Maggie's Farm

It's been repeated so often that it's become a mantra. Google search. If you walk or run or elliptical or stairmaster or hoeing the fields or whatever over 10,000 steps daily, you have an "active life;"  if under, you fall into the "sedentary life" category.

Nobody wants to think of themselves as leading a "sedentary" life because it sounds slothful and decadent, not luxurious. There are roughly 2000 steps per mile, but it's about the steps, not the distance. It is probably not a bad rule of thumb to do it, just to stay fit, energetic, and vigorous.

Urbanites walk far more, in the course of a day, than suburban or rural folks. My theory is that that is why city folk are trim, and country folk tend towards the bulky, but I am sure that fashion plays a role in it too. City people need to look like they have their act together or they won't get any respect.

Is age. Bad luck probably comes in second:

This is something that gets obscured in today's medical reporting--everyone, as they get older, will get sick for some reason and die at some point. The biggest risk factor for heart disease and cancer isn't BMI, cholesterol, blood pressure, etc....it's age. And to a large extent, the incidence of those diseases is random; doing everything right lowers your risk of disease, but not to zero, and usually not to that small a fraction of the risk for the general population.

The studies like this, of course, are more correlation than causation, but, in my experience, red-blooded men require more than three. The healthier fellows will be more vigorous and horny, so they will have more of these things. Strong young men in energetic relationships seem to need 2-3 per day.

But what about women? How many orgasms per week correlate with health and well-being?

It is not only true in medicine, it applies to all statistical research. Here's Why Most Published Research Findings are False.

1 Boring Old Man has been devoting himself to uncovering the Pharma-Psychiatric research cabal, but nobody is really listening. My rule of thumb is to take everything I read with a a few grains of salt.

Just kill off those nasty fat cells that you have been over-feeding: Obese Monkeys Lose Weight On Drug That Attacks Blood Supply of Fat Cells.

Assuming this will be somewhat safer than bariatric surgery, we'll all be able to eat all we want and as inactive as we want, and we'll all be as skinny as models. Being in shape will lose all of its virtue because it will be effortless.

Maybe being fat will then come into fashion.

One of my favorite topics to get annoyed about here are the American (and northern European) food fetishes.

Indeed it is a symptom of prosperity that a civilization can obsess about what they eat rather than whether they eat. This occurrence is an anomaly in the short history of Homo sapiens.  In the past couple of decades, many have fetishized their food as if what you eat were a major determinant of your fate in life (fatness aside - but recent studies say being fat isn't so bad for health either). "Eat this - it's good for you." Says who? Grandma? Brown rice and whole grains? Are you kidding me?

I have had four main categories of gripes:

1. What the latest research says. Eat Broccoli, then it's Avoid Broccoli. Avoid salt, but now salt is encouraged. Potatoes are carcinogenic. Avoid fats, but now it's avoid carbs (carbs will fatten you up and fat won't). My point is that whatever you read will be obsolete in a few years. Nobody on earth knows what the ideal human diet is, and that is because humans are basically opportunistic omnivores, designed to feed on whatever they can find.

2. "Supplements": A major scam and rip-off with a remarkable marketing machine, but I will not talk about that today.

3. "Genetic engineering": Unless you collect your food in the woods, pretty much everything you eat has been genetically engineered for thousands of years (except maybe mushrooms).

4. "Organic food": Back to clever marketing again directed to those who know no science or biology. Finally, Scientific American has a piece ripping apart the entire "organic" food fetish. Mythbusting 101: Organic Farming. Want to pay extra for "organic" for no reason whatsoever? Whole Foods shareholders thank you very much.

Sometimes I think that food fetishes must be a mild, verging on normative, form of eating disorder. I'll have my hot dogs with chopped onion and extra bright yellow mustard, thanks, with Lay's potato chips and a cold beer. Is there anything better on a summer day?

When I was in training, a wise old Doc told me to tell the old folks to eat all the salt they like, but to take their blood pressure medicines if they have hypertension.

It's Time to End the War on Salt. The zealous drive by politicians to limit our salt intake has little basis in science.

Still, if you have congestive heart failure, it might help your management to limit salt intake.

There are countless myths about diet and health. The truth is that most of it is driven by wishful thinking, the wish that we might control our fates as easily as by deciding what to have for supper.

The only dietary-related thing (besides basic sustenance) that probably helps health to some extent is to get your Vitamin D from plenty of natural sunlight (instead of from pills or diet) over much of your body, while avoiding sunburn and avoiding obsessive use of sunblock.

By Dr. Joel Levine: When the Doctor Goes Home: The Coming Indifference of American Medicine.

Thirty years ago, the training and practice of medicine was deeply rooted in "inherited" values as much as craft. Physicians were in a noble discipline recast into paladins protecting society, even a bit of its soul, against an implacable adversary. Training was both arduous and flawed (inflated egos and autocratic mice that roared) but with a central purpose. When done well, doctors successfully confronted their most difficult internal challenges, fear of the power of illness and the willfulness to make important decisions when the consequence was uncertain. This "old" medical culture was best expressed by a single term: "My patient." It was as far from provider and client as you could possibly get. "My patient" conveyed both bond and responsibility.

We are about to burn the bridges to this tradition from both ends.

Read it all, because this is what is coming to your town soon with Obamacare. Some of you have already seen it. Mass-market medicine, by the rule-book, "delivered" by anonymous "providers" to the masses. I plan to stick with the old ways for as long as I can.

While preserving my usual skepticsm about what "studies say...", it does make sense that humans would need a good dose of full- body sunlight daily.

Recent studies say 40 mins/day (without sun block), or 20 minutes per side or until done to taste.

With unblocked sunlight over enough of your body, your skin produces the right sorts of Vit D that you need for full health, vigor, and maybe even cancer prevention. Roofers get enough but, in my experience, roofers often tend to destroy themselves with crystal meth and/or alcohol. It's a roofer thing.

The alternative is to do the research yourself and try to figure out what kind and what amounts of Vit D a person ought to take as pills. As I have posted here in the past, Vit D is the only vitamin I take on the advice of all of my doc friends. However, I also take my shirt off whenever I can.

Happiness is a state of undress: why it’s time to stop worrying and love the bikini ...

Dietary Supplement Fact Sheet: Vitamin D

(Men, middle-aged and above, also probably need a baby aspirin and Vitamin L - Lipitor, but don't take medical advice off the internet. Including mine.)

We linked a a paper in Scientific American a while back, Health Care Myth Busters: Is There a High Degree of Scientific Certainty in Modern Medicine?

We know, for example, that when a patient goes to his primary-care physician with a very common problem like lower back pain, the physician will deliver the right treatment with real clinical benefit about half of the time. Patients with the same health problem who go to different physicians will get wildly different treatments. Those physicians can't all be right.

Overall, physicians are said to get it wrong around 50% of the time. I suppose that is possible. I get it wrong on a regular basis. Dr. DB says he trusts no-one in medicine, including himself.

More from the Scientific American article:

Give surgeons a written description of a surgical problem, and half of the group will recommend surgery, while the other half will not. Survey them again two years later and as many as 40 percent of the same surgeons will disagree with their previous opinions and change their recommendations. Research studies back up all of these findings, according to Eddy.

I would add, "Don't treat a test result." I have seen that end badly many times. 

I wrote yesterday about how Psychiatry is tending towards treating symptoms rather than people. Perhaps it is a general tendency in medicine today to retreat from the personal to the technological. See Treat the Patient, Not the CT Scan.

Medical care is not science. It is applied science - and an art. No checklist of symptoms, blood tests, and CT scans can sum up what is ailing an individual human, whether physically or mentally.

It must be clear by now that the dehumanizing trend in Medicine is something that I deplore. Good docs have to be more than good technicians who follow consensus protocols.

More on that in a letter to the New York Times here.

No, Virginia, there is not a little pill to fix everything that ails your heart and soul. It's the new fad, however. Your soul isn't troubled: you just have a little chemistry problem. Better living through chemistry!

In the New York Times, Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy.

It's not just about money. It's more complicated than that, but it's all very sad, in my opinion. I will not go into all of the reasons now other than to say that any doctor, Psychiatrist or not, who doesn't take the time to know you, and just wants to know your disease, isn't worth your time or your hard-earned money.

OK, now I'm depressed by my profession. Where's the pill for that?

I know two Oncologists who are being pushed out of private practice by Medicare price controls. Why are they losing money on their practices? Medicare price controls on their services, despite the huge costs of chemotherapies.

As I understand it, chemotherapy administered in a hospital can be charged at a higher rate than in an office. Thus it is viable for a hospital to take over a private practice and make money, or at least break even, on it.

Interesting article on government medical care price controls: Confessions of a Price Controller. A quote:

Medicare ignores the market, setting prices for physician services based on an academic theory with its roots in the Soviet Union and implemented by the American Medical Association. Those prices do not reflect the value patients receive from their care, and they do not reflect shifts in the demand for particular kinds of services (such as primary care) as the population ages or as more people have health insurance.

Here's what I do: I teach, for free. I work at an urban charity clinic where I donate my time. (I have no idea whether, if, or how the clinic is compensated.) I have a private practice in which I adjust fees in order to consult anybody who is referred to me. I accept no insurance plans, no Medicare, no Medicaid. All I have to worry about is covering my monthly bills.

Docs with high overheads - large staff, machinery, materials, high rents, high malpractice insurances, etc. do not have the luxury of operating as I do.

I count myself as very fortunate to be able to have an old-fashioned practice. I can do whatever I chose to do, and I like it that way.

From an article about the wonderful Dr. John Ioannidis of the above title in The Atlantic (my bolds):

In poring over medical journals, he was struck by how many findings of all types were refuted by later findings. Of course, medical-science �never minds� are hardly secret. And they sometimes make headlines, as when in recent years large studies or growing consensuses of researchers concluded that mammograms, colonoscopies, and PSA tests are far less useful cancer-detection tools than we had been told; or when widely prescribed antidepressants such as Prozac, Zoloft, and Paxil were revealed to be no more effective than a placebo for most cases of depression; or when we learned that staying out of the sun entirely can actually increase cancer risks; or when we were told that the advice to drink lots of water during intense exercise was potentially fatal; or when, last April, we were informed that taking fish oil, exercising, and doing puzzles doesn�t really help fend off Alzheimer�s disease, as long claimed. Peer-reviewed studies have come to opposite conclusions on whether using cell phones can cause brain cancer, whether sleeping more than eight hours a night is healthful or dangerous, whether taking aspirin every day is more likely to save your life or cut it short, and whether routine angioplasty works better than pills to unclog heart arteries.

But beyond the headlines, Ioannidis was shocked at the range and reach of the reversals he was seeing in everyday medical research.

Clinical research always must be taken with a grain of salt, and today's "best practices" will be tomorrow's worst. The general press is utterly incompetent at evaluating such studies. I think they just grab at potential headlines, eg Study: Broccoli Cures Causes Cancer.

I know plenty of folks who have been told to "Take it - studies say it might help, and won't hurt." Who knows? I find it amusing to think that today we are no longer certain of a direct relationship between cholesterol levels and heart disease.

As an intro, see the fourth toon down. I am not willing to pay $45. to post it. (I would pay up to $3. to use it.)

When I was a lowly intern, I was presiding over an ER when we got a radio call around 9 pm about an accident in a mall parking lot involving two cars with kids in them. A head-on, both cars going about 35 mph (that equals a 70 mph accident). When the ambulances arrived, four kids grey, not breathing. DOA. A Mom, still almost pink but dying with head trauma. A Dad, straight to trauma surgery for internal bleeding.

I have never assigned so many people, so quickly, to body bags and the morgue.

So when I read pious government utterances about "preventive care," I just have to laugh. People who talk about that have no idea what they're talking about. Doctors advise people to lose weight, to exercise, to quit smoking, to lower their carb intake, to drink only two wines/day, to wear bike helmets, to use condoms, to eat your vegetables (why? I don't know), to take their medicines, etc., every day. Blah, blah, blah. I might as well advise them to never leave the house because they might get hit by a bus. In the end, people do what they want, and adults are adults. Nobody lacks information and, in my view, if you want to be fat, then go for it.

Personally, I intend to remain trim, fit, athletic and energetic, but I am not interested in sacrificing my life and fun and adventure on the altar of "health" and "safety." There is no vitality or joie de vivre in that. I enjoy a little danger, stress, and excitement. I have crossed crevasses and climbed mountains and kayaked Grade 5 rapids (and almost drowned) and spent many hours on the back of motorcycles. I faced a p-ed off Cape Buffalo (and killed it. Regret it now - there was no point to it), and I sky-dived once. We always drove too fast. We quit all those things when we had young kids, despite the fact that my brother could have raised them very well indeed, and we had good life insurance.

Since everybody dies, and, with modern medicine, dies in a lengthy and expensive and often wretched drawn-out process (80% of US medical costs are in the last year of life), all "preventive medicine" can even hope to do is to delay the process a little bit.

However, it cannot even do that, really. It's 90% wishful thinking: The Big Lie of Preventive Care.

Another good toon from The New Yorker: "Tell me straight, Doc. How long do I have to ignore your advice?"

People love to make fun of Psychiatry, but here's a sample of what life could be like in a world without us.

Remember that Dr. Benjamin Rush, the founder of American Psychiatry, was a signer of the Declaration of Independence. He was vehemently opposed to the chaining of the mentally ill, and proposed treating them with compassion and understanding. He also opposed slavery.

Image is Benjamin Rush, MD. Charles Wilson Peale, 1818.

Medicine has always abounded with quackery, and placebo effect is real. Hope springs eternal...

However, when tax dollars are expected to pay for it, it's another matter: Europeans Cast Critical Eye on Homeopathy.

In a free country, folks are welcome to buy their own quackery if they want, on their own nickel. Most docs privately think of Chiropractic as quackery, but the Chiropractors have a lobby in DC, and I believe there is a legal injunction against MDs terming chiropractors "quacks" in public. They sometimes do help people with sore backs. I am just imagining the debates about whether federal guidelines will include crystal therapy and massage therapy.

American medicine itself has little intentional quackery, but many treatments which are of dubious value. For examples, futile treatments for terminal cancer, or those $15,000 treatments for "Chronic Lyme". Thus far, in America you can pretty much get whatever medical treatment you want regardless of its usefulness for you. Problem is, others are usually paying for it.

My prediction is that government-controlled medical care will be determined by politics and, to some extent, politically- or bureaucratically-oriented docs. That is not good medicine.

Good medicine is individualized, not based on statistics.

Medical technology has confused the simplicity of death. One quote from the piece at New Atlantis:

...as long as the ventilator remains, that body does not look like a corpse. It remains warm, like the living, and the organs continue to do the work they have always done, albeit with the assistance of chemical interventions. Most significant and most challenging, from the point of view of common sense, is the fact that the heart still beats. The injury to the brain has destroyed the centers in the brainstem that regulate breathing�thus the perpetual need for the ventilator. But the heart of an animal�even one profoundly injured�has its own �inherent rhythmicity,� its own originative source of motion. This means that heartbeat and circulation have no absolute dependence on the brain in the way that respiration has. The heart, without any input from the brain, can continue to beat as long as its own tissue is intact.

The characteristic puzzle of the total brain failure condition, then, is this: the body remains warm and pink as blood courses through the vessels; the vital organs continue performing their work; but the human being as a whole, permanently unconscious and permanently and profoundly disengaged from his surroundings�eyes closed, making no response to pain, making no effort to breathe�seems something short of alive.

Regular readers know how much I love Stats. Peter Donnelly is wonderfully fun here: How Stats fool Juries. I don't think the lawyers understand the stats either, but you can in a few minutes. (H/t Bird Dog via the Right Wing Prof)

People hate it when I burst their bubbles about eating habits, but facts are facts. Everybody likes to imagine that they can control their health by what they eat, but there is no real evidence for that unless you are starving to death or fat as a pig. (Ordinary American fatness has minimal health effects, but major aesthetic effects).

Here are some real facts for readers who fuss about their food. In my view, unless you are on a serious diet, anybody who fusses overly much about what and when they eat has an eating symptom. Harmless enough, but a symptom.

(Everybody has his share of neurotic symptoms. It's human.)

I will say it again: the only reason to fuss with your food is to make it taste good - and to stay skinny and fit so you look good, have endurance, and do not offend others with your unpleasant appearance.

Hey, honey. Get that beer man over here. I need a cold one or two to go with my Sabrett's.

The women of the world owe a giant debt of gratitude to Hungarian physician Dr. Ignaz Semmelweiss.

Mocked and ridiculed by the experts, he was correct that puerperal fever, which killed many mothers, was somehow spread by doctors and nurses who did not disinfect their hands.

The germ theory of infectious disease had yet to be explained in the 1840s, but he was a practical doc, not a theorist.

- Should you take an aspirin, or a baby aspirin, daily or every other day to reduce your risk for nasty cardiovascular events (heart attack, stroke)? Check it out.  As I once mentioned here in the past, all male docs I know over 40 take a baby aspirin daily.

- Middle-aged women get Frozen Shoulder. Know what it is? It's not an excuse to avoid vacuuming, doing the dishes, or sex. It's a nasty thing.

- Also, I recently heard a talk about ADHD. There is a strong association between ADHD and Social Phobia, which I thought was interesting. However, it's confusing because ADHD is such a confusing pattern of symptoms since it is so commonly combined with other diagnosable problems: bipolar disorder, anxiety disorders, depression, conduct disorder, antisocial personality, etc. It's a mess of a diagnosis.

Obesity is probably decreasing in the USA. What changed (in 1998) was to change the definition of obesity down to 30 lbs. overweight, thus adding millions to the "obese" column.

There's no way somebody 30 lbs overweight (by whatever standard is used) is what people consider obese. 30 lbs overweight is "plump," pudgy," or, as they used to say, "sleek" or "prosperous-looking." In women, "matronly."

In fact, being 30 lbs overweight has no ill medical effects at all. The aesthetics of it are, of course, highly subjective.

Bremelanotide. It's a nasal spray, works quickly. Looks like it can be bought online.

Is it a party drug, or a medical drug? I do not know. Haven't tried it yet, personally, but I probably would if only for my educational purposes...

All of the late middle-aged docs I know are "scientifically" curious about it. It is said to be the only true aphrodisiac. If it has no serious side effects, I can see this drug leave Oxycontin in the dust on the black market.

Not everybody, for sure, is fully satisfied with his or her sex life, unless young and in love.

All doctors know this: The "Preventive Care" Myth from Krauthammer.

Preventive care is expensive, and has a very low yield. Things like mammograms do not exist because they are cost-effective: they exist because people want them. 

When somebody collapses and stops breathing, make sure you remember how to do CPR. Just make sure you don't do it to some person who simply fainted, because you can be sued if you break a rib. Legal protection for Good Samaritans in the US is fading fast. Still, every citizen ought to know how to do this.

I have had to do it twice, once in a parking lot and once in church. One lived, one died.

Hanson at Overcoming Bias posts the graph below from the British Medical Journal. It says they looked at 2500 treatments, so I suspect this isn't just medicines. I'd like to see the list to determine whether it only included standard treatments like antibiotics for pneumonia or stents for coronary artery blockages, or whether it includes things like homeopathy and massage therapy.

I don't know what to make of the Terra Incognita of the 46% of "unknown effectiveness." I want to see the details.

Dr. Bob has penned a definitive essay on the topic of preventive medicine. It's all true, and all docs know it. One quote:

It looks like we are on the subject of health freedom today. What I have observed over the past ten years is that people increasingly equate insurance coverage with medical care. That's sad.

In my view, it's a pathologically infantile sense of entitlement when people expect others to take care of them. Sad, indeed when Americans can afford their cars and car insurance and computers and iPods and cell phones etc. but expect somebody else to pay their bills if they get sick.

My view is that every responsible adult needs cheap catastrophic medical coverage - what used to be called Major Medical, with the deductible of your choice. Budget into your life the costs of your kid's broken arm and annual $120 camp physical - or don't have kids. If there's a big problem, the Major Medical will cover you. Like if you have a heart attack, break your back falling off a ladder, or if your kid gets shot in the eye with a BB gun.

I want to know what the Dems want to cover with their grand plan to "reduce" medical costs:

Will they cover Reike, massage therapy, homeopathy, acupuncture, chiropractic, crystal therapy, therapeutic touch, late-term abortion, breast enhancement, plastic and cosmetic surgery, hopeless chemotherapy and radiation therapy, eye movement therapy, light therapy, Chinese herbal medicine, hypnosis, social workers, bunion removal, in vitro fertilization, elective Psychoanalysis, alcohol rehab, penile implants, heart transplants, high colonic cleansings, liposuction, ingrown toenails and toenail fungus, Native Indian Soul Renewal, and liver transplants?

And do you want politicians making these decisions for you?

Me? I want the government 100% out of medical care and medical choices, because they have no idea what they are doing. No more of a clue than they know how to run GM - or the corner candy shop. I know what my private family policy covers. I chose it, I pay for it, and it's cheaper than the family's car insurance.

What the heck does the government have to do with these decisions, anyway?

There is no convincing evidence that "healthy eating" - whatever that is (eating "organic" vegetables?) - or a "healthy lifestyle," eg exercising daily or whatever - has any beneficial effect on your long-term medical future. 

Those things might - or will - make you feel better, happier, and more functional, and nobody likes to carry 30 lbs. of unecessary lard around with them, looking like a muffin-top or worse. Nothing to do with health, though. And that is why "Lifestyle Medicine" is quackery which has been foisted on a credulous public.

One quote:

...it�s little wonder, then, that the results of every major randomized, controlled clinical trial of healthy eating and lifestyles to date have been ignored, downplayed, or explained away... or their benefits greatly overstated. As incredible as it seems, they have failed to demonstrate significant benefit in preventing chronic diseases of old age, like the big three diabetes, heart disease or cancers, or in living longer. Nor has any healthy eating intervention been credibly shown to give everyone a government-approved BMI.

Other than avoiding smoking and substance abuse, and taking our medicines, our fates are sadly not in our hands.

Carpe diem: every day could be your last.

I majored in Statistics in college (with a minor in English Lit), but my stats sophistication is a bit rusty now. But it's not so rusty that I do not raise my brow at any latest stats reported in medicine, or especially in Psychiatry - and especially genetic studies.

As Gene Expressions points out, it's partly because a p-value of 0.05, commonly used in such studies, is unrealistic for these things. It's straight out of How to Lie with Statistics, which is essential reading for all high school students.

As the man says, if there is a genetic serotonin link with trauma and depression, it has yet to be proven.

In his second post on the topic, Why are most genetic associations found through candidate gene studies wrong? he makes the key point:

For nearly all diseases, reproducible associations have small effect size and are only detectable when one has sample sizes in the thousands or tens of thousands (for many psychiatric phenotypes, even studies with these sample sizes don't seem to find much). The vast majority of candidate gene association studies had sample sizes in the low hundreds, and thus had essentially zero power to detect the true associations. By the argument above, in this situation the probability that a "significant" association is real approaches zero. The problem with candidate gene association studies is not that they were only targeting candidate genes, per se, but rather that they tended to have small sample sizes and were woefully underpowered to detect true associations.

While I find the field of behavioral genetics to be as fascinating as anything else in this world, I always read the latest gene-behavior studies with the highest skepticism. (Do I think real Bipolar Disorder has some provable genetic underpinning? Yes, I do, even though I do not think it has been adequately proven yet. But not much else genetic in Psychiatry has been adequately proven in my view. Schizophrenia maybe, IQ almost certainly, but possibly not homosexuality, or depression, or alcoholism.

The trick to getting papers published is to run your numbers so they show something. It's not rocket science if you know how to do it: just look at the climate studies. (Even Einstein fudged his math. He happened to turn out to be right, though, as far as we know today.) Science is about hypotheses, not Truth.

No good deed goes unpunished.

Well, that is surely not always true, but with the economic downturn, the charity medical clinic at which I volunteer one day per week has seen a sharp upturn in lawsuits against us Docs and the clinic this year.

The medical defence lawyer we have now engaged (we have had no complaints or suits for 10 years until January 2009) tells us that we should now regard each patient as a potential enemy. (Our clinic's founding Christian philosophy is to regard every patient as a friend and neighbor.) 

He tells us that our notes must be guided by the principle of CYA (your notes are legal documents, not medical reminders as we had thought) and that every decision a doc makes contains some basis for a suit in the hands of a hungry lawyer because all medical decisions are judgement calls and every situation is unique.

He also told us that recessions tend to see more suits against doctors because more folks are looking for cash, and much more so in charity settings. Plus the tort lawyers are hungry too - but they always are. He also advised us to refuse to treat any patients with substance abuse histories for our protection - other than alcohol.

He actually said "Do not be kind. They will screw you whenever they decide to." He has been around the block a few times.

I do not like this at all. A Psychiatrist/Psychoanalyst cannot do the job under such conditions. Furthermore, I can not and will not endure any relationship in my life without mutual trust. I am considering resigning (even though I was one of the founders of the place) and finding some other outlet for my charity. Maybe prison work, where you can safely begin with the assumption that everybody is a liar and cheater and working the system - and take it from there.

My position on the Board, plus my volunteer time (all unpaid) doubles my legal liability. I just want to do my best, tithe and double-tithe my time, and avoid hassles that do not fit into my life - and legal fees that I cannot comfortably afford.

And no, I would never work for ObamaCare. Never. I did not go into medicine to be a government employee. I went into medicine to work for my patients, doing my best, with no intention of looking out for lawyers.

It's tough for doctors because we are often held responsible for people who either do not want, or do not accept, our help and advice. But, as long as their name remains on our rolls and as long as we persist in trying to be constructive, the lawyers can get us.

I have been burned several times by keeping them on the rolls in the charity clinic, only to be sued by them eventually for not doing a better job "taking care of them." What? I am not a professional mother and I do not "take care of" anybody. I am a doctor, not a caretaker and, despite the modern lingo, not a "care-giver" either.

Like all doctors,  I try to work with my patients - and do not take care of them, or I to try to bring them around to where I can work with them.

If I were more self-protective, I would not even try and would just say "I cannot help you. Good bye," but that is not my medical tradition. My medical tradition is that you are a friend to your patients, whoever they are.

Novalis presents such a case. More practical docs than I am would just throw them out of the office. However, after being punished and hassled legally several times by going the extra mile, my heart grows harder. 

Indeed, good deeds often are punished and yes, it does lead to some bitterness especially when it is performed on a charity basis. I have never been sued or hassled by a private, self-paying patient. 

The news mills are ginning up yet another medical crisis storm these days in an effort to pave the way for gummint medical care by the same good folks who run the DMV and the post office. They seem to imagine a problem with cost, access, and insurance. Maybe we are a nation of crybabies, because we have the best medical care in the world with which to pamper our so-called precious selves.

It's time we got beyond that self-love, and cared about the Greater Good. I have a few simple, rational, Utilitarian solutions.

Cost: Cost is driven by technology and modern pharmacology, cancer treatment, crocks (people obsessed with their health), gomers ("gomers go to ground"), and futile, guilt-driven end-of-life treatment for annoying old or sick relatives. The cost of American medical care can be dramatically reduced by forbidding all cancer treatment other than Oxycontin and at-home 10-gallon morphine pumps, all medical treatment for those over 57 (the children are our future!), all CT and MRI scans, all blood tests, and all medicines other than friendly, holistic, herbal organic ones. No more vaccinations - they cause Autism. No more antibiotics - everybody knows that they make people sick. Eliminate Dermatology (just stay out of the sun, people). Eliminate Opthalmology (bad eyesight is from masturbation - it's your own fault). Eliminate Psychiatry (mental illness is socio-political mind control). Eliminate Urology (do you want a #3 gauge tube stuck up your urethra?). Eliminate Surgery - it is physical assault on comatose victims. Eliminate Neurology - it's just nerves.

Access: Doctors are like waterfront trade unions: they limit their numbers to keep their payments high enough to join country clubs, to buy boats, and to take vacations. My idea: anybody who gets a C or better in Organic Chem is automatically admitted to a government medical school. Lots of good, caring people are weak in math and chem and bio and stuff, but that's who we need more of. My medical school flunk-out rate was 18%: what a waste of talent. Plus there are too many Jews and Asians in medicine anyway, and too few people of color or of gender identity diversity. So, with this increase in the numbers of docs, fees could go down to $5 per office visit and the docs who don't like it can open dry cleaning shops, cigar shops and wine shops like they do in Canada.

Insurance:  Medical insurance is a dumb idea. Why expect your neighbor to pay your medical bills when they will be so low under my plan anyway? They will be cheaper than your garbage pick-up, your newspaper subscription, your cigarette costs, your car payment or your monthly payment for your big screen TV. (Did you ever notice how nobody complains about the cost of their TVs, computers, or Life Insurance?) Or just save your money if you want and die quietly without complaint, dude, and make space for the next generation. Too many people on the planet and, let's face it, life isn't all it's cracked up to be anyway. A vale of tears and toil, a tale told by an idiot, full of sound and fury, signifying nothing. What's the big deal about death? Didn't your parents teach you that life is a bitch?

I opted out of Medicare years ago. I felt morally torn about doing so, but finally my bookkeeper refused to do any more of their paperwork. That settled it.

My compromise was to institute a generous sliding fee scale for Medicare-aged folks. (My general policy is to never decline a referred patient because of money.) From a young Doc, in the WSJ:

Here's something that has gotten lost in the drive to institute universal health insurance: Health insurance doesn't automatically lead to health care. And with more and more doctors dropping out of one insurance plan or another, especially government plans, there is no guarantee that you will be able to see a physician no matter what coverage you have.

Consider that the Medicare Payment Advisory Commission reported in 2008 that 28% of Medicare beneficiaries looking for a primary care physician had trouble finding one, up from 24% the year before. The reasons are clear: A 2008 survey by the Texas Medical Association, for example, found that only 38% of primary-care doctors in Texas took new Medicare patients. The statistics are similar in New York state, where I practice medicine.

More and more of my fellow doctors are turning away Medicare patients because of the diminished reimbursements and the growing delay in payments.