Plan B if things go down the drain?

[deleted109597]

STOP TALKING ABOUT AUSTRALIA IF YOU WANT IT TO BE AN OPTION FOR US IN 5 YEARS.

Also, almost every UK doctor that could leave the UK has now. To go to Australia.

---

Members don't see this ad.

 

[bravotwozero]

yup. everybody come to Texas NOW!

 

[GeneralVeers]

yup. everybody come to Texas NOW!

I've hear that Iowa is great too. It's up and coming in Emergency Medicine!

 

[Apollyon]

Become a weed doc. Guy I know that is a urologist started doing it. He only certifies pot cards - doesn't dispense. Cash only - won't even take a money order. He says that he is so busy, and it is now the majority of his patients. And this is in the middle of the forest (you're as likely to see an elk as a deer).

 

[Birdstrike]

Become a weed doc. Guy I know that is a urologist started doing it. He only certifies pot cards - doesn't dispense. Cash only - won't even take a money order. He says that he is so busy, and it is now the majority of his patients. And this is in the middle of the forest (you're as likely to see an elk as a deer).

I suppose...if you don't mind violating federal law with every Rx you write.

 

[Apollyon]

I suppose...if you don't mind violating federal law with every Rx you write.

Dude, I'm not doing it. And, notwithstanding your sanctimonious and simple response, do you consciously chastise yourself when you exceed the speed limit, saying, "if I don't mind violating traffic laws"?

 

[Fox800]

I suppose...if you don't mind violating federal law with every Rx you write.

I mean, this is pretty rich, coming from a pain guy. Sure, this plant is more dangerous than the stuff your colleagues prescribe on the regular.

 

[martvubo]

I mean, this is pretty rich, coming from a pain guy. Sure, this plant is more dangerous than the stuff your cohorts prescribe on the regular.

Bird has outlined his practice setup on here and it's pretty anti-opioid so that's a non sequitur. Not only are the opioid prescribing habits of other pain docs unrelated to any point Bird might make about his own prescribing, but the opioid crisis is unrelated to the fact that marijuana is federally illegal, so separately from the issue of morals (which Bird's post didn't address), there is legal risk.

 

[Apollyon]

Bird has outlined his practice setup on here and it's pretty anti-opioid so that's a non sequitur. Not only are the opioid prescribing habits of other pain docs unrelated to any point Bird might make about his own prescribing, but the opioid crisis is unrelated to the fact that marijuana is federally illegal, so separately from the issue of morals (which Bird's post didn't address), there is legal risk.

He didn't directly address morals, but it certainly appears inferred. And, the post you quoted speaks to "your cohorts", verbatim, and not to his prescribing habits. I just wonder why you chose to stop into the EM forum, to completely deconstruct something that is rather straightforward.

And, despite marijuana being Schedule I, the dispensaries are out in the open. The federal government has made the enforcement a low priority.

Again, I'm not doing it, but some docs are.

 

[VA Hopeful Dr]

He didn't directly address morals, but it certainly appears inferred. And, the post you quoted speaks to "your cohorts", verbatim, and not to his prescribing habits. I just wonder why you chose to stop into the EM forum, to completely deconstruct something that is rather straightforward.

And, despite marijuana being Schedule I, the dispensaries are out in the open. The federal government has made the enforcement a low priority.

Again, I'm not doing it, but some docs are.

And if they change that policy tomorrow a lot of people are in trouble.

Personally I think it should be legal, but as long as it is schedule one I will have nothing to do with it at anytime.

 

[martvubo]

He didn't directly address morals, but it certainly appears inferred. And, the post you quoted speaks to "your cohorts", verbatim, and not to his prescribing habits. I just wonder why you chose to stop into the EM forum, to completely deconstruct something that is rather straightforward.

And, despite marijuana being Schedule I, the dispensaries are out in the open. The federal government has made the enforcement a low priority.

Again, I'm not doing it, but some docs are.

I'll agree to disagree that moralizing was implied by Bird's post (though it clearly was inferred by you and Fox); he truthfully said you're violating the law with every prescription, not that you're condemning your soul.

I know it said "your cohorts", that is partly why I pointed out "that has nothing to do with Bird's post", but even if Bird were running a pill mill, it wouldn't change the second issue: that marijuana is illegal. I also feel it shouldn't be, but it is. Prescribing lots of opioids is probably harmful more often than not, but if you follow guidelines, it's legal to prescribe them without any concern that only a change of who's in office could change enforcement without some accompanying published policy change-- that mental safety net doesn't exist with marijuana, and for risk averse people (like many physicians) that's worth acknowledging.

 

[Fox800]

I'm truly ignorant here, is there federal law that makes it illegal to prescribe medical marijuana - to simply dole out the prescription? I live in a state that doesn't have MM.

 

[VA Hopeful Dr]

I'm truly ignorant here, is there federal law that makes it illegal to prescribe medical marijuana - to simply dole out the prescription? I live in a state that doesn't have MM.

Drug Scheduling

Drug Schedules Drugs, substances, and certain chemicals used to make drugs are classified into five (5) distinct categories or schedules depending upon the drug’s acceptable medical use and the drug’s abuse or dependency potential. The abuse rate is a determinate factor in the scheduling of the...

www.dea.gov

 

[martvubo]

I'm truly ignorant here, is there federal law that makes it illegal to prescribe medical marijuana - to simply dole out the prescription? I live in a state that doesn't have MM.

It is legally the same as prescribing other schedule Is. The actual consequences are probably less, because let's be realistic, who honestly thinks marijuana is as dangerous as heroin? But legally, if charged by the government, or sued by someone (e.g. they claim you overprescribed and that caused harm) you are in a similar (but more sympathetic) pickle. The way around this has historically been that the physician "recommends" trying medical marijuana without prescribing it, and lets the dispensary assume any liability-- in decriminalized states though, nobody is coming after the dispensaries; I would be concerned that a change in enforcement could put pressure on dispensaries to say "well my customer's doctor said he should try it, I was yielding to their expertise" and there probably hasn't been a trial yet to set the precedent for how successful that defense can be.

I apologize if my first post came across antagonistic-- I feel like we share the view that marijuana should probably not be illegal. I just wanted to offer the counter point that regardless of whether it should be, it still is, and that poses a risk (probably extremely small risk, but non-zero).

 

[Apollyon]

Personally I think it should be legal, but as long as it is schedule one I will have nothing to do with it at anytime.

And that is the gist of it for me. Hell, even if it dropped off Schedule I, I still won't be prescribing it.

 

[Birdstrike]

Dude, I'm not doing it. And, notwithstanding your sanctimonious and simple response, do you consciously chastise yourself when you exceed the speed limit, saying, "if I don't mind violating traffic laws"?

Yeah. I get that you weren’t serious about it, So, whatever. it’s no big deal.

But I think you missed my point. I was not raising a moral objection. I was simply trying to point out the fact that all it takes is a simple change in federal administration for these laws to be enforced. If that happens, there’d be reason to be sweating it. People keep forgetting weed is still illegal in all 50 states according to the guys that give us our federal DEA licenses. Personally, I don’t want the headache for a few extra bucks, however small the risk. And also, I practice Pain, so I have to be extra careful with the extra scrutiny.

But if the Feds legalize it, then different story. Obviously some people, have a much greater risk tolerance than me. I’m okay with that. If prescribing weeds cards is their jam, then they can have at it. I’m happy to let them dominate that lane.

It’s like the quacks pushing unproven CBD oil & stem cells. My reputation & self respect is worth more than a few quick bucks.

 

[Birdstrike]

I mean, this is pretty rich, coming from a pain guy. Sure, this plant is more dangerous than the stuff your colleagues prescribe on the regular.

I have much bigger fish to fry than to moralize about “your plant.” But I do care about protecting my license, career and income. Whether I think weed is a big deal or not is irrelevant as long as the guys who allow me to have my license consider it schedule I.

But if you want to make up your own rules and dabble in weed on the side, I’m not going to lose sleep over it. You do you.

 

[FiremedicMike]

-Weather
-Cities (Sydney and Melbourne are some of the most liveable cities in the world)
-People
-Sane immigration policy
-Doctors are still paid decently, unlike most of the rest of the world

Cons
- Terrible food (and expensive)
- High taxes
- Expensive to get to

Don’t forget giant insects....... (con)

 

[GeneralVeers]

Don’t forget giant insects....... (con)

Oh yes forgot! The giant spider pictures I take every time I go are terrifying. Plus everything, even the caterpillars are venomous.

 

[EctopicFetus]

I thought it was difficult and/or an arduous process to get licensed to practice in NZ or AU? Does anyone know someone who's gone through the process?

A bunch of my co residents did this before settling down. I don’t think it’s super tough.

 

[betamale]

I would seriously consider moving to Canada, or the Middle East. Job market is pretty tight for ED physicians in Canada, but not so in places like Dubai or Qatar. I’m a non drinker with kids so having a nightlife is not an issue for me, nor is cultural compatibility...

Lol, I know someone that did that (Middle East locums). Did not last long...'cause you have to live in the Middle East, gross

 

[aafisahar]

Good to know. I didn't know there was a demand for EM docs in the middle East. I knew there was a huge demand for specialist physicians and they were offering 250k tax free with transportation and housing covered.

Uae, dubai, kuwait, qatar are actually very reasonable places to live in. Everywhere but saudi arabia -_- nobody should live in saudi arabia

Most of the expats there will be Indians, Pakistanis, and bengalis. The labor class that has gone there, is probably not the most proficient in English though.

ya, a cards fellow I know took a job in Dubai. Paid off all his loans the second he signed, 1M salary, housing paid for, personal chauffer, chef, etc. Seemed like a crazy sweet deal. Not sure what the downsides were.

 

[GeneralVeers]

ya, a cards fellow I know took a job in Dubai. Paid off all his loans the second he signed, 1M salary, housing paid for, personal chauffer, chef, etc. Seemed like a crazy sweet deal. Not sure what the downsides were.

I travel to Dubai once a year to see friends. Honestly not a bad place to live. Western restaurants/hotels which serve alcohol, and most of the people you interact with out an about are Western expats from UK, Australia or Europe. I would definitely consider moving there, but when I've asked recruiters about salary they say it's about $300K. Not worth the move yet......

 

[TooMuchResearch]

Sign me up.

ya, a cards fellow I know took a job in Dubai. Paid off all his loans the second he signed, 1M salary, housing paid for, personal chauffer, chef, etc. Seemed like a crazy sweet deal. Not sure what the downsides were.

 

[Groove]

I don't really have a side hustle. I day and swing trade on the side and have been for a few years. I'm actually pretty good. I suppose I could do that full time if I wanted but I doubt I would want that to be my full time gig. You can make some money but can also lose money if you're not disciplined. I'm just not interested in real estate. It would depend on whether the salary drop was specific to EM or all specialties. If it's just specific to EM, I'd probably do a fellowship and switch over to pain, CC and/or addiction/palliative care. I wouldn't mind being a mercenary EM doc for some of these middle eastern countries but I don't have an olive skin gene in my body and would be the white American covered with sunscreen and probably would get kidnapped and decapitated by a terrorist splinter cell. I'm not terribly excited about losing my head. If there were an easy way to move to NZ or AU with decent compensation, I would probably strongly consider that.

I'm drinking Balvenie scotch (14y Caribbean cask) and seeing double as I type this....I saw 29 pt's in my 9 hour shift tonight and I'm just glad I have a day off tomorrow. Carry on.

 

[gro2001]

Any idea what the job is like? Volume of patients? You're not going to get sued, but do you have dozens and dozens of patients just waiting to be seen. I'm assuming there will be no death by charting either.

For example in New Zealand, once you become a "consultant EM physician" after some qualifying exam, you're seeing maybe 8 patients a day, mostly when your Junior doctors need you as a "consult". And if you think someone is at the end of their life, you can essentially decide to not pursue further workup. Here pushy family members don't even let the 90 year old Grandmas rest in peace.

As with most things, it can vary quite a bit based on the hospital, but in general the "consultant" (ie senior attending; someone who's been boarded and practicing for a few years) is a very cush job, especially at a teaching hospital. Generally speaking, as a consultant you don't usually see patients by yourself (although some places are moving to more of a consultant run service) and it's up to you if you want to write notes (most of the time if a resident or 'specialist' (ie junior attending) write a note, you don't have to). So you may go entire shifts without 'seeing a patient' in the traditional US sense of the word, though you'd be aware of the patients in the area and what's going on with them. The charting that does happen is also much lighter than in the US.

 

[gro2001]

Yeah training in a country where sipping some alcohol will land you in a sandy hole for life sounds like a good place to work.

Sipping alcohol does not get you in trouble anywhere except Saudi (don't go to Saudi). Neither Qatar nor Dubai are completely dry. Both allow purchasing of alcohol for use at home and both have bars, nightclubs, etc (though these can only be on hotel premises, so the best restaurants are at hotels and all bars and nightclubs are at hotels also). I've lived in both for a few years. I routinely host cocktail parties and drink my fair share of whiskey without any issues.

Public intoxication and, even more so, driving under the influence of alcohol are dealt with very strictly though, so that would get you in trouble.

I am not saying that the nightlife and adult entertainment in the Persian Gulf countries is great, and that might be reason enough to not want to work or live here, but it's not nearly as bad as you make it sound (except in Saudi).

But yeah, wouldn't necessarily recommend training in either country. The quality of residency training in the US, particularly in EM, is much higher in the US.

 

[gro2001]

I don't really have a side hustle. I day and swing trade on the side and have been for a few years. I'm actually pretty good. I suppose I could do that full time if I wanted but I doubt I would want that to be my full time gig. You can make some money but can also lose money if you're not disciplined. I'm just not interested in real estate. It would depend on whether the salary drop was specific to EM or all specialties. If it's just specific to EM, I'd probably do a fellowship and switch over to pain, CC and/or addiction/palliative care. I wouldn't mind being a mercenary EM doc for some of these middle eastern countries but I don't have an olive skin gene in my body and would be the white American covered with sunscreen and probably would get kidnapped and decapitated by a terrorist splinter cell. I'm not terribly excited about losing my head. If there were an easy way to move to NZ or AU with decent compensation, I would probably strongly consider that.

I'm drinking Balvenie scotch (14y Caribbean cask) and seeing double as I type this....I saw 29 pt's in my 9 hour shift tonight and I'm just glad I have a day off tomorrow. Carry on.

There are plenty of white Americans living in Dubai and Qatar. I think you'd find it challenging finding even one example of someone getting 'kidnapped and decapitated' in either Dubai or Qatar. Those aren't Baghdad.

 

[Tenk]

I will probably just take a pay cut because I am lazy af and have no debt other than a cheap mortgage.

 

[deleted836128]

DUBAI WAS LITTTT!



Sorry, everyone talking about Dubai got me thinking about this video. And Dubai DOES sound lit. Sign everyone up for a personal chef! LOL.

 

[Birdstrike]

ya, a cards fellow I know took a job in Dubai. Paid off all his loans the second he signed, 1M salary, housing paid for, personal chauffer, chef, etc. Seemed like a crazy sweet deal. Not sure what the downsides were.

I guess if you know the language and don't mind moving that far, double your specialty's average salary is a pretty sweet deal. I'm not sure how stoked my wife and two tween girls would feel about it, though.

 

[Fox800]

ya, a cards fellow I know took a job in Dubai. Paid off all his loans the second he signed, 1M salary, housing paid for, personal chauffer, chef, etc. Seemed like a crazy sweet deal. Not sure what the downsides were.

Yeah I would do this in about one second.

 

[gro2001]

I guess if you know the language and don't mind moving that far, double your specialty's average salary is a pretty sweet deal. I'm not sure how stoked my wife and two tween girls would feel about it, though.

I am not trying to convince anyone to move to Dubai or anything, and those crazy salary numbers sound outdated, but you can easily get by as a doctor without speaking Arabic. Mostly people speak at least some English. Those who don't aren't all Arabic speakers. Most non Arabic speakers are about equally split between Hindi speakers, other Indian subcontinent dialect speakers, and Arabic speakers. You can almost always find someone to interpret from among the nurses or other doctors.

Socially you really don't need any other language except English.

 

[carbonizedeyesockets]

I am not trying to convince anyone to move to Dubai or anything, and those crazy salary numbers sound outdated, but you can easily get by as a doctor without speaking Arabic. Mostly people speak at least some English. Those who don't aren't all Arabic speakers. Most non Arabic speakers are about equally split between Hindi speakers, other Indian subcontinent dialect speakers, and Arabic speakers. You can almost always find someone to interpret from among the nurses or other doctors.

Socially you really don't need any other language except English.

My understanding was that english speaking EM physicians are provided a personal interpreter for shifts. Maybe hospital depended or no longer a thing?

 

[Birdstrike]

Socially you really don't need any other language except English.

Hmm..That's cool. I went to France not too long ago and it was the same way. Pretty much everyone was cool speaking English as long as I made a feeble attempt to ask, "Do you speak English?" in French.

I wouldn't mind taking a trip to Dubai. I've heard it can be interesting and if there was anywhere in the Middle East I'd travel to, it would be there.

 

[GeneralVeers]

Hmm..That's cool. I went to France not too long ago and it was the same way. Pretty much everyone was cool speaking English as long as I made a feeble attempt to ask, "Do you speak English?" in French.

I wouldn't mind taking a trip to Dubai. I've heard it can be interesting and if there was anywhere in the Middle East I'd travel to, it would be there.

It's the only place in the ME worth going to (maybe Oman as well). Qatar is a waste of time, but Dubai and Abu Dhabi have some gorgeous architecture and are incredibly safe for Westerners. They have four Cheesecake Factories so you know they are somewhat civilized.

 

[bravotwozero]

I will probably just take a pay cut because I am lazy af and have no debt other than a cheap mortgage.

Not necessarily a bad route, just depends on how big the pay cut is...

 

[Birdstrike]

\

Despite its flaws, it will certainly be a better place to practice than a "Medicare-For-All" Bernie Sanders nightmare that we might get in this country.

For "Medicare for all" to become a reality several things need to happen, and all of them must happen or it dies:

1) Either Warren or Sanders needs to win the presidency. This could happen, but it's far from certain and elections as we know, are hard to predict on election day, let alone a year out.
2) Democrats would need to hold the House. More likely than not this will happen, since they already have it and the House map favors the Dems.
3) Democrats would have to win the Senate. This is possible, but less than a 50% chance, since only 1/3 of the Senate is up for election in 2020 and the Senate map favors the GOP.
4) They'd have to get a Medicare for all bill, that necessarily must outlaw and bankrupt all private insurance companies, all of which have been lining the pockets of both Republicans and Democrats for decades and expect paybacks.

In my opinion, any one of those could easily happen. 1-3 happening would not be a shock (although I think the Senate will be tough). But honestly, I think the need to outlaw and bankrupt private insurance companies, which are huge and have bribed the politicians in both parties, is a less than 0.1% proposition. Politicians of both parties, will choose their best interest and lining their own pockets over principle 9 out of 10 times. This is what makes a Medicare for all system so unlikely to come out of our political system, in my opinion.

 

[Hercules]

Politicians of both parties, will choose their best interest and lining their own pockets over principle 9 out of 10 times. This is what makes a Medicare for all system so unlikely to come out of our political system, in my opinion.

If you think it’s only 9 out of 10 times, then you have much more faith in our politicians than I do...

 

[Birdstrike]

If you think it’s only 9 out of 10 times, then you have much more faith in our politicians than I do...

I’m an idealist

 

[GeneralVeers]

In my opinion, any one of those could easily happen. 1-3 happening would not be a shock (although I think the Senate will be tough). But honestly, I think the need to outlaw and bankrupt private insurance companies, which are huge and have bribed the politicians in both parties, is a less than 0.1% proposition. Politicians of both parties, will choose their best interest and lining their own pockets over principle 9 out of 10 times. This is what makes a Medicare for all system so unlikely to come out of our political system, in my opinion.

This is why the "public option" will be the preferred route. On its face this sounds reasonable as you aren't outlawing insurance companies outright. The completely predictable outcome of any public option will be that in 5-10 years it will replace most insurance plans, including employer sponsored ones. We would be left only with private insurance for the wealthiest segment who choose to pay the massive premiums. This will be Medicare-For-All in everything but name only.

 

[deleted941485]

This is why the "public option" will be the preferred route. On its face this sounds reasonable as you aren't outlawing insurance companies outright. The completely predictable outcome of any public option will be that in 5-10 years it will replace most insurance plans, including employer sponsored ones. We would be left only with private insurance for the wealthiest segment who choose to pay the massive premiums. This will be Medicare-For-All in everything but name only.

I think most intelligent people in HC already know the implications of an open public option means a slow death. The only way you get private insurance buy in is if they get the money from the government and then they skim off the top to issue what amount to essentially Medicare Advantage plan.

I do love the NYT articles that suggest that a public option will “compete” in the marketplace with other insurnace plans.

Nothing typifies competition like being forced to subsidize your competitor.

Oh btw, your competitor makes all the rules you must follow. Can run deficits for years. Set premiums below cost as a result. Declare war, seize property, print money, and set interest rates.

Otherwise it’s totally a competition.

 

[GeneralVeers]

I think most intelligent people in HC already know the implications of an open public option means a slow death. The only way you get private insurance buy in is if they get the money from the government and then they skim off the top to issue what amount to essentially Medicare Advantage plan.

I do love the NYT articles that suggest that a public option will “compete” in the marketplace with other insurnace plans.

Nothing typifies competition like being forced to subsidize your competitor.

Oh btw, your competitor makes all the rules you must follow. Can run deficits for years. Set premiums below cost as a result. Declare war, seize property, print money, and set interest rates.

Otherwise it’s totally a competition.

I think there are enough true believers, that the Senate, Congress, and President would enact a Public Option despite the objections of insurers. Since they aren't outlawing anything, it would be difficult to have it challenged in court. Once the new Public Option has taken over the majority of the market, it's easy for government to incrementally legislate private insurers and hospitals out of business.

 

[deleted941485]

I think there are enough true believers, that the Senate, Congress, and President would enact a Public Option despite the objections of insurers. Since they aren't outlawing anything, it would be difficult to have it challenged in court. Once the new Public Option has taken over the majority of the market, it's easy for government to incrementally legislate private insurers and hospitals out of business.

Precisely why public option is the sneaky incremental approach to total take over of the system that economists and politicians have always dreamed.

It’s a death knell for real commercial
Insurance. And you are prohibited from offering any services already covered by said plan so it’s not like you could even offer anything else.

The only way the private insurers win is if they become the middle man btw he govt funds and the providers. That’s it otherwise they’ll be relegated to some meaningless corner of the health as space.

 

[GeneralVeers]

Precisely why public option is the sneaky incremental approach to total take over of the system that economists and politicians have always dreamed.

It’s a death knell for real commercial
Insurance. And you are prohibited from offering any services already covered by said plan so it’s not like you could even offer anything else.

The only way the private insurers win is if they become the middle man btw he govt funds and the providers. That’s it otherwise they’ll be relegated to some meaningless corner of the health as space.

They've TOLD US that this is what they want to do. I'm not sure why some people believe a public option is anything less than a takeover.

Once they control 75% of the market government can force providers to only take the public option.

 

[deleted941485]

They've TOLD US that this is what they want to do. I'm not sure why some people believe a public option is anything less than a takeover.

Once they control 75% of the market government can force providers to only take the public option.

They don’t because it doesn’t happen right away. Which is why everyone is on board with it. 5-10 years is too long in the public’s mind and long enough for most of the lawmakers to run out their terms and move on to writing their memoirs and 100K per speech dinners about being brave courageous hero’s for getting this passed.

If the industry fails to block this then the only positive is you have about 5-10 years to find yourself some supplemental income avenues cause your medicine day job just isn’t gonna cover it.

 

[bravotwozero]

The insurance companies are far more likely to immediately destroy our livelihoods than the government is at this point. Wasn't the whole reason this thread got started because of the balance billing legislation? Who do you think is behind that?

 

[deleted941485]

The insurance companies are far more likely to immediately destroy our livelihoods than the government is at this point. Wasn't the whole reason this thread got started because of the balance billing legislation? Who do you think is behind that?

It really boils down to control of fees be it private monopolistic entities or government buearacracies and their never ending talking heads. It needs aggressive opposition and aggressive PR and hounding those in office.

You have to be willing to fight back but I’m just not seeing that especially when most docs are now getting ready to leave medicine anyway and enter retirement.

 

[KeikoTanaka]

Realistically how low could salaries for various specialties go in a M4A system even?

 

[Birdstrike]

This is why the "public option" will be the preferred route. On its face this sounds reasonable as you aren't outlawing insurance companies outright. The completely predictable outcome of any public option will be that in 5-10 years it will replace most insurance plans, including employer sponsored ones. We would be left only with private insurance for the wealthiest segment who choose to pay the massive premiums. This will be Medicare-For-All in everything but name only.

And as the inevitable lack of funds causes it to wither away through rationing, it necessarily becomes a deprived, VA-like model of neglect, where it takes an act of Congress to accomplish what used be be achieved with persistence and a few phone calls. Then, start the helpless pleas for privatization and course reversal.