Clinic

The lost and windblown, the inarticulate and the speechless, people who don't take their meds, people who take their neighbor's meds, dangerous people looking out from passive eyes, cheerful and grateful people, a fifteen year old mother of two, criminals in handcuffs, old soldiers with watchful family caretakers, men with sexual obsessions, some with new knife wounds, a man with prostate cancer who has been denied insurance coverage because his insurer has him listed as a female, men with old bullet wounds, a young man who has burned the word "BITCH" in the skin over his left deltoid with match heads because he "wants to own a motorcycle", self conscious hookers for "a checkup", meticulous and dignified old black men, brain damaged young men from institutions living in wheelchairs and wearing helmets, girls in tight clothing built like wasps, soft speaking street toughs, men and women working under the table, some healthy people who come for the friendly atmosphere, Arabs struggling with the language, students who want an exam under an alias, a man paralyzed by a bullet with a strangely distant acceptance, small business men who don't provide insurance for their employees either, sick people "lost to followup", many who have never had anyone nice to them or care for them ever.

Budget and Citizen Cuts

Some numbers. The budget for the U.S. in 2011 totals 3.834 Trillion dollars. This can be broken down into Discretionary and Non-Discretionary Spending.

Non-Discretionary Spending is made up of those expenses that have been agreed to or contracted; expenses that cannot be avoided without disruption. These include a) Payment on the National Debt: 251 Billion, b) Vet Benefits: 68 Billion, c) Social Security: 730 Billion, d) Income Security (Dept. of Labor): 580 Billion, e) Medicare: 491 Billion, f) Medicaid 297 Billion. Total: 2.417 Billion Dollars.

Discretionary Spending is more arbitrary and reactionary; these expenses are current non-contractual costs and are military. They include a) Military National Security: 895 Billion, b) Non-Military National Security: 520 Billion. Total: 1.415 Trillion.

The debate over the direction of the government has been poorly focused but seems to be generally concerned about federal government growth of responsibility with a parallel growth in size, expense and influence. (Some would refer some of these areas to the states.) So apparently these people hope to cut the expenses. Where? Social Security? Medicare? These programs were started not as "entitlements" but as "investments", "savings accounts". People put money in with the expectation of taking money out later. And, having done that, they did not save that money themselves. Payment on the National Debt? Medicaid? Where will the cuts come from? The Military? And all of these expenses are rising as the population grows older. And the Debt Service: It is 251 Billion this year but rates are low and the deficit this year will be at least 1.2 Trillion Dollars and there is no reason to think it will be lower next year. All of these expenses are permanent and rising. How will this be solved?

There has been some scorn leveled at those who want less spending because of this very conundrum. But it is unfair to blame these people because they can not solve this problem now. The problem was initiated long ago. The problem is that the government has promised more to its citizens than it can deliver. It is no more complex. The complex part occurs when the government stops or decreases its payments. Then the burden of cutting the costs will slide away from the complainers and return to those who created the problem: The elected officials. They will have to decide where the cuts will come, whose promise to renege on, which citizen to sacrifice.

Read Your Own Stats

It is generally said--but really not believed--that most American jobs are created by small business. 75% of all U.S. businesses have no payroll; they mostly are self-employed people in unincorporated businesses. They account for 3.4% of reported national business receipts.

Small businesses with a payroll are a different matter. The Huffington Post recently reported that small business was responsible for 93% of the jobs in the last 15 years. A Census report examining from 1988 to 2004 showed that businesses with fewer than 20 employees accounted for 90% of all firms and 97% of all new jobs. But these numbers have a twist: Nearly all net job creation from 1980 to 2010 were in companies less 5 years old. If you guess that that number was a dot com bubble, in the collapse from 2007 to 2010 it was 67%.

More. Immigrants with graduate degrees make up 8% of immigrants annually. But, according to the WSJ, immigrants founded or co-founded 25% of all American high-tech firms from 1995 to 2005 and 24% of U.S. patents.

These are pretty shocking numbers and one would think the topic on every one's lips would be how the society could take advantage of these dramatic observations. And encourage them. The first thing that comes to mind is the tendency of communities to fight over the relocation of existing industries. By these numbers, that is the last thing they should be doing. They should be finding small start ups and fostering them. They should be making taxes easier, funding easier and recruiting easier. But one never hears of any of this. Instead we hear that the new Dodd bill intends to decrease angel investing by 75% and delay successful funding for start ups by 3 months.

We seem wrong more often than chance would allow. Perhaps there is some self-destructive thing hidden in success. Or perhaps these incredibly bad decisions are the subtle work of some patient enemy who has wormed his way into our governmental processes. More likely it is the work of Mediocrity, that persistent hanger on, feeding mindlessly off the achievements of others, fussing about the workplace like so many sorcerer's apprentices.

A Song

In response to the complaint that this blog is preoccupied with politics, medical care, government and similar arcana, .....a song!


The Falconer

I always hoped that we would live forever,
And if not us then our devotion be
A point of permanence amide the chaos
But you see...

There is no center, all things drift and ride;
Opinions seem the depth of newsprint on a page;
Men bend to standards, perhaps one just renounced,
And Proteus is now a sage.

Our future soars away from us on falcons' wings,
A subject to the hidden currents of the skies,
What easy thought will swing our minds around?
What upstart winds blow ancient infantries?

And white clothed candidates tell us they will lead,
And I'm Candide with deja vu;
They say that we control our destinies
And I am Merlin passing through.

And so with you, my dear, your love for me is fad;
Last year I sang a solitary song;
But now, like love, I am in style this year
And like a dress can be put on.

Obama is Innocent!

Obama, Dodd, Barney Franks, Pelosi...all these "leaders" are under attack for our problems in the economy. That anger is misplaced. There are several basic errors that have led to this current mess. The people involved made decisions based on their own gain without any regard for the social implications. "Material abundance without character." People took 125% on a house knowing they would never uphold their end of the bargain. Second, the ingenuity of people--especially dishonest people--will always outstrip that of the regulators. The regulators will always be a half a generation behind; they will always be fighting the last crisis. Finally, the debt/deficit crisis is not contemporary, it is the result of errors that are several generations old and these problems have been faced and deferred every year since. Political errors voraciously accepted by the public. These foolish efforts at undergraduate economic manipulation and social engineering--aside from the corruption--are founded on obvious, obvious demographics that would never allow them to be successful. That does not excuse the current leaders who will continue the errors, if allowed. But the point here is that these errors have become institutionalized. They must be solved, the byzantine mess must be unwound carefully and with control. Otherwise they will be unwound haphazardly and in chaos.

Health Care, Medical Care and Managers

Several articles have appeared, conveniently, raising the question of the possible shortage of medical personnel in the next years. Some state that disaffected medical people will leave the profession, some that the increase of patients will overwhelm a stable physician population. One article suggests the rise of "physician extenders" (PA's, nurse practitioners) to make up the deficit.

The physician problem is already here. Every office offers anecdotal reports with significant declines in insurance reimbursement. Inefficient offices will be collapse; physicians who are already burdened because of time demands, age detriments or simple morale fatigue will likely leave. This new health scheme was created with little input from anyone (it would be interesting to know who wrote the bill) but physicians had the least input of any involved group (other than patients.) The reason, of course, is that this plan is not concerned with medical care, it is concerned with health costs. When confronting costs, as Wal-mart can testify, quality is the first to go.

A generation ago I spent some time in what was then East Germany and met a number of medical students. They were all in a two year program out of high school. All were women. When I asked where the male students were I was told, "The men here go into engineering. Medicine is women's work." This is the product of one of government's fondest wishes: The belief in incrementalism. If there are varying levels of expertise in any system, there must be a very high and a very low quality that is necessary. Thus much of the routine medical work can be done by low quality personnel. After all, medics are superficially educated and they see a lot of serious injuries first. So do EMT's. Consequently the belief that the lower rung of medical complexity can be managed by lower rung personnel. The problem in medicine is that the first encounter usually determines the complexity. And stabilization is a lot different than management.

We are entering a very different time in medicine, the time of the manager. Medicine is extremely complex. It is a true profession; its foundation is vows. It is only incidentally a product. It now will become primarily a product, subject to all the stresses and pressures of others. That will solve a problem for the managers as a profession will not allow compromise in quality or motive. If the profession is destroyed or diminished, everything is negotiable. Soon medicine will be less available; then good medicine will be less available.

Finally real medicine will be scarce and available only to our betters.

The Tyranny of Good Ideas

I hope to read the new Ferris book; he's more than informative, he is educational. His current book argues that science has been the engine of Liberal democracies, wealth and freedom. Inherent is the development of experimentally confirmed beliefs in contradistinction to beliefs developed by logic or reason. The scientific method emerged and then replaced the belief system that had been the focus of philosophical thought since the Golden Age of Greece. No longer would an idea have merit because of its thoroughness, its symmetry, its depth or its elegance. From now on, mankind would be freed of the tyranny of "good ideas". Now we would demand proof before we would commit our lives and our children to a notion--however clever. Good ideas would remain just that, ideas, without proof of the hypothesis. The divine right of kings will go the way of the geocentric universe.

At least usually. We still have the Lamarckian dialectic materialism with its weird cult leaders like Lysenko, Keynesian economics still presents itself as law, and foods are periodically banned like books on The Index. And the hallmark of liberal democracies, the bureaucracy, is immortal; it staggers on regardless of the value or effectiveness of the notions that created it.

We are in thrall to opinions, heartfelt sometimes, but opinions. Talk radio has made an industry of them. Politicians are fond of mixing them with some moral imperative to buttress them and infuse the audience with a bit of righteous fervor. But they are no longer charming national anecdotes and quirks; we are too big. Now when things fail there are giant implications. War. Economic collapse. Doom. Despair. We have forgotten the Enlightenment, the most important period between the Renaissance and the physics/industrial age. We still are seduced by dogma, by a coherent and lovely argument. Particularly an argument that purports to be kind.

Dogma has its place in those areas we cannot explore or answer. Dogma used to have some protective qualities too. The fear of dragons and the flat earth kept men from the dangers of the sea (and also the adverture's rewards.) But we are more confident now. Now we follow the dogmas that promise to improve our lives, right our wrongs, balance our bank accounts.

They call these dogmas "projects", "programs" and "change"; I call them uncontrolled experiments. Wear protective clothing and goggles. Put the dog in the basement. Hide the women.