conscious decisions about their health, not just their health care. Worrying about one's health and taking proper steps to ensure it should never be the responsibility of some third party. Why would it be? This mindset betrays the worst sort of authoritarian parentalism in our government. If I were a cynic, I might think that the people who want to create this sort of dependency for even the most personal of matters are only trying to create a large segment of the population who will continue to vote for the person or the party who will continue that life-support. If I were a cynic.

The notion that the medically indigent are somehow unwitting victims of circumstance is held only by some of those who have never actually worked with this population. The generations of dependency have caused them to be completely irresponsible, in many cases, making poor lifestyle choices and further increasing their need for health care. It is a vicious cycle. They choose cigarrettes instead of medicine, then complain about the limits on the numbers of medicines they are allowed under the Program. This is ridiculous. I am exhausted, both as a hard-working taxpayer and as a physician. It is high time for us to begin the process of withdrawing benefits - not just for financial reasons, but because it is cruel to continue to convince people that the government can do a better job taking care of them than they themselves can.

Tuesday, July 1, 2008

Health Care: Rights and Responsibilities, Part I

At the heart of the current debate about health care is a fundamental, although oft-overlooked central question. Each person must answer this question carefully, because there are ramifications involved in the choice, many of which are unpleasant. The question simply put, is this:

"Is health care a right?"

In order to fully contemplate this question and formulate an individual answer, we must first examine it, dissect it, and try to truly understand what it is, exactly, that we are asserting with our answer. There are two main terms in this question, namely "health care" and "right", and we will examine them in turn.

Health care is a bit of a loaded term. It is subject to variation in definition depending on the age, race, geographical origin, language, and even life experience of its user. With such a wide range of interpretations, it is daunting to attempt to assign a value to this commodity which has been increasingly regarded as something to which all should have equal and unquestioned access. And it is this exact obscurity that fuels the continued debate about what that free access would mean, both to the recipient and to the person or people who are made responsible for the provision of that service.

There is an inherent "slippery slope" element to the definition of universal health care. Even nations with the longest history of mandating this service continue to grapple with the issue of what, exactly, constitutes the "health care" to which they assert their citizens have a "right". For example, most universal health care proponents would argue that routine obstetric care should be provided. What is less clear is whether there is an equal right to elective pregnancy termination. Similarly, although one of the commonly claimed benefits to society stemming from the provision of universal health care is the reduction in cost to society that is gained by providing previously inaccessible preventive care to the people, thereby reducing expensive management of chronic diseases. But what is society willing to do to those who knowingly reject this preventive care and opt instead through action or inaction to get what would have been a preventable disease? Will that person be removed from the rolls of the covered? That seems incredibly unlikely.

Boiled down, the basic principle behind the desire for universal health care by those who support it for the right reasons, is a genuine altruistic desire to create equity in a system that is used by so many. The unfortunate reality is that providing any need-based service is inherently inequitable. Those that use more of the services are always going to gain more, and pay less. Those that benefit the system most, by working hard, doing well for themselves, paying a much higher tax-rate, making good decisions, and taking care of themselves, will pay more and benefit less. Even among the utilizers of the system there is inequity. One need look no further than the current Medicaid system to see that there are those that overuse, even abuse the system to the detriment of both the system and to those who are more responsible users. Partial solutions to these problems have already been tried to very limited success. In Alabama, for example, in a failed attempt to save the cash-strapped system, a system of limits on numbers of visits and types and amounts of medications were put in place. This had several consequences, none of which had the desired effect. First, there were those for whom the restrictions on the numbers of medications had dire effects. It is not at all uncommon, as any family doctor or internist will tell you, for a patient to require many medications to regulate their numerous chronic health problems. The poor medical control of chronic health conditions that resulted, contributed to by the limit on the number of covered visits, caused the system to fail to do its most basic jobs - provide adequate care and reduce the cost to society from untreated patients. It is a devil's game - pay until there is no more money and nobody gets care or reduce what you will pay for and only a few get care in a system that could accurately be described as unfair.

To be sure, there are also those who support universal health care for wrong reasons. There are those who would love to be the gatekeepers between the citizens and something they need as desperately as they need health care. Only the power to regulate food and the ability to regulate energy would be greater powers, and there are some who are suggesting that too.

But what of this notion of health care as a right? What exactly constitutes a right? Who gives these rights? Should health care be considered a right?

A person, we would all agree, has a right to walk, unmolested, down a street. His right is protected by the Law, but there is no guarantee that he will, in fact, be able to make it down the street. If another person hits him with a rock, then that person has violated his rights. He is breaking the Law, along with the first man's skull. The Law may punish the second man for violating the first man's rights, but the Law can do nothing to unhit the first man, or to make it never have happened. That one is easy, but is also silly. It does demonstrate an important point, however. Whether you believe that we derive our rights from a Creator, as the founders did, or from some Universal Source otherwise undefined, or from our historical, evolutionary ability to live together in groups, the bottom line is the same. There are rights, but there are no guarantees. I have what I believe is a God-given right to live unmolested by others, work for my livelihood, start a family, raise my children, and enjoy the fruits of my labors. I have absolutely no guarantee, however, that those things will definitely happen. God, or the Universe, or evolution, or bad decisions, or plain old bad luck may prevent me or not allow me to have those things I listed. I may not be attractive to the women I like, and may stay single. Surely the need to procreate and continue our species is in the same category of importance as the need to be healthy. Strangely, however, the government has not yet promised Universal Relationships in the same way they've promised Universal Healthcare. Is not procreation a right? What about couples that remain childless, despite their best efforts? This is a devastating situation. Don't they have a right to produce children? Perhaps their fertility treatments should be fully funded as well? If not, then why not?

My point is simply this. We have a right to "pursue happiness", not a right of guaranteed happiness. Similarly, we all hope and pray that we have good health. But this good health is not a guarantee. It is a blessing, or a stroke of good luck, or good karma, or whatever you believe. It is no more government's to give than it should be theirs to take away.

What of the people who provide this health care if it is a right? If access to health care is to be guaranteed, how is it to be guaranteed? What if the health care providers refuse to work under the new circumstances? It is already clear how the government responds to the physicians that provide their services to the currently governmentally-insured. Medicare reimbursements continue to drop at the same time that costs are going up. Many physicians are opting out of Medicare for this reason. So what if the same happens on a larger scale under the Socialized System? It seems to me that if that guarantee is to be made, there are only two options for the guarantor.

They can agree to pay more under duress, in which case they are at the mercy of the health care providers. This exact problem in other countries has caused many of the governments with Universal Health care plans to literally outlaw the practice of medicine outside the government system. This is horrifying to me. Just think about what this means. The people who have made a conscious decision to seek health care they pay for themselves are prevented from doing so by the government. In this sense, the government, rather than being the vehicle by which the people are able to exercise their rights in safety, becomes a literal obstacle to the free exercise of the right to buy something you want to buy. And all because they want to be, they must be the only provider of the health care "right" if the Socialized System is to succeed.

The other option for a government faced with physician resistance is to force compliance. Once health care is promised, it must be delivered. If physicians are not willing to work for little or nothing, then perhaps they must be forced to. Compulsory service was outlawed in this country centuries ago. I pray that we are not heading down that road. Many would love to see a world in which the people who are perceived to be "rich" are brought low - made to suffer. But think about that for a moment. How many generations of gifted doctors do you think it would take for those with gifts in the medical field to choose not to enter a field in which there was a real possibility that they might be disenfranchised, or even forced to work for no profit? Those people would choose other, less dangerous work. I really can't imagine what sort of person would be attracted to a job where there was no chance of making a living. But somehow we expect this of these "physicians of the future".

For my own part, I feel that health care, like health itself, is not a right, but is instead a blessing, and one's own responsibility. I say this, fully realizing that this, too, carries with it some problems.