Dr. Doug McGuff’s The 21 Convention Presentation in 2 Words: You’re Fucked

Update 10/25/2012: Doug’s entire presentation, the subject and content for this post, is now online at YouTube:

…Well, you can quibble and call it three words since it’s a contraction, but you’ll get the point either way.

Two years ago, Doug presented at The 21 Convention along with Mark Sisson. Word is, his presentation has more views than any other from this event in any year. Over 163,000 views at this point. Here it is.

That was more about exercise and diet. This time, he took a big risk. He spoke to 20-something men about the health care crisis and how you’re so fucked. Say what? He’s gonna talk to people who see themselves as a cross between immortal and invincible, about something they see as having no application to either?

Yep. That’s Doug. Like me, it’s always my message that counts and if the message is real, they will come.

But I still winced, a little. That was short lived.

…As an emergency room physician of 23 years, Doug has presided over the deaths of over 10,000 people. That is, Doug’s is the last face they ever saw if they saw anything, and that’s why the last slide in his presentation suggested that people develop a good measure of face-to-face kindness. …He’s told hundreds, if not thousands of mothers and fathers that their child is gone—and as recently as last week: an 11-yr old who just begged his mom to ride the ATV. Doug had to tell his mom of the final outcome of her decision. …And don’t get me wrong. I’m not for nannys, and I doubt Doug is either. It’s the vehicle and context of situation.

Doug’s was not some run-of-the mill bashing of “Obamacare” you’d see at any Tea Party Rally intended for the consumption of confirming bias, God & Country morons who are generally beyond hope (I’m always a sucker for redemption though). Rather, it was designed with respect for the intelligence of young men looking to better their lives and take The Red Pill. Because Doug, as I, largely considers the general population over a certain age generally lost to persuasion of any kind (I’m always a sucker for redemption though). They’re already completely hooked in and connected into the Matrix and whether it’s their fault for being there or not, it doesn’t matter. It’s what they bargained for—at the expense of all these young people—and they’re gonna get what they bargained for no matter what burden it places on those young people Doug was talking to.

The young people generally have no awareness of it—just like the 60-70-80-somethings, now, had no idea when they were 20 that huge chunks of their lives and what they could do and accomplish and enjoy would instead go into the collective, to support the general morass, with the huge cut coming off the top for the marauding political class. But even that was modest by comparison to what those young men are up against now. Within a few decades, the young people will not be carrying a half person on their back as they do now, but 1 1/2 people. And don’t give me the line that “I paid in.” That would be valid if you got an account statement every month. You did not. What you paid went to people now dead or dying. That money is gone. It was stolen from you in that great Ponzi Scheme and your great argument is that since you were stolen from to pay for others, others should be stolen from to pay for you.

…But I digress.

The brilliance of Doug’s presentation was that he played history teacher. He took the time and effort to explain every single federal law concerning health care since the very first one, which I believe was in the 1920’s (Doug, please correct in comments or otherwise elaborate, if you like). His thesis was this: every single one served to separate the sacred doctor and patient fiduciary relationship—that sacred relationship that, at base, used to motivate the best and brightest to go into an enormously respected profession that was justly rewarded when accomplished competently, as well it should. But when each of these acts eventually had untenable untended consequences, nothing was ever rolled back. It was always doubled down.

He took an hour to go through about a dozen federal acts, where each in succession served to further collectivize, hostpitalize, and institutionalize medical care. Each served to further remove both doctor and patient from any awareness of the level, extent and cost of treatment—channelling more and more decision and payment to third parties, with tax breaks galore. But medical care is no more removed from economic reality than anything else. When you spend your own money on your own stuff, you care about price and quality. When you spend someone else’s money on someone else, you don’t really give much of a shit about either, unless you’re a dishonest activist or politician—who only lies when you open your mouth.

I can’t begin to go through all dozen, or however many acts—so I revert to my 2-word descriptive. There’s one that stands out a bit, however—signed into law by the most “conservative” Republican to hold presidential office in most people’s memory. That was 1986, and it’s called the Emergency Medical Treatment and Active Labor Act (EMTALA). It mandates that, for any hospital that accepts money from government:

…to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. Participating hospitals may only transfer or discharge patients needing emergency treatment under their own informed consent, after stabilization, or when their condition requires transfer to a hospital better equipped to administer the treatment.

I dunno, but there’s your national health care right there (for anyone with even the most base understanding of economics—which, I admit, is in single digit percentages). As Doug pointed out, how long do you think it took the more clever, street-smart to realize that was a health care plan at your expense? Just go to the emergency room.

Doug also pointed out why: “regardless of […] ability to pay” really means regardless of willingness to pay. Here’s where this gets very ugly, thanks to that “freedom loving” Ronald Reagan. Based on Medicare billing limit schedules, Doug provides $350,000 worth of emergency room services each year he’s not compensated for. Not only that, but he’s an independent physician in a group that provides ER services to hospitals. His overhead, or cost of doing business at all as a doctor is about $40 per hour (ref: an old comment on my blog from him…maybe more now). So get this. He does $350,000 at Medicare rates worth of services, get’s paid zero, and pays out of pocket $40 per hour—for as many hours as it takes to bill $350K to Medicare—for the privilege of saying “I’m a doctor” at cocktail parties, and getting to practice emergency medicine and save lives—and they save far more on the spot than anyone else.

In the end, he takes home about 30% of what he actually works for. Oh, and that’s before taxes.

But that’s not all. You see, there’s a criminal provision to that law. Unless Doug attends to anyone in need in the emergency room, out to 250 yards from the entrance, he can be criminally prosecuted. Criminal statutes of this sort call for treble damages. That means whatever they come up with as a fine for not providing free services for those unable or unwilling to pay, it’s tripled. But that’s not all. The “victim” of not receiving unable-or-unwilling-to-pay services also gets treble damages. So to keep ass out of jail, the doctor is up for 6 times the amount of whatever fine gets negotiated (Doug, can you provide some sense of scale for such fines or otherwise elaborate on nuts & bolts of the thing?).

Now I ask you: with just that one law and downstream consequences, isn’t it amazing that doctors still pursue the profession at all? I think Doug is hugely frustrated and I’m quite confident it’s not about the money. I think it’s about having a real doctor-patient relationship foremost. Think about it. You spend 20 years in education to be trusted to make decisions about life & death situations, and just like an astronaut or an airline pilot, you want to make them. You want to be good.

But far more than that—and I firmly believe this is true for Doug, though I didn’t ask him—emergency room medicine means that if you don’t know what “seconds count” means, you’re not fit. Imagine the ability to save a life where 99.9% of the people on Earth would have to through up arms and cry. I don’t know what makes a man willing to go into the office every day when he’s being denied 70% of what he’s worth, and has to pay taxes on the 30% he actually gets, but I have a sneaking suspicion.

They use what you love against you.

Doug can save a life when seconds count, and I imagine he loves that, as any man of his character would.

What was his conclusion? Stay out of “The Belly of the Beast.” Don’t get sick. Eat Paleoish, exercise…all that stuff. He doesn’t want your business.

…Someone asked in one of my recent posts:

McGuff’s biceps are looking huge or is it his shirt?

Judge for yourselves.

IMG 1056
Life Saver

Alright, now it’s your turn. What do you think about all of that?

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  1. Sean on August 21, 2012 at 01:17

    Richard, you didn’t mention Doug’s book and blog.

    Body-by-Science was the first strength training book I bought when I first got into paleo (it was on Kurt Harris’ recommended list) and is a great intro into HIIT training ideas, different types of muscle fiber, exploding ‘cardio’ training, etc.

  2. Tuck on August 20, 2012 at 19:18

    Now we know what happens to you when you let yourself slide all the way down the slippery slope.

    • Richard Nikoley on August 20, 2012 at 19:19

      Meaning what, exactly?

      • Tuck on August 21, 2012 at 15:07

        You start off with one litter intervention, and everyone says “Don’t worry, this is all we’re going to do!”

        Then you start moving down the slippery slope, and the interventions start coming fast and furious.

        And then you wake up one day and realized You’re Effed. It’s nothing but interventions.


      • Tuck on August 21, 2012 at 15:07

        That should be “one little intervention”…

      • Richard Nikoley on August 21, 2012 at 17:05

        Ah, OK. Thanks for the clarification.

      • Tuck on August 21, 2012 at 18:29

        No prob. Nice meeting you at AHS, btw!

      • Richard Nikoley on August 21, 2012 at 19:18

        Thanks Tuck. I’m always embarrassed when I can’t remember the names and faces of everyone who said hi to me, but I sure do appreciate it and I hope I was nice to you.

  3. MAS on August 20, 2012 at 19:27

    Dr. McGuff for Surgeon General!

    • DML on August 20, 2012 at 20:30

      See that’s part of the problem: There should be no Surgeon General.

      ….I’m going to be for now and not expound upon the numerous reasons why I declare this….

      • DML on August 20, 2012 at 20:39

        …I’m going to be *lazy* for now…

      • Richard Nikoley on August 20, 2012 at 21:29

        DML, it’s derivative of what I often say when discussions of who ought be the next president.

        Nobody should be president.

  4. Chris Gabel on August 20, 2012 at 19:38

    We’ve been on a 50 year slippery slope with this. Ever since Truman failed to get a universal health program. The politicos have chosen an incremental strategy.

  5. Contemplationist on August 20, 2012 at 19:42

    Great talk
    But even the Good Doc missed some stuff. Obviously it’s impossible to cover everything in the 100 years in 90 mins. But I beg and plead you to read this amazingly comprehensive analysis of the roots of the rot in health care in America by Kevin Carson. You obviously may not agree with everything but I haven’t seen anything more comprehensive.

    It has blown every single argument of the statists out of the water for me. No defensiveness left. Not even with the emotional extortion of YOU GONNA LET PEOPLE DIE ON DA STREET?!?!
    Every single person interested in US health care needs to read that paper.

    • DML on August 20, 2012 at 20:37

      Hey Contemplationist,

      Good choice! Carson’s article is among the best I have ever read on the health care issue. In fact, I have to say Carson’s body of work is pretty stellar overall, even if he does go off the deep end sometimes.

      • Contemplationist on August 20, 2012 at 22:36

        For me its not among the best, but THE BEST. You can find a thousand articles on various individual moving parts that are rusty, but Carson puts it all together and adds his own analysis.
        Agree also about the deep end part lol. But whatever, as if anyone ever agreed 100% with another soul.

  6. noah on August 21, 2012 at 12:20

    I agree with you. Love is abused exactly like you describe it. Also, “hope”

    None of the political ideas in the game has the solution to the kinds of problems we face. Some rational amalgamation may be part of a solution, but its politics we are talking about and I just said “rational” haha. :(

    Our ideas of money, value and ownership are outdated.

    We already possess the knowledge to make technology that would make most manual human labor irrelevant.

  7. ad ligtvoet on August 21, 2012 at 01:48

    Hi Richard,
    I have been a long time reader and listener of Doug’s ideas and material and participate on his site with comments.All I can say is that I have huge respect for him.He always hits the nail excactly on different situations going on .Healthy mind in a healthy body.
    Rgarding the health care in your country it’s my opinion that the best one can do is indeed to take care of oneself by living the way promoted by you ,doug and the rest of a very smart crowd. Here in the netherlands persists also a health care crisis as it is called,primarely as a result of a ever older growing population , the rise of diabetes and obesitas etc..That is the reason givin ,but it is a ever older ‘sick’growing population unwilling to do something about it because they have a right of medical care since (most) they paid for it , or the idea in peoples mind that medicine will take care and they can go on with the way they do. The costs are rising every year and that leaves less money to spent on good nutrition etc.. Costs most are forced to pay but with every year less services one may use . Much complains here in the netherlands with no solutions . In short ,many problems here too like I guess in many other countries. Having a firm idea about Freedom and society will be part of the solution and I don’t see this happening soon.So for me it helps have clear in mind that nobody owns my life and to act according that idea. That is why I haven’t voted in almost 30 years(sounds familiar?).

    • Richard Nikoley on August 21, 2012 at 07:03

      ad ligtvoet

      Wish I’d never voted. I think ’96 was my last time.

      • ad ligtvoet on August 23, 2012 at 09:18

        How timing.The whole voting shit has started here again.Ofcourse healthcare is a subject that plays a important role.Curious who will burn his fingers on that one since a lot are sick and need medication and/or care.So that is a large part of the population with a right to vote.I got my vote card yesterday in the mailbox.Guess what I did with it.No..not that ,it wasn’t soft enough so I just throw away.
        Read today that the E.U. wants to stop to subsidide rich (big) farmers.They get that money so they export their(grain) products against a lower price.OH man what a mess.

      • Richard Nikoley on August 23, 2012 at 10:39

        “OH man what a mess.”

        NOBOBY will EVER vote their way out of it.

  8. Phocion Timon on August 21, 2012 at 04:16

    My overriding rule-of-thumb: when the politicians step in, the situation and the citizens are immediately fucked.

  9. rob on August 21, 2012 at 05:38

    I try to improve the health care system by not participating in it, a lot of people are totally insane about their health. Few weeks ago my receptionist makes an appointment with her doctor cause she has some swelling under her jaw. So I say “Oh those are your lymph glands, something provoked a response from your immune system.” She looks at me like I have three heads. She goes to the doctor, doctor says her lymph glands are swollen, prescribes her some penicillin and asks the usual “by the way are you allergic to penicillin” question. Now my receptionist is back but she’s in a state of high anxiety because she might, unknowingly, be allergic to penicillin, and she’s not sure if she should risk taking the pills. After much agonizing she takes the penicillin but wakes up in the middle of the night terrorized that she might be having an adverse reaction to it. So it’s back to the doctor to swap the pills for a different non-penicillin anti-biotic. A day later the swelling in the lymph glands is gone, which would have happened anyway even if she had never gone to the doctor.

  10. Elenor on August 21, 2012 at 06:07

    That’s always the quandary. (I used to be medical affairs director for an ambulance corps: I see Doug’s situation from the other side.) People are SOOOOOOO stupid! Sooooo unwilling to learn about … well… it seems everything!

    When my nephew was 5 or 6, my sister said she and her husband were looking to buy a house with a pool. “Great!” I said, “and you both are going to take a first aid course before you move in, right?” “Well, no, we hadn’t thought about it. Is that the law in CT?” “ARGH! No! But what are you going to do if Alex drowns — wring your hands till the ambulance comes?!”

    The elderly woman married (for years) to a man with advanced cardio-myopathy — calls 911 and is shrieking because he’s dying; and after he dies, she (and her lawyer, of course) SUE the 911 system because the dispatcher “should” have explained to her how to perform CPR (over the phone! WHILE he was dying!). (!!) How many years had she known he was ill — and hadn’t bothered to get training?

    (When my husband died last year, *I* knew how to perform CPR (alas, to no avail) — but I certainly didn’t ‘blame’ anyone! And I get a … well… some sort of semi-good feeling, because when the ER doc (tip o’ the hat to Doug) came in to tell me Michael was gone, I stopped him and said, “I used to be medical affairs director for an ambulance. I already know.” So, gave him a small break…)

    I’m in my mid-50s and have no health care insurance. I have health *care*, of course, it comes out of my pocket, without a(n industry-) negotiated reduced rate! I’m always annoyed that ‘everyone’ refers to “not having health CARE,” when what they MEAN is not having someone else to pay for it, so they don’t have to! If we smart folks would start ever-so-carefully (and loudly) differentiating between health care and health INSURANCE … well…. I suppose it would just be pissin’ into the wind, anyway… Nevermind. {sigh}

    • Richard Nikoley on August 21, 2012 at 07:15


      Thank you for that echoing insight. I’m sorry for your loss. At least you know you did everything that was in an individual’s power to do in that situation.

      Very high salute to you.

  11. Jan's Sushi Bar on August 21, 2012 at 07:15

    I went to school with a man who became a podiatrist and quit because of the regulations, red tape and sky-high malpractice insurance rates. He now teaches science in an “alternative” high school – you know, one where they send the kids who are too much for the teachers and administrators (who have their hands firmly tied when it comes to disciplining the little thugs) at mainstream schools. The fact that he finds that preferable to being a podiatrist, for crying out loud, just makes me shake my head in wonder.

    My husband and I have a small software business; it employs 7 people. We have just begun to move everyone to a high-deductible health insurance plan where they pay their own premiums and are encouraged to open an HSA – we, as an employer, can no longer afford to offer a group plan; the premiums are nothing short of outrageous. I can tell you that these people are far more conscious of their health habits and how often they go to the doctor now that they’re responsible for that premium, the rate of which is based on their current health, and that first $4,000.

    • Richard Nikoley on August 21, 2012 at 07:24

      Jan, I could go on and on about the health insurance for my company. I looked at HSAs twice but the premium reduction here in CA (with a young workforce to boot) was so insubstantial to my bottom line that I kept the full maintenance. In other words, I could have full service with a small co-pay for x, and going to something like a 2k deductible and where the employee had an HSA saved the company very little and served my employees far less, so I stuck with what I already had.

      Screwed either way.

  12. JohnC on August 21, 2012 at 09:17

    I don’t know much about U.S. healthcare but there are a couple of glaring things that seem to jump out:

    You seriously don’t think the doctors themselves bear *any* responsibility for the situation? They are just powerless and helpless people without a voice? Bullshit! Doug may be one of the good ones but for every Doug there are probably many more who just want a bigger house, nicer club memberships etc etc.

    Why in the world does it cost Doug 40 dollars an hour in expenses? I can’t fathom how that is even possible.

    • Richard Nikoley on August 21, 2012 at 09:55


      Very good questions. Just got an email from Doug and while he’s headed off into the belly of the beast now, he’ll be commenting later.

      To your first question, you nailed it. In fact, one of Doug’s slides was to point blame at doctors. It’s complex, but essentially, en masse, it appears it was always short term gain at the expense of fucking doctors down the road–much like debt financing of everything is doing to everyone right now, all over the world.

      Overhead is simple. As a doctor, he either has to do the red tape or hire someone to do it for virtually everything he does, and then there’s the hugely expensive malpractice insurance he has to carry or disclose to patients he doesn’t, and no hospital would allow him to practice in.

    • Joe on August 21, 2012 at 10:00

      The individual doctors can opt-out by quitting. That’s their “voice.”

      As individuals, they have about as much influence on medicine as individual voters do on US policy.

      And $40 an hour isn’t much. Any guess on what malpractice insurance premiums run for guys tasked with converting 200 pounds of organ meats back into something called a “motorcyclist”?

      • Richard Nikoley on August 21, 2012 at 10:17

        Yep, Joe, that’s it. In Spiro Angnew fashion, “love it or leave it.”

        Thing is, many love for many reasons and I think Doug loves to save lives when seconds count and so few others can. In a hostiptal ER, he has the tools and technology at his disposal to do that and being of the high character he is, he just sucks it up. But it’s not right.

        BTW, here’s an old post of mine that is basically a quote of what Doug posted at De Vany’s place way back when. “Orcas in the ER.”


  13. Doug McGuff, MD on August 21, 2012 at 10:42


    In my talk I demonstrated how the slope has not been at all slippery…it has been very gradual. Sort of like cooking the frog in the pot. If you turn the heat up slowly, he doesn’t realize he is for dinner. The slope is never slippery until very close to the end.


    I am sorry about the loss of your dear husband.

    John C,

    If you could have been present for my talk, one of the earliest slides placed the blame of this whole mess squarely on the shoulders of doctors. At each step they have traded short-term gain for long term destruction. The 40 dollars comes mostly from malpractice cost, some from the cost of documentation which is required to get paid and to protect oneself medicolegally, some goes to billing overhead and employees hired to meet government-mandated administrative and regulatory burden. By the way…I would love a bigger house and nicer things, there is nothing wrong with that, unless you sell your soul to get them.


    Thanks for your comment. Quitting is the final defense. It is the only way to make those who wield force understand that the knowledge to do what I do is mine. However, it is not an easy solution. You have to choke down decades of training and experience as a lost opportunity cost. Plus, there is nothing to compare to easing suffering or saving a life. That is the essence of evil…to use your virtue against you…like the child murderer in the movie “The Green Mile”.

    • Joe on August 21, 2012 at 12:48

      Dr. McGuff,

      I know that it’s a Hobson’s choice. I actually know an ex-ER doc who finally quit about five years ago. I imagine he was good, too…Stanford Med, the works. He opened up to me and I was kind of stunned by how little he made for the pressure and lifestyle required. (He was actually making more from a not-particularly-impressive diet website he’d started on the side as a hobby.)

      The pressure, hours & the limited money he could deal with, but the regulations (and hospital politics) finally made him decide he’d had enough.

      there is nothing to compare to easing suffering or saving a life.

      I imagine there are about a billion horrible things about your job, but I envy you your memories of the lives you saved. There are very few people who can know with utter conviction that their existence made the difference, so often. It must be nice.

      People who think doctors are in it for the money are ignorant. People who want money become pizza franchisors. Crap ingredients bought in railcar quantities, minimum wage labor, scalable, entire business model fits on a checklist, addictive product that sells better than hotcakes even if shit in quality? $$$$$$$$

      Here’s the post that brought that to mind (from here: :

      A friend of mine once ran a chain of 100 pizza restaurants. He bought them out of near-bankruptcy and completely turned them around. I asked him what was the key to success of running 100 pizza restaurants.

      “I’ll tell you the one secret,” he said. “Make round pizzas”. It turns out that too often the pizzerias were making odd-shaped pizzas. Or would be delivered with the wrong ingredients. Or would be delivered too early or too late. He essentially said, “don’t make basic mistakes” and you will be successful. He didn’t set out as his goal to make “the best pizza in the world”. Nothing close (almost by definition: his chain was made up all of Dominos pizza stores). He just wanted to do nothing wrong. The stores completely turned around and became super successful. He eventually sold them and made a lot of money.

      Your book, your gym, your practice — none make as much financial sense as pushing pizza.

      Someone who becomes an ER doc is basically the opposite kind of person.

      Thank God.

      That is the essence of evil…to use your virtue against you…like the child murderer in the movie “The Green Mile”

      And like what happens in most divorces. One can’t get away from evil without getting away from people entirely. Even ourselves.

      All part of the adventure, I guess. :-)

      Thanks for your book, btw. I bought it and it’s excellent.

      And I’m unlikely ever to be in your ER, but thank you for your work there, too.

  14. Natalie on August 21, 2012 at 11:45

    My uncle has been a physician in the us since 1990. Every year, he says, he felt he was spending more and more time on forms and legal issues and less with the patients. And, having been a doctor in the Soviet Union before moving to the States, he thought he knew everything he there was about the red tape.

    • Richard Nikoley on August 21, 2012 at 12:39

      Oh, Natalie.

      The Soviet Union in quotidian, whatcha gonna do today terms was arguably more free than we are in a number of ways. The Nomenclatura (ask your uncle what that means if you don’t know) had really no means to ensure for the sort of red tape we do. Red tape costs a lot of money, both to fill out and to administer, unless you’re just going to make people jump through the hoops to fill the shit out, then toss it in the can and chalk it up to a clever way to motivate compliance to diktats.

      But in the US, we’re “unbridled capitalists” which means we have entire multi billion per year industries from tax preparation services to medical billing services that are basically force imposed overhead on life.

      I’ve bee to the USSR when it still was, China when it had a concrete pedestal and a fully employed person directing traffic rather than lights, and about 20-30 other countries. In Japan, I could buy a bottle of whiskey or a 2-liter keg of beer from a vending machine 100 yards from the house I occupied for 5 years. Laughing stock deserved.

      In terms of alcohol, there are Islamic countries that prohibit it outright, and the US–where the lesson that should be learned is to never let a group of Puritans get in a boat–to my knowledge, the only country in the world that requires ID.

      I get carded now more than I did in my 20s because “we card everyone.” I have a good line for that, that I always use whether they like it of not:

      “well, better stupid than fired.”

      They use what you love and what you need to survive against you and they eve require you to be stupid in the face of people who ought to be respecting you for your service.

      I love America. I loath the United States, if you can come to grips with the distinction.

      • Joao Eira on August 24, 2012 at 17:14

        Portugal also requires an ID, if the cashier suspects the buyer is younger than 18 (used to be 16 not long ago) and am pretty sure most European countries have it as a law also.

      • Richard Nikoley on August 24, 2012 at 19:11

        Could be now, and that’s a shame. It was never my experience in the 80s and 90s anywhere.

      • elizabeth on August 26, 2012 at 14:02

        “well, better stupid than fired.”

        LOVE IT! I AM SO STEALING THIS LINE! I do look very young for 50, but I don’t look as if I’m under 35. Let alone under 21.

  15. Eric on August 21, 2012 at 12:00

    Will the talk be available online at some point?

    • Richard Nikoley on August 21, 2012 at 12:46

      Yes it will Eric, as will mine on Paleo Epistemology and Socialogy, a version of my AHS talk expanded from 20 minutes to an hour+. It normally takes Anthony some months to make them available (see The 21 site for what’s already there….lots), as part of the deal is he packages them in DVDs to support himself the the continuation of the conference each year and bringing a very impressive group of speakers together.

  16. Amy Haines on August 21, 2012 at 14:29

    Anthony Johnson’s 21 Convention is relevant and important on more levels than just teaching young men to be PUAs (and if you see only that in his Project and vision than you are a limited individual). The matters that you, Richard, and Dr. McGuff, and the entire cadre of presenters showcase during the Convention are so critical for young people to understand – from a perspective of politics and economics, whether or not you choose to vote, go rogue, get married, stay single, or even stay in the USA. I’m glad you were invited to speak there, again, and I look forward to watching the videos.

    My life was quite literally in the hands of a dedicated doctor and her nursing staff this morning. I had a baby just after midnight today and began to hemorrhage. I lost 3 pints of blood and had a 1200 cc clot that needed to be removed in order to save me from emergency surgery or death. I felt myself slipping away, half in pain from the manual expression of the clot and half in euphoria as I fell downward into some soft place I did not know. My husband’s voice anchored me to the present and the doctor expertly cleared the problem. I’m here typing this response now due to this woman’s expertise and training. I seriously doubt she was thinking about the money she would make from performing this service, even though I would gladly take out a second mortgage on my house to pay her for my life. I do not believe doctors get into their field for the money, either – though adequate compensation for the use of that doctor’s expertise and training is only fair. And this is the heart of it, for me.

    The modern health insurance/health care landscape seems to regard doctors as slaves – to their patients, to regulations, to red tape, and to politics – and not as men and women willing to apply knowledge and talent to saving and improving lives. Dr. McGuff’s overhead costs make him a slave to the very industry he loves, surely a quandary of proportions I cannot fathom. Surely very few doctors would (or could) walk away from an injured person out of spite or malice or ability to pay, and yet the first person blamed when a patient feels slighted is the money-grubbing doctor. What our society expects from doctors versus what doctors get out of the deal is seriously imbalanced.

    I cannot help myself when these matters arise in conversation, Richard, so pardon me for taking this response in a bit of a different direction. You mentioned that Dr. McGuff used history as his vehicle for the points raised in his talk, and a perspective of history is critical. Yet our (failing) public schools (and I know Bea is a teacher and I admire her dedication to her job, which sometimes may feel as frustrating as Dr. McGuff’s position) do little to offer students a perspective of history in order to put these concepts in context. What could we possibly expect from our future generations when they only receive one side of a long and complicated story – the side which essentially says we are all slaves to each other? In the five years that I taught high school, I saw very little objective education occurring and much indoctrination into a system of thinking that devalues the hard work and talent of others except when it is pressed into service to those who do not wish to work, or pay, or develop their own skills.

    • Richard Nikoley on August 21, 2012 at 17:02

      Wow Amy. Wow. First, glad you’re ok. Second, that you can write a comment like that is a testament to your will and the competence of that doctor and team. Third, boy or girl? Fourth, congratulations.

      To your last paragraph, I spoke to this a bit in my presentation, how even history gets used not to spin illusion and deception toward a lower quality of knowledge than is true of those dealing always in hard facts of reality.

      • Amy Haines on August 22, 2012 at 06:01

        Thanks, Richard. A healthy boy, and we are all going home tomorrow. Looking forward to getting back to my bone broth and calf’s liver to rebuild the blood.

        I know Anthony has a lot of work to do with the convention and the vids might not be posted for a while, any chance yours might show up on FTA earlier, or are they Johnson’s copyright?

      • Richard Nikoley on August 22, 2012 at 08:42

        No, Anthony controls. He puts it all out on DVD first, then releases individual presentations one by one over time as a hook to get the DVD. Clever. My shorter, AHS version of the presentation should be out pretty soon though.

  17. reaLife on August 21, 2012 at 18:43

    saw a doctor friend in L.A. she said her overhead was 70% works 80 hour week. yep! see LifeExtension Mag Sept editorial “A deadly waiting game.” and I thought socialist Canada was bad when it is included with our taxes but is effectively a mirage with deadly delays in the system and now my concierge doc wants $100/month availability fees!

    • Richard Nikoley on August 21, 2012 at 19:21

      Doug mentioned in his Q&A I think that there’s a website where you can see the wait times for various procedures in Canada. He went on to explain how for some procedures, the risk of death is quite high in that interim period but when they do die, it’s never chalked up to that wait time but to the original problem.

  18. Contemplationist on August 21, 2012 at 21:14

    The American Medical Association started this ratchet of corporatist-socialism when they lobbied to have doctors licensed professionally and medical schools to be accredited by the state. Most people have no clue about this history from back around 1920.

  19. ad ligtvoet on August 22, 2012 at 03:51

    I also want to mention that doug also saves lives by helping preventing bad health through his strength training facility .For him as a doc. he also has to be carefull to be not involved as a doc. in this business.He wrote a nice article about that a long time ago (if I remember well).Maybe he can react to this situation too.

  20. Robert Ve on August 22, 2012 at 03:53

    All of this is so fucked up, yet most people don’t have a clue. It’s truly amazing that people just don’t get how evil the state is. So many problems and they all lead back to the same source.

  21. Srdjan Ostric on August 22, 2012 at 04:02

    This was a nice post Richard. I am glad you wrote it.

  22. Jack Kruse on August 22, 2012 at 04:42

    No law has ruined my specialty of neurosurgery more than EMTALA. Moreover, the hospitals try to use that law to force us to take all and everything no matter the risk, medical situation because they can and do make money on these cases while we shoulder the medical legal risk of the case. I am sure Doug will back me up on this. Neurosurgeons carry the highest medical malpractice risk in medicine. In some states like Florida, the coverage can cost three million to five million dollars a year just to work. This is untenable when they have cut our pay for the last 15 yrs by over 1000%. So what did the neurosurgeons do? They went naked without med mal coverage in Florida. They told the world they could not afford 3 million dollars a year t provide call. Then they dropped call all together. What happened then? Then hospital based systems after 18 months caved in and finally offered pay for call services. The pay was not enough for the service so many neurosurgeons left Fl. The ones that stayed radically changed their practices to survive. Moreover, about 6 years ago if you got a brain injury in Orlando, Fl there were no neurosurgeons on call in the city for 6 months because of this quandry. So anyone who got injured had to be lifelighted to another city for care, further reducing their prognosis because of this rule. The same thing is going on now in cities across the country. EMS is not told about the hospital’s neurosurgery call situation and sometimes people are brought to hospitals where no service is available. This happened in my own hospital with regularity for 8 yrs. Not once did it make the papers. Why? The media is in bed with the big corporations. The hospitals refused to pay neurosurgeons for this coverage because for 50 years they got this service for nothing until the medical malpractice costs went higher than what we make by 5 times. Just so we are clear…..med mal insurance for NS in Fl costs us 3 million per yr and the avg neurosurgeon salary about 600,000 a yr. You do the math. It is called unsustainable. The hospital still made money on these patients because down the road the state medicaid funds would pay them for any patient who required a hospital stay over 3 days in an ICU. The surgeon who came in the middle of the night, risked his practice because of a possible law suit in this case, ruined his sleep, and his next day schedule, got nothing. Most administrators of the hospital never even said thank you. They were told at hospital meetings this was our duty. I can not tell you how many times I have been told this. To add injury to insult…….we are required to take care of that patient until the acuity of the situation is over no matter the risk to us. That patient loses no rights in this case either. If they can’t pay a dime, the federal law says we must do it for free and they still have the ability to sue us for any reason at all.. Maybe no you wonder why some of us are a bit grumpy? If we don’t offer this acute care in this manner, the law says we can face 50K fines per occurrence. That can be 50K a day for a patient who is refused acute care. The rule was used for years to try to control neurosurgery coverage until some of us got smart and creative. You cant get around EMTALA…….but you can change the scope of your practice and drop services. That is precisely what has happened. Who loses……..you the public. And none of you knew this was going on for the last 10 years.

    I am glad Doug put this one out. Many in the lay public have not a clue what we face. They just like to beat us down for a variety of things. This is just a small taste of the shit we get served. I could write for days on some of the things the health care complex has done to my particular specialty that would make your head spin. My parting advice is this……before you go on vacation off the grid, call the local ER and make sure they have specialty coverage in all areas of medicine and if not then ask them what they do? I bet you’ll be surprised to find out they do not have to disclose that info to the public. How is that for risk assessment? If you’re going to be doing something that could put you at risk you might want to think twice about doing it there. There are only 3800 neurosurgeons in the USA. About 2/3 of them no longer offer cranial ER coverage. You do that math now.

    • Richard Nikoley on August 22, 2012 at 08:36

      Thanks for adding all that to the mix, Jack.

      Sure looks like a cobbled together ‘universal coverage’ to me, at the expense of doctors, hospitals and the public.

  23. Jack Kruse on August 22, 2012 at 04:45

    And no……..I have never walked away from a patient in need since I became a surgeon. I just think you need to know what guys like me, Doug, Dr. O and Ron Rosedale face daily before you piss in our cornflakes. If we do nto get tort reform……..well you the public will pay dearly.

  24. Doug McGuff, MD on August 22, 2012 at 09:26


    Thanks for your input. EMTALA has affected call coverage more than anything. I discussed how no specialist in his/her right mind wants to be called in at 3am when there is a 70% chance they will not be compensated, will be open to full liability and will lose income from the other parts of their practice while they carry out their “duty”. A law designed to ensure the poor get access to emergency care and on call specialists actually ends up making it impossible. Even if one wants to provide this level of indigent coverage, it is not financially sustainable, you will be out of business in no time.

    My solution for EMTALA was to use CMS rates to determine the level of service and to allow that to be deducted from taxable income. Specialists then would be willing to provide indigent care up to the amount they earned in the paying part of their practice. Indigent care would thus make their income essentially tax-free. This has been proposed and rejected. The government does not want a solution…it wants control.

  25. Andrew on August 22, 2012 at 10:35

    Just wanted to offer some perspective. I am a medical student, currently at the largest hospital in central Europe. When, and if, I finish medicine after 6 years of hard study, I’ll start to earn about 1000 dollars a month. But, as there aren’t enough doctors, I will have to work for maybe twice the amount of what’s normal in the long term.
    But you need to work after school, which often means you work for “0.1” cotract…100 dollars…but in reality it’s normal full time…they know you are in a trap and will sign it as you need it for your career…
    Actually, the quality of care is top class…the same as in Germany. The price of material is the same, but everything here is “free” and the payments for hospital are lower than for average hotel…this country saves money on doctors.
    I think it’s great people don’t have to pay for super expensive operations (brain tumours etc.)…they couldn’t. On the other side, this means people don’t value what is free…many of them are really surprised when they come to Britain and have to wait for the doctors 10x the amount of time even for “banal” procedures.
    In our country doctor doesn’t have time to really talk to patients, so the care is 9/10 and the feeling is 5/10, in Britain it’s often like care: 8/10 and feeling “10/10 after 30 minute chat with doctor.
    When I meet any doctor here, they make jokes about the need to leave abroad…but when I see the exodus of doctors, it’s not a joke anymore.
    The politicans know all this, but money is money. They “hire” an old professor who is presented as a “hero who doesn’t leave the country” and who says “it’s necessary to work all the time, the doctor has to learn this way, I did this in USA 50 years ago!”:-) The reality is this guy plays golf at the castle and runs marathons, while young doctors burnout or go abroad.

  26. Steve on August 26, 2012 at 09:44

    As a nurse, I have no idea why anyone today would rack up the huge bills to go to med school and become a MD, then put up with all the shit that comes with being a Doc. The only way I MIGHT be inclined to do it is thru the military, where you come out fully trained and debt free. I can only imagine how bad the bureaucracy will become once Obama care comes into full effect. I know as a nurse, I often feel like most of my shift is about making sure the paperwork is filled out, and certain things are done that need to be done to satisfy Medicare, the state, etc, etc., and after that, I worry about the patient. I hate it. It is the biggest reason I am looking to get out of bed side care. I can only imagine how bad it is for the MD’s. There is no way this new system is going to work out, at least that I can see.

  27. Jessica K. on August 27, 2012 at 05:59

    By focusing on healthcare, we are losing focus of the real problem: health.

  28. […] few days later I blogged about Doug's presentation in detail: Dr. Doug McGuff’s The 21 Convention Presentation in 2 Words: You’re Fucked. Lot's of good comments on that post expounding upon the […]

  29. Julien Couvreur on February 28, 2013 at 23:12

    Dr McGuff’s presentation above is one of my favorite analyses on health care, as it shows the play-by-play effect of various interventions and how they led us to the current messed-up situation.

    However, there are two aspects which I am having hard time reconciling with observations by Steven Brill in his recent essay ([1]):
    1) McGuff claims that hospitals are struggling to survive financially. But they earn massive profits according to Brill’s data.
    2) He states that patients, especially Medicare/Medicaid patients, are a liability and financial loss center to hospital and they filter on admission. But Brill points out that some hospital advertise to those populations.

    I would love to get Dr McGuff’s view on these two questions and more generally his reaction to Brill’s essay. I would much appreciate if you could forward my questions, as I could not find his contact information to reach him directly.


  30. Angus on February 10, 2016 at 14:27

    SO much wrong with this diatribe. 350,000USD of ER care that he isn’t paid for, are you kidding me? That’s as much as as 2 neurologists for ODHB at Dunedin Hospital in NZ. Your US healthcare system is broken, and it isn’t because of “ObamaCare” it is because of decades of erosion of socialised heathcare due to lobbying from insurance companies. For 2,500$ US per person we have some of the best healthcare in the world. We lag on bowel cancer screening because that is one of the few areas where insurance companies can save money by detecting early, so the US is far and away the best there. You are not fucked, except the lobbyists semi-broke Obama care by the time it was finally passed.

    • Richard Nikoley on February 11, 2016 at 06:35

      Well that’s a mixed message.

      Insurance is a form of socilizing costs. It works well for automobiles, homes, and a whole host of other things. That is doesn’t for health care is not a problem with insurance per se, but of state interference in markets.

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