Coming Contractions

Is the current economic downturn just a painful recession, or is it something more?

At the risk of sounding apocalyptic (I’ve been doing that a lot lately), it seems that the conventional wisdom (that this is just a severe recession which will correct itself within 1-2 years) is increasingly naive.

Several essays I would recommend to you for your consideration.

 ♦ Ray Dalio: Recession? No, It’s a D-process, and It Will Be Long

When I first started seeing the D-process and describing it, it was before it actually started to play out this way. But now you can ask yourself, OK, when was the last time bank stocks went down so much? When was the last time the balance sheet of the Federal Reserve, or any central bank, exploded like it has? When was the last time interest rates went to zero, essentially, making monetary policy as we know it ineffective? When was the last time we had deflation?

The answers to those questions all point to times other than the U.S. post-World War II experience. This was the dynamic that occurred in Japan in the ’90s, that occurred in Latin America in the ’80s, and that occurred in the Great Depression in the ’30s.

Basically what happens is that after a period of time, economies go through a long-term debt cycle — a dynamic that is self-reinforcing, in which people finance their spending by borrowing and debts rise relative to incomes and, more accurately, debt-service payments rise relative to incomes. At cycle peaks, assets are bought on leverage at high-enough prices that the cash flows they produce aren’t adequate to service the debt. The incomes aren’t adequate to service the debt. Then begins the reversal process, and that becomes self-reinforcing, too. In the simplest sense, the country reaches the point when it needs a debt restructuring. General Motors is a metaphor for the United States.

Dalio’s interview is essential, IMO, to understanding where we are, and cutting through the haze and maze of a million pundits talking about a “recession.” His tone is particularly noteworthy, lacking in histrionics or talk of “catastrophe” — thus making him all the more credible.

 ♦ Jaque Attali, Wall Street Journal Europe: We’re Heading Toward a Global Weimar:

This growth of public debt, on top of private debt, can only lead to catastrophe: the bankruptcy of households, banks, even countries. What has happened to Iceland can happen to larger countries as well, if panic seizes creditors. Anything is now possible, including the collapse of the global banking system, whose losses would have grown beyond reach of rescue.

This panic could be set off by the realization of the insolvency of the system. It could also be set off by political or terrorist movements: A number of determined groups, with even limited means, could organize speculative attacks on banks, leading to their collapse.

Then we could arrive at a global depression. It could even be followed by hyperinflation, provoked by the immensity of the monetary means created since the start of the crisis; the depression would allow the debt to be reduced to nothing, to the benefit of the borrowers. The world would then be experiencing a depression ready for inflation, a global Weimar.

His proposed solution, however, should set off a few alarms:

… the world’s institutions should be reorganized. We can’t have a globalization of the market without a globalization of the rule of law…

… it’s quite obvious what should be done: Merge the G-8 with the U.N. Security Council, allowing the chief Southern powers, such as India, Brazil or Nigeria, to join in. Place international financial institutions under the protection of this restructured Security Council, and put it in charge of setting up real global regulation, to control financial institutions; to modify the Basel Accords, by suppressing “mark to market” models; and to organize the revival of the production of public goods (water, clean air, freedom) world-wide.

In the long run, the world will be organized around a new coalition of nations, sharing the burden of these challenges, not around a single country, as is the case today.

Can you say, “New World Order”, boys and girls?

 ♦ Donald Sensing: America is, in fact, bankrupt

Much moaning and groaning has been going on about how the $800 billion “stimulus” bill will saddle future generations with mountains of debt. And it will, though that’s not my main complaint … future generations were already saddled with not a mountain of debt, but a Himalaya range of debt. In fact, using Generally Accept Accounting Practices, a formal set of accounting procedures abbreviated as GAAP and the kind used to audit corporations, the total American federal debt actually is greater than the economic output of the entire world.

Gulp.

 ♦ Fortunately, Europe will save us — or not: High-risk, high volume lending to ex-Soviet block Eastern Europe is not working out so well: Eastern European currencies crumble as fears of debt crisis grow:

Hungary \'s forint fell to an all-time low on Monday, and Poland \'s zloty slumped to the lowest in five years on plunging industrial output. Half of all loans to the private sector in Poland are in foreign currencies so borrowers face a severe debt shock after the 40% fall of the zloty against the euro since August.

“We \'re nearing the level were things could get out of hand,” said Hans Redeker, currency chief strategist at BNP Paribas.

 ♦ But at least you have your pension to fall back on: Maybe it’s time to cash out, buy gold, and keep it under your mattress. Pension Tsunami:

That approaching wave of pension debt is bigger than it looks. The purpose of this site is to provide an overview of the multiple pension crises that are about to drown America’s taxpayers.

 ♦ Richard Fernandez hopes we can, but doesn’t sound very confident: Avoiding the End of The World

One of the reasons government has a hard time managing complex systems is that politics treats events largely like linear systems. Politics interprets events in the context of its mythology. But if politics is in the best of times the art of lying to ourselves in the broad day, politics in crisis is the vice of lying to ourselves while we are falling off a cliff. And when fables meet a changing environment disaster is often the result. The second difficulty is that government is a ponderous, elephantine beast. Bureaucracies are nearly always behind the curve. Part of the requirement is to get ahead of the problem and cut out those parts of governance which contributed to the problem. But what to do when government is already part of the equation; when only government has the legitimacy to do some of things which need doing? It \'s like hoping a patient who shot himself can successfully self operate to remove the bullet.

 ♦ When all else fails, learn from the Soviet Union: Dmitry Orlov is an interesting guy, who immigrated from the Soviet Union at age 12 and traveled back many times during its disintegration and subsequent social collapse. He finds a lot of parallels between the Soviet social collapse and our current economic disintegration. He is decidedly a pessimist on where things are headed, but has some interesting and entertaining insights on how societies function (or don’t) after social or economic meltdown: Social Collapse Best Practices:

I was very well positioned to have this realization because I grew up straddling the two worlds – the USSR and the US. I grew up in Russia, and moved to the US when I was twelve, and so I am fluent in Russian, and I understand Russian history and Russian culture the way only a native Russian can. But I went through high school and university in the US. I had careers in several industries here, I traveled widely around the country, and so I also have a very good understanding of the US with all of its quirks and idiosyncrasies. I traveled back to Russia in 1989, when things there still seemed more or less in line with the Soviet norm, and again in 1990, when the economy was at a standstill, and big changes were clearly on the way. I went back there 3 more times in the 1990s, and observed the various stages of Soviet collapse first-hand…

Here is the key insight: you might think that when collapse happens, nothing works. That \'s just not the case. The old ways of doing things don \'t work any more, the old assumptions are all invalidated, conventional goals and measures of success become irrelevant. But a different set of goals, techniques, and measures of success can be brought to bear immediately, and the sooner the better.

 ♦ And finally, proof that the world really is coming to an end: Playboy‘s going broke: The magazine has fallen on hard times, with flaccid sales and lack of market penetration. It’ll be a shame to see the Playboy Center fold … I guess no one reads it “just for the articles” anymore. Playboy, Posting Loss, Says It Would Consider Sale

None of these essays really consider another factor: the black swan — the unexpected and unpredictable occurrence which renders all prior assumptions invalid. Think: a major Middle East war, with shutdown of oil supplies; a large-scale mass-casualty terrorist attack or nuclear terrorism; a massive natural disaster, such as an earthquake which levels, say, San Francisco. With the world in its current economic state of instability, the effects of such an event would be amplified many times over.

These are, as they say, interesting times. They are a time for prayer, not panic; a time to reassess priorities; a time to prepare for future difficulties and uncertainty.

And a time, above all, for faith.

A Brave New World

Newsweek has declared: We are all Socialists now.

Well, I suppose that’s now true — although it might have been useful information to disclose, oh, about six months ago. Whatever. The agenda is disclosed only after the fix is in. The bad news is, though, the situation is in reality far worse than our resigned embrace of socialism. Socialism is far more a symptom than the disease.

We are entering a brave new world.

America has come relatively late to this party. Most of the world, at least the Western world, has sailed before us into these treacherous and jealous waters, some becalmed in economic doldrums and others perished in their whirlpools of revolt against the inevitable oppression of such systems often bring. We have lived for some decades in this country, under the presumption that we are a free, liberal democracy, where personal freedom, a spirit of entrepreneurship and risk-taking, and a financial system which fostered these character traits in promoting prosperity and wealth have happily coexisted. In reality, this American narrative has been far more myth than reality for a long time now. It may well be arguable whether it has ever really existed at all. We have boasted of our independence and courage while ever more tightly holding our nanny’s hand.

Western culture and civilization, manifested in its highest and most successful form in the American experiment, was grounded in the Christianization of Europe over many centuries. This process — religious, cultural, ethical, and moral — created a fertile ground for societies which prospered culturally and economically based on their respect for the individual, their recognition of the dual nature — good and evil — of the human spirit, and a high view of men as created in the image of God and imbued therefore with a strong inner moral sense and a desire to create in freedom.

This system led to economic prosperity, cultural excellence, and the advancement of science, by basing its worldview on an enlightened reason, and by grounding its economic principles on a system of justice and personal integrity. And yet, within this very system, were contained the seeds of its own ultimate destruction — not through any inherent flaw in its underlying moral and ethical principals, but rather by intellectual advancement through science and technology, empowering not only great technological and economic advances, but also fomenting the dark hubris of arrogant human autonomy.

As Western civilization became increasingly sophisticated through exponential increases in scientific knowledge and technological advancement, there began a divergence from the very empowerment of that civilization in the individual moral compass of Christianity which not only empowered its great intellectual advances, but restrained the perverse consequences of those same technological and financial advances.

Detached from its moral grounding by its intellectual paradigms, the West has become increasingly and intractably secular. We now look to science for all answers about life; we have experts for everything; the new creation of Christianity has devolved into the evolutionary hopelessness and purposelessness of survival-of-the-fittest reductionism. We have become no more than random chance, with no purpose higher than our survival in this life, and no meaning beyond genetics or neurotransmitters or selfish genes. Morality, ethics, self-restraint are but social constructs convenient to our survival — and eminently disposable when the need arises.

The consequences of this imperceptible but profound change in worldview, centuries in the making, have brought us to our current state. We no longer trust the individual, based on the inculcation of moral and ethical values through family and cultural tradition, but instead trust no one, multiplying laws, rules, and regulations to micromanage behavior no longer restrained by the inner moral compass and now-discarded social mores. We no longer look to the individual, and family, the community, the church, to be the prime movers of support or those who fall by life’s wayside, in poverty, ill health, economic or social misfortune. We have outsourced our hearts, contracting with those most ill-suited to the task of compassion: those who by our own appointment or their own unbridled ambition have become our leaders in government.

We talk in terms of left and right, liberal and conservative, but such labels disguise and distort the true reality: we are engaged a war of world views, a war which has become increasingly lopsided in favor of the secular. We have gone from a Christian culture to a Gnostic culture, where knowledge is God, knowledge is power, and power is everything. We have now granted, by means of indifference, ignorance, and deception, the unrestrained levers of this power to our government, which was to have been our servant, but now becomes ever more our master. We have lived under the delusion that these two worlds may live together in harmony, but such fantasy has been demonstrably shown to be catastrophically false.

Those who live by certain conviction of a divine and beneficent deity, upon whose absolute principals lie the foundations of all moral behavior and societal harmony, may tolerate the corruption of secular man who rejects such notions, having as they do a clear-eyed understanding of the fallen nature of man. The secular, on the other hand, can broach no such tolerance: secularism is instead an aggressive and metastasizing malignancy which, while speaking tolerance, seeks only the extermination of that which by its very existence stands as a condemnation of their views. For to be religious, moral, ethical, and grounded in the consequential absolutes which transcend and measure the heart of men is to stand as an intolerable affront to the notion that man alone is the measure of all things.

We referred to this unbridgeable chasm as “the culture wars” — but it is far more than cultural differences and tolerably different perspectives. It is, in fact, a war on absolutes, and it is a war in which the secular by most measures are triumphing. The lost battles are legion; from the removal of old vestiges of religious practice and speech from the public square; to the relentless undermining of traditions regarding family, sexual behavior, public propriety, and respect for others in speech and behavior; to the hollow ethics which speak of honesty and integrity while reveling in bribes, extortion, and the abuse of power; to the absence of everything noble and honorable in our cultural expressions of art, music, and entertainment, the relentless assault of arrogant secularism in all its cultural and political forms has ground our fragile moral and cultural framework into dust.

We stand now at the edge of an abyss. Our technological wizardry, fueled by our moral blindness and hubris, has created a global firestorm — economic and otherwise — which threatens to consume us all. Nations are bankrupt; huge corporations and institutions owe far more than their assets; nation-states are increasingly impotent at providing core and essential services necessary for a safe, stable, and economically prosperous society. The world is going bankrupt, at the light-speed of its digital communications and global commerce.

And we stand at this precipice, in great peril, as those who have fostered this disaster now scurry about pretending to fix it. In our drunken materialism, we bought what we could not afford with money which we did not have; we promoted and elected those leaders who will tell us the same lies which we told ourselves as we catapulted blindly into our current crisis. We hope through a government of crooks and cronies to legislate a stable, fair and compassionate society, when neither we ourselves nor those whom we placed in our have any moral framework by which to establish such a just and equitable society. The criminals sit in the judge’s seat, comprise the jury, and mete out their punishment — and we wonder why our lives and situation becomes increasingly chaotic, dangerous, and violent.

It is a time at which one might hope for some wisdom among the elected; some humility at the daunting task now faced; some responsibility to look out for the common good rather than simply grasp for more power. Yet the fools we have empowered to govern us continue to whistle through the graveyard, pretending in their hubris that the dark forest path upon which they are hopelessly lost really does lead to Paradise — if we only run faster.

We lived in a profoundly unsettling and unstable time, almost apocalyptic in its potential for calamity. Our Gnostic guides assure us, in their high knowledge, that they have the answers — when in fact they do not even understand the questions. The liberty, the prosperity, the promise which was inherent in the Western culture engendered by Christianity, brought to its highest in the American experiment, is drawing to a close, its lifeblood long since drained by those who saw no evil except by those who pursued the good, who saw no answers save those their darkened minds could conceive and by which they might rule. How quickly this edifice will crumble is but pure speculation, but crumble it must. What will remain, or arise, in its stead, is as yet unknown.

We are indeed entering a brave new world.

Lamb Stew

I’ve been pretty quiet on the writing side of late — a bit of burnout, I guess, mostly from work and dealing with family issues. My wife is executor of her mom’s estate, and although I’m trying to keep an arm’s length from the matter, some relational speed bumps have arisen, which are hard to entirely shut out. I have gotten wrapped up in similar conflicts before, and some of the same issues (and players) are at it again.

Sigh.

So I’ve been focusing on more relaxing pastimes to stay sane, including (re)learning to play the guitar (more on this anon) and cooking. In a moment of inspiration today, I decided to cook up a lamb stew. Despite being pretty much off-the-cuff, it turned out outrageously well (if I do say so myself — and my wife agrees) — so here it goes:

Lamb Stew

    1 leg of lamb, trimmed, boned & cubed
    1 cup red wine
    1/2 cup olive oil
    1 tbsp garlic oil
    4-5 cloves of garlic, crushed
    ground pepper
    1 tsp sea salt
    4 Medjool dates, pitted

Place all of the above in a large bowl, and marinate for 1-2 hours, stirring periodically. While you’re waiting, prepare & cook the vegetables:

    2 onions, sliced
    3 carrots, sliced
    3-4 tbsp olive oil

Saute the vegetables in a Dutch oven about 15 minutes until the onions soften. Remove from the pan.

Drain the marinade, and brown the lamb in the Dutch oven. Remove from the pan.

    6 Roma tomatoes, pealed & coarsely chopped
    Ground pepper

Saute the tomatoes until dissolved. Add the marinade. Add the following spices:

    1 tbsp cumin
    1 tbsp coriander
    1 tbsp paprika
    1/2 tbsp ground ginger
    1/2 tbsp alspice
    1/2 tbsp nutmeg
    2 tbsp tomato paste

    6 Medjool dates
    1 cup chicken stock.

Add the meat, onions and carrots to the pan with the tomato saute, and add the dates and the stock. Stir well, cover, and cook over low heat for about 1 hour.

Remove the meat and vegetables from the pan, leaving the gravy. Turn up the heat and uncover to cook the liquid down a bit.

Thicken with a flour-butter roux (about 1-2 tbsp butter/flour)

Garnish with slices of roasted red bell peppers, and serve with curry couscous and fresh steamed green beans with lemon butter.

Seriously yummy comfort food for a winter’s eve.

Give it a go — it’s an easy meal (total prep & cook time about 3 hours), and well worth it.

Back soon, God bless.

Redefining Humanity


Gerard Vanderleun recently posted a thoughtful and moving essay on the topic of abortion, and his own personal reflections and experiences with it.

The crux of the abortion dispute is, as mentioned above, the question of when human life begins. At this point, we all know the opposing political and religious positions. At some point, human life begins and the fate of the fetus is either at the absolute will of the mother or it is not. Nevertheless, it is still hard to say exactly when humanness happens since: 1) We do not agree on the term “human,” and 2) as a result, all evidence on this issue remains anecdotal once you strip away the slant of the “research” that supports your preferred result.

When does the fetus become human?

This question, on one hand, seems all-important, yet at another level seems absurd beyond belief. It is a question which would never be asked were it not for the idea of ending a pregnancy by abortion. What reason would there be for such a question? A woman becomes pregnant, and is expecting a baby: this is the expectation of motherhood since man and woman first began procreating. In its natural course, barring unforeseen problems, a child is born — a unique instance of humanity, a living being like none other before or after. It is only in the context of deliberately interrupting this process — ending the pregnancy deliberately — that the question of of the humanity of the unborn fetus has been raised.

That such a question is raised with any seriousness is evidence of a profound denial — the denial required to end an unborn child’s life in the womb. To raise the issue of the humanity of those not yet born, to imply that the fetus is anything other than a human being, is to salve the deep discomfort of the soul inherent in the termination of a life. For we know, innately, that the unborn is alive, and human, and to justify its extinction we must engage in extraordinary contortions of conscience. Thus we say the fetus is an extension of the mother’s body, which it clearly is not; we refer to it as a blob of tissue or protoplasm, dehumanizing its unique and extraordinary human potential; we call it a “potential human”, as if at some magic point a switch is thrown to turn on its humanity — while never stopping to define what that humanity is, or why there is no humanity in the split second before our chosen transition time. We draw false and foolish analogies: the fetus is no different than a skin cell, or a “sacred sperm”, or a tumor — thus denying the extraordinary creation which occurs when the genetic map of two parents fuses into a new life, with an infinite capacity for uniqueness, change, experience, and creativity of its own. For we are created to create; we are engendered to engender; we are conceived to conceive again in an endless and infinite way: to conceive new ideas, new works, new accomplishments, new relationships, new failures and successes, and new life itself, in the generation which we ourselves engender.

From the moment of its conception, that which we so dismissively call a “fetus” begins a journey extraordinary beyond imagination. Using the inscrutable road map of its unique DNA, the developing human undergoes constant change and growth — a process which ends not at birth but some 25 years later when its full physical maturity is reached. Organs form; primitive cells differentiate into complex systems dedicated to tasks both present and future. Before its mother knows of the pregnancy, at 6 weeks, the heart and circulatory system is formed, and the heart is beating; the primitive cells forming the brain and spinal cord are in place and developing; facial features, including eyes, ears, mouth and nose are evident. By 8 weeks, fingers, toes and fingernails are present, as is the digestive system. By 12 weeks, virtually every organ system is formed and differentiated; the rest of the pregnancy is almost entirely about growth and the maturing of these intact systems. The information map for this extraordinary yet orderly complexity — and for far more, including intellect, personality, gifts and skills, — and yes, liabilities — is contained in the fertilized egg in its entirety. We are what we will be, from the the instant of our conception.

We deny what is self-evidently human for many reasons. Our secular and utilitarian culture has lost its sense of wonder at the miracle of that which is the creation of a new human life. Our children are no longer gifts but burdens, impeding our acquisitional materialism and imposing themselves on our pursuit of self-interest and self-gratification. We must dehumanize first, then destroy, the unborn child, that we may live out the delusional fantasy of unrestricted sexual license without consequences; that we may continue the self-deception that somehow we are masters of our own destiny; that we may perpetuate the fraudulent vision that our relationships are about self-fulfillment rather than sacrifice for the good of our progeny and the society and culture in which they will partake.

In introspective moments of regret we may mourn the potential loss, the wistful thought, that we have aborted a Beethoven or a Ben Franklin. Yet even this mild melancholy misses the point, showing the shallowness of our own humanity, as we find comfort in the rarity of such genius, while dismissing the loss of that far more tragic: the loss of the common, in all its richness and variety. It is not the loss of a Mozart we should mourn; it is the empty place where a merchant, a mechanic, a muse, a minstrel might have stood. It is the compassionate mother, the inspirational teacher, the clever repairman or comical co-worker who will never live to enrich the lives of others in ways trivial and transcendent. Our losses are incalculable, because we have destroyed them before we knew their worth. We sacrifice our hope and our future on the altar of calculated convenience and cold rationality.

It is not merely the loss of those who might have lived which we suffer; it is we who survive, who make these mortal choices, who are changed as well. For if the humanity of our children is fungible, redefined, discarded and spent on the expediency of convenience and self-interest, such expediency will not long remain in the dark chambers of the abortion suite. We will, in banal, measured, rational steps, soon judge the humanity of all with the same jaundiced eye. The disabled, the mentally ill, the elderly and frail will soon find our cold and rational eye cast upon them, as we find their lives ever more a burden, ever more useless and wasted, all too easily discarded as we pursue our utopian vision of perfection through self-worship.

Yet our Darwinian dream marches on, leaving the weakest to fall by the wayside in our evolution from compassionate humans to rational beasts. Survive we may — but at the ghastly price of wagered humanity lost.

The Crush of Covenant

Well, I finally did it: I quit.

Walked into the boss’s office, gave him a piece of my mind, tossed my resignation letter on the desk, and told him exactly what he do with his stinkin’ job. “Take this job and shove it”, as the country song goes.

Felt great. Been wantin’ to do this for a loooong time.

What led me to such a drastic, disgruntled display of ill-demeanor?

Here’s just a few vignettes from the past few days:

Monday 7 A.M: It’s Monday, my regular ER on call day. Full office scheduled. The ER calls — at exactly 7 A.M. Which means the weekend call guy, who goes off at 7:00, hasn’t answered his pages for the last 2 hours. Bastard. There’s a term for this: it’s called “dumping.”

The patient: a 90-something man with Alzheimer’s dementia, from a nursing home. Not any nursing home, mind you: one specializing in the care of Alzheimer’s patients. Ads on the radio about how caring and compassionate they are — you’ve heard ’em. Creme’ d’ la creme, and all that. Chronic Foley (urinary) catheter for incontinence. Despite their fawning attention, he somehow managed to grab his Foley and pull it out — with the balloon inflated, of course. He’s bleeding. A lot. The caring, attentive staff at the home has also neglected routine catheter care, so it has basically eaten its way through his penis. He now pees (if he could) through a hole just over the scrotum.

The ER staff can’t get the catheter back in. Not just because the anatomy ain’t quite normal (the P.A. is still trying to insert the catheter into the end of the penis, and can’t figure out why it won’t go in) — but he’s agitated. Really agitated. 4 nurses and counting to hold him down, still throwing punches. (great left hook!). Clearly this isn’t going to work — he’ll need to go to surgery ASAP, so this can be done under anesthesia — putting in a more permanent bladder catheter through a small hole in the low abdomen. With a big-ass balloon he can’t pull out. Hopefully.

Monday 9 A.M.: Inform my office staff that most of my busy morning office has to be rescheduled, the rest will have to wait. They are not happy. The patients rescheduled will not be happy – most have waited over 6 weeks for their appointment, and probably another 6 for their new one. C’est la vie. They will likely think my “medical emergency” means I’m on the 1st tee with my golfing buddies. Whatever. The more urgent ones will get squeezed into another day, already overbooked. Then they can be even more unhappy because the doctor is running late, and “Their appointment was at 10:00 A.M., dammit, and their time is valuable.”

Monday 1 P.M.: Back from surgery, the few longsuffering and surly patients from the morning clinic seen and (somewhat) assuaged. Short conference with my billing specialist, a soft-spoken pit bull with lipstick who daily does battle with the forces of evil and corruption (a.k.a., insurance carriers and Medicare), and wins an amazing number of battles. But not today.

Mr. Jones, you see, had a prostate problem. So he needed a fairly simple test to check for obstruction, called a uroflow, to evaluate whether his prostate was causing blockage. Charges for this procedure? About $325.

Sounds like a lot of money to pee in a jug. But it’s a very special jug. The equipment which measures and records his urinary efforts cost over 6 figures (it has a number of other highly specialized functions as well, lest you think it’s too extravagant for such a lowly task). The specialized catheters used to measure pressures for the more sophisticated tests cost well over $100 each — and are single-use disposables. Setup, cleanup, patient instruction and assistance by my back-office nurse, about 20 minutes of her salary, benefits, health insurance, 401(k) contributions. Overhead to keep the office open (rent, supplies, maintenance, malpractice insurance, licenses, etc., etc.), about $200 an hour. Oh, and my interpretation of the test and conclusions about how best to treat the patient is included in the fee.

What the insurance usually pays for the procedure: about $125.

What Mr.Jones’ insurance company paid: $0.

The reason? Mr. Jones’ policy doesn’t cover in-office surgery. “But peeing in a jug isn’t surgery!”, you protest. As did I. But the CPT service code has been incorrectly categorized as surgery by our friends at the AMA, in their massive annual tome used by insurers and federal payors to determine payments for medical services.

So I sat down and wrote a detailed appeal letter, explaining in a clear, courteous, and detailed manner that peeing in a jug is not surgery. Dictated, proof-read, sent off. My time? About 20 minutes. My reimbursement for that time? $0 (Called your attorney lately and chatted for 20 minutes, for free? Didn’t think so).

One month later, the response arrived: Appeal denied. The letter explained how the medical situation had been carefully reviewed: first, by their highly-trained Resource and Review Nurse; then by a panel of esteemed physicians and other health care providers; and finally, because of the seriousness of the matter, by their Medical Director (whose 7-figure income reflects the gravity and burden of such decisions). The verdict?

Peeing in a jug is surgery.

Of course, it is never prudent to take the last shred of hope from the hopeless, so they politely inform me that I may submit a Level II appeal — which requires pleading to the AMA that the categorization of peeing in a jug as surgery, in their massive annual CPT coding tome, is an error. And, of course, they will be more than happy to reconsider the matter once the AMA has agreed, and changed their rules.

Oh, and have a wonderful day! We cannot tell you how much we appreciate your outstanding care for our insured clients!

Monday, 1:10 P.M:: Billing conference, part II. Mr. Smith, another nursing home patient, had blood in the urine. Came to our office for a cystoscopy, a visual inspection of the bladder. Found he had a small bladder cancer, and was scheduled for surgery in a few weeks. Went back to the nursing home until then.

In the past, billing for such a procedure was simple: submit the claim to Medicare, get paid (about 40% of my billed fee, about 10-20% less than my overhead to perform the procedure) by Medicare a few weeks later.

Then Medicare changed the rules. Since Mr. Smith is in a nursing home, the nursing home must now bill for my cystoscopy, get paid by them — and then pay me, if and when they get around to it. But, of course, they have no motivation to do so — since I have no recourse against them if they fail to bill it, or bill it incompetently and get denied, or refuse to pay me.

So the executive summary: I get nada for Mr. Smith’s procedure.

The unintended consequence of this little change in Medicare regulations? Urologists and other specialists now refuse to do procedures in the office on nursing home patients, since they don’t get paid. The procedures either don’t get done — or the patient has to be admitted to the hospital when his bleeding gets bad enough, where his cystoscopy will be performed at a cost to Medicare of, oh, about 500-fold what it would have been if I did it in the office.

Medicare, of course, will be ecstatic: their payments for office procedures will plummet, after their careful review of regulations helped trim “wasteful and unnecessary medical spending” from their budget. The jump in costs for hospital procedures which results from this shell game are, of course, because of greedy health care providers, fraud and abuse, and more wasteful medical spending — and come out of a different pocket, so’ll they’ll never make the connection. The politicians are sure to trim those frivolous expenses as well, by carefully reviewing the regulations and implementing more “fraud and abuse” abuse, as they seek high quality, affordable health care coverage for all.

Tuesday, 1: P.M: Mr. Smith’s nurse from the Alzheimer’s Home calls, and says he has some blood in the urine from his new bladder catheter (which is expected). “How much?” “Dark pink, no clots.” “Have you irrigated it?” “Yes, and we’re sending him back to the hospital.” “Is the catheter draining well?” “Yes, but we’re going to send him back.” “Is he stable, blood pressure OK, any pain, blood count OK?” “Yes, do you want him to go by ambulance or do we call 911?” “He doesn’t need to go back to the hospital.” “Well, he’s going anyway. We can’t handle this.” Yeah, I guess that’s why they call it a nursing facility. God forbid you should deliver, you know, nursing care.

14 hours later he returns to the nursing home after an ER visit, perfectly stable medically, just as he was when he left the nursing home. About an $8-10,000 medical junket, because a nurse couldn’t, or wouldn’t, handle basic nursing care.

Wednesday 9:00 A.M.: Mr. Johnson is waiting when the office opens. His is a sad story: prostate cancer, had successful surgery to remove it, and is cured. Developed scar tissue afterward and couldn’t pee. Opened it up and he couldn’t not pee — bad incontinence. Had a prosthetic device placed, an artificial urinary sphincter, nine months ago. Worked beautifully, Mr. Johnson is happy. 8 months later, leaking again: Mr. Johnson is not happy.

Took him to surgery yesterday to repair it. A tiny leak had developed, and the pressure on the sphincter cuffs was lost — an uncommon but known problem with these devices. Replaced the components, hooked it up, tested it thoroughly, worked great. The device has a control valve located in the scrotal area to open the cuffs when you need to pee, which was one of the components replaced. It has a locking button, which holds the cuffs open, as things are too swollen and tender for the patient to use it for a while. Locked the cuffs open, tested it again several times, everything’s perfect.

He goes home, and can’t urinate. Somehow the lock released on its own — which isn’t supposed to happen. Goes to the ER, where they try to put a catheter in, rather indelicately, and left it in — which greatly increases the risk his sphincter prosthesis will get infected, and have to be removed. And he needs to go back to surgery, since it is far too painful to try to lock the cuffs open now, and he will need a temporary bladder drain through the skin until the swelling goes down.

Mr. Johnson is not happy. I am not happy.

Not to be too whiny, but the responsibility of this profession at times can be crushing. At the risk of seeming hyperbolic, you really do, to a greater or lesser degree, take patient’s lives in your hands when you assume their care. Not just the life-and-death stuff, although that’s sometimes part of it too. No, it’s the rest of their lives which come under your responsibility. It’s the drug to treat a serious disease, which causes serious side effects or unintended adverse effects on their other diseases. It’s the surgery to cure cancer which can have painful, disruptive, frustrating complications, even when the cancer is cured — and even when the surgery is competently and expertly performed. You are, in the end, responsible. When the side effects happen, you are responsible. When the patient fails to follow treatment advice, or has unrealistic expectations despite your best efforts to temper them, you are responsible. When the pharmacist sends the wrong drug; when the nurse fails to notice an important problem; when the technician doesn’t properly clean and sterilize the instrument; when the prosthesis fails to operate as designed: you are responsible.

Perhaps in some alternate universe, where Gucci-loafered lawyers with fat cigars parse guilt in mahogany-gilded chambers, the responsibility would be meted out in scrupulous fairness to all involved. But as a physician, where our relationship with the patient is one of covenant, not contract, those responsibilities become ours, because we commit to the patient’s best interest, no matter what, while orchestrating the complexities and complications of this enormous technological beast we call 21st century medicine. This gleaming beast can accomplish enormous good — or ghastly harm. And much of the behemoth we seek to command is not under our control — yet we remain responsible nevertheless. So we lash, kick, prod, and goad the monster, trying to reign in the mind-numbing complexity and tie up the endless loose ends, as the monster snarls back and snaps at your head or pummels you with its tail. And never forget your own frailty: perfection is unattainable despite your most obsessive, strenuous efforts. The country doc with his black bag could do little good and cause little harm; small errors today, even unrecognized, can multiply and spiral into disaster at frightening speed. This fact alone crushes many a doctor with its gravity, as witnessed by the high rates of physician burnout, suicide, divorce, and drug and alcohol problems.

The feeling is like a punch in the gut, only worse. I am not happy. I am depressed, and angry, and fearful, and discouraged — and convinced that with my level of competence I should be flipping burgers at McDonalds. Self-condemnation is a narcotic, savored and craved by perfectionists: noxious in flavor, but oddly salutary in the self-pitying comfort of its dark and fetid euphoria.

It does not pass easily.

Wednesday, Noon: Mr. Smith, with the Alzheimer’s, is back in the ER, and they are calling me. No preliminary call to me this time from his nursing home — they just sent him back. His 4-by-4 inch gauze dressing around his new bladder catheter is bloody — about a silver-dollar sized area. The ER doc sees and evaluates him: still demented, still medically stable as a rock, blood count unchanged. The ER doc changes his dressing, and sends him back to the nursing home. So, here we are, some $20-25,000 spent on this poor man, because his nurses are inept, lazy, incompetent, and can’t change a g*d-damned dressing. No one at the nursing home will have their pay docked because of this travesty; no one will be fired or fined. Medicare will pay its fractional part of the costs, oblivious to the incompetence which triggered it. The hospital will eat the difference.

And life in the circus of 21st century medicine will go on.

And so, enough is enough: the camel’s back has snapped. I quit. It’s not the first time, by any means; likely won’t be the last. My boss is very understanding, and he’s been through this all before. That’s one of the skills you need when you’re a self-employed, solo physician.

He knows I’ll be back at my desk tomorrow, as if nothing happened. Ready to start it all over again.

* All names are, of course, fictional.

Friday Links

For your weekend reading pleasure:

 ♦ On Edmund Burke, the French Revolution, and our current culture war: Conservatism and the Culture Wars:

Therefore, establishing an empire of desire requires more than political triumph, more than legal protection. Like all progressive ideals, it requires the destruction of the sentiments and pieties that lead people to think otherwise. This ideological project takes on the familiar distortions of all modern propaganda. “Words take on new meanings”, James Kalb writes in The Tyranny of Liberalism, “hatred comes to include opposition to liberal initiatives, while inclusiveness requires non-liberals to abandon their principles and even their identity. Tolerance treats objections to liberalism as attacks on neutrality that are oppressive simply by being made.”

 ♦ Paul Cella: The Crisis of Anomie

It is a particularly distressing feature of our age that even thoughtful men do not perceive the crisis into which they have been thrown. They profess ignorance of its depredations; and they even grow annoyed when pressed with its evidences. Say to them, “It is an extraordinary fact that for some decades now high culture in this country has nurtured an open detestation of the social order which gave it life and resources”; or “It is a marvel that American artists and men of letters concern themselves most passionately with disparagement and falsification of their inherited tradition” — and your tale will return void. Its accuracy will not be overtly denied, but it will be somehow disregarded. Or inquire of such men whether they think it noteworthy that though we are among the richest of all societies, we are very far from being the happiest: the puzzle will induce a blank stare or a blanker shrug. To resist or avoid reflection upon this bespeaks of a psychological numbness of some depth.

It is very easy, I think, to underestimate the strangeness of this state of things, this languor combined with bafflement. Even its prominent specimens no longer shock. It is certainly arresting to observe a society afflicted by, for instance, increasingly frequent, demonic acts of murder-suicide perpetrated by and against schoolchildren, or by disgruntled ex-employees against their former co-workers. What shall we call those whom it fails to disturb beyond the fleeting moment?

 ♦ The coming health care rationing: Obama Will Ration Your Health Care (HT: Maggies Farm) See also: The GOP Should Fight Health-Care Rationing and Take Two Aspirin and Call Your Congressman.

 ♦ He will have to change his name, once he stops moaning: Woman gives naked intruder a painful squeeze

PORTLAND, Ore. (AP) – The Multnomah County Sheriff’s Office says an 88-year-old woman fended off a naked intruder by grabbing the man’s crotch and squeezing.

Deputy Paul McRedmond says the man got into the house Tuesday through a sliding door. He backed the woman into her living room and pushed her face down onto a chair.

That’s when the woman reached behind and squeezed. The man tore free and fled…

Troutdale police arrested 46-year-old Michael G. Dick of Gresham.

Just another case of robbing Peter to repay gall.

 ♦ Get a scorecard, know the players: Israel & Gaza: Israel \'s strike on Gaza: a primer (HT: Donald Sensing)

 ♦ Everything you ever wanted to know about screwing: When a Phillips is not a Phillips!

 ♦ And while we’re on the topic…: No, not that kind (well, kinda sorta) — but how the media can screw up reporting a study in order to, you know, make it fit their narrative: Like a Virgin: The Press Take On Teenage Sex

 ♦ Crime doesn’t pay – but sometimes it can be damned clever: The Seven Best Capers of 2008

 ♦ “How much do you have to hate someone to not proselytize?” Penn Jillete (of Penn & Teller fame), an avowed atheist, meets the Real Deal, and is deeply touched:
 

Somehow I’ve got a feeling that he has a very interesting future ahead…

That’s all for now — God bless, back soon.

God of Loss and Grace

The Anchoress tells of receiving heartbreaking news: the prospect of losing her hearing:

Yesterday morning, though, came a straw I have dreaded my whole life, and I finally drew it: the “you are losing your hearing” straw…

The loss was discovered, of course, due to that dismal ear infection of the past two weeks, but the hearing in that afflicted ear is only slightly worse than the other. Upon reading my test results the doctor asked if I had worked around airplanes for the past 20 years, or if I had fronted a rock band. “Severe degeneration! hearing aids!”

The pain of such a loss is real, and it is deep — it can neither be trivialized nor ignored. Some will deaden the pain by drink, others by denial or depression, or one of a host of other means whereby we mitigate the pain while refusing to embrace it.

We live with sense of entitlement: we should be free of pain and suffering. For most, such dire news — particularly about health and well-being — is a devastating blow, devoid of meaning and justice, a cruel trick of fate, perhaps, or some sort of karmic retribution for evil done in this life or one prior. It is at best random misfortune, at worst a cruel robbery, a brutal injustice. There is no making sense of it — it is without reason or purpose.

Yet for the Christian, things are supposed to be different. We serve — as an article of faith — a God of love, and when one has committed their life to such service, the reward of such a severe trial raises a host of uncomfortable questions: Is God unfair? Is this punishment for sin? Is He capricious, toying with me, playing me for the fool, demanding my obedience then rewarding me with pain and loss?

The Anchoress responds as many would — with rage:

“I drove home pounding the steering wheel and telling God I thought He was pretty damned unfair, after all. I demanded that He listen to me and make me a sensible answer about why things were going as they were, why at only 46 years of age I was increasingly debilitated, increasingly arthritic, increasingly feeling like a 65 year old.

It’s not enough that I must sometimes use a cane, or that I wear glasses, not enough that I am constantly bruised, often fatigued into stupidity and inarticulate, stammering aphasia, not enough that my body is scarred all over and that my skin is under seige simply because I am Irish! now I am going to need hearing aids? Now I am going to be deaf? What has my husband ever done to you, that you need to inflict this sort of wife upon him?

Oh, I howled. I ranted.

And it was so out of character for me to do so – this has not been my way, to shake an angry fist at God and make demands. I didn’t like doing it – it felt so wrong. So wrong, not to simply be thankful for my blessings – for all the good things, and all the “not too bad” things.

But I was so angry.

Anger at God — a frightening, even terrifying thought. At worst it presents images of lightning strikes, fire and brimstone, judgment, destruction. Better to pretend you’re not angry, hide it from God lest He send another, more awful plague in retribution.
Continue reading “God of Loss and Grace”

The Celebration of Hope


The lady on the morning “news”, in her warmest and faux-sincere voice, said it sweetly: “This is the season of hope and joy” — and moved on quickly to tug at the heartstrings with some touching story of the downtrodden redeemed, a perfect production for this “holiday” season.

I don’t really think she understands the things of which she speaks.

I often wonder, when watching the scrupulously secular stars of media utter such banalities: what, exactly, is the basis of your “hope”? Is it the optimism of wishful thinking, the notion that in our oh-so-progressive world, things will simply get better and better, hurtling at light-speed toward an inevitable utopia? Is it the hope of new politics, new icons of power to guide us out of the wilderness of war and hatred with an enlightenment found nowhere else? Or is it simply the Big Lie, repeated ad infinitum until it becomes Truth, designed to deaden terrifying voices of angst and uncertainty which screech like harpies just beneath a consciousness deadened by frenzy, acquisitional obsession, and the myriad addictions which numb our fears and deaden our souls.

Yet it is a season of hope — or more precisely, a season to celebrate a perpetual and profound hope, not the emotional hopiate mainlined by the hopeless, dragged out like some green plastic tree from a dusty closet to adorn a meaningless holiday, no longer called “Christmas.”

So what is this true hope, this enduring and transformational power which we celebrate this season, yet abide in throughout the year?

It is the hope of true harmony, God and Man in right relation, the only source for Peace on Earth.

It is the hope, beyond reason, of forgiveness of the unforgivable, of acceptance of the rejected, of healing of sick and mortally wounded souls.

It is the hope of conquest of the demons which drive us, enslaving us in what masquerades as freedom.

It is the hope of deep joy, not mere shallow happiness.

It is the hope of a purpose beyond self-satisfaction, of a meaning beyond random chance, of direction for the lost and aimless.

It is about God becoming small that Man may become great, in Him.

It is about sacrificial love, the emptying of self, the death of pretense and a life of humble dependence.

It is about a Child who became Man so that men might reclaim the wonder and joy of children.

It is about infinite love, abounding mercy, endless grace, transformational power.

It is about Christ: humble in birth, extraordinary in life, sacrificial in death, glorious in resurrection.

It is about our hope — the only true and certain hope — the hope of those who know, and serve, and rely on Him, and His gentle hands which lift us up, and cherish us, and carry us home.

It is about Christmas, when Light entered the world and changed it forevermore.

That is our hope, and nothing less.

Have a most blessed and Merry Christmas, and may the peace of God rest upon you and yours.