June 10, 2019

This post began as a catharsis against the raging foolishness in our country right now. Whether you choose to read it or not is irrelevant: I still feel better ;-).


About 3 decades ago I began the not painless transition from liberal to conservative. Leftists would say I became evil, racist, and misogynistic. But a smoke-screen of ad hominem attacks does not establish truth. It’s the last refuge of the foolish, uninformed…or evil.

I grew up in New York City. The Awakening in the ‘60s (often euphemistically termed the Sexual Revolution but encompassing a much more profound societal change) occurred during my childhood, and the Vietnam War was the pivotal event of my young adulthood. I was protected from the draft by my college attendance and a high draft number, so I had only vaguely formed opinions about the war and was relatively apolitical, with most of my energy directed toward study, getting good grades, and my medical school ambitions. Still, (and I only recognized this later in life), my sole exposure was to liberal social and political views. I remember Barry Goldwater being defined as a racist and wondered how he’d managed to become a viable national political candidate. I thought little about the Constitution and I took our form of government for granted. Back then, there were no controversies about reciting the Pledge of Allegiance (except for the brief period when the phrase “under God” was stricken), and no one took the knee. The historical view of the United States as taught in grades 1 through high school was net positive. This, despite the headlines proclaiming institutionalized racism in the South almost daily during my grade school years. Though women had come a long way sociopolitically, there were still obvious barriers in the workplace at a time when a preponderance of male breadwinners, stay-at-home moms, and intact families with married couples were much more the norm.

Ironically, I heard my first conservative views after moving to another of the bluest states in the land, California. Channel flipping, I came across a relatively new (at the time) conservative radio talk show pundit by the name of Rush Limbaugh. For the first time, I heard views and political/cultural analyses that were foreign to me. The more I listened, the more a great deal of what he was saying rang true. My reaction? A combination of anxiety and fear. At the time, I was a busy, relatively apolitical physician with a young family, just trying to get through each busy day. I’d come to California with vaguely negative feelings about President Ronald Reagan, but I suspect I’d have been hard-pressed at the time to factually support them. Now, I thought, am I becoming a … Republican? It took a while to get comfortable with my new ideas, and longer to switch political parties.

It took even longer to recognize that neither political party represents me. Oh, the Republicans talk a good conservative game but their actions belie their words. Out-of-control spending, a disastrous and growing deficit, an unwillingness to fix our seriously broken immigration system, and crony capitalism speak to serious dysfunction. These failures spawned the Tea Party movement, which appears to be as effective as a garden hose on a wildfire. The Democrats are worse, supporting policies they don’t even know are disastrous (or don’t care), but at least they tow their party line. The calls for ever-increasing spending and taxation and growing government to solve all our ills, (many or most of which were spawned or nurtured by the beast they wanted to nourish) inevitably morphed into a Leftist ideology of overt support for “democratic” socialism, despite alienating swaths of their liberal supporters (at least one of which tells me no party represents him, either).

So now we’re left to see how it all plays out. A major paradigm shift is due, as foretold by prior historical cycles, and soon. We are Rome, and even those that see it are powerless to stop it. When the historical tsunami strikes, my prayers are that that high ground is not far off, and that God provides us with enough lifeboats and a safe landing zone.



May 15, 2019

I’m a “senior citizen.” From this lofty perch of advancing age I’ve had the privilege of seeing many changes, and have been hoodwinked more than once. I can’t speak with authority about eons past (although I’ve read others’ thoughts and experiences from bygone eras), but I can say that within my lifetime I’m both amazed and appalled at the efficiency and pervasiveness of an infrastructure built around the premise of disinformation.

Some of the workings of this unprecedented-in-human history digital loudspeaker are intentional, the rest a product of their own making, but it is built on a powerful communications dictum: If you repeat something often enough and loud enough, it assumes the veneer of truth.

Complicating matters, bias is difficult to perceive by the biased. And who is to determine who is biased, since they themselves may be tainted? Those truly seeking truth look for facts over feelings. But in the new digital world facts can be easily hidden like saplings in the midst of a great tropical forest (you know, the one that was “disappearing,” only it wasn’t).

Those purveying falsities or who are unwittingly or knowingly buying untruths come in three flavors: foolish, ignorant, and evil. The foolish buy without due diligence, getting secondary gains from group identity, supported by the illusion of acceptance under false premises of a greater good. They have little capacity to change. The ignorant, while similar to the foolish, could change if they took the time to inform themselves, but find it easier instead to accept the pervasive thought in the circles they routinely travel, with repetition and acceptance defining “truth.” Evil is, well … evil.

Bias is a dragon that is difficult to slay. Only the twin spears of an open mind and courage to explore new ideas can overcome it.

It’s a constant battle.


October 15, 2018

If you watch Hulu, or even if you don’t, you’ve probably heard about their original series, “The Handmaid’s Tale,” a dystopian drama about what I imagine is the Left’s vision of right-wing values carried to their logical extreme. For those unfamiliar, it’s a story centered around the main character’s struggle in a U.S. city post Crisis/Apocalypse based on a fascistic interpretation of Scripture. The secondary premise is that the vast majority of women have been rendered infertile (by a virus?) and the prime directive is to preserve the human race through enforced and highly protected procreation via the remaining fertile women. The city is run by totalitarian pseudo-religious Commanders in crisp black suits governing a cadre of red-garbed and 17th-century-hatted Handmaids subjected to ritual rape by the Commanders, to claim the babies for their blue-garbed wives. Law enforcement is maintained by public hangings and mutilation. Black-uniformed assault weapon-wielding military types are everywhere and the closest bastion of freedom lies north in, you guessed it, Canada. I’m barely touching on the brutality of the society, but you get the idea.

The series is well-written, well-acted, and expertly produced. If it weren’t for the fact that it represents a not-so-subtle tribute to Leftist foolishness, I’d have nothing bad to say about it (other than, at times, it can get a tad tedious and heavy-handed on the message side, to the detriment of plot pacing).

So now it’s time for a series characterizing the logical extension of the Left’s beliefs, right? Don’t hold your breath.

First of all, unless you’ve been hiding in a closet, the vast majority of the powers-that-be in Tinsel town are not just liberal, but full-blown leftist. Creating the mirror opposite (in truth, both sides end in fascism) of this series would be as unnatural to them as a fish walking down Hollywood Boulevard. But more importantly, there’s no need—we’ve seen their beliefs play out in real life every day: the rise and fall of the Soviet Union, the slow, steady corrosion of life in Cuba, and the dramatic fall from freedom and economic grace of Venezuela, to name just a few.

In truth, the next series, “The Left Turn into Hell,” may come, but it will be a documentary.


March 26, 2018

The current, intensified debate on managing gun violence in the wake of the tragic Parkland, Florida school mass murder has become so politicized, I felt the best way to deal with it was the same way I handled the topic that launched this blog—with fact-finding. As with the healthcare debate, the issue is thorny and complex, with everyone pointing to their favorite devil and often ignoring the others.

Like many others, after learning of the latest soul-draining tragedy, I felt compelled to reexamine my own beliefs. To be transparent, I’m a 2nd amendment supporter and enjoy target shooting and the ideal of self-defense. The more I listened to both sides, the more I recognized I didn’t have enough facts at my disposal. So what are they, really? We have to look at all the devils.

The 2nd Amendment:

For: The times are different than those of our Founding Fathers with a stable government. We have too much gun violence. Te 2nd Amendment has increased the amount of guns available (we have an estimated 300,000,000) and created a toxic “gun culture.” We have more gun murders per capita than any other country. Per the recent CDC gun research study, “The U.S. rate of firearm-related homicide is higher than that of any other industrialized country: 19.5 times higher than the rates in other high-income countries.”

Against: The Founding Fathers recognized an armed citizenry as a major bulwark against tyrannical government, having just freed themselves by dint of arms. Today, we are not immune, particularly as the size and power of government continues to grow, insinuating into more and more areas of our lives. History shows us that the first step any despotic regime takes is to disarm the populace. The number of lives saved far outweighs the number lost. That same CDC study showed, “Almost all national survey estimates indicate that defensive gun uses by victims are at least as common as offensive uses by criminals, with estimates of annual uses ranging from about 500,000 to more than 3 million per year…in the context of about 300,000 violent crimes involving firearms in 2008.” The number of gun homicides annually has been in the mid 10,000s and has been steadily declining since the 1990s. The number of suicides has been roughly a third higher, and flat.

Gun ban/confiscation:

For: Reducing the number of available weapons reduces gun and violent crime. It’s common sense, and the Australians did it in 1996 with favorable statistics. While other factors play a role, gun ownership in the U.S. is the ascendant culprit. The idea that factors such as violent gaming play a large role is unsubstantiated.

Against: The statistics regarding the Australian gun confiscation/ban do not clearly demonstrate efficacy. Per, “Australia banned certain semi-automatic, self-loading rifles and shotguns, and imposed stricter licensing and registration requirements. It also instituted a mandatory buyback program for firearms banned by the 1996 law…. In all, more than 700,000 weapons were surrendered.” Indeed, the number and rate of homicides has fallen. However, there is no consensus on whether the laws reduced homicides and gun violence and homicides (and suicides) because the decline began before the laws were enacted. In addition, the violent crime rate remained steady. Guns aren’t the problem, people are. There are already enough laws on the books. They need to be enforced. Mental health is a major issue and exposure to game violence at an early age. Mass murders have been linked to violent video games.

AR 15s/ “Assault weapons”/large capacity magazine ban:

For: No one needs these weapons for self-defense. They are over-kill, more deadly, and their availability makes it easier for the demented and criminals to commit mass murder. They should be restricted to the military and law enforcement. The Australian ban/confiscation discussed above demonstrated that while there were 13 gun massacres (defined as killing of 4 or more people at one time) in Australia in the 18 years before the laws were enacted, going forward there were no gun massacres. The U.S. has more mass shootings than anyone else. This must stop. The U.S. leads the world in per capita gun ownership and violence from mass killing.

Against: David Leyonhjelm, a Liberal Democratic Party member of the Australian parliament, wrote in a piece for the Australian Finance Review, “The full truth is that Australia’s close neighbor New Zealand – a country very similar to Australia in history, culture, and economic trends – has experienced an almost identical time period with no mass shooting events despite the ongoing widespread availability of the types of firearms Australia banned.” He also indicated that there were several mass murders by other means, principally fire. Per sources quoted by, “…the authors of studies cautioned that NFA-like [Australia-style gun control plans] wouldn’t necessarily achieve (and have not achieved) the same results in the United States, in large part because Australia’s geography makes it much easier to control the flow of arms into the country.” The statistics are overstated. Per capital mass shootings place the U.S. 6th or 11th (as of 2015).

“‘Something’ must be done”:

For: The pattern of mass killings appears to be intensifying and past responses have been inadequate.

Against: Policy is not best instituted as a visceral response to an egregious incident, as it is more likely we will enact laws that are overbearing, ineffective, and redundant. The most recent mass shooting highlighted not the absence of applicable laws but failure on many levels to enforce. It is noteworthy that the most deadly mass shooting in 2007 (Virginia Tech) involved handguns and not assault rifles (hence resulting in no political outcry against the NRA). We need to step back and see if the problem is with implementation of the laws already in place or if other causes besides the presence of guns are major contributors that have been inadequately addressed.

Potential solutions:

We all agree “something must be done.” We differ in just what that “something” is. Just as most gun control advocates are coming from a place of compassion (although some are being manipulated by groups with a larger, left-wing agenda), the same is true of most gun-rights supporters. Branding the latter as evil, uncaring about the kids, or Neanderthal is unfair and unproductive. Using kids, usually the least informed, most easily manipulated, and most motivated by “feelings” as front-men (or women) in a campaign for gun control is political and unproductive.

Enforce existing laws: Before blindly promoting more gun control laws, the laws already on the books must be widely and honestly promulgated and discussed with the general public, and the failures to enforce them also be widely publicized. This is necessary so there can be a public discussion of the processes necessary to fix this

Deal more decisively with mental illness. Gun violence restraining orders (GRVOs) should be universally instituted.

Increase our school security: Protect our schools. Get rid of the notion of “gun free zones” that only paints a target on our most vulnerable. Trained securtiy personnel and yes, willing teachers, should have the necessary tools to halt active threaths. Again, we must honestly publicize the extent to which the failure of local authorities and the FBI contributed to the recent mass killing by allowing someone who should never have been allowed to purchase any weapon to acquire the AR-15, and address this.

Do not name mass shooters in the media. There is ample evidence that these monsters are motivated by fame and publicity.

There are also some changes that are less likely to be effective but are worthy of discussion, such as raising the age of purchase of semi-automatic rifles from 19 to 21. I believe this would turn out to be largely ceremonial as the evidence cited above suggests that this will have little, if any, impact on overall gun homicide and violent crime rates. And while in theory it will make it more difficult for younger sociopaths to commit mass murder, this hasn’t been proved and the effectiveness of such a policy will likely take a very long time to assess. Against implementing this is the compelling argument that people this age are permitted to serve in the military and vote.

Also worthy of debate but much less likely to have a substantial impact is closing the widely publicized gun show “loophole.” Again, this would likely be largely ceremonial, as this mode of acquisition of weapons of mass destruction is extremely unlikely based on the statistics. However, opposition to this measure is often cited as proof that gun rights activists are blindly against what is perceived as “reasonable” gun control. It’s possible from a public perception standpoint that the benefits may outweigh the “slippery slope” concerns (not entirely unfounded in this political climate) against it.

Finally, stop the virtue-signaling. It must be recognized that measures being clamored for against the AR-15s, and semi-automatic rifles in general, will have little impact with respect to overall gun violence and homicide. If the goal is to stop mass shootings, a laudable one by any rational person’s standards, the cost to our rights and the under-publicized benefits of ownership of these weapons by law-abiding citizens, must be factored into the equation. Especially since the value of outright bans of additional classes of weapons beyond automatic is unproved and may even be detrimental. In any case, simple-minded, reflexive, “feel-good” policy-making and name-calling must stop. We shouldn’t be “shooting from the hip” on this issue.


February 11, 2018

OK, the title of this rant is an exaggeration; we haven’t been solvent in decades. Still, I’m sick and tired of hearing about the need for our ruling class to “compromise.” What it gets us is a two-year, $400 billion spending bill that increased the federal debt by more than $1 trillion. The bill passed in the Senate 71-28, with 16 Republicans and 11 Democrats voting nay. In the House it passed 167-73 (56%-43%), with 57 Republicans and 119 Democrats voting nay. Rand Paul stood up to protest, and irritated his colleagues. Per Jeff Crouere, writing in an op-ed for Townhall, “Senators of both parties were left fuming, with most of their ire directed toward Paul.”

Well, Paul, I’ll stand with you. Compromise is like telling someone who makes $80,000 and carries $100,000 of debt while spending another $100,000 per annum that he’s really got to cut his spending to $90,000—someday. But for the next couple of years, at least keep it to $110,000, okay?

Everyone agrees we should cut spending. Few believe we must actually do it. It’s too hard.

It’s easier to focus on the reputed imminent demise of the planet than imminent demise of the economy. I’ve heard the arguments that the burgeoning debt is “no big deal” and arguments that it will sort itself out (unfortunately, the living are not the ones that will be doing the sorting). Some believe this can go on forever. While I believe sane people can argue all day where the spending cuts need to occur, the idea that we can drift on into eternity borrowing, overspending and overprinting is delusional, and history bears this out (in case you haven’t noticed, we’re not speaking Latin).

It’s now clearer than ever that there exists not a progressive and a conservative party, but a more progressive and less progressive one.

The definition of insanity is doing the same think over and over again and expecting a different outcome” may be cliché, but America seems to have become yet another poster child for it.


January 14, 2018

But he or she does need your understanding.

In the course of my career I’ve seen many changes. The most alarming is physician morale. In my new, semi-retired capacity I’ve had a bit more time to spend on various medical sites that solicit physician comments on various topics, and it’s hard to miss the more pervasive mood of dissatisfaction.

I was in clinical practice for almost 40 years. Six years ago I went part-time and limited my practice to outpatient, spending the other half of my time in a capacity as a consultant/medical records reviewer for a company that provides services for hospitals and case managers helping to accurately assess the individual acuity of care that affects reimbursement. A little over a year ago I left clinical practice and continued in my part-time position. When I attended a training course for this latter vocation 6 years ago, what surprised me was the number of relatively young, “in their prime,” docs looking to join the ranks of medical reviewers, either half- or full-time. They were clearly in an advanced stage of clinical “burn-out.” Much is currently being written about this phenomenon. This, along with with my personal experiences, suggests that burn-out may be reaching epidemic proportions.

Medicine, some segments of it more than others, has always been a high-stress profession. For doctors “worth their salt,” caring for the weak and infirm carries a heavy burden of responsibility. In a bygone era, although the hours were long and the consequences of mistakes no less dire, the knowledge base and tools of the trade were less complex and dramatically inferior. Beyond certain surgeries and a limited number of marginally effective medications, much of the physician’s business was diagnosis (also more limited) and hand-holding. Today, doctors are tasked with deciding when to use, or harder still, withhold, a myriad of new, advanced techniques and therapies that are changing at an accelerating pace, in an ever older and sicker patient population. And this in the setting of an ever-changing series of guidelines intended to provide more cost-effective care. Failure, or perceived failure, is met with a much greater potential for litigation or loss of license to practice. And the government and medical boards are watching. Closely.

Doctors now have to not just certify, but continually re-certify. The process involves an ever-increasing battery of tests and requirements that many physicians feel, judging by comments I’ve seen repeated time and again, are less for the purpose of ensuring up-to-date clinical competence than generating revenue for a progressively burdensome bureaucracy.

The upshot of all this is fewer people entering primary care medicine, a looming physician shortage, and a loss of sense of medicine as a profession. This is a perfect storm at a time when Medicine has become just competent enough to manage chronic illness well enough to “squeeze every last ounce of life out of us” at great expense, in an era of burgeoning debt and aging baby-boomers.

Mid-level practitioners (nurse practitioners and physician assistants) have evolved to help fill the gap and reduce costs. While there are clearly many arenas in which this kind of help is beneficial, many specialty-based physicians (myself included) have experienced an increase in referrals from mid-levels, raising questions of just how much $$ we’re saving. It’s not unreasonable to assume that, in some circumstances, cost savings may be undercut by over- or under-diagnosis, since by necessity mid-levels have less intensive training and fewer academic requirements for entry (occasional overlap notwithstanding). I’ve worked over the years with many skilled, competent mid-levels and appreciated their help, but don’t see expanding this sector of the medical community at the expense of the physician pool as an ultimate solution.

What can we do?

In the intermediate to long term (20-40 years) many of the current problems will be solved by an evolving knowledge base and artificial intelligence. In the short term, I’m convinced we could streamline the training of physicians without compromising quality. Much of the initial 2 years of medical training could be completed in the undergraduate years (there’s been a trend toward increasing clinical exposure earlier, but not nearly as aggressively as I’d like to see). More clinical slots for interns, residents and fellows are needed. A thorough review of the government-mandated and medical board oversight and re-certification processes is in order, from the ground up. To accommodate ever-changing regulatory requirements for reporting, our EMRs (electronic medical records) have become monsters (perhaps you’ve noticed during an office visit your physician’s red, bleary eyes hardly ever meet yours any more). This will eventually be conquered by AI, but at present may be as much a problem as a solution.

Lastly, give your doctor a kindly pat on his or her back (perhaps, in this supercharged environment, a friendly smile will suffice). It will say, “I understand.”


October 9, 2017

A big story making is making the rounds that is telling about the state of our society: Dove’s apology for a “racially insensitive” ad about their product.

For those of you who haven’t seen it (it’s been removed but being shown as the centerpiece of reportage on the debacle), a black woman with a dark brown shirt (with a small bottle of Dove in the lower right corner) is shown morphing, as she removes the shirt, into a white woman with a pale tan shirt, and the effect is repeated with a third woman with dark hair and a medium complexion wearing a mid-range colored shirt. Honestly, after seeing the ad, I had to go back and recheck it online to see what all the hoopla was. So, clearly, I’m racially insensitive.

Maybe that’s not such a bad thing.

If I were racially sensitive, I’d have recognized (as I did after doing some Internet research) that there is a history of racist ads in the past with cartoons depicting black people being “washed” white with soap. In that context, I might be inclined to view this modern incarnation as more of the same.

If I were racially sensitive, I’d assume there was a conspiracy among the Dove ad committee that commissioned and approved the piece to run the risk of alienating a large swath of their consumers, both black, white and anything in-between, because of deeply ingrained racism.

When you view the world through racially sensitive lenses, it’s easy to find what you’re looking for. Unfortunately, for many, impugning racial insensitivity is tantamount to calling out bigotry. But perhaps “racial insensitivity,” for most people, is a product of the true goal: color-blindness. If you have a non-bigoted, racially insensitive person, and set this as the baseline, might that not redefine the racially sensitive person as “hypersensitive”? And does this hypersensitivity (or lack of insensitivity) unmask covert bigotry in the person crying foul? Something to think about.

Like most of us, I understand the inherent evil of racial prejudice and bigotry, but I think I’ll stick with my “insensitivity.” I understand why the makers of Dove had to go belly-up—it was the right corporate decision. But I’m not selling anything.

And when it comes to the idea that I have to look for hidden racial bias in everything, I’m not buying, either.


September 25, 2017

When you get away from the emotion, the current hoopla surrounding the mass kneeling in the NFL during the national anthem is both simple and complex.

The story, as most everyone knows, began with the Colin Kaepernick’s one-knee “salute” during the pre-game playing of the Star-Spangled Banner, purportedly in protest of social injustice by law enforcement against the black community. Since then he’s become radioactive from a business standpoint and remains a free agent. Things simmered until the president’s recent commentary that kneelers should be fired, sparking a more broad-based exercise of the right to kneel (approximately 1-in-8 players per the media). It’s not entirely clear that the new kneelers are protesting the “racist nature” of the country; many analysts feel that the ascendant motivation at this time is support of their colleagues’ right to free speech and defiance of the president.

Both sides have cogent arguments: The kneelers supporting the First Amendment, the anti-kneelers asserting that disrespecting the anthem, the flag, and the country casts aspersions on first responders and the military, and that both the manner of the protest and the venue are inappropriate.

The business leaders in the NFL don’t have the right to abridge the First Amendment, but they do have the right and responsibility to establish dress codes and rules of behavior to protect their company and brand names. In this case, to date, beyond adopting a hands-off posture on Kaepernick, they have not done so. Corporations are not ideological and have one nerve ending: money. We can expect them to sit tight and watch the bottom line.

The talking heads will take a view according to their respective ideologies. On the Today Show this morning, while host Savannah Guthrie paid lip service to the complexity of the issue, their on-line survey regarding the question of the audience’s perception of the kneelers presented the choices, “It’s their right” and “It’s disrespectful,” omitting “All of the above.” One wonders if this option even crossed their minds.

There is only one arbiter of this newest manifestation of our increasing national ideological divide: The American people. They will decide to purchase the NFL product in its current incarnation, or walk.

You get to decide.


August 7, 2017

The American public is frustrated. Congress has its lowest approval rating ever. And they just can’t seem to pass a healthcare bill. The only surprise is that anyone’s surprised, and even that should come as no surprise. Let us gaze upon the elephant(s) in the room:

First, almost everyone hates the do-nothing Congress but continues to elect the same career politicians over and over again, pointing the finger at “the other guy.”

Second, everyone wants healthcare reform unless it involves rescinding expanded benefits that the prior legislation meted out.

Third, everyone wants laws that require emergency rooms to provide urgent care irrespective insurance or ability to pay (that’s what a compassionate society does, right?) but no one wants a mandate to purchase health insurance.

Beginning to see a pattern?

Congress can’t fix a system that needs a major overhaul in both the way we think and the way we conduct business until we accept the fact that we need to overhaul the way we think and conduct business. A politician’s lifeblood is votes. Everyone accepts the need for increasing efficiencies and trimming waste and fraud in healthcare, and many embrace increasing competition in the insurance marketplace. Some are convinced a single-payer system is the answer (see below). But it will not be enough. The burgeoning ranks of the elderly infirm with fewer workers to pay for their care doom any of the current plans to failure. For any clear-thinking healthcare worker the trajectory of premiums for Obamacare was inevitable from the day of its conception. Gravity says you go down, and the laws of economics say, “You don’t get sumthin’ for nuthin’, as much as wishful thinking tries to obscure this truth. With bunsiness as usual, the many hidden taxes in Obamacare were insufficient to sustain the mandate of covering all pre-existing conditions and extending insurance for “minors” until age 26, on top of providing mandated non-essential care. And it’s only going to get worse.

What’s the answer? Health care rationing, otherwise called “death panels” by those that want to quash any reasonable discussion of the topic.

We’ve always had covert rationing (shhh!). Anyone who thinks a homeless street person gets the same level of care as a movie star or professional ballplayer (or Congressperson, for that matter) is living in a fantasy world. That being said, the excesses in the U.S. system are more enormous at all levels of care than most people realize. I will illustrate with a single example: At a recent meeting I attended there was a discussion about the suitability of placing an artificial valve in a patient that had a critical narrowing of the exit valve of the heart, otherwise known as aortic (valve) stenosis, which kills someone within 1-3 years of onset of symptoms. Until a few years ago, the only treatment was an open heart operation, but innovative minds developed a procedure to place a valve inside the old, calcified valve via an artery without surgery, known as transcatherer aortic valve replacement, or TAVR. This particular patient was in her late 60s to early 70s, had advanced alcohol-related liver disease (but was no longer drinking), and had begun to show signs of reduced blood clotting and fluid accumulation in the belly known as ascites related to her diseased liver. Although her life expectancy from the liver disease cannot be precisely predicted from the information I have, it is not unreasonable to postulate 3-5 years. Her aortic valve disease would probably kill her within 1-2. She was deemed a high risk surgical candidate so is being triaged to TAVR. It is more difficult to find the average cost of the procedure doing an Internet search than a cost-effectiveness figure ($50,000 is considered the benchmark for qualitylife-years gained, or QALY, originally based on hemodialysis figures), but $52,200 ± $28,200 is the estimate I found, representing a purported net loss for the institution (as opposed to surgical valve replacment which supports a net gain). Assuming that this patient has no complications (likely, but certainly not guaranteed), you will reduce her short term risk and improve short term quality of life significantly. However, you now have a patient with another terminal illness (end-stage liver disease) at even higher bleeding risk due to the aggressive antiplatelet drugs needed to prevent valve clots, who will likely live longer to be in and out of the hospital in her final years to palliate her progressive liver disease. (Of course, it is possible that the medications could shorten her life, as liver patients are prone to bleeding for many reasons.) Now extrapolate this example across the country and across different illnesses and medical specialties, and you’ll begin to get a sense of the magnitude of the problem.

So, are these doctors greedy, incompetent, or stupid? Absolutely not. A terminally ill patient with advanced cancer and low life expectancy would never come up for discussion. However, that large (and growing) senior population with serious chronic illnesses we’ve become so proficient at eking every last ounce of life from is a much more difficult decision for doctors. Often, they feel that societal issues should not come between the physician and the patient, and everyone is loathe to place the responsibility for these tough decisions in the hands of the government. The upshot of all this is that we’ve abdicated the responsibility to address this overtly. And no wonder: Opening oneself to the criticism of being an uncaring bean-counter is no more appealing to a physician or layperson than to a politician seeking reelection.

So what can we do?

We can set up committees made up of doctors, clergy, citizens, social workers, economists, and yes, politicians to examine clinical scenarios and/or actual patient cases and determine suitability and feasibility of a particular high-cost interventions, adding into the equation societal and fiscal constraints. (There are those that believe a single-payer system will solve the system’s ills, perhaps by overtly or covertly addressing this; I’m skeptical, but the debate is beyond the scope of this rant). This independent committee approach unburdens the caregiver of the responsibility for factoring in issues extraneous to the patient. However, this concept will not be well received. Consider the outrage engendered by recent British government intervention in its decision to prevent a high risk procedure on an infant afflicted with a congenital ailment. Although in this case I agree with the critics, as it was reported that the funding was obtained by the family from private sources, there are other high-profile examples of widespread censure of attempts to limit life-giving care in patients with poor prognosis (i.e. Karen Ann Quinlan and Terri Schiavo, to name a couple).

So what will we do?

All indications are that we will continue to posture, discuss repealing and replacing or modifying Obamacare, and either do it or not. For me, it doesn’t matter. Without fundamental changes that I believe the American people, at this time, are unwilling to accept, the downward economic medical spiral will persist. The forecast is for increasing debt paralleling that of the greater economy (of which healthcare comprises 18%). Like a junkie needing greater and greater cash infusions, it will need to hit bottom before it changes.

I know this is a pretty grim, some might say pessimistic, prediction. And there is always the chance that the exponential advance of technology may save us by completely changing the face of medicine. Unfortunately, we don’t have a lot of time.

The truth is, elephants in a small room make quite a mess.


May 17, 2017

If you’ve been trying to find out what’s going on in the world—you’re out of luck. You see, the media is preoccupied. In case you haven’t heard (and if not, you’d better stop binge drinking)…James Comey was fired.

There may be other important events occurring in this world of over 7 billion people, but none of them can hold a candle to this, the most significant of the present time—if the incessant media coverage is any indication. I thought perhaps it was just me agitating over the endless, redundant reportage and analysis of the firing of the FBI director by President Trump, an admittedly newsworthy but hardly earth-shattering event; but a recent poll documented that about a third of those asked had no opinion on the story. I don’t think the politicos and the journalists are in that camp.

I suppose it’s no surprise in an increasingly polarized political/ideological environment that this sort of psychosis will play out. The left, particularly Trump haters, believe or fervently want to believe that the president is in cahoots with Russia as this is the quickest and easiest route to impeachment, so spinning the firing as an attempt by Trump to smother the investigation is very attractive. The obvious about-face (you may recall a chorus of demands for Comey’s departure rang out after the Hillary email debacle) would be comical if it weren’t so disturbing. There were no complaints about Russia’s nefarious actions prior to Trump’s unexpected rally and win, as raising concerns of a tainted election would have been counterproductive to the anticipated Hillary rout.

In an Unraveling that precedes a Crisis, this type of behavior does serve a useful purpose: It plays nicely into the denial necessary to maintain the present degree of unstable equanimity. By avoiding the red-lining economic, cultural and societal issues that are being systemically neglected in the setting of a chaotic international scene, side issues provide cover for the fact that these failures have no simple solutions and may have progressed beyond the ability to reverse. Furthermore, many of the governing elite, media, and citizenry avoid it by not seeing it at all. The mindset, or the hope, is that “things are always like this, go up and down, and will eventually turn around.” This is actually true. However, a study of history reveals that these 80-100 year cycles “turn around” after a period of costly, deadly collapse and reset amidst a collective gasp of incredulity by the populace. And a positive final outcome is not preordained.

I used to see myself as a doomsayer. It’s true that the cries for a reversal of our present intransigence, for fiscal and personal responsibility and smaller government are more strident but are lost in an echo chamber of indoctrination for social justice and entitlement. Now I reserve my optimism for the post-Crisis reset: I still believe that there may be enough idealism left in America to rebuild the ethos that underpinned the foundation of this, the greatest experiment in human history.

I just wish the cure didn’t require electroconvulsive shock therapy.