Who Are My Lawyers?-- Gilbert Schaffnit

     One of the first stories Gilbert Schaffnit told me was about his representation of Rodney Long in 1994.  Together with Gloria Fletcher they had been able to secure, in a jury trial, Long's acquittal following two federal grand jury indictments for drug conspiracy charges.  Mr. Long called Schaffnit his "F. Lee Bailey-like attorney," and said Schaffnit and Fletcher had  helped him "to team up with the Holy Ghost to beat this Goliath called the Feds."  Long went on to serve on the Gainesville City Commission for numerous terms.
     Mr. Schaffnit was not full of bluster or bravado when he recounted the story of that trial.  As a matter of fact, he said he had felt unsure about the outcome until the moment the jury announced its verdict.  "You never know about juries," he said.  "They are totally unpredictable.  I was nervous as heck up to that moment, and as surprised as everyone else afterwards."
     I like this about him.  He isn't skating by on conceit.  He understands his place in the big scheme of things, and knows that defense law is not necessarily about running all over the opponent, hollering and blaspheming.  Schaffnit has a sense of propriety, and doesn't want to make enemies.  "I have to keep working with these people, whether I win or lose a case," he said about government prosecutors and judges. So I retained him.  Some of my friends thought I should have chosen an animal of an attorney, a wolf, a lion, a three-headed monster.  But I didn't feel like hanging out with someone like that for the next who-knows-how-many years.
     He also regaled me with stories about the pornography cases he gets asked to defend, and a missing-person-whodunit-probable-murder case in Curacao--a tale fit for a bestselling crime novel.
     I guess it's standard practice for professionals to pull out these narratives as a sort of running oral history curriculum vitae for potential clients.  I do it myself, from time to time.
     "I had a patient with that same numbness and weakness in the legs, and I made the diagnosis of Guillaume-Barre," I've heard myself say.  Is this information--or boastfulness?
     Or, to a patient:  "I've seen that rash before--it's lichen planus, and here's what you do about it."  Sometimes stories are just information.  
     When Mr. Schaffnit recounts his memoirs he takes obvious pleasure in them, laughing at the funny parts, piecing together his identity for you, and everyone around you, out loud.
     What are clients thinking, when they sit around listening to lawyers' these war stories?
     What you're supposed to think:  This guy really knows his stuff, and he's smart, and experienced.
     What you're really thinking:  What do these stories have to do with me?  Am I paying for this time?
     What effect it finally has on you:  This guy's got the confidence, and reputation, and personality to handle my case.
     Mr. Schaffnit has a boyish charm, and not an ounce of malignancy.  He is acutely aware of politics within the local judiciary, and doesn't want to get in the way of the long-term aspirations of others--not even his opponents.  While this can be exasperating for clients who want to destroy their accusers as a way of exonerating themselves, that wouldn't be fair play for Schaffnit.  I think he felt genuine compassion for Corey Smith, my prosecutor, when Smith's big trial in Tallahassee flopped earlier this year. He had to make references to the case because it had been the excuse given by Smith for not paying attention to my case.
     "Corey Smith is incredibly busy," Schaffnit told me, as though expecting my sympathy.  "He's under a lot of pressure from his bosses, all the way up to the top.  They're under direct orders to find healthcare fraud, and prosecute."
     "Even people who aren't guilty?"  I asked.
     He didn't answer, at first, instead squeezing his lips together and looking up at the ceiling.  Then he said, "There's a lot more going on for federal prosecutors than you realize."
     Prosecutors are caught up in politics, and lawyers like Schaffnit are caught up with prosecutors.  I am a tiny fly stuck on one of the sticky strings of a political-judicial-financial web meant to capture dollars for a national system in arrears.  It's hard for anyone, even lawyers, to know the best tactics for extricating me from the entrapments utilized by our federal government.
     If it's true that the best lawyers are killer types, I'm doomed.  Mr. Schaffnit doesn't look lethal, and he's probably too cheerful to chop off someone's head in court.  But I can't discount his thirty-six years of experience in north Florida, taking on cases as unsavory as murder, rape, drug trafficking, child pornography, identity theft, and vandalism.  He seems to know everything about everyone in the northern and central Florida court systems--and "knowing the enemy" must count for something.
     Maybe his innocuous exterior is, in part, a bluff.  Despite his decency and bonhomie, and his harmless avocations (he loves to watch cooking shows), maybe he won't compromise when it's time to speak up on my behalf.  And postponing that time, frustrating as it is for me, seems to be part of his strategy.  

Are My Lawyers on My Side?

     This is a dangerous question, somewhat like, is your spouse being unfaithful, or are your kids, who got power of attorney to take care of you, stealing your social security checks and mortgaging your house?
     Do I really want to know the answer?  Because if I do, it may change my orientation to my little world, and alter my mood.  I may not be able to foster hope if I get an unhoped-for answer.
     Maybe it's easier to live in a little hobbit of a life with happy trolls and trees that talk, and butterflies, and weird TV news of how horrible it is out there, far away from one's everyday life.  I know people who live like this.  "Just give me happy news," they say.  They want the fabrications that make it possible to get their creaky, corporeal selves out of bed every morning.
     I've accumulated $115,000 in legal fees, and still don't have a clue what's going on.  You'd think this  amount of money might buy me something--but I think it amounts to enough for introductions.  My lawyers have warned me that $100K is a dribble in a deep, dark well when it comes to federal cases, which are full of really important, and powerful, and expensive people.
      My legal fees include those from lawyers hired to defend me against other lawyers who acted with gross disregard for standards of professionalism, mainly when it came to presenting their bills.  And it includes lawyers who advised me about the lawyers who might defend me against lawyers who grossly overcharged once they started to defend me against the government, whose charges are invisible.  (See the July 1, 2012, "Why I Was Forced to File a Pro Se Motion," and August 4, 2012, "Another Lawyer Tale.")
     When the Gainesville Sun called one of my lawyers, Gilbert Schaffnit, the reporter asked for a comment, and Schaffnit gave what amounted to a defense of the government, not me.
     According to the article, Schaffnit said a court order in the case enables patients to get access to copies of their medical records that were confiscated in the raid.
     In fact, it has been exceedingly difficult for patients to obtain their records--and most of the ones who have tried gave up in frustration.  The FBI requires a ten-step process to retrieve specific records, as well as payment up front for copying and postage--for documents I created, safeguarded and still need to care for patients properly.  One prosecutor, Bobby Stinson, said after our flunked court hearing that it was too expensive for the government to copy large numbers of charts, and it would take about two weeks to mail a copy of any document.  Two weeks is no help at all in an emergency--so far there have been twenty such emergencies in which a patient's chart would have prvented pain, confusion, or hospitalization.
     I'm not sure why my lawyer, Mr. Schaffnit, didn't say any of the other things that happen to be true about my situation, such as:

          1.  It's very difficult for Dr. Colasante to get copies of the records she needs for patients.
          2.  We have NO IDEA why the government is investigating Colasante Clinic.
          3.  We hired an independent coding expert, who did an outside audit, and could find nothing to justify the federal investigation.  
          4.  The government has been accorded terrific powers, alongside which ordinary citizens like Dr. Colasante have very few options.
          5.  This has got to be difficult for a doctor in a small community.
          6.  The government has a seven-year statute of limitations, therefore this case could go on and on without our having any clue about its nature.
          7.  It often happens that when a federal case falls through, government agents try to save face by drumming up civil charges, and collecting fines that help pay for the inapposite investigation. 
          8.  It's likely that one or more grand juries have convened for the purpose of indicting Dr. Colasante, but so far an indictment hasn't been delivered.  Perhaps it's because she's so innocent that even a grand jury--known to indict just about everyone--can't find cause for the government's intrusion.
          9.  A court hearing failed to allow Dr. Colasante access to the affidavits that gave the FBI permission to raid her clinic and bank accounts.  The government's reason keeping the affidavits sealed seems to be, simply, that they can.
         10.  For the past ten years the prosecution of choice for the government has been healthcare fraud.  Although large scale medical fraud scams are bankrupting Medicare, they're hard to track down because they doesn't involve real doctors or medical facilities.  So government agents go after clinics, because they're easy to attack, in the hope of giving the appearance of doing their job for taxpayers.

     Maybe Mr. Schaffnit didn't say any of these things because he's skillful and experienced, a real tactician who understands that this case, like so many others, is not about guilt or innocence, truth or lies, but about greed, manipulation, position, money and politics.
     Neither is the case concerned with a noble pursuit of justice, something we might hope for as the hallmark of our preeminent judicial system.  It's not about lawyers choosing ethical positions from which to speak in defense of clients;  it's not about using facts and rhetoric, in the manner of Seneca, to reach a satisfactory conclusion.
     No, our cultural and organizational ethic allows opposing parties to flout or bend the rules in order to "get the job done."  What is "the job"?  To recollect money for an impoverished federal government, and to do it by going after doctors, no matter what the cost to the country.  The money taken back justifies the means used to do it.
     Mr. Schaffnit is sympathetic toward the government's tenuous position.  He knows that if he offends the federal prosecutor and his agents he might make matters worse.   He's looking after their reputations.  "You've got to understand, these guys are under a lot of pressure from above," Schaffnit appealed to me.  Then I understood that it must be his plan to tiptoe around their egos, and preserve their reputations.
     Wait--isn't he supposed to be looking after my reputation, and managing my defense?
     That's what I thought.  But this is a contest, not a case.  In a contest you don't crush the other person's ego.  It's not even about winning, or my getting exonerated.  Oddly, I seem to be involved in a situation requiring that we all keep the government's (shaky?) image intact, even if people like me have to pay for it.  
     How am I going to help those government agents who need to worm their way out of their wrongly-held position?  How can they justify the money they have spent on my case?  These are the questions, it seems, that should concern me--not, selfishly, saving my own skin.
     Why can't the prosecutor admit he has made a mistake, and back out of my case?  Because a prosecutor who wants to run for political office, eventually, is more likely to succeed as a conqueror than a seeker-after-truth.  Besides, he can't afford another failure, at least not this year.
     I guess I'm not ready to know whether my spouse has been unfaithful, or my children corrupt, or which side my lawyer is on, at least not yet.  I'm still making an effort to defend Mr. Schaffnit, because he has a reputation for success and decades of experience behind him.  Besides, he's a nice guy--despite his defense of the government, his insistence on inaction, and this waiting game--which is like having to keep my manners at a tea party.
     The problem is, it's a tea party before a decapitation.  Government indictments, when they happen, can lead to years in prison, if someone doesn't get the defense right.  That's not a party I want to attend.  

Change.org--Please Sign My Petition

     Please sign my petition to United States Attorney General Eric Holder, and the Department of Justice, asking them to require the prosecutor, Mr. Corey Smith, to open the affidavits containing justification for raiding Colasante Clinic.

     Here is the link:
       file:///Users/colasante/Desktop/Petition%20%7C%20Show%20Cause%20for%20Raid%20on%20Colasante%20Clinic%20%7C%20Change.org.webloc

     Here is the body of the petition:

    The FBI raided my solo medical clinic and will not tell me why.  FBI agents also forfeited my clinic and personal bank accounts, leaving me without capital to pay my staff or bills after the raid.  A court hearing requesting return of all my patients' medical charts, return of funds, and an opening of the affidavits explaining the reasons for these damages failed on all three counts, because government agents have acquired terrific power since passage of statutes allowing them to bypass certain civil rights in the name of the war on drugs, the war on terrorism, and HIPAA.

     My clinic has been under investigation since June 2010.  It was raided on June 16, 2011.  It may be five more years before I am informed of the government's suspicions, or am able to get patient charts back, because there is a seven-year statute of limitations on investigations like this.  My lawyers cannot find a reason for the raid, nor could an independent consult hired to analyze billing and coding records.  But they say there is nothing they can do.  Meanwhile, my patients' medical care has been affected by the loss of their records, and my reputation and self-esteem have been damaged.

     Mine is not an isolated case.  Many doctors undergo audits, Medicare payment denials and "take-backs," investigations, raids, and bank forfeitures at the hands of overzealous government agents eager to further their reputations, and to patch holes in the national debt with money from raids and forced settlements.  It is so expensive and time-consuming to defend one's innocence in court that lawyers, including mine, often recommend settling.  Settling means turning over money without ever being given a reason, or being granted due process, and seems like an encouragement to the government to do this again and again. 

     With the implementation of the Affordable Healthcare Act in January 2013, the United States will need 40 million new doctors.  Yet the government has stepped up its attacks on doctors by auditing en masse, accusing us of billing errors, and refusing to pay for services through Medicare.  There is no workable appeals process.  For this reason, and to steer clear of the defamation of character caused by raids like mine, 37% of physicians say they plan to retire in the next 10 years.  The rest are joining corporate group practices, working for the government, or thinking about quitting.

      The government should reduce the seven-year statute of limitations on raids and investigations, so that government prosecutors cannot hide evidence (or the absence of evidence), effectively holding people like me hostage for an intolerable numbers of years.

     Please support my petition demanding the Department of Justice to show cause for the raid on my clinic, and to do so immediately.  This will bring to the foreground the problems doctors face--especially solo doctors--and rescue me from what feels like a police state, making it difficult to concentrate on patient care.  It will also bring to light the milieu of pressure and fear within which doctors practice.  These conditions must change if we are to have enough doctors left to care for people, and any solo doctors at all.

     My blog, solodocssolong.blogspot.com, gives more details about my case.  

        

How to Lose Weight--A Doctor's Advice

1.  Buy a pack of 3x5 cards.  Each morning, write the date on the card.  Every time you put anything in your mouth, write it down.  This includes every sip, taste, chip, chicklet, or breath mint.

2.  Stop drinking calories.  Don't  drink anything with calories, even if the drink label implies it's "healthy" (e.g., Smartwater, Vitamin Water, Gatorade, or 100% juice--they're all bad).  Calories from drinks cause weight gain without a sense of fullness.  If you drink one 12 oz coke a day beyond your calorie needs, you'll gain 15 pounds a year.  (Some studies even show that diet drinks cause weight gain, despite the absence of calories.)

3.  Walk, or exercise in any way beyond your current activity level, for five minutes a day.  Every week, increase this amount by one minute a week.  In five weeks you'll be up to ten minutes a day.  In thiry weeks you'll be up to thirty-five minutes a day.  If you think you can't exercise, turn on the radio and dance for five minutes.

4.  Stop watching TV.  People burn more calories sleeping than watching TV.  If you can't stop watching TV, reduce your TV watching as much as possible, and resolve never to eat while the TV is on.

5.  If you like to count, don't count calories.  Instead, count:

          a) Grams of fiber.  Eat 40 to 45 grams of fiber per day.  Fiber content of food is available in lists online.  For packaged food, it's available on the package, grams per serving.

          b) Servings of fruits and vegetables.   Eat nine servings of fruits and vegetables a day, but not juice.  Fresh, local products are best. Chips and french fries don't count as vegetables.

6.  Make a decision to cook everything you eat for one day a week, minimum.   On this day, don't eat out, don't buy microwavable, canned, or already-prepared meals, and plan to make a meal from real foods:  e.g., poached salmon, brocolli, baked potato, fresh fruit with yogurt.  If you are inclined, work up to doing this to the point where you only eat out once per week.  The time spent cooking should be considered future savings on time spent in the hospital or nursing home.

7.  Eat one serving of beans a day.  Eat one serving of cultured food per day:  yogurt, sauerkraut, kimchee, miso, pickles, buttermilk.  If you don't eat cultured foods, take a lactobacillus ("probiotic") capsule daily.  Probiotics help the GI tract utilize nutrients better, and they probably improve the function of the immune system.

8.  Get enough sleep.  For most people, this is about eight hours a night.  Too little sleep triggers production of cortisol, a stress hormone, which then induces cravings for fats and carbohydrates.

9.  Ask a doctor about any of the following prescriptions:  Byetta, Victoza, metformin, Wellbutrin, Topamax, phentermine.  Or consider these supplements:  Rhodiola Rosea, Magnolia officinalis, chromium picolinate, 5-HTP, linoleic acid, phellodendron amurense, hydroxycitric acid, green tea polyphenols, green coffee bean extract ($19.99/mo at Sam's).

10. Join a group:  Weight Watchers, TOPS (Take Off Pounds Sensibly), or Overeaters Anonymous are national organizations.  People who participate in a weekly support and information-sharing group focused on weight loss have greater success and more sustained weight loss than those who use the internet or try to lose weight alone.

Thoughts while Jogging with My Staff

     The Colasante Clinic running coalition got together again yesterday, after a regrettable hiatus, to run two miles.  It was long past dusk and there was a gamey breeze tossing about the Howard Bishop Middle School track where we met up after work.  Running with others improves motivation.
     "My body feels like a ten ton truck," I lamented, halfway through the first lap.
     "We haven't been running together for two months and one day," the medical assistant informed us cheerily.  She wasn't short of breath, because she had kept up with the running program on her own.  I had bailed out, however, and so had the others, with the usual vacant excuses:  "It's too hot.  It's raining.  I don't have time.  I forgot my running clothes.  There are too many mosquitoes.  I'm hungry.  I'm exhausted.  I have to write in my blog.  I didn't sleep last night.  I have a headache.  Maybe tomorrow.  Maybe the next day."  Truth was, we just plain didn't want to run.   We thought we were plenty noble, just showing up for work, taking care of patients.  But our morale had been suffering.
     "Can't we just lose fifty pounds while crocheting and watching movies?" moaned another provider., panting to keep up.
     "Yeah, and let's include a glass of red wine and some brownies in that request," I added.
     Most of the people on my staff want to lose weight--so do the patients, and so do most Americans.
     I recommend setting a goal of ten percent of a person's current body weight.  A two hundred pound woman, then, wouldn't feel so hopeless aiming for a twenty pound weight loss, instead of sixty.  Studies show that overweight people who are able to lose ten percent of their body mass are enjoy vastly improved health, and have a lower risk for heart disease and diabetes.  Once that ten percent falls off, the patient is sometimes optimistic enough to lose another ten percent.
     My staff and I invite our patients to join us at the track, but it's rare for a any of them to show up.  However much they want to lose weight, most can't seem to commit to a regimen.  I can't blame them.  I stopped running, too, for two months.  And one night last weekI ate an entire pint of Haagen Dazs rum raisin ice cream for dinner.
     How can I help my patients?  This question is constantly on my mind.  I sometimes feel like a failure as a physician, because I know that losing weight and exercising is exactly what would cure many of them of all their ills--more than the pills and easy panaceas they constantly request.
     But I'm failing to convince them, or  inspire them, or fix the fattening culture in which we're enmeshed.  Is being overweight and inactive a psychological problem?  Or is it a problem amplified by corporations which aim, via in-your-face ads, to increase consumerism?  Or is it compensation for our empty spiritual lives, lack of community, breakdown of family?  Is obesity related to environmental toxins, food additives, or malnutrition?
     Malnutrition?  Yes, my patients are obese, and malnourished.  Many are deficient in vitamins, protein, and probably trace minerals, even as their blood is gushing over with cholesterol and fats, and their legs are swollen with fluid--signifying too much salt, and too much sitting.  It's no secret:  much of the food available to us is empty of real nutrition.  It shouldn't even be classified as "food."
     I donated my clinic waiting room for Weight Watchers meetings, because there isn't a single site for my patients on the east side of Gainesville.  It took three months and a lot of paperwork to get approved.  But now, we can't recruit the minimum number of members--fifteen--to start having meetings.
     Surely there are fifteen people who could commit to a proven weight loss program (Weight Watchers is the most successful weight loss program in the world) on the east side of Gainesville. Ninety percent of my patients want to lose weight--need to lose weight, more than anything else, to cure their symptoms.  Almost everyone in America would benefit from regular, vigorous exercise.  But I am failing at the all-important task of motivating people to join the $10/month gym down the road, or show up at the track to run with our group, or eat more nutritious foods, or join Weight Watchers.
     I have considered giving classes in nutrition, gardening, cooking, food shopping.  Our clinic put together a program for obese children two years ago.  I try to address, during clinic visits, the emotional underpinnings of overeating, and the relationship between food and feelings of deprivation, or childhood abuse, or pain, loneliness, grief, pain, boredom, lack of purpose, and hopelessness.
     I didn't solve any problems last night, as I ran eight laps with my staff.  I kept thinking about my patients, and how great it would be if I could get every one of them down to a normal, healthy weight.
     And at least, for a change, I wasn't thinking about the federal investigation, or the raid, or injustice, or my begrimed reputation, or FBI agents, or spurious crackdowns on fraud that give government agents an excuse to pose as protectors of the people.  For an entire twenty-five minutes, I wasn't thinking about any of that stuff.
       

How Do You Borrow Millions When You're Broke?

     Several months before Pat McCullough purchased Hawthorne Medical Center she phoned me.
     "One of my bank loans fell through," she said.  "I want to propose something.  Why don't you carry the loan for me?"
     "Why don't you get another loan?" I asked.
     "I've tried every bank and lending organization I know," she pleaded.  "They're just too unstable."
     "I don't believe you," I told her. "Why don't you borrow against your personal property."
     "I just don't have enough to do it," she said.
     "I don't want to loan you money."
     "You know I'm good for it," she said.  "I'm absolutely sure I'll be able to continue the success you've had at the medical center--with your help, of course."
     Pat said she could still make the down payment, with a loan from her bank in Kentucky, but she wouldn't be able to get loans for any more.
     One of the banks that was (supposedly) willing to lend Pat money was Silver State, and it had indeed gone bankrupt--along with twenty others at the time--in the nation's banking crisis of 2009.   But the "bank official" had met with me and Pat, and Pat's "consultant" in Tampa just a few months earlier.  Now I wonder if that meeting was a scam--fake business cards, lots of bluffing, reassurances that everything was going to be fine.  It's also possible that a bank official participated in a plan to defraud his/her own bank.
     Because I wanted to work full-time on the autism farm project, and because Pat had delayed closing on the sale for more than a year--taking copies of all bookkeeping and patient billing records (after signing a confidentiality agreement)--I did end up carrying the bulk of the loan for the purchase of Hawthorne Medical Center.  Pat made a down payment on the day of the sale, March 16, 2010, and rationalized not writing a check that day, as agreed, for the consultant who had told me about Pat in the first place.  As part of the negotiation, Pat was supposed to pay him--but she never did.  She was also supposed to fund the employee retirement plan for the prior year--she never did that, either.  And she signed a lengthy contract, agreeing to make loan payments to me every month for the next five years--she made three payments over a five-month period, then stopped paying altogether.  She also stopped responding to any calls from me or my attorneys.
     Pat didn't send monthly profit-and-loss statements, as she had contracted to do--until my lawyers demanded them in August and September, 2010.  I looked at them and knew immediately that they were a product of invention, having no relation to real expenses and profits.  Pat barred me from stepping foot on office property six weeks after the closing, and made all the employees sign a document agreeing never to speak of anything having to do with office business outside the office.  For the first month after the change of ownership I worked daily at the clinic, seeing patients, training a physician assistant Pat hired, and expecting to explain clinic protocols to Pat and a few other new people.  But Pat wasn't interested in anything I said, expressing either irritation or boredom in our few conversations--very odd behavior for someone who truly intended to run a medical clinic, and who had no prior experience.
     How, then, did Pat manage to accumulate $12 million in debt over the next year?  If she saw that the clinic was not doing well, wouldn't the first line of action be to ask me for help?  We weren't enemies--in fact, Pat had suggested that we would be "best friends" because we "had so much in common" and there was "a lot we could teach one another"--but that was before the sale.
     After the sale of Hawthorne Medical Center, Pat needed me to be gone.  She couldn't afford to have someone poking around while she carried out her real intentions.  Employees who questioned her were fired.  Those who expressed loyalty to me were treated with scorn.  The bookkeeper who had managed payroll and paid bills for the medical center for years was suddenly cut off  from financial information about the business.  Pat had her "accounting people" in Lexington, Kentucky "take care of the bills"--which meant, mostly, that none of the bills got paid, and evidence of clinic revenues was hidden.
     Payments for medical services that had been provided prior to the sale came in--and disappeared.  Pat hired nursing and billing staff solely for the purpose of reviewing claims and collecting as much as possible on the outstanding accounts she had acquired.   Staff members called me after hours and said, "We're getting paid, because we can see that checks are posted to patient accounts--but we don't know where the money is going."  The moment insurance payments were deposited into the local M & S bank, it was transferred out, according to one front office employee who saw forms for wire transfers pass over the fax machine.
     Pat's representation of profits and losses in August and September 2010 showed impossible losses.  The two financial statements she sent me had to have been falsified.  She sent the financials she needed me to believe, proving  that a) she couldn't make payments on the loan I carried for her, and b) I was somehow responsible for the "failure" of the medical facility.
     Meanwhile, however, she managed to secure more loans from banks--including her local bank in Kentucky.  How could she do this, if her personal and business assets were as low as she reported in her statements to me?   Banks don't give loans to businesses that are failing.  Pat must have represented the financial status of Hawthorne Medical Center differently to banks and other lending institutions, especially at a time when the banking industry was subject to heavy scrutiny.  But then, I'm making the assumption that a bank employee would never collude with a borrower in such a way as to compromise the bank.
     Pat McCullough never moved to Florida, despite owning a new business that had required all the time, stamina and acumen I could muster when I was in charge.  I was experienced, understood the patients, and had excellent staff, yet I couldn't leave for a few days without concerns--this is what it means to run successful business.  There were no outstanding debts when the sale was consolidated--in fact, there were substantial credits, which Pat did not refund to me. 
     Instead of spending time at her new medical center, Pat took frequent vacations (including three weeks in Paris two months after the sale), and commuted to Hawthorne between four-day weekends at her ranch in Kentucky.  The demise of the business had to have been a planned affair (as was the "bankruptcy"), therefore its ownership was temporary.  Pat had a strange business strategy, unless you look behind the scenes.  She accrued debt after debt, which was easy to do with vendors and service-providers who relied on my good name, and the credit rating of the medical center.  She kept my name on many of the accounts--which I discovered months later, when collection agencies started calling me at home.
     So, how does someone who has all the assets of a solvent and thriving medical center--including 8,000 patient charts, two experienced physicians, and four other providers, with the prior owner just down the road as a consultant--and who receives insurance payments daily, as usual, and who sells the existing equipment for cash, then leases "new" equipment (but doesn't pay for it), and who doesn't pay  bills--even shirking payroll for so many weeks she gets reported to the Labor Board--and who declares in a written statement that she has become insolvent in a matter of months--how does such a person manage to borrow and lose (in a bad economy, when banks are going under) (and then be granted bankruptcy relief for) $12 million--or $4 million--or $2 million--(how many millions she borrowed is not quite clear) in just over a year, not including the debt for the purchase of Hawthorne Medical Center?
     It takes some smarts, or guts, or maneuvering, or misrepresentation, or a really cool plan, or charisma, or the opposite of empathy, or--would you call it sleuth-work?--to shyst so many people, and come out clean.  Now, all Pat has to do is wait for a whistleblower fee to fall into her bank account, and she can say, with a snicker, she won.
     

Late Summer Sangria

Here's the Sangria I serve at the summer office party each year.  It's great on a hot, sunny day.  I complimented the server while I was drinking it on a trip with my third son, celebrating his graduation--then the chef came out to receive my praise, and gave me the recipe in French--"a bottle of this, a little of that...."  His restaurant, a modest spot where you sit at little tables along the cobblestone street is Le Vieux Fort Cafe, and is in Carcassonne, France.

3 bottles red wine
2 quarts orange juice (fresh-squeezed best)
1/2 cup fresh lemon juice
3 cups dark rum
1/4 cup grenadine
1/2 cup sugar (or 1 cup simple syrup)
fresh sliced pineapple, oranges, and peaches (3 cups)

Mix all ingredients, adding fruit at the end.  Allow to rest in the refrigerator several hours before serving over ice, or straight.  

Chinese Eggplant

The end of summer in Florida is the least productive for garden vegetables.  The only local items at the market are peppers, okra, pumpkins, persimmons, and eggplant.  There are so many different ways to prepare eggplant, however, that it can seem as though you're eating a different dish every time.  Here's one of my favorites.  It's easy to make, and tastes even better than the eggplant in Chinese restaurants.

1/4 cup sesame seeds
10 Asian eggplants (4 pounds), skin on, cut into one-inch cubes, 
1/2 cup peanut oil
1/4 cup toasted sesame oil
1 tsp salt
1/2 tsp pepper
3 inches peeled ginger, minced
1 or 2 hot peppers, minced
8 scallions, minced
1 cup mild white wine, or water
7 Tbsp soy sauce
3 Tbsp rice vinegar
1 Tbsp brown sugar
2 Tbsp cornstarch, stirred into 1/4 cup water
Fresh basil or cilantro

     Heat a large skillet or wok.  Add sesame seeds and stir until fragrant and lightly toasted.  Set aside.
     Add  one-third of the peanut and sesame oils to the skillet and raise the heat--then stir-fry 1/3 of the eggplant until soft, sticky, and lightly browned.  Remove from pan to a serving dish, and repeat the process, 1/3 at a time, with the remaining eggplant.  Salt and pepper the eggplant.
     After the eggplant is done, add to the hot skillet the ginger, peppers and scallions, stirring for a minute or two.  Then add the wine or water, soy sauce, vinegar, brown sugar, and cornstarch mixture.  Stir until thickened, adding more water or cornstarch mixture to make the consistency sauce-like.
     Return the eggplant to the pan.  Sprinkle with basil or cilantro, then with toasted sesame seeds.   Serve over brown jasmine rice.  Sliced oranges make a good side.  Serves 4-6.

Summer Office Party

     I held an office party at my house this weekend.  The summer party is fun because it's a family affair, whereas in December we have a more formal holiday party--with couples, dancing, and the ribald laughter and racy gift exchange that are typical of medical staff gatherings.  The tension of life, death, sickness, anxiety, rules, regulations, time constraints and the inexorable demands for perfection during clinic office hours give way, in our leisure time, to something approaching all-hell-breaking-loose.     

     I chided the employees before the party:  "Your admission ticket is a child."  Therefore, we had the pleasure of watching lots of children galloping and cavorting across the broad yard, and I was able to cradle in my arms one chubby-cheeked baby after another.  At my insistence we held many contests--the kids were all for it, but the adults had to be coaxed away from their lawn chairs and the grilled chicken.  When was the last time you played "Musical Chairs," and had to bump bums with your office confreres?  When did you last watch a couple dance "The Shag" for a prize of a toy skeleton, or a bottle of Crown Royal?  Still, the box full of colorfully wrapped gift-prizes was not enough to lure all the self-conscious adults onto the deck for the dance contest, or onto the trampoline for a flipping tournament, or into relay races or swim competitions--but they did play some rowdy volleyball, and I saw some cutthroat personality traits during rounds of ping-pong and air hockey.  The "Limbo" challenge was not to be missed--participants finally lowered their bellies beneath a rope suspended only fourteen inches from the ground!  And one adult beat all the kids in jump-rope, making it to 147 jumps before the rope hit her shins.  

     One year the party lasted late into the evening, and under the stars there burst forth from my straight-laced employees' wide-open vocal cords such big voices, and such sultry melodies, and such voluptuousness and beguilement that I knew I had a lot to learn.  I thought to myself, "I don't know these people," and "We need more parties."

     Employers like me are in danger of seeing our employees in only one dimension.  This encourages us to pigeon-hole the very people we depend on for our survival, and then to react to them as though they are nothing but workers.  In fact, small businesses are most successful when people work together as a unit, depending on one another to get the big jobs done, and offering moral support and even physical sustenance in times of need.  

     "Need a beer, Doc?" I sometimes hear from one or two of my staff at the end of an especially difficult week. They sense my level of tension, and my exhaustion.   When one or another employee is having car trouble, there's always, "I can give you a ride," or "Can I help you with some jumper cables?"  When the security system gets tripped in the night, my nurse practitioner will rush in to turn off the alarm and figure out what went wrong.  When one employee has foot problems, the others give her sit-down work to do.  When another is sick, they all change shifts to make sure the office has maximum coverage.  Everyone in the front desk area is cross-trained to do every job, and there are no slackers--if there were, they wouldn't last.  The nursing area functions like a big, well-oiled machine:  if one person misses a beat, the whole operation comes to a halt.  "What's going on?" I'll demand of the first person I see, when we've run out of forearm splints, or Toradol injections, or when an IV isn't set up in short order for a very sick patient.  "Whose job is this?  Who's not up to speed?"  

     When an error is made, however small, I ask each employee the same question:  "How many errors are allowed in a doctor's office?"  The answer:  Zero.  Why is medicine so intolerant of incompetence?  Because one error could cost someone his life.  

      Small businesses can't tolerate the lassitude, ennui, imperfection, and malingering that are so common in bureaucracies and large corporations  In a small clinic, everyone knows when one person isn't pulling his weight--and the pressure to "do the job or disappear" is strong.  Colossal businesses solve the problem of shirkers and idlers by "laying off" large numbers of employees in one fell swoop when it becomes apparent that the work performed doesn't come close to expectations for the aggregate.  But lay-offs aren't necessary in small offices, because staff members are self-selected for the job.  Personalities have to mesh, and people must perform--and in medicine, they must perform perfectly.  For this reason, I no longer hire applicants who have spent years working at University of Florida, or Shands, or in nursing homes.  Perhaps this bias is unwarranted, but my experience has shown that these applicants don't have the stamina or work-ethic to meet the standards of a small, freestanding medical clinic.  They complain, or call in sick, or log onto Facebook, or answer their cell-phones while on the job--or they simply quit.  The job is just too tough, if you're used to being coddled by corporate parent-equivalents.

     Office parties are a chance for me to see my employees as human beings, who are responsible to--and important to--others.  While this may not make me more sympathetic when it comes to errors, it increases my appreciation for what these special people are trying to do in their lives, and how heroic their lives are.  I understand how much I need them, precisely because they are who they are, and I begin to realize why they are so good at their jobs in my clinic.  

     There is always a measure of conflict when people work alongside one another, because none of us sees the world in exactly the same way.  But human beings are communal creatures, and our conflicts are our greatest strength, if we move toward them rather than avoiding them.  In the minor abrasions we sustain as we bump up against one another in the workplace, in our disagreements and our little laments, are the seeds of self-revelation and the possibility of something greater being accomplished.  Each person's input has merit, and the effect of our work together is a greater force than all the separate units added up.  When I interact with my employees outside the work environment, at these parties, for instance, I have a chance to see how unique each one is, and I remind myself:  These are real people, with a lot more going on in their lives than what I see every day--I need to take care of them, and cherish them, because they are taking care of me.

     

"Strange Culture"

     "Strange Culture" is a film that depicts the way government agents take advantage of their power to deprive us of our civil rights.  It is one example of how FBI agents and federal prosecutors misuse the expansion of power granted to them in the name of the "war on terrorism."  You can watch this eerie 75-minute chronicle of one man's tragic run-in with puffed-up government officials who are protected from all penalties for the misuse of power, on YouTube.  Here is the link:  http://www.youtube.com/watch?v=cMPk9-1uifA 
      "Strange Culture" has relevance to my quandary, because it describes an FBI blunder not unlike the one at my clinic, followed by a scramble on the part of government agents to rationalize the time and money they wasted.  It conveys the turmoil caused in the life of an ordinary, productive citizen by uncalled-for government intrusion.
     The government, apparently, is incapable of saying, "I'm sorry."  The government never admits, "We made a mistake."  As far as I'm concerned, this is a pathological problem that exposes the core of the American psyche.  We are a culture full of destructive ego, bloated with power, overbearing, bulldozing, narcissistic, self-aggrandizing, and lacking in empathy.  These are personality traits one observes in dictators, and in people with psychopathy, and in brittle, self-serving authorities who always have to be right.  There is something psychologically wrong with our government--and our government is a mirror of our citizenry, and the showpiece for the world.
     Many of my blog readers are, strangely, from Russia, China, and South America.  Why do I have readers who herald from places where political dishonesty and debasement of human rights have been the rule, or where the government is in flux, and ideas about what it means to be free are of vital importance?  I am embarrassed for them to see that here, too, it's possible for ordinary people to be harassed, accused, and arrested by government agents, with little or no cause, or a "cause" based in prejudice and fear.
     Steve Kurtz is an artist and was the subject of "Strange Culture."  He and his wife were in the midst of preparing for a show featuring art-political works about genetically modified foods.  The components of their pieces included Petri dishes in which were growing colonies of a harmless bacteria, serratia.  On the day of the opening, Steve woke to find that his wife had died unexpectedly, of heart failure.  He called for emergency help.  When the police arrived, they made fear-based assumptions about the Petri dishes, and took Kurtz into custody on charges of terrorist activity.
     How could the police justify such a drastic reaction?  In the wake of September 11, 2011 many statutes were passed to "protect America"--statutes that continue to grant federal agents wide-ranging powers over American citizens.  Because of the omnipotence we have accorded our government agents, they were able to bar Kurtz from his house, to seize his belongings, and to accuse him of terrorist activity.  The same statutes also allowed government agents to invade my clinic, take vital documents including patients' medical charts, and confiscate all the money in my clinic and personal bank accounts.  No explanations are required from the government.  Their documents can remain sealed, it seems, forever.
     These statutes also give FBI agents the right, with meager suspicions (based, it seems, on individual agents' embarrassingly poor intuition) to raid your home or office, to haul away your electronics and other personal belongings, to cordon off your property with yellow "Do Not Cross This Line" tape, and to make you an object of suspicion in your community.
     How much protection do Americans really need?  So much that we are willing to give up our civil rights for the fantasy of safety?  So much that we are willing to live in a police state?
     What the government's agents did to Steve Kurtz, and to me, is not protection--it's a waste of time and money.  As far as I'm concerned, the powers accorded to government officials--like Special Agents Robert Murphy and Carissa Bowling, and U.S. Attorneys Corey Smith and Bobby Stinson, in my case, and like the prosecuting attorneys in Steve Kurtz's case--are opportunities for power-bloated agents to exercise their particular prejudices, their greed and envy, their sublimated drives toward violence, their unwillingness to do the painstaking research that should be required for ground their suspicions--before they wreck people's lives--and their confidence that being employees of the government grants them immunity from punishment.
     Government officials tried to pin on Steve Kurtz charges of terrorism, wire fraud, and mail fraud, based on his having used the U.S. mail for obtaining a benign bacterial specimen for his art, the film explained. "He was charged with possessing weapons of mass destruction," a friend reported "for which he faced twenty years in prison."  The odd thing about the fraud charges was that no one--not the seller, nor the postal system, nor the police, nor the public--felt "defrauded."
     "The government has an overwhelming amount of force in such cases," said the film's commentators.  "The FBI was interested in Steve's politics.  They wanted to frighten anyone who questions what is going on in this country."  The atmosphere of fear created in the aftermath of 911 allowed for passage of the Patriot Act with overwhelming support.  People consented to give up their rights, at that time--and those rights have not since been restored.  A decade later, we still don't have all the facts about the events of September 11, 2001.  But we've lost a lot of our liberty.
      "Civil liberties only flourish in times of peace," said Kurtz.  "The execution of the law is at the discretion of government officials."  If government officials were questioning Kurtz's source for the Petri dish specimens, their charges would have amounted to a civil--not a federal--crime.  Instead, the prosecutor in Kurtz's case enlarged the minor infringement that he suspected into a federal crime, punishable in a stricter federal court,  "When a civil dispute is turned into a federal crime, it expands the government's power hugely," explained a law expert.
     In cases like Kurtz's, and mine, the government colludes against the public good.  "Federal prosecutors care only about getting convictions--that's how they gets promotions and raises," said Kurtz.  "There are no guarantees, no safeguards, for the individual citizen."  These cases are not about finding out the truth.  They are about the prosecutor winning a case.  When the truth is subservient to gross power, or when it becomes completely irrelevant, there is no ethical basis for society.  "Might makes right," then becomes the only law that really matters.  

Who is My Prosecutor?

      Assistant U.S. Attorney Corey J. Smith is the prosecutor presiding over the investigation of my medical office, Colasante Clinic, which was raided by dozens of FBI agents on June 16, 2011.  On August 6, 2011 my personal and business bank accounts were forfeited, with Mr.  Smith's permission, leaving my business with no liquid assets for continued operation, and no means of paying for legal representation.   I know of no good reason for the government to have assaulted my clinic and my reputation in this way.
    Colasante Clinic has been under investigation for two years, three months, and six days.  The investigation was initiated in response to a whistleblower report filed by Pat McCullough, who purchased and bankrupted, in little over a year, my previous clinic--which was well-respected, solvent and had 8,000 patient charts--in Hawthorne, FL.  She needed to deflect attention from her wrongdoing, including misrepresentation of clinic assets to banks in order to gain approval for bank loans.
     Ms. McCullough's accumulated $12 million in debts was forgiven, astoundingly, in June 2011, in a Chapter 7 Bankruptcy filed in Lexington, KY..  During her brief ownership of Hawthorne Medical Center, Ms. McCullough found it easy to use her brash certainty, claims of victimhood, and unctuous charm to bamboozle vendors, lenders, insurance companies, local businesses, employees, consultants, and--perhaps--government agents.  Where did the $12 million go?  That's anybody's guess.
     On September 14, 2011 an emergency hearing took place at the Alachua County courthouse.  During the daylong hearing my lawyers requested return--or copies--of the 3,000 patient charts confiscated during the raid, as well as enough working capital to allow the clinic to conduct business.  They also requested that the affidavits giving the reasons behind the investigation be opened.
     Mr. Corey Smith represented the government at this hearing, along with U.S. Prosecutor Bobby Stinson.  Mr. Smith's argument against returning my patients' medical records was that copying them would be too time-consuming and costly for the government.  He stated that any important records could be obtained by following a procedure outlined by the FBI.  That procedure required ten steps, several weeks, and a cost to be borne by the clinic--and it proved unworkable.  Most patients, moreover, are still unable to obtain records directly from the FBI office.
     Mr. Smith's reasons for refusing to open the affidavits were twofold:  1) "Even redacted affidavits (with blackout of names or other identifying information) might put the witnesses at risk," and 2) "Dr. Colasante only wants to know what's in the affidavits so that she can build a defense."  Those reasons were good enough, apparently, for Magistrate Gary Jones, who presided over the hearing and permitted the affidavits to remain sealed.
     Mr. Smith had to delay his attention to the Colasante Clinic case because he was busy with another case, which went to court for seven days and ended February 20, 2012.  He was attempting to convict four former executives of Vanguard Fire and Casualty Company, on grounds of fraud.  A grand jury had indicted them, but everyone knows that grand jury trials are formalities--one-sided, conducted in secret, controlled by government officials, and in no way a declaration of guilt.
     The executives of Vanguard Casualty were charged with making false statements about the company's financial status in the wake of the 2004 hurricanes, after a spate of claims demolished the company's assets.  The statements were made to Florida's CAP fund as part of a request for help.   Here's the link:   

http://www.justice.gov/usao/fln/press/2011/mar/vanguard.html

     What happened?  It took six years and $500,000 of government money to bring the case to court.   (How did the defendants last that long, I wonder.  "The government moves slowly," my lawyers warned me.)  The four accused executives faced five years in prison for conspiracy, and ten more years for each count of fraud.
     The case was heard by U.S. District Judge Robert Hinkle.  On Feburary 20, 2012, after seven days in court, midway through the hearing, Judge Hinkle did something highly unusual:  he halted the hearing, and issued a judgment of acquittal.  He stated that he hadn't done this in fifteen years.
     The four executives were released from all charges of fraud, in the middle of the hearing, because Assistant Prosecutor Corey Smith had so little evidence to support his case against them.  "How can it be a fraud case, if they said, 'Here's what we're doing'?" Judge Hinkle asked in court.  He also declared  that the government had, in fact, proved that the defendants were innocent.
     Here's the link to a report about the Vanguard Casualty trial and acquittal:

http://www.wctv.tv/news/headlines/117212078.html

     This was not a good outcome for Mr. Smith.  This is not how a prosecutor makes a reputation and climbs up the government ladder.  Wasting government funds on cases that have no merit is a public disgrace.  I wonder what Mr. Smith was thinking, as he reviewed the facts of the Vanguard Casualty case before the trial.
     I  also wonder if Assistant U.S. Attorney Corey J. Smith is planning to do something similar in my case, to have me indicted, and take me to court, in order to prove my innocence in front of a judge, and in front of the entire country?
     I will not go gentle into that good night, as Dylan Thomas's phrased it.  Perhaps my attorneys are right, telling me to avoid criticizing the government.  I don't have to criticize the government--our judicial system and public attorneys are on view for all of us to observe.  Are there any consequences for federal and state attorneys who misconstrue or inflate the evidence brought before them, and who waste our government's time and tax dollars?  Is being an Assistant U.S. Attorney a position with tenure?  Can Mr. Smith do this again and again, without consequences?  Is this like other government jobs, from which employees--no matter how incompetent--never seem to have to worry about getting fired?

My Ideas for Fixing our Healthcare System, 4

     My favorite patients are the ones who have no insurance, yet understand that they need to invest something in their own healthcare.  They don't want to pay exorbitant monthly premiums, only to find out--once they're desperate--that their insurance doesn't cover the first $5,000 if they have to be hospitalized, or doesn't include birth control, or insists on a 20% copay when they need surgery, or requires "prior authorization" for an MRI--which is likely to be "declined."
     Sometimes an uninsured person accompanies a relative or friend who has come in for a doctor visit. The uninsured person tries to "piggyback" a free visit on top of the insured friend's visit.
     "Would you mind looking at my throat?" she might ask.  Or, "I know I'm not your patient, but what do you think about this rash?"  What's a doctor to do in this situation?
      "Why don't you go up front and get established as a patient?"  I suggest.  "Then I can take care of you properly."
     "I can't," is the standard reply.  "I don't have insurance."
     "I'll bet you pay more for maintenance on your car every year, than you do on your body," I say.  "Which is more important."
     Since these individuals aren't paying monthly premiums--and how can I blame them, with family insurance rates now averaging $14,000 per year --I recommend that they invest a small portion of that in "body maintenance."
     I suggest $250.  For this amount, I can do a physical exam in my office, and up to four tests, such as a chest x-ray, EKG, urine test, spirometry, labs--whichever are relevant, based on the patient's age and condition.  I evaluate these patients fully, exploring their past history, daily habits, family background, and current symptoms, and I do a complete physical.  If they have an acute problem, I treat that as well.
     Afterwards, I sum up my findings.  "If I were you," I may say, "and I had another $250 to spend, here's how I'd spend it--to prevent problems down the road."  The recommendations vary, based on each patient's circumstances.  The money might best be spent on nicotine patches and acupuncture, to quite smoking.  Or, the patient might benefit from a stress test and additional labs.  Or, I may suggest spending it on a health club membership, a pair of running, shoes, massage therapy, herbs or vitamins, couple counseling, a pelvic ultrasound, dental care, surgery to remove a skin cancer, cortisone in a hip joint, or balance training to prevent a fall.
     My point is this.  Doctors work best when they are permitted to use their experience and training to help patients achieve better health.  We are good detectives, so long as we aren't subject to a long list of absurd requirements by government task forces, insurance companies, auditors, or other policing agencies.
     Let's give patients a budget to spend on their own health.  If patients had, say, $1,000 a year, I physicians could probably keep most of them out of trouble.  I'd counsel and exhort them, prescribe medicines as tools, measure their progress, and commend them on their successes.  Do any of the people who put together the Obamacare plan understand how vital these "soft" interventions really are?
     There are no recommendations that apply across the board to every patient--this is where "task forces" and "advisory boards" get it all wrong.  Medicare's new quality assurance panels, for instance, make the assumption that every diabetic patient needs exactly the same tests and treatments, at exactly the same intervals.  This information may be of some use to physicians, but forcing us to fit every patient into an algorithm, and punishing us when we don't, distracts us from who the patient really is, and what that patient is willing to do, and what is going to work, finally, in that patient's case.  This information is far more important when it comes to improving the overall health of our patients (and lowering their cost) than any edicts from above about what referrals to make, and what tests to do.
      Getting to know a patient as a person in a medical setting makes an enormous difference in the implementation of good medical treatment.  Since we family physicians relate to our patients over many years, with compassion and depth, we discover what makes them tick, and we know how to motivate them.  There are many factors--social, psychological, familial, economic, and cultural--that affect how people care for themselves.  Family physicians have the most leverage with patients, and can inspire them to change, when necessary, because we know them, and we really care.
     Patients should be allotted an annual budget, and could choose their own physicians, in the same way that consumers choose products and services in every free-market economy.  Physicians who don't meet a certain standard wouldn't survive--just as any business will fail if customers don't value its services.  Patients should be assigned a health score--based on their risk for hospitalization, severe illness, or death--and physicians should be rewarded for preventing bad (and expensive) outcomes.
     Medicare has suggested that doctors should be rewarded for keeping patients healthy.  But the methods proposed for doing so are too simplistic.  Some physicians have an affinity for the very old, or very sick, or for end-stage patients, while others have young, healthy populations.  Without a baseline measurement of a patient's risk, it's impossible to measure how well a physician has managed to prevent illnesses, or hospitalizations, or early death.
     Insurance companies use health status and age as predictors of illness and death--we could borrow their parameters to give each patient a "health grade."  Patients might be motivated to improve their grade by following health recommendations and taking preventive medicine seriously.  If you were given a health grade of 70 out of 100, and you trusted the system within which you were being assessed and treated, wouldn't you want to find out how to bring up your grade?
     As things stand, patients don't know their health grade.  In my clinic, I sometimes try to communicate this information to them, along with advice about how to improve their health and longevity.  When I speak in concrete ways--"You're are likely to have a stroke or heart attack in five years if you don't do x, y, and z,"--patients usually listen.  While I don't like to make predictions that might be interpreted, unconsciously, as instructions--for instance, to have a stroke or heart attack--I think it's important for patients to understand that their lives are finite, and their bodies are not immortal.
     Too few of us realize that our personal choices have a lot to do with our health--and our deaths.   Maybe we believe in magic, or we exclude ourselves from what we know about the human body.  Maybe the current medical system has infantilized patients, so that they become dependent on doctors for their lives, or blame them for illness, or set them up as autocrats, or deities, or idiots (I've seen all these)--then the patients are never forced to assume their own portion of responsibility for their health, wellness, sickness, and final outcome.
      A health score assigned to patients could bring home the reality of each patient's likelihood of getting sick and dying.  It could help patients value the gift of their lives, and might inspire them to take better care of their bodies.  It might make them more open to vital information about how to improve their health-- a health score that goes up as a result of personal effort would be its own reward.
     So, in my healthcare system, patients would be assigned a health grade, doctors would be rewarded for inspiring patients to improve that grade, higher grades would likely be associated with lower national healthcare costs, and patients would be given an annual budget to spend on their health, however they wish, under the direction of a family physician--whose understanding and assessment of each patient would be the cornerstone of a healthy population.
  
      

Discombobulation

     Some weeks are worse than others.  This one was not good--my poor, forbearing staff can attest to this.  Every day I felt like throwing in the towel.  It seemed to me that one patient after another could have been sent as a spy by the government--trying to trip me up, checking to see if I really did what my clinic billed, if we really spend that much time with patients..  The mindset which assumes there are threats all around belongs to the conditions of warfare, not the world of doctoring, mothering, gardening or business management.
     One angry patient called and threatened to go to another doctor if I wouldn't write off his co-pay.  He said he'd been promised he could be seen "for free" at hist last visit, way back in March.  There was no indication of such a promise in the computer nor in our handwritten notes, nor was there a waiver in his chart, nor any good reason to waive his copay--so I figured he was a manipulator--or an undercover agent.  Prior to last year's government raid such a thought wouldn't have occurred to me.
      Many of my real patients have been interviewed by FBI agents, and tell me that one line of questioning has focused on my willingness to allow patients to be seen without a copay if their symptoms amount to an emergency and they don't have money, or if they sign an affidavit attesting to the fact that they are in a period of severe financial hardship.  Although this is perfectly legal, and my office is the only one to bear the cost, the FBI agents would like to show that I have a "pattern of writing off copays"--and turn this small act of benevolence into a crime.  The government and insurance company rationale is that if I'm willing to write off the copay for a patient, I should also be willing to write off the entire charge for the insurance company.  (Charity should be distributed evenly, they seem to think, to rich and poor.)  But Blue Cross posts yearly profits in the hundreds of millions--in 2011 it reported reserves of $1.15 billion--whereas some of my patients tell me their annual income is less than $5,000.  I can hardly justify writing off a bill  for "someone,"  i.e., a corporation, with huge profits every year, nor can I consider a reckless, spendthrift government a charity case. 
     The FBI agents can't find wrongdoing in my life or my clinic--because I haven't done anything wrong.  Therefore, they can't justify the federal charges they've imputed by the fact of the raid, so the next step in saving face is for them to trump up civil charges. 
     Another patient insisted that he had lost his prescription for prednisone--for the third time--and needed a new one.  I no longer trusted the story of this otherwise intelligent, well-heeled, ingratiating man who has spent a lot of time insisting that his gout pain is terrible, and also asked for pain medication in amounts that could cause harm. 
     "I don't see signs of gout," I told him.  "Your toe isn't swollen, red, or tender."
     "Yeah, but I really need pain medicine," he said.  "You can't see what's in-side."
     I thought I saw a smirk of contempt flash from the corners of his mouth, and his right shoulder was rolled forward--two of the telltale signs that indicate someone is lying.
     "Let's talk about your diet, because that's the real treatment for the problem of gout.  Can you reduce the amount of beer you're drinking?  Beer-drinking in hot weather can trigger gout."
     The patient feigned irritation.  "Are you going to give me what I need or not?  Cuz I need to get back to work."
     A third patient pressured my staff for "nerve medicine."  The only one that worked, she said, was Xanax--the most addictive prescription medicine in the world.  When I entered the exam room to treat her, she asked me in six different ways for the prescription.
     "Just a few," she said finally, as though we were forging a compromise.  "I can't sleep."
     "But you have THC in your urine, and our prescription policy states that we cannot give controlled substances to patients who use street drugs."
     "I can't survive without weed," she told me, her voice escalating.
     "I think you can," I said.
     "Obviously, you have no understanding of anxiety," she said.
     "There are other ways to manage anxiety, but it will take time.  I can help you."
     "If you won't give it to me, I'll just have to get it somewhere else," she warned.
     "That's your choice," I answered.  "But don't pretend I'm your partner in crime.  I'm still willing to help you in a medically sound way."
     Was this patient prompted by the feds, or am I just getting paranoid?
     When I leave work and arrive home each evening, I put on my muck boots and hurry down to the pond behind the house, flashlight in hand--because it's always dark.  This is where I recover from the day.
      As I approach the water I hear the plop-plop-plop of frogs, their sensitive nervous systems registering my footsteps, clambering from their mudpads into the cold, clear depths.  I squat down low and stare into the water, where spiders dart across the surface before taking nosedives.  Black beetles tool around like miniature submarines.  There are schools of baby minnows--I'm the one who got them started with a breeding kit.  I wasn't sure the pH of the water, at 6.0, would be alkaline enough for them to multiply, but it looks as though they're going to make it.  When the lead minnow swims to the right, they all follow suit.  This synchrony of movement provides a glimpse into the choreography of nature, which underlies everything--it must be directed toward a goal.  The pond offers insights about how the whole universe works, and it restores my faith.  I walk away the pond and its little creatures with the same sense of having been restored that taking communion from a priest bestows.
     I look for the alligators, whose eyes sometimes reflect the shine of my flashlight.  I haven't seen them for a month, nor have the snapping turtles bobbed their heads above the surface.  They gave the pond its aura of power, and danger, which I transferred to my situation with the government.  Don't mess with me, I've got weapons in reserve.  What are the weapons to use against sinister forces?
     Last week I saw at the east side of the pond a floating mass of gelatinous globules--hundreds of them--with black polka-dots at the center.  It undulated like an enormous jellyfish when the dogs took a swim a few yards down.  These are toad eggs which take seven days to hatch.  I looked very at one, using a magnifying glass, and the black dot was revealed as a tadpole-in-the-works, complete with a knobby head and tiny eyes.  The tadpoles will eat algae and dead insects over the next three to four months, as they undergo the phenomenal transformation to toads.
     I usually stare into the water until the mosquitoes claim a victory over my meditiation, then I trudge back to the house under the moonlight.  The feds, the office, the billing, the coding, my suspicions, the incompetencies of our methods of governing ourselves as a race, the sadness of the human condition, unfairness, illness, grief, longing, death--all of these are relativized, for me, by the fact of this pond.  

Romney and His Gaffe about Entitlements

     The political analysts say that if things keep going the way they've been going, in just a few years more than half of American families will be paying no federal income taxes.  This information was not invented by Romney.  One in seven Americans currently receives food stamps.  One in a hundred Americans is incarcerated or on parole.  This situation is very expensive.
     The Tax Policy Center reports that in 2011 46% of American households paid no federal income tax, and in 2010 it was 47%.  This is the Romney figure bootlegged by someone and reported in Mother Jones, and now it's being used to advantage by Obama supporters.
     Romney's detractors are outraged, saying this is proof that he doesn't care about them, he's just another rich guy who doesn't understand the problems of the poor.  The tax breaks and handouts, however, are the product of exemptions passed by lawmakers on both sides of the fence.  Most tax credits are for lower-income families (less than $50,000 per year), some are for the elderly, and .002% are for multimillionaires (one thousand are billionaires paid no federal income tax in 2011).  There are tax credits for work, kids and education--and most of us would agree that these are a good way to invest our excess wealth, but not they hobble the economy in the long run.
     We are all familiar with the attitude of entitlement--it's a style of thinking that seems to characterize many privileged kids in this country--as well as the phenomenon of codependency.  Entitlement is a belief in one's social and moral "right" to have access to certain benefits.  We all feel entitled in certain ways--to have access to air and water, for instance.  But most Americans believe other kinds of entitlements are part of our national philosophy:  the right to bear arms, the right to pursue prosperity, the right to a basic education, the right to speak our minds.
     I am in favor of entitlement programs as they currently exist for underprivileged people in this country.  But the programs need fine-tuning, and our budget for such programs can't be unlimited.  Once legislation is enacted for putting such programs into place, it seems that it never undergoes alteration--legislation is difficult to reverse.
     Those of us who are parents understand that giving our kids, for instance, unlimited money for their lives without requiring something in return is a recipe for failure.  It is difficult, when we see them suffering, not to "help"--but sometimes emergency help simply perpetuates their difficulties, and that's the beginning of codependency.  It's the old "give a man to fish, or teach him to fish" dilemma.  In my own case, I told my sons early in their lives that I would pay for their college educations if they met two conditions:  they could not use illicit drugs, and they had to maintain A's and B's.  A college education was an entitlement, in this scheme, but not a right--and it required something of them.  Given that I was still repaying my own college loans more than fifteen years after graduation, I thought the chance to get a college degree without the prospect of burdensome debt would inspire my children.  But the psychology of the human personality is a strange thing.  Not everyone is inspired by gifts or entitlements--some people just want to keep getting more.  Instead of acknowledging the gift of a college education, my sons sometimes raised objections to the conditions:  "Why should we have to get A's and B's?  Who are you to tell us whether we can 'party' or not?"
     Legislated entitlements, then, must be very carefully monitored.  Are they working to inspire people?  Is the economy such that it allows for individual success?  Are the objections raised by recipients of national benefits valid, or are they evidence of a dangerous narcissism that is the basis for the term, "a sense of entitlement" when it is used in the pejorative way that Romney used it?
     Entitlements are based on our assumption that there should be social equality--but people are not equal, not at birth, and not throughout life.  Nevertheless, having some national provisions for every citizen to be given an opportunity for a life lived creatively and successfully--as defined by that person-- paradigm of freedom that most of us would support.  Self-reliance is an Emersonian ideal that forms the backbone of America's ideology.  Assisting others as they move toward self-reliance, then, should be the goal of entitlement programs, not making them dependent on handouts.
     Here is the link to the bootlegged tape of Romney talking about his political strategy:   http://www.motherjones.com/politics/2012/09/secret-video-romney-private-fundraiser
     In this tape I don't hear a lot of terrible judgment about Americans who don't pay taxes, so much as a plan for targeting potential voters.  Romney simply stated that he can't count on votes from people who want to continue to receive benefits like extended unemployment payments, or welfare, or a free college education--those people's votes will have to be conceded to Obama.  Maybe he's right.   I don't know, because I'm not a campaign analyst.
       Political candidates are always in an awful position:  they have to do what's necessary to win elections, but that isn't the same as outlining a plan for improving the country.  The first job requires a lot of bluff and bravado, the second is shrewd and intellectual, and requires a degree of thoughtfulness that never seems to help win elections.
     Romney expressed frustration at the number of Americans needing or receiving entitlements--I agree with him that this is a huge problem.  Our budget can't continue to support both an enormous military and the cost of social entitlements--including the administrative expenses our bureaucracy is so good at wasting in the execution of government programs.  It's too bad Romney couldn't have expressed more sensitivity about the problem of people needing aid, and receiving aid.  What's the matter with our economy, that so many Americans aren't working and paying taxes?  What's the matter with our national psychology, that many of us prefer to let our benefits run out before exercising resourcefulness with regard to our futures?  Where is the inspiration that once drove our great-great-grandparents out west in search of gold, land, prosperity, fresh ideas, the possibility for a brand new life?
     Why are my children, and yours, not always inspired by the entitlements they've been offered?  Why is it that some people want more, and begin to believe that they deserve more, even when their coffers are full--while others seize the few chances they've been given, and head with all their valor and might for the victory-line?  A real political strategy for changing this country would take into account the human psychology behind the phenomena of inspiration and endeavor--not just economics, or ideology, or politics, or the moral superiority which has gotten Romney into so much hot water.