Ways To Start Medical Care Reform by Carl Douglass

Ways To Start Medical Care Reform

Carl Douglass

Neurosurgeon Turned Author Writes With Gripping Realism

Author Masterminds Charter Member

Health care insurance in the United States is too expensive; health care delivery is too expensive and is in serious need of reform. This is not a political statement; it is a simple statement of fact, and we should get away from the political win or lose mentality that has suffused the rhetoric about reform. In this article we will look at the parts that waste, abuse, fraud, and serious crime, play in that expense—excessive and correctable expense that needs reform. According to the Associated Press, the U.S. health care system squanders $750 billion a year--close to 30 cents of every medical dollar on unneeded care, byzantine paperwork, fraud, neglect, abuse, and other waste, based on information from the influential Institute of Medicine. Despite the very considerable effort and expense by law enforcement, the numbers have not changed significantly in the last decade.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a national Health Care Fraud and Abuse Control Program (HCFAC) under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS). At its inception, the law recognized that much of what medical care costs the consumer, the insurance companies, and the government, comes from misuse or outright crime involved in medical care costs. By the law, acting through the Inspector General, a program of investigation and enforcement was designed to coordinate federal, state, and local law enforcement activities to monitor and to gain control of health care fraud and abuse.

Now in its twenty-third year of operation, the program’s continued success confirms the soundness of the concept of legally enforceable control and of a collaborative approach to identify and prosecute the fraud, especially the most egregious instances of health care fraud, and to prevent future fraud and abuse. It is presumed based on past experience that such expenses will only increase without greater scrutiny. It is imperative to protect program beneficiaries—i.e. the patients, as opposed to concentrating on the large companies primarily. It is also widely recognized that we need to do better, to bring costs down, and to rid the system of those who prey on innocent patients and payors.

During Fiscal Year (FY) 2017, the Federal Government won or negotiated almost two and a half billion dollars in health care fraud judgments and settlements, and it attained additional administrative impositions in health care fraud cases and proceedings. As a result of these efforts, as well as those of preceding years, in FY 2017, $2.6 billion was returned to the Federal Government or paid to private persons. Of this $2.6 billion, the Medicare Trust Funds received transfers of approximately $1.4 billion, and $406.7 million in Federal Medicaid money was similarly transferred separately to the Treasury.

Enforcement actions in FY 2017 resulted in the Department of Justice (DOJ) opening 967 new criminal health care fraud investigations. Federal prosecutors filed criminal charges in 439 cases involving 720 defendants. A total of 639 defendants were convicted of health care fraud-related crimes during the year. Also, in FY 2017, DOJ opened 948 new civil health care fraud investigations and had 1,086 civil health care fraud matters pending at the end of the fiscal year. In FY 2017, the FBI investigative efforts resulted in over 674 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 148 health care fraud criminal enterprises. That year, investigations conducted by HHS’s Office of Inspector General (HHS-OIG) resulted in 788 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 818 civil actions, which included false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters.

HHS-OIG also excluded 3,244 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs. Among these were exclusions based on criminal convictions for crimes related to Medicare and Medicaid (1,281) or to other health care programs (309), for patient abuse or neglect (266), The amount reported as won or negotiated only reflects the federal recoveries and therefore does not reflect state Medicaid monies recovered as part of any global federal-state settlements. As a result of licensure revocations (973). HHS-OIG also issued numerous audits and evaluations with recommendations that--when implemented--would correct program vulnerabilities and save program funds.

The FBI is the primary agency for exposing and investigating health care fraud, with jurisdiction over both federal and private insurance programs. Health care fraud investigations are considered a high priority within the Complex Financial Crime Program, and each of the FBI’s 56 field offices has personnel assigned specifically to investigate health care fraud matters. Field offices proactively target fraud through coordinated initiatives, task forces, and strike teams, and undercover operations.

In 2011, $2.27 trillion was spent on health care and more than four billion health insurance claims were processed in the United States. It is an undisputed reality that some of these health insurance claims are fraudulent. Although they constitute only a small fraction, those fraudulent claims carry a very high price tag. Insurance companies generally must pass the costs of bogus claims--and of fighting fraud--onto policyholders. Victimized businesses must pass the cost of rising insurance premiums onto their customers by raising prices for goods and services. Many larger corporations also spend millions of dollars a year to investigate and prevent fraud. This contributes to a premium spiral that can price essential insurance coverage--often state required--beyond the reach of many consumers and businesses.

The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year. Think what the country could do for medical care for the needy with that money flowing into the proper coffers. At least $80 billion in fraudulent claims are made annually in the U.S., the Coalition Against Insurance Fraud estimates. This includes all lines of insurance. It’s also a conservative figure because much insurance fraud goes undetected and unreported.

Medical Care and other types of fraud imposes serious financial and personal costs on consumers, businesses, government and our society. Insurance swindles victimize innocent people of every income, age, education level, ethnic background, and region of the U.S.

The majority of health care fraud is committed by a very small minority of dishonest health care providers.

The most common types of fraud committed by dishonest providers include: 

• Billing for services that were never rendered, e.g. by utilizing identity theft, by fabricating entire claims out of whole cloth, or by padding claims with charges for procedures or services that did not take place.
• Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding"-i.e., falsely billing for a higher-priced treatment than was actually provided such as inflation of the patient's diagnosis code to a more serious condition consistent with the false procedure code.
• Performing medically unnecessary services solely for the purpose of generating insurance payments-such as nerve-conduction and other diagnostic-testing schemes to pad billing.
• Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments. This is widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as "nose jobs" are billed to patients' insurers as deviated-septum repairs, or eye-lid cosmetic procedures under the guise of “repair of drooping eyelids interfering with vision.”
• Outright falsification of a patient's diagnosis to justify tests, surgeries, or other procedures that aren't medically necessary.
• Unbundling - billing each step of a procedure as if it were a separate procedure.
• Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
• Accepting kickbacks for patient referrals.
• Waiving patient co-pays or deductibles for medical or dental care and over-billing the insurance carrier or benefit plan (insurers often set the policy with regard to the waiver of co-pays through its provider contracting process; while, under Medicare, routinely waiving co-pays is prohibited and may only be waived due to "financial hardship".

There are also crimes of violence against people and property in which people’s health, lives, and property, often are endangered by insurance schemes. Such crimes fall under the following categories of criminal behavior:

    Staged auto crashes. Lives are jeopardized when innocent motorists are maneuvered into car crashes staged by crime rings to collect large injury payouts from auto insurers. A family of three was burned to death when a setup crash went awry after their car was hit by two large trucks on a California freeway. A grandmother in Queens, N.Y. died when her car went out of control after she was maneuvered into a staged crash.

Murder for life insurance. Someone murders a spouse, relative, or business partner, etc. to collect on the victim’s life-insurance policy. Coverage often is worth $200,000 or more.

Unneeded surgeries. Patients are maimed, disfigured, and forced into lives of permanent pain when dishonest doctors perform unneeded and often botched surgery to inflate their insurance billings. Cancer, spine, heart, and eye, surgery are among the procedures and surgeries inflicted on trusting patients. Many victims are elderly, poor, and homeless. The patients, the insurance companies, and governments, are all victims of these crimes.

   Arson. Homes and businesses are burned down for insurance money. The lives of firefighters, family members, and neighbors, are jeopardized. Numerous people have died or have been seriously injured by insurance arsons. Arson fires also often burn nearby homes and businesses, thus magnifying the property damage and insurance costs. Doctors and hospitals must rally to care for the injured victims, often without pay.

Stolen premiums. Most insurance agents are honest. However, there are corrupt agents who pocket client insurance premium checks without buying the promised coverage. This leaves the clients dangerously uncovered and surprised to find out that they are bare of insurance when payments come due. Agents also increase a policyholder’s premiums by secretly adding unwanted coverage to policies.

These crimes spend scarce taxpayer resources. Fighting insurance fraud is a major expense for federal, state and local governments. The efforts--while necessary--divert often scarce government resources needed to fight other serious crimes:

    State fraud bureaus. States conduct extensive anti-fraud efforts, funded by taxpayers and insurance companies. Most states, for example, have anti-fraud agencies that investigate suspected insurance swindles and refer cases for prosecution.

Police and other law enforcement. Federal, state and local law enforcement all investigate insurance cases, often jointly with insurance companies.

Prosecutions. Taxpayer-funded prosecutors devote considerable time and resources to pursuing fraud cases in court. Many cases are complex and require extensive time and expense to earn convictions.

Federal government. The federal government annually spends several billion dollars fighting Medicare and Medicaid scams. This diverts scarce taxpayer resources from meeting the important healthcare needs of America’s elderly and poor.

All of the efforts to pursue medical care crime cost a great deal of money and will cost more in the years to come.

To date, $80 Billion a year is lost to Americans through insurance fraud: That figure is the equivalent of providing a new car or truck for 2.4 million drivers, enough for every driver in Oklahoma. You could buy 219,280 new homes, an amount equal to half of annual home buyers in the U.S. We could fund global humanitarian aid for more than the next three years. We could finance UN peacekeeping for nearly ten years. We good people could fund federal cancer research and training for the next sixteen years, or pay 8.75 million in-state students’ tuition for their first year at a four-year public undergraduate university; or we might pay salary of every high school teacher in the U.S. for two years.

There is another way of looking at that large sum of money that is now lost to us. Think of insurance criminals creating their own company. That company would rank in the top 10 percent among the Fortune 500 in yearly revenue. It would be 35th overall in the nation. However you look at it, eighty billion dollars is a lot of money—too much to throw away to crooks or by losing it in foolish ventures.

It is generally accepted that only somewhere around ten percent of all medical fraud and crime are detected, investigated, brought to trial, convicted, and pay significant fines, and/or serve prison terms. An important reason for that low incidence is that there are not enough law enforcement officers to handle the loads. We need more people, money, and training, to improve by 20-30%. The DOJ and FBI estimate that $2.7 billion could be saved by improving oversight, stopping fraud, and abuse, within the Medicare Advantage and Medicare prescription drug programs alone.

Lest you think I am exaggerating, let me share some examples:

   In 2001, HCA [Hospital Corporation of America] reached a plea agreement with the U.S. government that avoided criminal charges against the company and included $95 million in fines. In late 2002, HCA agreed to pay the U.S. government $631 million, plus interest, and to pay $17.5 million to state Medicaid agencies, in addition to $250 million paid up to that point to resolve outstanding Medicare expense claims over and above fines. In all, civil lawsuits cost HCA more than $1.7 billion to settle, including more than $500 million paid in 2003 to two whistleblowers.

In July, 2010, the Medicare Fraud Strike Task Force announced its largest fraud discovery ever when charging 94 people nationwide for allegedly submitting a total of $251 million in fraudulent Medicare claims. The 94 people charged included doctors, medical assistants, and health care firm owners; and 36 of them have been found and arrested.

 In October, 2010, a network of Armenian gangsters and their associates used phantom healthcare clinics and other means to try to cheat Medicare out of $163 million, the largest fraud by one criminal enterprise in the program's history. The operation was under the protection of an Armenian crime boss--known in the former Soviet Union as a "vor,"--Armen Kazarian. Of the 73 individuals indicted for this scheme, more than 50 people were arrested on October 13, 2010 in New York, California, New Mexico, Ohio and Georgia.

 In June, 2015, Federal officials charged 243 people including 46 doctors, nurses, and other medical professionals with Medicare fraud schemes. The government said the fraudulent schemes netted approximately $712 million in false billings in what is the largest crackdown undertaken by the Medicare Fraud Strike Force.

In April, 2019, Federal officials charged Philip Esformes of paying and receiving kickbacks and bribes in the largest Medicare fraud case in U.S. history. The largest case of fraud brought to the Department of Justice took place between 2007 and 2016.  Philip Esformes, 48, owner of more than 20 assisted living facilities and skilled nursing homes was the leader of the ring. Former Director of the Outreach Program at Larkin Hospital in South Miami, Odette Barcha, 50, was Esformes’ accomplice along with Arnaldo Carmouze, 57, a physical assistant in the Palmetto Bay Area. These three constructed a team of corrupt physicians, hospitals, and private practices in South Florida. This is how that complex scheme worked: bribes and kickbacks where paid to physicians, hospitals, and practices to refer patients to the facilities owned and controlled by Esformes. The assisted living and skilled nursing facilities then admitted the patients and billed Medicare and Medicaid for unnecessary, fabricated, and sometimes even harmful procedures. Additional charges to Medicare and Medicaid included prescription narcotics prescribed to patients addicted to opioids to entice the patients to stay at the facility in order for the bill to increase.

According to Medscape Medical News, August 9, 2019 (by Ken Terry), a Washington DC physician was indicted for nearly $13 million in Medicare fraud. The scheme involved submitting false claims to Medicare for complicated procedures that were never performed, according to the DOJ [Department of Justice].In an indictment filed July 30 in the District of Columbia, physiatrist Frederick Gooding, MD, aged 68, of Wilmington, Delaware, was charged with 11 counts of healthcare fraud. He was arrested on August 1.

The indictment stated that from January 2015 to August 2018, Gooding participated in a healthcare fraud scheme in which he submitted Medicare claims for injections and aspirations that were not medically necessary, not provided, or both. Gooding allegedly knew that the injections were not provided. To disguise his scheme, he allegedly falsified medical documents to make it appear as if the purported medical services billed to Medicare were medically necessary.

Gooding submitted or caused the submission of more than $12.7 million in claims to Medicare, the indictment alleges.

In 2010, the Delaware Medical Board suspended Gooding's medical license for 6 months after one of his patients died after receiving an injection to treat pain, He was also barred from administering cervical block injections.

The indictment of Gooding resulted from an investigation led by the Medicare Fraud Strike Force, which is a joint initiative of the DOJ and the Department of Health and Human Services. Since it was formed in 2007, the Medicare Fraud Strike Force has charged nearly 4000 persons who collectively billed the Medicare program for more than $14 billion, the DOJ press release stated.

And 2019 is only half over. It may eventually cause an minor increase in taxes to assemble a larger and more effective policing and investigative service, but any cost would be far overshadowed by the monetary rewards accruing to the government, to say nothing of the human benefit to the patients.

Suffer the Little Children-1 - by Carl Douglass

Suffer the Little Children-1

Carl Douglass

Neurosurgeon Turned Author Writes With Gripping Realism

AuthorMasterminds Charter Member

I am an old man and have been through more than my share of life threatening, potentially life ending, health issues. Many older men and women complain to me about how annoying the noise is children seem to have to make. Some of those people have chosen to live in cloistered neighborhoods that exclude children because they want nothing to do with the pesky little beings. Some of my more religious friends complain that children in church are noisy and make it hard for them to hear the latest reiteration of a select group of sermons. As I recall, those sermon topics are neither new or so complex that missing a word or a sentence or two would constitute a serious loss. But that’s just me.

I happen to love the cooing, attempts at talking, the outbursts of enthusiasm, and even the brief crying of a baby who has no other way to express him or herself. Why is that? Because the noise they make is the stuff of life. Those children are the future, and I am happy I get a little longer to share in the joy they bring into the world. Christ said—to paraphrase—suffer the little children to come unto me for such is the kingdom of heaven. The little children and their aviary like noise is about as close as I ever expect to get to that heaven. Let me savor it.

Recently, my family had a miracle. Two of them in a row, I might add. A young couple in the family was unable to conceive. Despite all the sad-but-true commentary from those far older and many far wiser than they, the couple told a receptive part of the world of their plight and of their great desire to be parents.

Since this is the age of the Millennials, they did so on FaceBook. The first miracle happened three or four months later. A young unmarried girl and her family had the wisdom to realize that a sixteen-year-old girl is not in an ideal position to take on the sober responsibilities of single motherhood. She answered the FaceBook request, and the result led to the adoption of a beautiful, deeply loved, baby boy who entered a large and overbearingly attentive family. The new parents moved into parenthood with impressive gusto.

Four-and-a-half months after that--unassociated with the first response to the FaceBook posting by the new parents—a second young woman, a superior athlete, found herself to be, as we antiquarians might once have said, “with child.” Despite protestations by her grandmother, this second girl also sought out the above described prospective parents. The result was a smooth process that led to great happiness all around: a girl who could get on with her life, a baby with a future, new parents who have a baby brother close in age to their other new baby, an absolutely delighted—and more or less overly solicitous three generation retinue of family.

There have been hundreds of photos, texts, and visits. The first boy is a funny little rascal who charms everyone he comes in contact with because of his easy, noisy, laugh, and his love for the family dog. He also loves his little brother and holds on to him whenever he gets the chance.

The new boy sleeps all the time he is not eating or pooping. He is a sturdy little koala bear of an infant who coils up in a ball on your chest and sleeps the deep sleep of childhood while he warms your chest and steals your heart. I like his little noises. We have shared dozens of little videos of the parents and grandparents making the boys laugh. When I feel down, I get into my phone and just listen. Those noises never become passé or, unthinkable—annoying. I am the old great grandfather (name of Papa) who loves the new miracles as much or more than anyone.

We just celebrated one of the most beautiful and inspiring holidays in the nation’s repertoire of holidays—national adoption day—by clearing the last hurtle of legal adoption. The second baby is now officially, fully, and finally ours forever. The judge made the decree with enthusiasm and exuberance. The families who have benefited from adoption stood and cheered and cried. The moment was one of surpassing beauty.

Please, I beg, consider adoption. Save a girl, a baby, a set of childless yearning parents, two distraught families, a state with too many children wandering in the wilderness of what is unaffectionately known as “the system.” It is not a Republican thing, a Democrat thing, a Catholic thing, or a Protestant thing. It is a great American, Christian, Muslim, Jewish, etc. etc. thing.

Adoption deserves our every contribution. Children deserve all the love and care and protection we can offer. Adoption is inordinately expensive and stymies many otherwise perfect transactions. All of those among my readers who care, please push your legislators to change laws to enable rather than to hinder adoptions. Whatever the cost to We the People, it is money well spent for our country. We cannot afford the great economic, societal, judicial system, and human costs, of neglecting this vital personal, governmental, and investment-in-our-future, issue.

A Treatise On Writing Novels by Carl Douglass

A Treatise On Writing Novels

Carl Douglass

Neurosurgeon Turned Author Writes With Gripping Realism

AuthorMasterminds Charter Member

I tried to write poetry. With supreme effort, I could occasionally come up with two lines that made sense and rhymed. For the life of me, I was never able to get to the second two lines; so, I gave up and simply chose to be an aficionado, admiring poetry as an ardent arms-length spectator.

Next, I experimented with short story writing; but, by nature, I am too verbose. I needed a longer, broader canvas to paint my word pictures.

I settled for, worked at, and experimented with novels. In twenty-five or so years, I have learned some things I would like to share. The greatest things about novel writing are: the author can tell the whole story; he or she can—and must—be the god of the story, the only one who knows the past, the present, the alpha and the omega. The omnipotent author gets to make all the decisions, to get all the glory, to deflect all the criticism, and—in the end—to absorb the ignominy of failure. It’s worth it to be able to be the god of the book, to get the story out—even if only for a brief time.

Structure of a novel: There are obviously a great many variations on structure; but, in my opinion, all novels need a definable beginning, mid-section, and an ending. I admit to hating flashbacks. Here are a few suggestions related to that obvious structural need:

Prologues and Epilogues

It is not necessary to have either or both a prologue or an epilogue, and it might inadvertently result in the creation of a spoiler. However, I like them because it gives the author and the reader a mysterious glimpse of what might be and something to look for within—maybe a foreshadowing, or maybe just a trick. A prologue may be short or long, pithy or gritty, eloquent or Hemingwayesque. It should be enlightening of the story, usually containing or promising an element of surprise, and something for the reader to discover within the novel-in-chief—an “ah-ha” moment.

           

I wrote a prologue that was two pages long for The Sheep Dog and the Wolf which seemed to be entirely incongruous for the first third of the book. Then, I slipped the prologue content in; so, my readers could suffer something of a shock, at least a decided change of direction. In my latest book, The Rise and Fall of the Fifteenth Caliphate, I have a series of prologues—almost short stories—that illuminate the theme of the book-in-chief.

           

Epigrams

Epigrams can start a book, finish a book, or do the same thing for a chapter. They should provide an insight into the ongoing story, a link to the past, or a foreshadowing of the near future in the book. In my opinion, a clever epigraphic entry that is there for the sake of cuteness or some feeling on the part of the author that is not truly concerned with the story, usually falls short or is confusing, or just seems cute and out of place. The internet is a great source; be mindful of copyright privileges; and make your choice be pertinent. In a novel, author asides may indicate amateurism and seem to be a failed attempt at cleverness. Be careful about injecting an “in-the-margin” and “off-the-cuff” comment that is set apart from the flow of the story. That type of insert suggests that the author is not truly the god of the book, but is just another onlooker, and one who needs to get his or her two-bits in from the peanut gallery.

           

First Sentence; First Paragraph; First Page

            This is the age of the millennials—a digital age when there is no patience for a less than stellar beginning or a slow buildup. The author or TV playwright gets ten seconds of sight and sound, or, at the most, a page of narrative before the readers’ eyes glaze over; and they seek a quicker fix.

           

The first sentence is likely the most important set of words strung together in the whole book. I remember the first sentence in Stephen Becker’s, The Chinese Bandit: “That summer they hanged a fat man at the Western gate as a warning and example to all.” Now, how can anyone not want to explore further? Then, there is the classic of Edgar Allen Poe’s, The Fall of the House of Usher, which is—if nothing else perhaps the record holder for the length of a single sentence: “During the whole of a dull, dark, and soundless day in the Autumn of the year, when the clouds hung oppressively low in the heavens, I had been passing alone, on horseback, through a singularly dreary tract of country, and at length found myself, as the shades of evening drew on, within view of the melancholy House of Usher.” That memorable two-breath sentence certainly sets the mood and—as a matter of desire—for pursuing a guilty little pleasure into the delicious darkness of Poe’s mind.

           

Make the first sentence a bugle call, or at least get the excitement going in that call, in that crucial first paragraph that follows. Fail in that and only a few devoted fans will give you the opportunity to share more than that one page. If the start is lifeless, the book will sink.

           

I remember being required to read, The Tale of Two Cities, by Charles Dickens when I was in high school. He wrote chapters as episodes for a weekly serial for Chapman and Hart, Publishers. In my adolescence—and still as an adult—I found the first 100 pages to be deadly dull, little more than turgid descriptions with no evident progress towards a captivating story. Thereafter, apparently, Dickens discovered his story and then raced forward in what was to become on the all-time best novels, and descriptions of the infamous Reign of Terror.

           

You are going to have to have an extremely loyal set of followers who will wait you out for a 100 pages. Lots of luck there.

Body of the Book

You, the author—and the god of the book—owe it to your congregation of readers to craft a good and compelling story. In my humble opinion, that is the foremost requirement of a good book. Many of the hundreds of thousands of efforts by authors never seem to get that. Those writers seem to be ignorant of Poe’s rules of story telling or of Hemingway’s example. Simply put, your story must have a plausible beginning, body, and conclusion that follow one to another in a logical “evidence-based” progression. It does not matter whether you write historical fiction, action or legal thrillers, suspense stories, horror, fantasy, science fiction, or even children’s books (think of Where the Wild Things Are, by Maurice Sendak), the rules still applies: the story is the thing. If you fail to get across your story, you will be doomed to be a lesser god, even a false one with more critics than fans; and your book will join the thousands of others that never get read.

The End

In television shows, an hour program has roughly thirty-eight minutes to tell the story in between the frequent opportunities to enjoy presentations of product and services research. Therefore, DNA results are immediate, complicated detective investigations last bare minutes, discovery of evidence borders on the miraculous with geniuses and totally cooperative ancillary services working together towards the desired end. Cops arrive at the locations of criminals with the speed of light, taking mere seconds to cross New York City, the United States, or even the world. TV requires a prodigious degree of suspension of judgment.

           

On the contrary, avid novel readers expect a great deal more from their authors. People who can read require, and expect, more detail, apt description, and logical progression of dialogue and events—in short, plausibility. Even in mysteries, it would be laughable in a novel for the characters to demonstrate the every day genius lightening quick conclusions coming from out of nowhere that they get on TV. In novels, travel is at a pace less than the speed of light (with the exception of Sci-fy, perhaps), and may be arduous or fun, but—at least—they are not yet interrupted by advertisements for toilet paper and tooth paste.

           

The god-like author must set the scenes and ensure that the reader is an involved onlooker, who is privy to what is transpiring with better intel than the characters acting out the story, but is never as good as that information that the all-knowing author possesses and is willing to transmit only grudgingly and over time. Description is necessary to make the characters come alive and to make a scene of action so clear that the reader feels as well as knows the story. On the other hand, excessive and irrelevant description is not useful for the story, except for the creation of what is meant to be “poetic prose.” Some poetic prose serves as no more than fodder for page flipping.

Above all, the scenes, the dialogue, the action, and the descriptions serve the end, the conclusion of the story in novel form. The conclusion should make sense—at least in retrospect—even in a mystery that concludes in the last sentence with an unexpected shocker. Unexpected is not the same as illogical or impossible. Surprises are fine so long as they are in accordance with the preceding evidence that constitutes the body of the story. Be as careful about the ending of your book as you are about your first sentence and paragraph. Never let it be said that “he (or she) seemed to be desperate to end the thing.”

Avoid being so weary with writing that you race to a finish, any finish, just to make it be done, and off to the publisher. You can kill off a beloved character, even the main character, but in so doing make it a measure of not totally unexpected and implausible tragedy or a way out of your writer’s block quagmire. You have truly failed if your faithful reader—who has gone all the way with you—reads the last paragraph or line with a sneer or a shrug and an exasperated exhalation, “saay whaa?”

           

Character Development

           

No character should be a flat, never varying goody-two-shoes or a villain so evil as to be devoid of rational thinking or some inkling of goodness somewhere in his or her makeup. If the genre of the book is about mindless crazies, zombies, and the like, then maybe there is an exception to be accepted. The only characters who need to think and to vocalize their thoughts are the main protagonists and antagonists. They are also the only ones who require full and continuing physical descriptions. Most other characters—those lesser beings—deserve only cursory and usually one-time descriptions and are seldom privileged by the god to speak and almost never to think.

           

Protagonists can make mistakes, have moral lapses, and cause harm. Antagonists can actually be good—at least at times—but they must be present to permit tension and opposition. Both character types need to become people we get to know and either like or dislike, but to be allowed a measure of tolerance and at least grudgingly an acknowledgment of their mind set.

As an example, my new book, The Rise and Fall of the Fifteenth Caliphate, is historical fiction which strongly features Abu Bakr al-Baghdadi, whose deeds are as reprehensible as humans get. However, in his religious beliefs, he fights for the preservation of his religion against usurpers, Christian crusaders, atheists, polytheists, kuffars, and people who simply and wickedly do not believe in God or the way God behaves in the same way al-Baghdadi does. It follows that all those misguided and wicked people—whom we may see as protagonists—need to be put down for the good of his cause. His way of thinking is logical and correct to him and his followers, however vile and perverted that mind set is to the regular Muslims and the vast majority of other people, particularly his victims. Through his prism, outsiders are all enemies, to the point of being the devil’s own minions. That said, you—as my reader—are likely to recognize a good many protagonists who are people a lot like us.

           

The gist of this presentation about important characters is that they need to be made believable. In that vein, be careful of dialogue. Make the speaking parts move along in keeping with the personalities of the protagonist and the antagonist, and with the end game as divined by the author—the god of the novel. Keep it all plausible and logical whatever your genre may be.

Dialogue

Be mindful of the impact of your characters’ dialogue. What charms the kitten loving Sunday School teacher may make the Sam Spade fan grit his or her teeth. The obverse side of that coin is the clinical gore of Kay Scarpetta and the harsh underworld slanguage of her colleagues and the denizens of the dark with whom she deals on a regular basis may turn the stomach of the Church Lady and quickly drive her and her confreres to more comfortable reading material. Mind your characters’ dialogue and to whom you are writing. Be consistent with your genre, at least in each book. Change genres if you want, but do not have offensive surprises for the Church Lady. Figure out if you are writing for tough old cops and retired marines, or is a more general readership what you have in mind? There is a readership for James Lee Burke’s character, Dave Robideaux and his tough scatological, profane, and irreverent patter just like there is for Kay Scarpetta’s vivid description of gore. Burke and Cornwall are masters of their crafts, and they know their audiences.

           

I know both sets of jargon based on a life among hard men, but I have chosen to moderate the language of my characters, to avoid frank sexual descriptions, and to leave room for the adventurous Church Lady to find something she can like in my “gritty realism” as my publicist says about me.

           

More dialogue and less “telling” is a good rule of thumb but one that is not so easy to master. Telling is a much easier and quicker way to move a story along efficiently, but it makes for less of a story. Study and research well if you intend to be brave and include language, dialects, regional jargon and intend to include foreigners whom you allow to speak in their language. Be especially careful with stereotypes such as ghetto talk. It may be convincing if done right and keeps up with the ever-evolving times, or it may be plain insulting. I suggest that if it is your aspiration to set a book in a region with conspicuously distinct dialects and accents that you either be from that locale and can speak like a native or consider studying the works of masters like Walter Mosely—e.g. The Devil in a Blue Dress, Mark Twain’s Huckleberry Finn, Joel Chandler Harris’s, Uncle Remus, or the legendary Robert Burns. If you want to write in a Yorkshire brogue, you had better live there for a couple of years. Even then, you will probably have to resort to plagiarism. Of course, you can invent your own language, place, and people, names like J. K. Rowley, if your bent is Sci-fi or fantasy. That takes great creativity and is more than I can muster.

           

Usually, dialect speech should be sparing. Throw in a few words or phrases to indicate that the speakers are using that mode of speech or that foreign language. Long stretches of such speech become a stumbling block and slow the progress of the story—which is more important than the dialogue, in my opinion—and dulls the enthusiasm of the reader. That is certainly one of the most important reasons for writing a book in the first place—to win that enthusiasm.

           

You are encouraged to comment on this opinionated treatise—unless you intend to be critical, and therefore mean, by definition—and you might have an opinion of value. It is possible that I could even learn something.

Able Archer-83, The Cold War, and Lessons for the Current Iran Crisis—Five

For my friends and foes, I have a disclaimer about this set of postings. I am squarely in the middle politically, religiously, and socially. I have no axes to grind. However, I do heartily believe in the truth or my version of it based on research for as objective a point of view as is possible. The facts are the facts in this work you are about to read, but the opinions are mine. In short, I believe the Able-archer-83 saga was a harbinger of things to come, and we ignore the lesson as it may apply to the current escalation of belligerence occurring between the United States and the Islamic Republic of Iran at our peril. I pray for the leaders involved that no one inadvertently pulls the atomic trigger.

Let us examine the questions and dilemmas posed by the standoff between Iran and its mercurial Supreme Leader, Ayatollah Khamenei, and the United States and its populist and attention seeking president. Since the 1979 revolution in Iran which deposed the Shah, the country has been ruled by a theocracy headed by a “Supreme Leader”—the autocratic controller of all aspects of Iran life, governmental, religious, military, social, justice, and economic. Khamenei has steadily eroded all rights to free speech, having a different religion, posting adverse comments about his regime and has pursued two principles of strategy: eliminating outside influences from contaminating his region—like democracy, libertarianism, Sunni Islam, western concepts of capitalism and judicial fairness (as opposed to God’s will, as dictated by Shi’ite cleric lawyers and judges). The other strategic working principle is to pursue an ever-increasing diplomatic interchange and interdependence with developing, non-aligned, and needy counties. It is an understatement of the first order to say that he cannot be influenced by Western reason, threats, or sanctions.

The abuses keep coming, in Khamenei’s mind. In April 2019 the U.S. threatened to sanction countries continuing to buy oil from Iran after an initial six-month waiver announced in November expired. According to the BBC, U.S. sanctions against Iran “have led to a sharp downturn in Iran’s economy, pushing the value of its currency to record lows, quadrupling its annual inflation rate, driving away foreign investors, and triggering protests.” (Wikipedia). The government of Iran has long recognized Jerusalem as the capital of the State of Palestine, but the American government does not recognize a “State” of Palestine, and it does recognize Jerusalem as the capital of Israel.

Khamenei and his minions deeply believe that western interests have always abused Iranians and other Muslims. He believes that the United States propped up the evil, rapacious, and corrupt Shah; and that given a chance, the “Great Satan” would depose his government and put in another puppet corrupt democrat who know-tows to the Americans. The sanctions placed on Iran by its enemies in the west come from the devil himself; so, any form of retaliation is sanctioned by God. God [in this case, Allah] is on Khamenei’s side and will not let him fail or the west to prevail. Hence, no sacrifice or risk is too much.

It is not all bravado or inflated bluster about Iran’s military capabilities: The government of Iran has a paramilitary, volunteer militia force within the Islamic Revolutionary Guard Corps, called the Basij, which includes about 90,000 full-time, active-duty, uniformed members. As many as eleven million men and women are members of the Basij who could potentially be called up for service. The Revolutionary Guards total 545,000 active troops.  Iran has an additional 350,000 strong Reserve Force. The total of Iran’s trained military force is upwards of 900,000. In an emergent or urgent situation, Iran could probably call up a million trained personnel which would enable the country to have among the largest troop mobilizations in the world—including the U.S. Would the U.S. win in an all-out conflict? Almost certainly, but consider the cost, as the president of the United States is doing at present.

The American president has made much of the importance of winning—especially against a totalitarian, terrorism exporting, and anti-American enemy—which accrues to his “Making America Great Again”—the overriding political purpose. It looks to the many of the nonaligned in the U.S. that we are approaching the scenario of the unstoppable force running into the immovable object. It is a serious question about when, not if, another Able Archer-83 incident propels us to or over the cliff.

Carl Douglass

Neurosurgeon turned Author who writes with Gripping Realism

Author Masterminds Charter Member

Able Archer-83, The Cold War, and Lessons for the Current Iran Crisis—Four

For my friends and foes, I have a disclaimer about this set of postings. I am squarely in the middle politically, religiously, and socially. I have no axes to grind. However, I do heartily believe in the truth or my version of it based on research for as objective a point of view as is possible. The facts are the facts in this work you are about to read, but the opinions are mine. In short, I believe the Able-archer-83 saga was a harbinger of things to come, and we ignore the lesson as it may apply to the current escalation of belligerence occurring between the United States and the Islamic Republic of Iran at our peril. I pray for the leaders involved that no one inadvertently pulls the atomic trigger. The Able Archer-83 exercise [culmination of Exercise Autumn Forge] was just that, an exercise. The hypothesis underlying the large military exercises was fictional, albeit something like well written historical fiction; some realities of the Cold War antagonisms were reflected in the scenario. The massive exercise involved 40,000 U.S. and NATO troops moving across western Europe, coordinated by encrypted communications systems. The planning included a scenario with the hypothetical opponent [Orange—fairly obviously the Warsaw Pact countries] opening hostilities in all regions of ACE [Allied Command Europe] on November 4, 1983, including numerous UK air bases. The defenders were the Blue [NATO], who declared a general alert but did not return hostilities at first. Two days later, Orange initiated the use of chemical weapons and by the end of that day had used such weapons throughout ACE. All of these “events” were simply part of the written scenario. There had been three days of fighting and a deteriorating situation prior to the start of the exercise proper. This was desired because—as previously stated—the purpose of the exercise was to test procedures for transitioning from conventional to nuclear operations.
 In the exercise, as a result of Orange advance, its persistent use of chemical weapons, and its clear intentions to commit second echelon forces rapidly, SACEUR [NATO’s Supreme Allied Commander Europe] requested political guidance on the use of nuclear weapons.
           The Soviet interpretation of the exercise could not have been further afield from the intention of the framers of Able Archer-83. Moscow Center sent a nearly frantic telegram to the London Center which was seen by the British spy, Oleg Gordievsky, and shown to MI-6:
 In view of the fact that the measures involved in State Orange [a nuclear attack within 36 hours] have to be carried out with the utmost secrecy (under the guise of maneuvers, training etc) in the shortest possible time, without disclosing the content of operational plans, it is highly probable that the battle alarm system may be used to prepare a surprise RYaN [nuclear attack] in peacetime
 On February 17, KGB Permanent Operational Assignment assigned its agents to monitor several possible indicators of a nuclear attack throughout the western world. These included any actions suggesting that there was a group associated with preparing and implementing decisions about RYaN—the KGB code name for a feared Western nuclear missile attack. They began a feverish surveillance and monitoring program of U.S. operating services, installations, and communications staffs. The 1983 NATO exercise introduced several new elements not seen in previous years, including a new, unique format of coded communication, radio silences, and the participation of heads of government.
 This increase in realism, combined with deteriorating relations between the United States and the Soviet Union and the anticipated arrival of Pershing II nuclear missiles in Europe, led some members of the Soviet Politburo and military to believe that Able Archer 83 was a ruse of war, obscuring preparations for a genuine nuclear first strike by NATO and the U.S.
 When no RYaN occurred, and the Able Archer-83 exercise came to its planned peaceful end, the Soviets heaved a sigh of genuine relief, and no one pulled the trigger. There must have been a good many officials on both sides who aged years during that fateful month. High schools in the United States often gloss over the angsts of the Cold War by describing it as a “stable balance of power” between the antagonistic east and west. The Able Archer exercise and the Soviet reaction to it was, in fact, an extremely dangerous period when the world was staring at the brink of a nuclear catastrophe. Most of the citizens of the world never knew a thing about it.
 Much the same scenario is possible in the confrontation between the United States and the Islamic Republic of Iran in the spring and summer of 2019. How heavy is the finger on the trigger? How stable and responsible are the leaders of the opposing nations and their military leaders?

Carl Douglass

Neurosurgeon turned Author who writes with Gripping Realism

Author Masterminds Charter Member