The obstacles to the practice of ethical, efficient, private medicine continue to grow noticeably, month by month. Illegitum non Carborundum says the sign on the bulletin board. It seems to have been overruled in Washington and countless state and corporate offices. The fatherless ones crank up new machines of torture with the added insult that I am required to finance their inquisitional torments. Their wheels grind exceedingly fine. A patient who suffered a stroke would be more comfortable with a simple tray-like armrest bolted to one arm of her wheel chair. Six forms, one of them an error, and a phone call result. The medical supply house gets $110 for what could not cost more than $25. I get only headaches and a threat of jail and fines if I cannot substantiate what I approve. The grinding is incessant and painful.
The hospital provides me with report cards on the charges I generate along with the revenue collected, omitting that their charges greatly exceed their costs. I am able to discover that the red ink they put to my account is really rather dense black ink when I insist on cost accounting. I am tracked on the units of blood I order crossmatched but do not transfuse, immunizations given, the number of patients I screen for depression.
One would think that my patients and I together lack the ability to determine what should comprise the substance of our encounters. My handlers can determine this from a span of hundreds of miles and months of time. Perhaps it is the shortage of sleep last night or the vomit on our shoes that encumbers us and not them. My patients and I can reach each other after 5:00 p.m., and we know each other's last names. Neither is true of Organization on High.
I want to report an epiphany! In these very oppressions of medicine are coded messages of hope. The managerial class, those wizards of the information age, is unintentionally signaling its impending demise. They think information alone is a surrogate for understanding. It is not so, and things keep slipping out of their control. The millions of units over which they pretend tight control --- patients, pharmacists, physical therapists, physicians, psychologists, nurses and so on --- collectively refuse to be herded. Mavericks abound. Inflexibly, the controllers turn to the only three maneuvers they know: more information, more rules, and greater penalties. These are no match for the creativity of all the controllees.
Consider, for example, the stunning financial penalties suspended over us for minute infractions which are not distinguished from mere errors but infused with assumed malice. The size of the penalties is a tacit admission that true enforcement is impossible. A thousand physicians fined $1000 would have a greater impact than ten physicians fined $100,000. The latter approaches the risk of a lightning strike so it must inflict the damage of one. It is government by terrorism. As Stalin knew, terror is most terrific if it is unpredictable and ghastly. No one should feel comfortable. All should be constantly under self-examination.
The rising technique of government and private regulators to require their minions to audit themselves is similar to the Chinese Red Guard tactics. The terror is sought without having to have the manpower to accomplish it. Re-audit only a few of the self-audited and be sure to find a few to smash.
At some point, however, a penalty ceases to be more penal despite increments. A ten million dollar fine for me is not worse than a one million dollar fine. I cannot pay either one. One is reminded of the European religious wars in the middle of this millennium in which one's dead opponents were occasionally exhumed in order to be burned or quartered. The frustration of the "victors" is palpable. If there is no effective resistance left, then why the show of vengeance? Who is the audience? You must know the watchers do not support you since you seek to impress them by the abuse of your defeated foes.
A few years ago a medium-sized hospital in our area had a report lodged against it for "patient dumping," a COBRA violation. That hospital was given a few weeks to rectify matters but was not even given the identification or specifics of the accusation. Torquemada, call Washington. Failure to correct the problem would result in the closure of the hospital. At huge expense, the hospital was eventually able to sleuth out the specifics and proved the offended patient was mistaken about the hospital he had been in. He had never been in the hospital he accused. Of course, no apology was forthcoming from the government. Terrorism works best when it is random. The threat was a bureaucratic success.
And, yet, from a wider view, that kind of governance destroys the objects of its governance. Each hospital closed, each hospital partly paralyzed by regulatory overburden, each physician who retires early, each patient who exits orthodox medicine into "alternative medicine," each person who just decides to pay out of his own pocket, lessens the future control by regulators. The regulator who too tightly controls his apparatus finds it shrinking. The urge to self-governance is widely distributed in the human race. The fences are climbed; the minefields are crossed.
There are actually rather few things which are amenable to central control --- waging war and the administration of justice are the only two that readily come to mind. Even these two benefit from layered authority, each layer of which has real scope for its capacities. Centrally-managed economies are a disaster, as we are likely to discover soon. We mistakenly believe that we do not have one. Education, child rearing, and, most certainly, the care of the injured and ill, are not manageable from afar. They each require a most personal and idiosyncratic flexibility. One would sooner be able to repeal the "law of gravity" than negate the primacy of the voluntary individual and family relationships in these areas. There is no number of regulations nor size of fines sufficient to change them. HCFA is a modern Xerxes, lashing waves of disease with even less ultimate effect than the ancient king had at the Hellespont.
The changes made by the centrists have become dervish-fast. Unbundling, once a sin, is transformed into a requirement for laboratory tests. Coding systems are not even learned before they are changed. "Deadlines" turn out to retreat in quite lively fashion. Capitation seems to be wavering under a deserved public backlash. Perhaps Oprah could develop a beef against it and help us out. These are not changes for the better, but changes to try to escape the mess made by the last change. They go from mess to mess. There is an occasional odor of bureaucratic desperation in the air. HMOs have an event horizon measured in months, hardly healthy for planning and development.
Notice how both public and private regulators seek to avoid courtroom adjudication of disputes. The ancient protections of being faced by one's accusers, of having specific charges lodged against you, of having clear statutes, of presumption of innocence, and so forth, are not wanted by the masters. They know they would rarely succeed even with such fairness as the remnants of our once-great system retains. It is not that reasonable antipathy toward the cumbersomeness and expense that drives this avoidance of court. It is an inward acknowledgement of the injustice of their cause. That knowledge must work corrosively on the consciences of those who are in the regulatory system. Will we see a trickle of conscience-smitten resignations from federal and state health regulatory agencies bearing the stamp of the testimony last fall regarding IRS tyranny against the poor in the same kind of shakedown by terrorism? Probably a few. Even an evil system contains persons of some character who have to live with themselves.
Another hopeful sign is in the shameless political posturing over medicine. Simple, informed reasoning is not what government now appeals to. That tactic would not support their desires to manage everything. The appeals are, rather, highly emotional and sloganized. Leading pawns in the contest are: the poor, the elderly, and the children. Especially, the children. Who can be against helping children? Children are as useful politically as they were militarily when they were made to walk in front of the armies of conquerors. Amid the showmanship of "protecting children" it is not noted that the resources of authority and money were taken substantially from families with children. After the politicos extract their third or so and distribute it among their courtiers the remainder is dispensed in rigid and unhelpful ways. Thus, a family loses a thousand dollars in taxes only to have it pay for a social worker to show up on their doorstep and terrorize them with seizure of their child because of an anonymous report. The atom of social governance is the family. As the civil government injures the family, it is tearing into its own cellular structure. It will collapse before the family does.
These then are marks of the collapse of this tyranny: escalating penalties, proliferating rules, virtually random punishment, avoidance of recourse to constitutional jurisprudence, growing databases, accelerating rates of change, political grandstanding and posturing, intransigent costs, and increasing refugees from a medical profession that is client to a tyrant state. The marks may be visible now only in a mirror as imprints on our back from the sole of the regulators' striding boots. Yet, they are losing control. Someday we will not need to look in the mirror. The marks will be on their faces for everyone to see. They will spell out TYRANT.
Recognition of signs which demonstrate an underlying social and economic structure that cannot be centrally controlled by regulators does not mean we can sit passively for things to happen of their own accord. These signs are signs exactly because we are active. Most members of AAPS probably have fits of despondence when considering the size and power of the foes of the practice of private medicine. The expenses and frustrations of educating fellow physicians, of litigating, of exposing government conspiracies are daunting. The ratio may not even be as good as two steps forward for every one backwards. Yet, the centrists ultimately cannot succeed. Our efforts against them are unwittingly joined by literally millions of co-belligerents acting somewhat independently, yet with a net vector against the mass of power in Washington and other nodes of illegitimate authority over medicine. Those millions on the periphery trying to mind their own business don't even have to all pull in the same direction to pull the center apart. It is not that we want to see the center of control of medicine shifted to us; we want to see medicine center between each healer and patient who share common beliefs and goals. There would be then millions of little centers. The remaining common center would be conceptual --- liberty, privacy, justice. It would not be an engine of political and economic power.
It seems to me that an orderly, civil restoration by incremental change is unlikely now. Unfortunately, a catastrophic collapse in medical care may be the only opportunity to see significant change. Should that occur it will not mean the efforts at reclamation of private medicine were wasted. Each effort can be seen as practice to improve the likelihood that what replaces the ruins is much better. We could well be acquiring the skills and assembling the material for a rebuilding rather than a reclamation. Potential leaders in a restoration would be the family, churches, private charities, and professional organizations that have not bowed the knee to socialism. Especially the first two. Each of these entities is a repository of legitimate governance over a limited sphere. We should work at growing up now so as not to have to hurry it up in the stress of the funeral of Big Brother. We can see the signs of Big Brother's terminal illness if we look at matters from the right angle.
AAPS has not confused information with knowledge or wisdom. The organization has sufficient of both to be of great help at such a time as may come soon.
Dr. Terrell practices family medicine in Florence, South Carolina and is a member of the Editorial Board of the Medical Sentinel.
Originally published in the Medical Sentinel 1999;4(1):31-33. Copyright©1999 Association of American Physicians and Surgeons (AAPS).