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I've a long record in editorial work in book and magazine publishing, starting 1974, a variety of other work experience, but have been, since 2001, recurringly housebound with insanely painful sporadic and unpredictably variable gout and edema, and in the past, other ailments; the future? The Great Unknown: isn't it for all of us?

I'm currently house/cat-sitting, not on any government aid yet (or mostly ever), often in major chronic pain from gout and edema, which variably can leave me unable to walk, including just standing, but sometimes is better, and is freaking unpredictable at present; I also have major chronic depression and anxiety disorders; I'm currently supported mostly by your blog donations/subscriptions; you can help me. I prefer to spread out the load, and lessen it from the few who have been doing more than their fair share for too long.

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"The brain is wider than the sky,
For, put them side by side,
The one the other will include
With ease, and you beside"
-- Emily Dickinson

"We will pursue peace as if there is no terrorism and fight terrorism as if there is no peace."
-- Yitzhak Rabin

"I have thought it my duty to exhibit things as they are, not as they ought to be."
-- Alexander Hamilton

"The stakes are too high for government to be a spectator sport."
-- Barbara Jordan

"Under democracy, one party always devotes its chief energies to trying to prove that the other party is unfit to rule -- and both commonly succeed, and are right."
-- H. L. Mencken

"Necessity is the plea for every infringement of human freedom. It is the argument of tyrants; it is the creed of slaves."
-- William Pitt

"The only completely consistent people are the dead."
-- Aldous Huxley

"I have had my solutions for a long time; but I do not yet know how I am to arrive at them."
-- Karl F. Gauss

"Whatever evils either reason or declamation have imputed to extensive empire, the power of Rome was attended with some beneficial consequences to mankind; and the same freedom of intercourse which extended the vices, diffused likewise the improvements of social life."
-- Edward Gibbon

"Augustus was sensible that mankind is governed by names; nor was he deceived in his expectation, that the senate and people would submit to slavery, provided they were respectfully assured that they still enjoyed their ancient freedom."
-- Edward Gibbon

"There exists in human nature a strong propensity to depreciate the advantages, and to magnify the evils, of the present times."
-- Edward Gibbon

"Our youth now loves luxuries. They have bad manners, contempt for authority. They show disrespect for elders and they love to chatter instead of exercise. Children are now tyrants, not the servants, of their households. They no longer rise when elders enter the room. They contradict their parents, chatter before company, gobble up their food, and tyrannize their teachers."
-- Socrates

"Before impugning an opponent's motives, even when they legitimately may be impugned, answer his arguments."
-- Sidney Hook

"Idealism, alas, does not protect one from ignorance, dogmatism, and foolishness."
-- Sidney Hook

"Let me never fall into the vulgar mistake of dreaming that I am persecuted whenever I am contradicted."
-- Ralph Waldo Emerson

"We take, and must continue to take, morally hazardous actions to preserve our civilization. We must exercise our power. But we ought neither to believe that a nation is capable of perfect disinterestedness in its exercise, nor become complacent about particular degrees of interest and passion which corrupt the justice by which the exercise of power is legitimized."
-- Reinhold Niebuhr

"Faced with the choice of all the land without a Jewish state or a Jewish state without all the land, we chose a Jewish state without all the land."
-- David Ben-Gurion

"...the proscribing any citizen as unworthy the public confidence by laying upon him an incapacity of being called to offices of trust and emolument, unless he profess or renounce this or that religious opinion, is depriving him injuriously of those privileges and advantages to which, in common with his fellow citizens, he has a natural right; that it tends also to corrupt the principles of that very religion it is meant to encourage, by bribing, with a monopoly of worldly honours and emoluments, those who will externally profess and conform to it;[...] that the opinions of men are not the object of civil government, nor under its jurisdiction; that to suffer the civil magistrate to intrude his powers into the field of opinion and to restrain the profession or propagation of principles on supposition of their ill tendency is a dangerous fallacy, which at once destroys all religious liberty....
-- Virginia Statute for Religious Freedom, Thomas Jefferson

"We don't live just by ideas. Ideas are part of the mixture of customs and practices, intuitions and instincts that make human life a conscious activity susceptible to improvement or debasement. A radical idea may be healthy as a provocation; a temperate idea may be stultifying. It depends on the circumstances. One of the most tiresome arguments against ideas is that their 'tendency' is to some dire condition -- to totalitarianism, or to moral relativism, or to a war of all against all."
-- Louis Menand

"The darkest places in hell are reserved for those who maintain their neutrality in times of moral crisis."
-- Dante Alighieri

"He too serves a certain purpose who only stands and cheers."
-- Henry B. Adams

"The law, in its majestic equality, forbids the rich as well as the poor to beg in the streets, steal bread, or sleep under a bridge."
-- Anatole France

"When bad men combine, the good must associate; else they will fall one by one, an unpitied sacrifice in a contemptible struggle."
-- Edmund Burke

"Education does not mean that we have become certified experts in business or mining or botany or journalism or epistemology; it means that through the absorption of the moral, intellectual, and esthetic inheritance of the race we have come to understand and control ourselves as well as the external world; that we have chosen the best as our associates both in spirit and the flesh; that we have learned to add courtesy to culture, wisdom to knowledge, and forgiveness to understanding."
-- Will Durant

"Glimpses do ye seem to see of that mortally intolerable truth; that all deep, earnest thinking is but the intrepid effort of the soul to keep the open independence of her sea; while the wildest winds of heaven and earth conspire to cast her on the treacherous, slavish shore?"
-- Herman Melville

"The most important political office is that of the private citizen."
-- Louis D. Brandeis

"If we desire respect for the law, we must first make the law respectable."
-- Louis D. Brandeis

"We can have democracy in this country, or we can have great wealth concentrated in the hands of a few, but we can't have both."
-- Louis D. Brandeis

"It is an error to suppose that books have no influence; it is a slow influence, like flowing water carving out a canyon, but it tells more and more with every year; and no one can pass an hour a day in the society of sages and heroes without being lifted up a notch or two by the company he has kept."
-- Will Durant

"When you write, you’re trying to transpose what you’re thinking into something that is less like an annoying drone and more like a piece of music."
-- Louis Menand

"Sex is a continuum."
-- Gore Vidal

"I contemplate with sovereign reverence that act of the whole American people which declared that their legislature should make no law respecting an establishment of religion, or prohibit the free exercise thereof, thus building a wall of separation between church and state."
-- Thomas Jefferson, letter to the Baptists of Danbury, Connecticut, 1802.

"The sum of our religion is peace and unanimity, but these can scarcely stand unless we define as little as possible, and in many things leave one free to follow his own judgment, because there is great obscurity in many matters, and man suffers from this almost congenital disease that he will not give in when once a controversy is started, and after he is heated he regards as absolutely true that which he began to sponsor quite casually...."
-- Desiderius Erasmus

"Are we to have a censor whose imprimatur shall say what books may be sold, and what we may buy? And who is thus to dogmatize religious opinions for our citizens? Whose foot is to be the measure to which ours are all to be cut or stretched? Is a priest to be our inquisitor, or shall a layman, simple as ourselves, set up his reason as the rule of what we are to read, and what we must disbelieve?"
-- Thomas Jefferson, in a letter to N. G. Dufief, Philadelphia bookseller, 1814

"We are told that it is only people's objective actions that matter, and their subjective feelings are of no importance. Thus pacifists, by obstructing the war effort, are 'objectively' aiding the Nazis; and therefore the fact that they may be personally hostile to Fascism is irrelevant. I have been guilty of saying this myself more than once. The same argument is applied to Trotskyism. Trotskyists are often credited, at any rate by Communists, with being active and conscious agents of Hitler; but when you point out the many and obvious reasons why this is unlikely to be true, the 'objectively' line of talk is brought forward again. To criticize the Soviet Union helps Hitler: therefore 'Trotskyism is Fascism'. And when this has been established, the accusation of conscious treachery is usually repeated. This is not only dishonest; it also carries a severe penalty with it. If you disregard people's motives, it becomes much harder to foresee their actions."
-- George Orwell, "As I Please," Tribune, 8 December 1944

"Wouldn't this be a great world if insecurity and desperation made us more attractive? If 'needy' were a turn-on?"
-- "Aaron Altman," Broadcast News

"The great thing about human language is that it prevents us from sticking to the matter at hand."
-- Lewis Thomas

"To be ignorant of what happened before you were born is to be ever a child. For what is man's lifetime unless the memory of past events is woven with those of earlier times?"
-- Cicero

"Hypocrisy is the homage vice pays to virtue." -- François, duc de La Rochefoucauld

"Knowledge is of two kinds. We know a subject ourselves, or we know where we can find information upon it." -- Samuel Johnson, Life Of Johnson

"Very well, what did my critics say in attacking my character? I must read out their affidavit, so to speak, as though they were my legal accusers: Socrates is guilty of criminal meddling, in that he inquires into things below the earth and in the sky, and makes the weaker argument defeat the stronger, and teaches others to follow his example." -- Socrates, via Plato, The Republic

"Every gun that is made, every warship launched, every rocket fired, represents, in the final analysis, a theft from those who hunger and are not fed, who are cold and are not clothed. This world in arms is not spending money alone. It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children."
-- Dwight D. Eisenhower

"The term, then, is obviously a relative one; my pedantry is your scholarship, his reasonable accuracy, her irreducible minimum of education, & someone else's ignorance." --
H. W. Fowler

"Rules exist for good reasons, and in any art form the beginner must learn them and understand what they are for, then follow them for quite a while. A visual artist, pianist, dancer, fiction writer, all beginning artists are in the same boat here: learn the rules, understand them, follow them. It's called an apprenticeship. A mediocre artist never stops following the rules, slavishly follows guidelines, and seldom rises above mediocrity. An accomplished artist internalizes the rules to the point where they don't have to be consciously considered. After you've put in the time it takes to learn to swim, you never stop to think: now I move my arm, kick, raise my head, breathe. You just do it. The accomplished artist knows what the rules mean, how to use them, dodge them, ignore them altogether, or break them. This may be a wholly unconscious process of assimilation, one never articulated, but it has taken place." -- Kate Wilhelm

"The most beautiful experience we can have is the mysterious. It is the fundamental emotion that stands at the cradle of true art and true science. Whoever does not know it and can no longer wonder, no longer marvel, is as good as dead, and his eyes are dimmed."
-- Albert Einstein

"The decisive moment in human evolution is perpetual."
-- Franz Kafka, Aphorisms

"All of old. Nothing else ever. Ever tried. Ever failed. No matter. Try again. Fail again. Fail better."
-- Samuel Beckett, Worstward Ho

"First they ignore you. Then they ridicule you. And then they attack you and want to burn you. And then they build monuments to you."
-- Nicholas Klein, May, 1919, to the Third Biennial Convention of the Amalgamated Clothing Workers of America (misattributed to Mohandas Karamchand Gandhi, 1914 & variants).

"Nothing would be done at all, if a man waited till he could do it so well, that no one could find fault with it."
-- Lecture IX, John Henry Cardinal Newman

“Nothing is more common than for men to think that because they are familiar with words they understand the ideas they stand for.”
-- John Henry Cardinal Newman

"Knowledge will forever govern ignorance; and a people who mean to be their own governors must arm themselves with the power which knowledge gives."
-- James Madison

"Those who are free from common prejudices acquire others."
-- Napolean I of France -- Napoleon I of France

"Our credulity is a part of the imperfection of our natures. It is inherent in us to desire to generalize, when we ought, on the contrary, to guard ourselves very carefully from this tendency."
-- Napoleon I of France.

"The truth is, men are very hard to know, and yet, not to be deceived, we must judge them by their present actions, but for the present only."
-- Napoleon I of France.

"The barbarous custom of having men beaten who are suspected of having important secrets to reveal must be abolished. It has always been recognized that this way of interrogating men, by putting them to torture, produces nothing worthwhile. The poor wretches say anything that comes into their mind and what they think the interrogator wishes to know."
-- On the subject of torture, in a letter to Louis Alexandre Berthier (11 November 1798), published in Correspondance Napoleon edited by Henri Plon (1861), Vol. V, No. 3606, p. 128

"All living souls welcome whatever they are ready to cope with; all else they ignore, or pronounce to be monstrous and wrong, or deny to be possible."
-- George Santayana, Dialogues in Limbo (1926)

"American life is a powerful solvent. It seems to neutralize every intellectual element, however tough and alien it may be, and to fuse it in the native good will, complacency, thoughtlessness, and optimism."
-- George Santayana, Character and Opinion in the United States, (1920)

"If you should put even a little on a little, and should do this often, soon this too would become big."
-- Hesiod, Work And Days

"Your Honor, years ago I recognized my kinship with all living beings, and I made up my mind that I was not one bit better than the meanest on earth. I said then, and I say now, that while there is a lower class, I am in it, and while there is a criminal element I am of it, and while there is a soul in prison, I am not free."
-- Eugene V. Debs

"Reputation is what other people know about you. Honor is what you know about yourself."
-- Lois McMaster Bujold, A Civil Campaign

"All that we have to do is to send two mujahidin to the furthest point east to raise a piece of cloth on which is written "al-Qaida," in order to make the generals race there to cause America to suffer human, economic, and political losses without their achieving for it anything of note other than some benefits for their private companies."
-- Osama bin Laden

"Remember, Robin: evil is a pretty bad thing."
-- Batman


Gary Farber is now a licensed Quintuple Super-Sekrit Multi-dimensional Master Pundit. He does not always refer to himself in the third person.
He is presently single.

The gefilte fish is dead. Donate via the donation button on the top left or I'll shoot this cute panda. Don't you love pandas?

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Contents © 2001-2013 All rights reserved. Gary Farber. (The contents of e-mails to this email address of Gary Farber are subject to the possibility of being posted.)

And you may find yourself living in a shotgun shack
And you may find yourself in another part of the world

[Blogroll now far below the sea line! Dive, dive, dive!]

You Like Me, You Really Like Me

Gary Farber! Jeez, the guy is practically a blogging legend, and I'm always surprised at the breadth of what he writes about.
-- PZ Meyers, Pharyngula

...Darn: I saw that Gary had commented on this thread, and thought: oh. my. god. Perfect storm. Unstoppable cannonball, immovable object. -- Hilzoy

...I think Gary Farber is a blogging god. -- P.Z. Myers, Pharyngula

...writer[s] I find myself checking out repeatedly when I'm in the mood to play follow-the-links. They're not all people I agree with all the time, or even most of the time, but I've found them all to be thoughtful writers, and that's the important thing, or should be.
-- Tom Tomorrow

‎"Gary Farber is a gentleman, a scholar and one of the gems of the blogosphere." -- Steve Hynd,

"Well argued, Gary. I hadn't seen anything that went into as much detail as I found in your blog." -- Gareth Porter

Gary Farber is your one-man internet as always, with posts on every article there is.
-- Fafnir

Guessing that Gary is ignorant of anything that has ever been written down is, in my experience, unwise.
Just saying.

-- Hilzoy

Gary Farber gets it right....
-- James Joyner, Outside The Beltway

Once again, an amazing and illuminating post.
-- Michael Bérubé, Crooked Timber

I read Amygdala...with regularity, as do all sensible websurfers.
-- Jim Henley, Unqualified Offerings

Okay, he is annoying, but he still posts a lot of good stuff.
-- Avedon Carol, The Sideshow

Amygdala - So much stuff it reminds Unqualified Offerings that UO sometimes thinks of Gary Farber as "the liberal Instapundit."
-- Jim Henley

...the thoughtful and highly intelligent Gary Farber... My first reaction was that I definitely need to appease Gary Farber of Amygdala, one of the geniuses of our age.
-- Brad deLong

Gary is a perceptive, intelligent, nice guy. Some of the stuff he comes up with is insightful, witty, and stimulating. And sometimes he manages to make me groan.
-- Charlie Stross

Gary Farber is a straight shooter.
-- John Cole, Balloon Juice

I bow before the shrillitudinousness of Gary Farber, who has been blogging like a fiend.
-- Ted Barlow, Crooked Timber

Favorite.... [...] ...all great stuff. [...] Gary Farber should never be without readers.
-- Ogged

I usually read you and Patrick several times a day, and I always get something from them. You've got great links, intellectually honest commentary, and a sense of humor. What's not to like?
-- Ted Barlow

One of my issues with many poli-blogs is the dickhead tone so many bloggers affect to express their sense of righteous indignation. Gary Farber's thoughtful leftie takes on the world stand in sharp contrast with the usual rhetorical bullying. Plus, he likes "Pogo," which clearly attests to his unassaultable good taste.

One of my favorites....
-- Matt Welch

-- Virginia Postrel

Amygdala continues to have smart commentary on an incredible diversity of interesting links....
-- Judith Weiss

Amygdala has more interesting obscure links to more fascinating stuff that any other blog I read.
-- Judith Weiss, Kesher Talk

Gary's stuff is always good.
-- Meryl Yourish

...the level-headed Amygdala blog....
-- Geitner Simmons

The only trouble with reading Amygdala is that it makes me feel like such a slacker. That Man Farber's a linking, posting, commenting machine, I tell you!
-- John Robinson, Sore Eyes

...the all-knowing Gary Farber....
-- Edward Winkleman, Obsidian Wings

Jaysus. I saw him do something like this before, on a thread about Israel. It was pretty brutal. It's like watching one of those old WWF wrestlers grab an opponent's face and grind away until the guy starts crying. I mean that in a nice & admiring way, you know.
-- Fontana Labs, Unfogged

We read you Gary Farber! We read you all the time! Its just that we are lazy with our blogroll. We are so very very lazy. We are always the last ones to the party but we always have snazzy bow ties.
-- Fafnir, Fafblog!

Gary Farber you are a genius of mad scientist proportions. I will bet there are like huge brains growin in jars all over your house.
-- Fafnir, Fafblog!

Gary Farber is the hardest working man in show blog business. He's like a young Gene Hackman blogging with his hair on fire, or something.
-- Belle Waring, John & Belle Have A Blog

Gary Farber only has two blogging modes: not at all, and 20 billion interesting posts a day [...] someone on the interweb whose opinions I can trust....
-- Belle Waring, John & Belle Have A Blog


Gary is certainly a non-idiotarian 'liberal'...
-- Perry deHaviland

Recommended for the discerning reader.
-- Tim Blair

Gary Farber's great Amygdala blog.
-- Dr. Frank

Isn't Gary a cracking blogger, apropos of nothing in particular?
-- Alison Scott

Gary Farber takes me to task, in a way befitting the gentleman he is.
-- Stephen Green, Vodkapundit

My friend Gary Farber at Amygdala is the sort of liberal for whom I happily give three cheers. [...] Damned incisive blogging....
-- Midwest Conservative Journal

If I ever start a paper, Clueless writes the foreign affairs column, Layne handles the city beat, Welch has the roving-reporter job, Tom Tomorrow runs the comic section (which carries Treacher, of course). MediaMinded runs the slots - that's the type of editor I want as the last line of defense. InstantMan runs the edit page - and you can forget about your Ivins and Wills and Friedmans and Teepens on the edit page - it's all Blair, VodkaP, C. Johnson, Aspara, Farber, Galt, and a dozen other worthies, with Justin 'I am smoking in such a provocative fashion' Raimondo tossed in for balance and comic relief.

Who wouldn't buy that paper? Who wouldn't want to read it? Who wouldn't climb over their mother to be in it?
-- James Lileks

I do appreciate your role and the role of Amygdala as a pioneering effort in the integration of fanwriters with social conscience into the larger blogosphere of social conscience.
-- Lenny Bailes

Every single post in that part of Amygdala visible on my screen is either funny or bracing or important. Is it always like this?
-- Natalie Solent

You nailed it... nice job."
-- James Lileks

Gary Farber is a principled liberal....
-- Bill Quick, The Daily Pundit

December 2001 January 2002 February 2002 March 2002 April 2002 May 2002 June 2002 July 2002 August 2002 September 2002 October 2002 November 2002 December 2002 January 2003 February 2003 March 2003 April 2003 May 2003 June 2003 July 2003 August 2003 September 2003 October 2003 November 2003 December 2003 January 2004 February 2004 March 2004 April 2004 May 2004 June 2004 July 2004 August 2004 September 2004 October 2004 November 2004 December 2004 January 2005 February 2005 March 2005 April 2005 May 2005 June 2005 July 2005 August 2005 September 2005 October 2005 November 2005 December 2005 January 2006 February 2006 March 2006 April 2006 May 2006 June 2006 July 2006 August 2006 September 2006 October 2006 November 2006 December 2006 January 2007 February 2007 March 2007 April 2007 May 2007 June 2007 July 2007 August 2007 September 2007 October 2007 November 2007 December 2007 January 2008 February 2008 March 2008 April 2008 May 2008 June 2008 July 2008 August 2008 September 2008 October 2008 November 2008 December 2008 January 2009 February 2009 March 2009 April 2009 May 2009 June 2009 July 2009 August 2009 September 2009 October 2009 November 2009 December 2009 January 2010 February 2010 March 2010 April 2010 May 2010 June 2010 July 2010 August 2010 September 2010 October 2010 November 2010 December 2010 January 2011 February 2011 March 2011 April 2011 May 2011 June 2011 August 2011 September 2011 October 2011 December 2011 January 2013

Blogroll is Always In Progress:

Roger Ailes
Alas, A Blog
The American Street
The Aristocrats
Avedon Carol
Between the Hammer and the Anvil
Lindsay Beyerstein
The Big Con
CantBlogTooBusy The Center for American Progress
Chase me Ladies, I'm in the Cavalry
Doghouse Riley
Kevin Drum
Fables of the Reconstruction
Gall and Gumption
Gin and Tacos
House of Substance
The Hunting of the Snark
If I Ran The Zoo
Lawyers, Guns & Money
Lotus: Surviving a Dark Time
Matters of Little Significance
Nancy Nall
Charlie Stross bastard.logic
Daniel Larison
American Conservative
American Footprints
Andrew Sullivan
Angry Bear
Balloon Juice
Beautiful Horizons
Bitch Ph.D.
Brad DeLong
Crooked Timber
Cunning Realist
Daily Kos
Debate Link
Democracy Arsenal
Edge of the American West
Ezra Klein
Glenn Greenwald 13th Floor
Hit & Run
Juan Cole
Kevin Drum
Lawyers, Guns and Money
List Project (Helping Iraqis who worked with us get out)
Marc Lynch
Mark Kleiman
Katha Pollit
Market Square
Matthew Yglesias
Megan McArdle
Metro Green
Pam's House Blend
Paul Krugman
Philosophy, et cetera
Radley Balko
Sadly, No!
Southern Appeal
Stephen Walt
Steve Clemons
Ta-Nehisi Coates
Taking It Outside
Talking Points Memo
The Poor Man
The Progressive Realist
The Sideshow
U.S. Intellectual History
Unqualified Offerings
Volokh Conspiracy
Washington Monthly
William Easterly
Newsrack Blog
Ortho Bob
The Poor Man
Prog Gold
Prose Before Hos
Ted Rall
The Raw Story
Elayne Riggs
Sadly, No!
Texas Liberal
Think Progress
3 Weird Sisters
Tristram Shandy
Washington Monthly
Ian Welsh
James Wolcott
World o' Crap
Matthew Yglesias
Buzz Machine
Daniel Larison
Rightwing Film Geek About Last Night
can we all just agree
Comics Curmudgeon
Dum Luk's
Glenn Kenny
Hoarder Museum Juanita Jean
Lance Mannion (Help Lance!
Last Words of the Executed
The Phil Nugent Experience
Postcards from Hell's Kitchen
Vanishing New York
a lovely promise
a web undone
alt hippo
american street
city of brass
danger west
fierce urgency of now
get fisa right
great concavity
happening here
impeach them!
kathryn cramer
notes from the basement
talking dog
uncertain principles
unqualified offerings
what do i know
crooked timber emptywheel
ezra klein
The F-Word
glenn greenwald
schneier on security
ta-nehisi coates
talking points memo
tiny revolution
Roz Kaveney
Dave Ettlin
Henry Jenkins' Confessions of an Aca-Fan
Kathryn Cramer
Monkeys In My Pants
Pagan Prattle
As I Please
Ken MacLeod
Arthur Hlavaty
Kevin Maroney
MK Kare
Jack Heneghan
Dave Langford
Onyx Lynx Atrios
Rittenhouse Review
Public Nuisance
Scoobie Davis
Nathan Newman
Echidne Of The Snakes
First Draft
Rising Hegemon
Cab Drollery (Help Diane!
Southern Beale
The Kenosha Kid
Culture of Truth
Talk Left
Black Ag=Q< Report
Drug WarRant
Nieman Watchdog
Open Left
Meet the Bloggers
Dispatch from the Trenches
Crooks and Liars
Campaign for America's Future
Iraq Today
Daily Kos
Lefty Directory
News Hounds
The Brad Blog
Informed Comment
UN Dispatch
War and Piece
Glenn Greenwald
Schneier on Security
Jim Henley
Arthur Silber
Julian Sanchez
The Agitator
Balloon Juice
Wendy McElroy
Whoviating (LarryE)
Scott Horton
Tennessee Guerilla Women
Looking Glass
Charles Kuffner
Brad DeLong
Busy, Busy, Busy
Oliver Willis
The Carpetbagger Report Shakesville
Down With Tyranny
Professor B
Monkey Media Report
The Grumpy Forester
Ian Welsh
Pacific Views
Booman Tribune
Matthew Yglesias
The American Street
Media Bloodhound
Liz Henry's Composite
The Heretik
Arizona Eclectic
Sisyphus Shrugged
Interesting Times
Talking Dog
Liberal Desert
Under the Lobsterscope
Seeing The Forest
Sean Paul Kelley's The Agonist
King of Zembla
Mark Kleiman
Liquid List
Elayne Riggs
No More Mr. Nice Blog
Fanatical Apathy
Blue Gal
Mark Evanier
Roger Ailes
Suburban Guerrilla (Help Susie with money!)
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People I've known and still miss include Isaac Asimov, rich brown, Charles Burbee, F. M. "Buzz" Busby, Terry Carr, A. Vincent Clarke, Bob Doyle, George Alec Effinger, Abi Frost, Bill & Sherry Fesselmeyer, George Flynn, John Milo "Mike" Ford. John Foyster, Mike Glicksohn, Jay Haldeman, Neith Hammond (Asenath Katrina Hammond)/DominEditrix , Chuch Harris, Mike Hinge, Lee Hoffman, Terry Hughes, Damon Knight, Ross Pavlac, Bruce Pelz, Elmer Perdue, Tom Perry, Larry Propp, Bill Rotsler, Art Saha, Bob Shaw, Martin Smith, Harry Stubbs, Bob Tucker, Harry Warner, Jr., Jack Williamson, Walter A. Willis, Susan Wood, Kate Worley, and Roger Zelazny. It's just a start, it only gets longer, many are unintentionally left out. And She of whom I must write someday.

Wednesday, July 29, 2009
ALL YOUR HEALTH CARE REFORM BASE ARE BELONG TO US, sez profit-seeking doctors. Because no one is discussing the issues brought to light by Atul Gawande.

The problems won't be cured until we deal with the culture of profit-seeking doctors:
[...] The question we’re now frantically grappling with is how this came to be, and what can be done about it. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.
Gawande found them.
[...] Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.

If doctors wield the pen, why do they do it so differently from one place to another? Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.


“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.

He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.

No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.

Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.

Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears and colonoscopies.

Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.

In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.

In a few cases, the hospital executive told me, he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ ”

“How much?” I asked.

“The amounts—all of them were over a hundred thousand dollars per year,” he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.

He didn’t pay any of them, he said: “I mean, I gotta sleep at night.” And he emphasized that these were just a handful of doctors. But he had never been asked for a kickback before coming to McAllen.

Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions—Boston, San Francisco, San Diego—became leaders in biotechnology while others with a similar concentration of scientific and corporate talent—Los Angeles, Philadelphia, New York—did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.

Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream.

Agencies that want to compete on quality struggle to remain in business, the rep said. Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.

“I explained the rules and regulations and the anti-kickback law, and told them no,” she said of her dealings with such doctors. “Does it hurt my business?” She paused. “I’m O.K. working only with ethical physicians,” she finally said.

About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.
And that's the problem that none of the health care reform proposals addresses. Hardly the only problem, of course, as has been endlessly discussed. But a crucial one.

Read The Rest Scale: 5 out of 5.

Thanks, Dr. Science!

ADDENDUM, July 29th, 10:32 p.m.: And here's a fascinating addition to this story:
McALLEN, Tex. — One of the largest sources of campaign contributions to Senate Democrats during this year’s health care debate is a physician-owned hospital in one of the country’s poorest regions that has sought to soften measures that could choke its rapid growth.

The Democratic Senatorial Campaign Committee collected nearly $500,000 at a reception here on March 30, mostly from physicians and others affiliated with Doctors Hospital at Renaissance, financial disclosure records show.

The event was held at the home of a prominent McAllen developer, Alonzo Cantu, a hospital founder, investor and board member who has raised prodigious sums from the Rio Grande Valley for an array of Democrats.

Another event at Mr. Cantu’s home, in September 2007, brought in at least $800,000 for the committee’s House counterpart, the Democratic Congressional Campaign Committee, according to disclosure reports. The House speaker, Nancy Pelosi, was in attendance and cut a ribbon at the hospital’s new women’s center while in town.

The hospital, which is in Edinburg, adjacent to McAllen, is working both sides of the aisle. Its political action committee, Border Health PAC, split $120,000 last year among House and Senate candidates, including Republicans.

Although Congressional negotiations over health care legislation are continuing, Doctors Hospital seems to be getting much of what it wants. Thus far, physician-owned hospitals have been insulated from some of the most onerous potential restrictions in the health care legislation moving through Congress.

Representative Pete Stark, a California Democrat who wants to clamp down on physician-owned hospitals, said their formidable lobbying had helped eliminate his proposal to limit physician ownership to 40 percent at any hospital.

“Particularly led by these guys in Texas, these guys who have been raising tons of money for contributions,” Mr. Stark said in an interview. “I am sure that some of my colleagues have been willing to hear them out.”


On at least three occasions in the last two months, delegations from McAllen have made the rounds of Capitol Hill to discuss their concerns, and blunt the effects of the New Yorker article.


One key provision would limit a hospital’s ownership by doctors to the level in place at the time of enactment. That is a change from previous language in House bills to restrict physician ownership to 40 percent. It would have forced Doctors Hospital, where physicians have an 82-percent stake, to be sold or required some of its owners to divest.

Mr. Stark said the change had been made “at a higher pay grade than mine.” The physician-owned hospitals, he said, “just thought they could buy their way out of it, and it’s a sad commentary on the Congress.”

Speaker Pelosi supported the tougher provisions in previous bills but aides said she was willing to accept a compromise to win the new restrictions.

Aides to Senator Max Baucus. Democrat of Montana, the chairman of the Finance Committee, and to Senator Charles E. Grassley of Iowa, the ranking Republican, said the Senate would never have adopted the 40 percent limit and that it was only fair to allow existing hospitals to maintain their ownership structures.


Whether or not there is cause and effect, some of the hospital’s beneficiaries have passionately supported its position. In November, the South Texas doctors raised nearly $60,000 for Representative Sheila Jackson Lee, a Democrat from Houston. Last week, Ms. Lee, who has a physician-owned hospital in her district, inserted comments in The Congressional Record against restricting the hospitals’ growth. She did not respond to requests for comment for this article.

Disclosure reports show that about 220 donors from the McAllen area contributed to the Senate Democratic committee for the March event. Receipts totaled at least $425,000, about 2 percent of the group’s collections for the first half of the year.

“We’re not naïve,” said Dr. Ambrosio Hernandez, a pediatric surgeon who gave $5,000. “We understand that politics plays a role in everything.”
There's a bunch more at the article. Read The Rest Scale: 4 out of 5.

7/29/2009 04:20:00 AM |permanent link | Main Page | | 2 comments


This is a fascinating post. The idea of anchor-tenants is really interesting.

It makes me think about power as it is wielded in all sorts of areas, including in group dynamics.

The most powerful voice in a group often creates a culture that is difficult to change. Whether or not the most powerful voice is also wise, efficient and flexible depends on the culture that supersedes it. (For example, a gang leader may be more or less aggressive toward police depending on the tactics of the police department.)

By Blogger Cardozo, at Wednesday, July 29, 2009 10:27:00 AM  

Indeed. And I expect almost everybody has experienced some version of "groupthink" leading to problems in one or more venues. This is another subset (or greater set) of that kind of influence.

By Blogger Gary Farber, at Wednesday, July 29, 2009 10:32:00 AM  

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