Universe On The Couch

US News has a whole feature this week on basically replacing physicians with lesser trained health care professionals. Don't expect me to not get emotional here. Today I focus on nurses.

The gist here is to replace doctors with nurses. You may have experienced this already. You go through all the hassle of scheduling an appointment with you doctor, take time out from your busy schedule, the hassle of driving there, paying to park, waiting in the waiting room,... Only to be told the nurse will be in shortly. I wouldn't bother coming in unless I was concerned enough to deal with it myself.

Nothing against nurses. They provide an essential service. It is often physically hard work and often unpleasant. They work at all hours on their shifts including when most of us sleep or have time off.

But let us first look at qualifications. One can be an RN with a two-year program. To practice medicine it takes four years of college. And that at a performance level good enough for the very competitive admissions process to get into medical school. Then four years of medical school, very rigorous indeed. Then at least an internship for a year. Grueling to say the least. Most finish a residency of at least three years, usually more. Who would you want?

So who would want to replace doctors? Let us start with nurses. The profession has a severe shortage of people doing actual nursing. This is funny in that the profession is overloaded with administrators. I saw this top-heavy more chiefs than Indians in the military and in hospitals everywhere. And with salaries pushing six-figures too. So they are pushing with their powerful lobbies to practice medicine. Sounds like ego and money to me.

The second culprit is insurance companies. Pocketing great profits screwing over the doctors and patients. Now they can pocket more money using lesser providers.

Third is the drug companies. More providers means more drugs prescribed.

Fourth is the government. They see the current costs of care and want easy solutions. Of course Congress will always go to Bethesda and be cared for by the top doctors.

Will this really save money? In the short term perhaps. Manipulated statistics will show positive results. But they will be misleading. Expect more bad medication outcomes given the nurse's limited pharmacologic knowledge. Sure they can probably handle 80-90% of the problems if further training is adequate. But what if you are that 10-20%?

There is also the over-reliance on expensive tests. When nurses played dermatologist all cost savings were lost because they biopsied everything, also uncomfortable and not without risks to the patients.

Is this the way to solve the nursing shortage? No way. Less nurses practicing nursing. The migration from the Philippines is causing huge problems there. Salaries are now quite high. It is not a bad deal to be a nurse when you figure the time invested vs. Benefits when you graduate.

In summary, replacing doctors with nurses:

1. Will not save money .
2. Will decrease the quality of care.
3. Will put patients at risk.
4. Will worsen the nursing shortage.

A co-worker came to me about a friend who has givne up everything to play this game on-line, a dungeons and dragons thing. He doesn't want to stop to use the can. He doesn't leave his apartment. Has food and whatever delivered, ordered on the Internet. No social contacts initiated. Lost a good job. Sounds like crack to me. Except for the eating. And they really get the shits.

I myself have a minor addiction here. The game is Civilization. I don't do it on-line either. The first version crashed my PC often and after an evening ER shift I would start around 12:30 and play to four. Hard to get up at seven. Phone calls from my girlfriend were irritating.

Version II was worse. The bugs and those of Windows worked out better. Endless hours again. A whole day off wasted. Still unshowered and unshaven when my gal arrived home at five on Saturday. I certainly didn't give up my job or any social activities, but fre time was sucked into this black hole.

So this XMAS I got my girlfriend to buy III for me. Oops. I have wiped out the French, Russians, Chinese and Japanese. Of course my garage door opener is still broken and I haven't addressed the tax request I got.

What is it here? Why so compelling? I figure its a few things. First it is a pastime that you never have to leave the house. Pastime means using up our awake hours. Killing time. Surf the net. Read the Sunday paper. Watch the game. And never leave the house. No rain, cold, snow. No assholes on the road, traffic, finding parking, paying to park,.. Dealing with people and their hostility, rudeness, cell phones,... Not haveing to bathe, shave, wear decent clothing,...

Second is the lack of ambiguity. It is clear who wins and loses. you conquer the world. Get to the next level. Best your highest score. Most of us have boring repetitive jobs and there is little tangible progress. Not much satisfaction of accomplishment.

Third is power. I control a nation. Conquer the world. Soar to the next star. Others get to be muscular warriors, powerful wizards and even mythical creatures. In our daily life our biggest power is often which channel to watch on TV.

I seem to have it under control. I do it when I would usually watch TV (except for FB and DVD's). But if it gets worse: Lost sleep, ignoring my woman, sore wrists, sore neck and shoulders and buggy eyes,... I will have to get rid of the game. Cold turkey.

One of you asked a question regarding my reference to substance abuse and dependent people to use AA and wondered if I thought there was other approaches. One concern was with the religious aspect of AA.

Yes there are other approaches. I am not a radical fan of AA.

First, let me define abuse. Abuse of a substance is continued use despite bad outcomes. For example, you get drunk and get a DUI. Oops. You screwed up. Poor judgment. I would not from that alone diagnose abuse. But get two or three and you have a problem with alcohol. Or you and your partner fight over your drinking or get nasty when drunk. You have medical problems or medications that are contraindicated and drink. And so on.

Now all use is not abuse. You get drunk one night. In lay terms you abused alcohol and you body, but medically this is not a disorder. Sometimes the line is blurry... But an otherwise healthy person who smokes pot once a week at home is probably not suffering from drug abuse.

Dependence is another issue. This means mainly that you have to use to prevent withdrawal symptoms. In a minor form that headache when you miss your daily coffee. You smoke pot daily and run out. And in a few days you get cranky. More serious, you are a wreck without that nicotine. Worse you are crawling the walls without you heroin. Most dangerous you get seizures when you miss that morning glass of Vodka (32oz tumbler).

Often both exist. You drink to prevent early withdrawal symptoms. A morning eye-opener. And drinking has impacted your life, yet you continue. Your doctor has asked you to cut down or quit for your health. Family or friends have confronted or avoided you. You lose your job. You cannot sleep well. You cannot perform sexually. You get in accidents. You do foolish things sexually, verbally or aggressively.

So what to do? Some people say enough and stop or cut way back. And that is that. But for many it is not that simple. And that is where AA can be useful.

First, it gives a cognitive structure to work with. An explanation. A program to follow step-by-step. You know it has helped millions. Just follow it. No need to think it out or read book after book. Just do it. It may sound passive and juvenile to some, but at the early stages that can be useful. A healthy regression. Besides addictions are infantile for the most part. A bottle is a bottle. Suck a nipple or suck a smoke.

Second there is a clear behavior plan. You can't drink. Ever again. It sound harsh and has been questioned. I don't think it applies in every case myself. But a period of extended sobriety lets the body and brain recover and breaks the addictive habits. But if using again leads back to the same place, quitting forever makes sense.

Third there is a support network. People in various stages themselves. They all have their stories. You are not alone. When you need help, there is someone to call.

Fourth it offers a social group. Recovery can be lonely. A whole life is built up around the drug. Happy hour, friends, even family. Activities are drinking activities: Boating, fishing, golf, parties, ballgames,... One may have to search AA groups for one to their liking. In a big city there are athletic groups, outdoor groups, religious groups, singles,...

Finally, it is independent of other entities. It is not a church. It is open to all and no fees charged. It is free of doctors and therapists. Last comment meaning?

So are there other ways to treat addictions? Doctors have three things to offer. First we can question and examine you and identify problems. We can get you to think about it as an issue and at times confront you. Feeling that enlarged liver. That blood alcohol level in the ER. Labs consistent with drinking in your blood counts and chemistries.

Second we can detox you, usually in the hospital. Some addictions can be life-threatening in detox. Others just miserable. We can take the edge off.

Third we have a limited number of treatments to reduce cravings and block the highs.

And I should add, we can avoid giving you more addictive drugs. I'd like to slap some of my profession for handing out Xanax and Klonopin like candy to alcoholics.

As for my negative attitude towards treatment programs, perhaps I am too harsh. But I do not see much good done. Plenty of money and time is spent and the same people come back again and again. This is an industry and as such fights for its existence. It looks like something is being done.

For many patients, it is a scam. Ideally they get benefits (VA, Social Security Disability, Medicaid, Food Stamps, ...) and buy whatever drug or drugs they like with your tax dollars. Then when the money runs out they show up for treatment. They get "three hots and a cot," drugs to chill the down-side, more drugs if they can con the doctor and maybe some entertainment. Go along with the program until the next check comes in.

OK I am harsh here, but I've seen it folks. From multiple angles.

The real question is do you want to stop? Then its grow up and take responsibility. Get help if you need it, but you are the one ultimately responsible. Nobody said it was easy, but that is life for most of us.

The swearing in. Fuck. Bush and company again. So what do the next four years hold...

We continue in Iraq. Our people die and the country remains in anarchy. Iran and North Korea continue on the nuke path. China and India grow. China and Japan finance our debt reluctantly with our low rates and falling dollars so we can buy more of their stuff. Bush pushes more tax cuts and more spending. American spend like crazy and build up more debt. They put money into the stock market thinking they will go up. Business as usual.

But this cannot sustain long. Interest rates are so low already. Consumers have tapped out their home equity and borrowed up to their gills. Not many can afford a home in some areas. Their is no real market for goods outside of the USA. Our trade deficit is huge. We even have a trade deficit with Palestine and Afghanistan! The whole thing is running out of steam.

One big shock and turmoil begins. Another 9-11 scale attack? Or worse? Showdown in the Middle East? Korea? Epidemic outbreak?

Here is one possibility. Israel sees Iran as a threat and bombs the hell out of them. Of course they succeed and destroy the nukes. We publicly are outraged while high-fiving them in private. This inflames the Muslim world and Israel is kicking all their butts with weapons from us.

The price of oil skyrockets. They don't want to give any to USA or our allies. The cost of gasoline goes up so Americans have less to spend on other stuff. So retail suffers. Businesses including agriculture get crunched with higher costs, tough to pass on with slowing consumer demands. People become unemployed and underemployed. Those with jobs get scared.

Americans tighten their belt. The house has been tapped. Wages are flat. Some will go bankrupt. Where to cut? Hold off on that new car, TV, sofa,... And maybe nix that health club membership. Or that overpriced cable, at least the premium stuff. Do you really need the Internet? Or that cell phone? Forget going to the movies or out to eat.

So business suffers. More jobs are lost. Homes, many now financed with little money-or none as down-payment and with the equity tapped out, hit the market, even as foreclosures. Home prices tumble. Mortgages go underwater, meaning they are higher that the current home value.

Interest rates go way up. Lending is risky and higher rates counter higher risk. The home market suffers further. Fannie and Freddie and Ginnae fall and take much of the market with them. The government seeing the results of that starts another monumental bailout. The Dow goes below 5000 and people are wiped out. Banks fail, pensions are bankrupt, 401's and such are toast.

Tax revenues are a fraction for bloated governments. Unable to raise money by taxing, they look at cutting spending. We are at war so that is preserved. Social Security is a sacred cow. Can't touch Medicare since seniors are a powerful voting block. Education and anything to do with kids will suffer. As will anything for the poor. But it will hardly be enough.

So the usual cop-out: Inflate. Borrow. The dollar sinks and sinks. Foreign investors bail on all things American since it isn't worth much. The money people managed to keep safe is now markedly reduced in value.

So a hyper-inflation and Depression! People are pissed. They aren't the tough individuals of the thirties. This is the whiny entitled America. They will throw a tantrum when the bottle is taken away. The elites will prosper of course. The poor and middle class will be on fire.

Bush will blame the Democratic liberals from FDR to Johnson to the current donkeys. He will cite scapegoats galore. Rove will spin something to get the majority behind him with more false promises and revenge on those culpable.

The Patriot Act and II will give them a ready data-base. The police state will take over. Goodbye freedom. Confiscate the gold of those that were wise enough to see what was ahead. Fundamental Christianity as the state religion. Those morals now law and enforced by tribunal. Books are burned. Citizens are implanted with a tracking devise. Your DNA is stored in a database.

OK that is a bit extreme. More likely things will churn along. The fraud will slowly suck the life out of the middle class. Jobs will keep leaving. The dollar will lose value. Stagflation will take hold. Wages will not keep up and neither will entitlements. The published inflation figures will be a dishonest manipulated underestimate of inflationary impact. People will wonder in five or ten years what happened?

OK economics is very complex and the experts never agree either. My most certain prediction: Bad things are going to happen.

Today's lesson class is the real story of a unique and well-marketed class of medications, the SSRI's or specific serotonin re-uptake inhibitors.

Our story starts with melancholia, know since antiquity, which is what we would generally now call Major Depression. For what its worth, famous people such as King Saul and Abe Lincoln may have suffered from this. It is a real disorder. But enough on that.

Now Medical science, if you want to call it that, had no real treatment for this. Our usual response is to drug a problem or cut it out of the body. So a drug was sought. Noting mood improvement in tuberculosis patients from a med, they serendipitously found monoamine oxidase inhibitors. This class works by inhibiting an enzyme that breaks down brain chemical called neurotransmitters. So more good stuff is in the brain and helps mood. Super Duper except all sorts of nasty side effects. The worst being the cheese effect where a certain chemical found in many foods and drink (red wine) causes a dangerous increase in blood pressure. You see, our wonderful drug inhibits good stuff too.

Then shortly after, another serendipity breakthrough. A compound developed to treat psychosis chemically similar to did not work for psychosis, but instead helped mood. So long cheese death. Hello dry mouth, sedation, constipation, weight gain,... (Actually much of this was with previous drug class too). Patients had difficulty staying on them and it was difficult to get adequate dosing. These tricyclic antidepressants worked by keeping those same chemicals out in the brain fluid instead of being sucked up in the cells. One more problem: A month's supply of them in overdose blocks heart conduction. Not good in a suicidal person.

Then a wonderful man at Eli Lilly (I met this guy, pleasant and new egotistical scientist) who took on the challenge of developing a substance that was specific to serotonin, one of many brain chemicals. This way you could get rid of many of those frustrating side effects. The birth of Prozac.

And this stuff was great. Suddenly many people were effectively treated in short order. Some were fully cured so to speak. Most were helped to some degree. I loved it. We could really help people. I had many success stories. We all did.

Prozac became a celebrity. News magazine covers. TV coverage. Even books.

Then the backlash. The evil Scientologists (why is science in that word?), always in hate with psychiatry and especially medication, invented some BC front organization to slander it. Sounds like Swiftboat Karl? The suicide thing made its first appearance. Then some psycho paranoid guy went postal and was on it. I read the case, seriously doubt Prozac had anything to do with it. But the lawyers saw a big money target.

Now it was apparent that there were some problems to me and my colleagues. Some people got energized, others sedated. Simple, change the timing to bedtime or first thing in the morning. The bowels moved rather quickly. Not a problem for many in Constipation Nation.

Yet the lingering problem of that sex thing. Serotonin is anti-sex. Some libido issues in both sexes. Difficulty climaxing for both sexes. Even erectile issues in some older males. Less intense orgasms too. Not good in treating a population already with higher incidence of sex issues. To date all sorts of remedies (more drugs) have been tried. None really works. Most are OK with it since it helps their depression so much.

Then we found all sorts of things could be treated. Obcessive-Compulsive Disorder for sure. Something non-addictive for anxiety. Good for Bulimia if they don't barf it up. And we even gave some complicated name for severe PMS so we could diagnose and medicate.

Of course the competitors all raced into the fray. This is typical. One company comes out with a blockbuster using a novel mechanism and the me-too's follow. First was Zoloft. I welcomed it for two reasons. First it didn't have all the bad press Prozac was getting. The expectations and beliefs about a medication have much to do with its effectiveness and tolerability. Second was it had a much shorter half-life, meaning it was eliminated faster from the body. A good thing for changing meds I thought, but now see advantage of slow elimination to reduce effects of discontinuation: Agitation, insomnia, dizziness,... The others (Paxil, Lexapro, Celexa,...) offer no real advantages. Everyone is individual in their brain chemistry, so one of the newer ones may be better for them.

So where are we now? Fluoxitine (Prozac) has gone generic-meaning cheap. Of course we have re-packaging as a pink pill to expensively treat PMS. The other SSRI's are still on expensive patent. The old drugs still work. Buproprion, which works on another brain chemical, is also generic, and lacks sexual problems. Both chemicals are effected by some newer medications. These may be the drugs of choice in the future. We will see.

So there is our tale. Observant doctors finding new solutions. A drug company comes through with progress. People are greatly helped. A start is born. The copy-cats follow. New stars may be out there now. Will a new med be the best yet? It will eventually happen. They certainly look good. The question right now is whether the new combined mechanism antidepressants are the next Michael Jordan or just a Kobe Bryant.

Recently out of my residency and military obligation a new and exciting medicine was marketed named Risperidone. Now the excitement was understandable. It is an antipsychotic. Psychosis is the doctor name for nuts. Psychosis is generally understood as marked alterations in the normal patterns of perception (hearing voices), belief (they're all out to get me and I know this to be absolute fact) and thought process (hard to follow and gives you a headache trying to understand what they are talking about. Now many things can cause this from a nasty brain tumor to PCP. The "pure" psychiatric diagnosis is schizophrenia, severe bipolar, psychotic depression or similar.

The problem is that all the medications available were nasty and the patients hated them. Shrinks gave whopping doses for sedation only increasing side effects. So many patient skipped them and relapsed again. They were only partially effective at best. And who wants to put up with very stiff muscles, your eyes rolling back in your head, dopey sedation, dizziness on standing, dry mouth, shaking,...?

But the superhero was in Europe-Clozaril. This stuff was clearly more effective, much more. I can vouch for that in my own practice. But superdrug had plenty of Kryptonite: Sedation, seizures and a very nasty decrease in white blood cells resulting in several deaths. So the FDA was slow to approve and the monitoring was extensive.

So along comes risperidone/Risperidal. The studies showed it was more effective and had less side effects. But there was this funny 3mg twice a day dosing for everyone, not something you see for any psychotropic except Antabuse for alcoholics.

So I tried it whereever it could be useful. I was, and continue to be unimpressed. I have seen the same stiffness and rigidity in the old stuff. It doesn't appear any more effective than the old stuff. It does however make buck for the manufactureer. I'm not saying it doesn't help many people and maybe others have done better with it. There are other new meds now in this class that are superior, at least in side effects.

I have however eaten some very nice meals and only by relocating missed my free golf weekend at a seaside resort. Thanks for the food, but I cannot see prescribing an expensive drug when it doesn't have much benefit over a cheaper one. The problems are minimized by lower doses, but then so also with the old cheap meds. I gave this stuff every attempt to find a good use and prove itself to me. I never expected Michael Jordan here, but Luke Walton would have been cool. Instead our hero is Sam Bowie. Who you ask? He was taken before Jordan, Barkley and Stockton in the 1984 NBA Draft.

Now into medical adolescence. They now call you doctor. An asshole behind your back.

Low middle-class wages now, so goodbye poverty. But a fellow intern did the math and our hourly wage was less than McDonalds. Luckily one of the hospitals we worked at was a county hospital where the cafeteria was mostly Mexican people who did not know the food was supposed to be bad. I ate there whenever I could get a freebie. If there is one thing anybody who wants the attendance of doctors should know, it is that free food will bring us out. Otherwise we have better things to do. Now the food was often better, catered to smaller groups.

One evolution obvious then was that guys dressed like Dad were being replaced with young pretty women just out of college. What better way to entice young male housestaff? A fix for both our oral and phallic fixations. (I believe the anal fixation starts with the later Metamucil years).

Which brings me to a story. She was tallish and blonde with a great figure. The guys drooled. Her fixes to us were Xanax and Halcion. The latter is a sleeper that had some problems. In one famous case a person using higher than the recommended doses and plenty of other abused prescriptions wet apeshit and violent. I think she killed somebody.

But Xanax was the push to the shrinks. This was marketed as an anti-anxiety drug that was not addictive like Valium or Librium. Mother's little helpers. These are all in a class called benzodiazapines. The generic names usually end in "pam": alpraxolam (Xanax), diazepam (Valium), lorazepam (Ativan). Indications are sleep, anxiety and muscle relaxation. They are also used in anesthesia to kill off memory of the event. Just the thing for daily life.

So by now the drug had been out several years and heavily promoted. Surprise surprise this non-addictive medication was so addictive we called it "velcro." Once on, most would not get off it. Most were substance abusers. Perfect thing for an alcoholic. A good way to chill after a cocaine run. It was even purpoted to have antidepressant properties. Never mind that every drug in this class before had both addiction issues and potential for depression.

So our residency program hated the stuff. One nasty chain-smoking alcoholic was on 2mg four times daily. I am a big guy and 0.5mg knocked me out. Yea I tried some of this shit. All in the name of medical science. So I figure I will taper and eventually stop this drug. This shithead went to the head doctor of the clinic to bitch. She told me not to make waves, this ornery jerk will never change. One of many pleasant experiences with this drug.

So bak to our rep. She was engaged or married so I pretty much ignored her. Then I was a tall very lean well-muscled guy just beginning to lose his hair, not the bald fat fuck I am now. So it must have pissed her off. So I got her attention. I also with some vocal pals were critical of Xanax.

So she freaks and brings in her boss, some marketing prick without a medical background to enlighten we the ignorant doctors. Quotes some study about anxiety disorders being the most frequent psychiatric disorders in the community. Ever heard of alcohol fuck-face? And the antidepressant bullshit. He was bombarded. We win. You lose. Thanks for the lunch.

My last year I was the Chief. One of my duties was liaison with the drug reps. I milked it. We had more free lunches that year than the previous three combined. And I negotiated the menu too. None of this Olive Garden shit. Or Subway. One hot Arabic married rep even gave me free Rogaine, then $50 a bottle, instead of the current $15 or so at Costco. I still didn't prescribe her drugs.

So I was playing them. Still, overall my view of them was positive. They treated us well while we were still the abused housestaff, underpaid overworked servants treating the poor and mostly ungrateful.

Welcome to Disneyland.

A mere pion is the medical hierarchy. Still casually dressed in the academic pre-clinical years. A classmate told me of a wondrous monthly event in the gym. She came to class after lunch with a bag of goodies. Well I sure was at the next one and did not miss many.

A tasty lunch of warm animal carnage of some kind. Tasty beverages. Yummy desert. Yea salad and starch too. Whatever. A room full of doctors, mostly the residents for free lunch. You go around the tables like any convention. Welcome to the Drug Fair.

Pretty pretty displays. Men and women in business suits to enlighten you on the virtues of their drugs. Plenty of glossy folders and papers and cards. Some scientific papers of course proving how wonderful this new drug was. And all sorts of little toys: Penlights, pens, notepads, balls, EKG calculators and even real medical books and booklets.

Then onto the clinical years. Those insipid short white coats telling the nurses and tech's, "Yes I am an idiot with no status here-please abuse me." But our friends the drug reps were there with goodies and yummy food-a respite from the yucky crap in the cafeteria-which they insulted us by charging for-especially given the outrageous tuition.

The drug rep is your friend in your time of low self-esteem, abuse, sleep deprivation and poverty lifestyle. I was pulled into the vortex unsuspecting.

This could go on a long time...

Let me start by saying I am no Democrat or liberal. I don't like socialism or the Welfare State at all. I was never fond of either Clinton. I was not impressed by Kerry or Gore.

But I still hate Bush. Is that word too strong? I think not. He represents a perversion of the things I believe in and many things I flat out disagree with. He has essentially made all the wrong choices in every arena.

First is personal freedom. If our country is about anything, this is it. Yet I am unpatriotic if I speak out against the policies of this administration? Is this not in the Bill of Rights? I am entitled to my opinion.

Related is my privacy. These fascists want to invade it all in the name of the War on Terror. I'll read what I want from the library or Internet. They are using 9-11 as a front to take away our freedoms and privacy. If somebody wants to frisk me, I think they should at least buy me a strong cocktail first.

Diplomacy is in shambles. Only being the biggest kid on the block remains. We all need friends, even if they don't always agree with us. Don't be such a whiner Rummy. The French, for example, are not categorically a bunch of arrogant wimps. They were right to pass on this asinine war in Iraq. Germany has seen enough senseless warfare. Sure the UN is a place where weak countries get a vote while we pay the bills and do the dirty work, but if it can prevent even a few conflicts it's worth the effort.

The War in Iraq was sheer stupidity. What did these dildos think? Sadam was a monster and if there is a Hell he will be at the lowest rung. But he did keep the radical Muslims under wraps in his own country and Iran in check as well. So now the whole mess is our problem. Iran and North Korea figure we have our hands full and are acting up. The terrorists are doing great recruiting-unlike the Army, Marines and National Guard. It's ironic that the of-adult-age-males (I cannot use the term adult because they do not have mature judgment, adolescent because they are rigid and not growing/exploring, and especially men-fro obvious reasons) who are responsible for all the military coming home in body bags shirked service themselves.

My biggest concern is the economy stupid asses. Does Bush even understand the disaster ahead? Or is he that dumb? The whole thing is a house of cards waiting to fall. Debt at every level is at record highs. The whole economy is reliant on artificially low and unsustainable interest rate. The dollar is falling. Fast. I'll admit all of Congress is avoiding the issue. But I doubt Bush will be in the street with a cup begging.

So what does the ass-face do? He pushes this Medicare drug benefit of dubious value through Congress. Of course billions more future debt are guaranteed in a program that will dwarf our obligations to Social Security.

Speaking of which, the private account plan is stupid too. It will sharply reduce the funds needed to maintain the program while putting more money into a corrupt and over-valued stock market. So people's retirement money is at risk and the brokers make money. Great idea.

Then there is the stem cell thing. Here is what appears to be the brightest new avenue of medical progress. One of the big areas of economic growth in the future will be biotech. Let's be serious about "high tech" now, it is past the gee-wiz phase. Porn on your cell phone and internet access while taking a shit are not spectacular advances. I'm sure China and Japan among others will proceed ahead and the bright scientists will flow away from instead of to America. Even Nancy Reagan is with me on this one.

Let's not forget gay marriage. A nice wedge issue for middle Americana. Who cares? Let them be. I suppose instead of encouraging monogamous stable relationships we should push them back into the promiscuous HIV closet and then pay the medical bills as they suffer.

And this values this. What values? I have read the Bible plenty, liklely more than Bush, and I don't see much Christian in him. Tolerance? Love? Forgiveness? Mercy? Mad Magazine did a great cartoon on this: Try "Jesus vs. Bush" on Google to find it.

My big question is just how bright is Bush? OK, he is not an idiot in the IQ sense. But he is likely of roughly average intelligence. Not good enough for President I say. The guy admits to not reading. The idea of a presidential library is a joke. What will they put in it? An unread Bible and an old Texas Ranger scorecard done improperly? He even surround himself with yes-persons (term used for Condi). He essentially pushed out Powell for voicing reason and didn't listen to top military. Perhaps he is just the puppet of an evil Cabal.

The future does not look bright. The Carter years may look like Halcyon Days.

There has been much written about why the assfaced fuck won. My take...

Let us begin with Kerry. Not a real inspiring character. Looks like Jay Leno if he stopped buying so many cars like a materialistic idiot and started moving his fat ass. He got the wishy-washy change-your-mind reputation, not entirely undeserved. His real work in Congress was a number of substantial inquiries of value which is not easily described to the ADHD American mind. He also offered no real plan besides "I'm not Bush." The last did not excite me, but was good enough.

Then there was the rich boy image. Blue-blood New England to be sure. But many of our leaders have been the elite. You have difficulty getting into politics without serious cash these corrupt days. And Bush is hardly Clinto or Reagan by background, muchless Abe Lincoln. The spoiled rich boy has had it all handed to him: Oil wells, Texas Rangers, Governor and now President.

Then there was that wife Teresa. A rich bitch to be sure. A loose cannon. With all that money, she hardly feels a need to shut the fuck up. But that's her right-freedom of speech. Still pissed off plenty of people. Still I see no real economic difference between the two families. The life of having 50 million vs. 100 million in the bank is very different from grossing 25K and 50K.

Then there was Edward. I voted for Kerry in the primary to keep this dickhead out. An American success story to be sure. A malpractice trial lawyer. At least pimps and drug dealers provide a service and are capitalistic rather than parasitic. This leach made millions suing doctors for bad outcomes, not serious mistakes. That's the way of medicine. It ain't perfect. There is a lot we don't know. And everybody makes mistakes. The medical profession has a much higher quality of work than most. Shit, you should see the crappy work recently done when my water heater leaked by the carpet kid and then the plumber who hacked the door as well. And don't even get me started on the "fixing" of the garage door. But I digress. The pretty boy sleazebag ambulance-chaser was a non-issue for most.

Now we get into the malingannt stuff. The Kerry Viet Nam thing. Here an group of duty shirking pansies set up this "we're not involved" SwiftBoat Liars thing. Maybe Kerry showboated a bit and likely shot some people. He could easily have gotten out of combat, but instead went in a fishing boat with a few guns down enemy waterways where they could take shots hidden from the jungle. Seems more scary than hanging out on the ranch to me. For details see apocalypse Now, the movie. This smear campaign is insulting to all veterans, especially those who served in combat. Let's spit on the Viet Nam vets again.

And Bush himself. Daddy got him safe duty. Now I have full respect for Gueard duty and it is essential for our security, but then it was an E-ticket out of Viet Nam. Then Bush went AWOL on a likely drunken cocaine binge. The record were destroyed. The ones found were fakes, but the an officer at the time says they essentially were accurate in account. Why not the same scrutiny to the Swiftboat Liars? And now the network of the fake document is under witch-hunt in mortal fear. Liberal press my ass. But you have to give Rove credit as the evil genius he is for making Kerry's service the issue instead of W's. Is W. For Wuss?

And his fans say W. Is decisive. He never changes his mind. I call that stupid. Moronic. Rigid. Inflexible. Don't confuse him with facts or logic or expert opinion. I suppose he is all-knowing since he sees no need to read.

But this election was about "values." That word can mean a lot of things. Some perverts "value" sexual acts with young children. That term must come from some de-constructionalist pop intellectualism of the sixties. W. And his supporter are the so-called Christians. Read the Gospels, at least the first three (John is not very historical), and see what Jesus actually said . Rove would have a field day with that stuff. The big issues being abortion (an old standby), gay marriage (a brilliant wedge issue to take the heat off all the failures of W) and stem cells (the new abortion issue). Europe must laugh at this shit.

Of course 9-11 was a wonderful event for Bush. They got to put in the Nazi Act (but call it the "Patriot" Act instead). That name reminds me of the novel 1984. Newspeak anyone? The sheep were frightened by a rainbow of alerts. Always a new plot against us. Only W. Who can protect us. Yea, a duty-dodging imbecile who took the month off before 9-11. And then he gets us into this wasteful war in Iraq that has no connection to 9-11, but most Americans still believe there is a connection. Without 9-11 and all related, attention would be on how much he has fucked our economy.

Which brings me to the economy. You can bet I will rant many times on this issue. But here I will limit myself to the election. The fundamentals are horrible: Household debt, Federal deficit, Flow of Funds and Trade Deficit. The stock market tanked. Many are unemployed or in lesser jobs. A series of tax cuts, record low interest rates and statistical manipulation have propped up the economy. And here's a fun fact: Bush has never vetoed a spending bill.

I would consider the last four years an utter failure. But the scared sheep of America, rigid and ignorant in their views, re-elected him. The spin by Rove was masterful, like a con-man, and sold us a piece of garbage at a high cost we will be paying for years.

Have I mentioned that I hate Bush?

Welcome to my first blog site. I have had my email rants and friends have encouraged me to get my ideas out there to a bigger audience.

My intentions are three. First to vent my ideas and explore them with the help of others. Second to get some intelligent discourse so needed in these times. And finally to entertain my friends old and new. Feel free to post.

The Universe On The Couch is about whatever I feel like "analyzing." Yes, I am a psychiatrist, which is the medical specialty involving the mind. You know, the one who gives drugs. My posts will sometimes be articulate and well thought out. At other times they will be rash and opinionated. Sometimes they will be the ravings of a lunatic.

My interests are quite varied. Some examples... Why I hate Bush. How the pharmaceutical industry is twisting medicine. Real solutions for health care issues. Why I hate Rove. Reforming the tax code. The evils of fiat currency. Our coming economic meltdown. A real perspective on terrorism. Movie reviews. Why I hate Cheney. The good and bad in religion. Diet and exercise. Cholesterol nonsense. Why most Democrats suck too.

Happy Blogging!