Thankful Thoughts

I'm posting today from beautiful Perdido Key in Orange Beach, Alabama. We arrived last night and have had a glorious morning playing on the beach. The weather is great, and the beach is perfect--with just enough other beachgoers for our children to make friends and have playmates, but by no means crowded. I've already had the chance to eat some gumbo and shrimp, so life is good.

It's an emotional trip for me. It's my first visit here in three years, since we evacuated this very place on the day Hurricane Ivan hit. Our two bedroom Gulf-front condo (which we co-own with another couple and the bank) took a pounding, and the restoration has been slow, difficult, expensive, maddening, and depressing. When I was here last, my children were babies, I was a partner and board member of one of the largest multi-specialty physician practices in the Southeast, I was busy in church teaching Sunday school every week and serving on the pastor search committee,and I was not yet forty years old. Today, I'm an exhaused almost-43 year old who has weathered a tumultuous year building my own solo internal medicine practice, a venture which has been both consuming and liberating, both frightening and comforting, and stressful yet strengthening.

This brings me to the title of this post--thankfulness. I am most thankful to my wonderful wife, who has stood by me while I have upended her life, and who has been instrumental in building what is now clearly a successful solo medical practice. Thanks to her unconditional love and her willingness to allow me to take risks, we have built what I believe is a unique medical practice, one that is making a difference in people's lives, and one that is positioned to withstand the turbulent times ahead for primary care medicine. Not only has Mary Kaye stood by me, steadfast, but she has home-schooled our children with measurable success, and along the way she's managed to complete re-licensure as a physical therapist to boot, providing much-needed financial support for our family during my practice start-up. Not one woman in a million could have accomplished what she's done, and I'm so proud of her I could burst. Oh yes, that's not to mention that I've also relied on her to take the lead in all the dealings required for restoration of our condo. In all things, in every aspect of my life, she has made better anything I've been part of. I love you, Mary Kaye.

I'm also thankful to God, who has blessed me with Mary Kaye and three wonderful, intelligent, rambunctious, and unique children. They are a joy. Granted, they are expensive, tiring, and exasperating, but they are mainly a joy. I revel in them even as I take seriously my responsibility to raise them. God has also blessed my practice, and I see His hand evident whenever I take the time to look. A close friend who has been a pastor has remarked to me how energizing it is to minister to people, even in the face of an exhausting schedule, and I see that also in my work--I feel a God-given sense of satisfaction and fulfillment when I help people through my medical practice. I almost feel that to talk about that God-given motivation may somehow cheapen it or open it to ridicule, so I won't dwell on it, but it's there, and it's real, and I'm thankful to God for His blessing in bestowing it.

The kids are studying the founding of America in their history lessons, and their study has opened my eyes anew to God's blessings on our nation. We all ought to be thankful to be Americans. I will often rant and criticize about political issues, but I must remember to be more thankful for our system of government. I do believe God had a special and unique plan in the founding of our nation, though I shudder in fear at how far we've strayed from His principles.

I'll close for now, with plans to post again during our vacation. Beach and nap and seafood are calling, and I'm thankful for them, as well...

Progress Report

Today's post will not be my typical laser-focused gem of nuanced and knowledgeable insight. I am fighting off a cold and Mary Kaye is off to a scrapbooking convention, so today is a lazy day home with the kids. It is an opportunity to post on several topics I've touched on in the past, however.

Plans are apace for the Open House my office is having August 23. The Open House is being held to celebrate the completion of our first year of practice. We never held a Grand Opening because we were too busy from the start, but I wanted to celebrate what I believe is a successful start for our efforts at delivering primary health care in a different and better patient-centered model. We also wanted folks to see our expanded office space, which we just finished remodelling a couple of weeks ago. We have almost doubled our office's square footage, and have doubled the number of patient exam rooms. Another reason for the Open House is to introduce Tina McCall, our new nurse practitioner, to my patients. Tina's presence will help us tremendously as we strive to be conveniently available to patients, and we want to give folks a chance to meet her, as well as to publicize that work-in appointments, especially on Fridays, will be more available. Finally, we wanted to use the Open House in a low key manner to introduce the new Premier Wellness option that we are now offering. As I've noted before, Premier Wellness is an optional retainer-based program in which patients pay an annual or monthly fee in return for a wide-ranging annual Wellness Review, as well as guarantees of quicker work-ins and generally enhanced levels of office time spent discussing health issues.

I have developed the Premier Wellness program in an effort to insulate myself and my patients from what I fear are impending devastating public policies regarding reimbursement for health care services. My fear is that, as third party/government payors exert more and more influence on health care policy, the traditional and precious relationship between doctor and patient will be irreparably harmed. Only a socialist would argue that the individual's best interest is always concordant with society's, or the government's. Unless the patient is paying for the service, someone else is calling the tune. The practical result, I fear, is that without Premier Wellness or something similar, all primary care doctors will be forced into becoming "office visit mills" with limited time and little satisfaction for both patient and doctor. If I can develop a model in which patients feel valued and empowered and really "cared" for, a model in which the patients themselves decide the value of the services and whether to pay for them, then I will have protected some modicum of the traditional relationship between doctors and patients. I will have also salvaged that ideal which should motivate physicians--the concept of servanthood.

Too often, conservatives cede the moral high ground to liberals who preach generosity and unity, but the truth is that none of the ideals I've spoken of above can occur unless the staff is paid, the rent is paid, and the monthly bills are paid. I love the old joke about liberals, that they're so generous they'll give you the shirt off someone else's back. I'm here in the trenches, trying to care for folks, but I'm also saying that providing the care people want costs money, and that's a truth that needs to be faced. My Wellness option isn't for everyone, but neither is any other single option. The thrust of my position, however, is that patients need to control the system, and that will not happen unless they are also paying the bills.

With regard to Premier Wellness, I'm excited that the response to my initial offering has exceeded my expectations. I have already seen one patient this week as a Wellness patient, and I believe that this patient felt , dare I say it, pampered and well cared for. I was able to take the time to speak with a specialist about one of this patient's health problems, and arrangements were made for an expeditious office visit with the specialist. This was all able to be accomplished because I was able to allocate extra time with this patient. Time--that is the most important asset I have to offer patients, and the commodity that patients are being deprived of in today's system.

I am also trying to find other ways to add value to the product I offer Wellness patients. I have arranged a substantial discount for membership at a local water-based therapy center, and I hope to arrange access to an entity that offers gym and exercise equipment. I would also like to have my Wellness patients meet annually with a dietitian for nutritional counselling, and I'm going to try to add that benefit at no extra cost to the patient. Offering these and other benefits will help these patients achieve their goal of good health and access to personalized care that is convenient for them. I am proud to be part of the process.

I'll close with a word about Presidential politics. It goes without saying that all the Democratic proposals regarding health care are horrible. Among the Republicans, there is a glimmer of sense. Giuliani, whom I've slammed for his pro-abortion stance, has made headlines recently with an outline which seems to try to apply market principles to health care spending by making individual health care premiums tax deductible. This proposal is good in that it weakens the artificial and harmful linkage between employment and health insurance. Mike Huckabee, who I believe is the most engaging and credible conservative in the race, has a good strong tax policy proposal called the FAIR tax. I need to learn more about his health care spending proposals. Huckabee needs to do well in an upcoming Iowa straw poll next week. I hope he does.

Patient Driven Health Care

It seems that a perfect storm of events has occurred over the last several weeks which has brought the discussion of health care delivery in the United States to the fore. The federally funded but state administered Medicaid plans, for example, are woefully underfunded and lacking in sufficient primary care and specialty care, and patients' frustration with a system which does not serve their interests has reached a critical mass. I've seen several recent newspaper articles on the subject, and just about all the Presidential candidates have their own ideas (mostly bad) about how to fix things.

But wait, you say, Medicaid is just a welfare program for the poor and chronically ill. You have Medicare, the federal government run program available (mandatory, actually) for those over 65. Didn't that program add a nice new drug benefit last year? It's saving me a bundle on my meds. What you soon-to-be Medicare patients don't realize is that when you turn 65, your doctor automatically gets paid about 30% on average less money for the exact same office visit with you, compared to when you didn't have Medicare. And it's illegal for you or your doctor to negotiate any fee higher than "Medicare allowable." How many doctors with full practices will be anxious to add new Medicare patients into their slots, which could be filled with non-Medicare patients paying 30% more for the exact same work? The answer is, Not Many, and therein lies a huge problem most people nearing 65 aren't even aware of. But it's real, and it's coming.

Unfortunately, another truth is that Medicaid, the federally paid but state managed health care system for the poor, pays so poorly that growing numbers of primary care and specialty doctors are refusing to lend their legitimacy to this fiasco by participating. Meanwhile Medicare payments to primary care doctors are down 9% in 10 years in inflation-adjusted dollars, and draconian cuts in payments to providers are on the way. Limitations in choice of, and even access to, providers are looming on the horizon.

Well, perhaps I'm guilty of overdramatizing a problem. Let's look at where all the new medical school graduates are going to finalize their training and choose their specialties. And over the past ten years, we've seen a stunning and unique drop in the students choosing general internal medicine, a drop of nearly 50 percentage points in ten years. These graduates are voting with their choice of specialty, and they are voting to choose more money over less, less work over more, respected work over ridiculed work, daytime work over night time.

The picture that I've drawn is one of a broken system, specifically a broken payor system. The health care you're given is still generally top notch, but that may not be for long. Clever, capable, driven young men and women will find other and easier routes to glory and service, without the debt, and where their services are appreciated. You appreciate your primary care doctor, you say? Well, unfortunately, the third party payor who pays your bills generally doesn't.

I'll give one actual example for your consideration. I recently bought a machine that allows me to assess for the presence of peripheral arterial disease. Having the machine helps me provide better care to my patients, most of whom have multiple risk factors for arterial disease. Incredibly, I get reimbursed more from Medicare for performing the test than I do for the office visit in which I use those test results to formulate a treatment plan! Not only do I get paid more for doing the test, but, even more ridiculously, it takes 5 or 10 minutes to read and interpret the test, while an office visit is 15 to 20 minutes on a good day. I'd be better off to stop caring for patients and just do ABI testing full time. Stories like this will be repeated and repeated until we finally realize that, in order to restore some balance to the health care market, patients must be put back in charge of their own health care spending.

The solution? I suspect there may be many solutions, but one solution for my small medical practice is to attempt to remove myself from being in bondage to the third party payors. I will attempt to offer to patients a guarantee of such a pleasurable and low-stress office visit environment, care that is focused on meeting the patients' needs, with bonus perks for Wellness-related services, that these patients will be willing to pay me an annual retainer just to get to be part of the practice--to have access to the annual Wellness review, the guaranteed work-in times, the "no-waiting" policy, the quarterly newsletter, the portable medical records on CD-ROM, the dietitian consultation, the massage, the discounted Aquatherapies and gym membership, and my personal cell phone number.

Having a cohort of patients who are focused on Wellness and who identify me as their doctor--that will make me no longer a slave to the third party payors, but will instead restore me to the traditional physician's role of being a servant of the patient. Instead of the government or Medicare or insurance companies determining what my services are worth, it will be the patients--the consumers of my services--who decide what they are worth. Nationally this concept is referred to as "patient-driven health care," and it results in excellent patient satisfaction survey numbers.

I believe in this concept so much, and I am so fearful of the status quo in medicine, that I am implementing a patient-driven, retainer-based protocol in my own practice. The response has been very encouraging, and I no longer have any real doubt as to its success. These patients have every right to expect from me top-notch medical care, efficiently delivered, in a manner that fits their schedule, not my own, and I am motivated to deliver for them and to be accountable to them for the results.

I'll let you know how it works out.

"Evidence-Based" Medicine?

My sister, who is an RN and studying to become a nurse practitioner, recently was required to interview a physician regarding what is known as "evidence-based" medicine. She asked me for perspective.

Here is the question:

The Interview Objective:
To determine individual perspective regarding the significance of research in generating an evidence-based practice for nursing.

Here is my response to her:

Evidence-based medicine is the substitute created by third party payors to replace the traditional boundaries of accepted clinical practice defined by the physician-patient relationship. While the research itself might be useful, the underlying impetus for the research is harmful to the practice of medicine. There will always be outliers among providers, who in a traditional model would likely be marginalized by other providers and by the community itself. With the rise of insurance and government payors and the concomitant weakening of the unique provider-patient relationship dynamic, traditional means to identify substandard providers have been weakened. In general, the American system of health care delivery is excellent, but the brokenness of the reimbursement system will inevitably lead, I believe, to a decline in the quality of care.

Insurance companies are driven not by altruistic motives, but by profit margins, and government by political considerations. While insurors today claim that it's good business to promote wellness and provide thoughtful care, the facts belie their claim. Anecdotal evidence abounds to confirm what is suggested by common sense---that insurance companies prefer to delay and challenge legitimate payments as much as possible. Employers, the traditional conduit for health insurance benefits for the last 40 years, pay insurance companies prospectively on a monthly basis for their employees' health benefits. Meanwhile, in my hypothetical, the insurance company withholds payment for a legitimate service routinely for three to four months. The interest rate "float" generated by this cash flow manipulation must generate millions upon millions of dollars for these companies!

But I digress. The question relates to the significance of the research in generating a particular model of practice. Again, most research is inherently helpful in contributing to the body of knowledge of medicine. Such research has, in my thirteen years of private practice, led to striking improvements in patient care, especially in cardiovascular disease. Examples include the improvement in mortality and morbidity from tighter blood pressure control in hypertensive patients or glycemic control in diabetics. We are currently in the midst of a dramatic increase in the use of statin drugs due to overwhelming evidence of their benefit. All of these treatment trends are beneficial to patients.

Unfortunately, clinical patient encounters resist the precision inherent in the scientific method. This makes quantitative assessment of patient care very difficult, and current methodology is very primitive. It's my belief that an excellent clinician might have, on the basis of a number of unmeasurable variables, poor results in such analyses. Patients don't come to the doctor with Problem X, Y, or Z. They come in as themselves, indivisible, and the art of the clinical encounter is in managing that session to the benefit of the patient. Treatment based on evidence is desirable but incomplete unless it is modified to a patient's particular circumstance. I recently put a patient on an angiotensin-receptor blocker for his newly-diagnosed hypertension, and his insuror resisted paying for the medicine. Evidence-based guidelines would suggest that I use a different and less expensive drug. But I know that this patient is resistant in coming to the doctor in the first place, would be non-compliant with any medicine with even mild side effects or an inconvenient dosing schedule, and his sister and mother developed a cough when placed on ACE inhibitors. His insurance company and the evidence-based reviewers don't care about these things. This is a trivial example but the first to come to mind, and it illustrates in a small way the factors which are encompassed in an encounter.

A provider who bases her practice on evidence-based medicine is an automaton who would miss critical nuances. On the other hand, a provider who incorporates evidence-based practices into a framework of basic science education, clinical experience and compassion will provide superior care. Payors and regulators, however, will not necessarily be impressed. This is one of the major sources of tension in American medicine today. At their core, evidence-based clinical guidelines are a tool for clinicians, but are not an end unto themselves.

End of my response.

I will soon post more on what I believe is a fundamental problem with America's health care reimbursement system. Notice that I intentionally specified "reimbursement." It may be self-serving, but my perspective is my perspective, and I think America's health care system is excellent. However, as I noted above, the health care system is imperiled by a broken payment system.

A note about last night's Republican Presidential Debate. Mike Huckabee again distinguished himself among a host of men who will say anything to be elected President. When I heard his response to a question about evolution, I wanted to (and did) stand up and applaud. Many folks have not taken the time to become familiar with Huckabee, but I urge you to take a look. He is an impressive guy. He has given I think objectively the best performance through all three GOP debates.

Immigration Amalgamation

My plan had been to wait until I'd read the recent bipartisan Senate compromise bill on immigration, until I realized the Senate apparently plans to vote this week before Senators have even read the bill. In fact, even today the final version is not yet drafted, so no one really knows what's in it. If a Senator can vote for something he knows nothing about, then I can certainly opine, as well. Since facts are in short supply regarding this bill, it is useful to look at who the supporters are, and compare them to the opponents, always looking toward the motivation of each side.

Amongst the supporters: the Bush Administration, most Democrats, the U.S. Chamber of Commerce, and some Republicans such as Lindsey Graham of South Carolina. The motivation of the Bush Administration is easy to deduce. Bush has always been a little leftward on immigration, I think because he views it as a demographic plus long-term for the GOP, and also because he really believes his rhetoric. Besides his judicial legacy, with the permanency of his tax cuts in doubt and with the failure of his Social Security reform, immigration reform would be viewed by opinion-makers as one of Bush's major accomplishments. President Bush is human and therefore not immune to such fluff, especially at a time when he is steadfast in the face of ferocious opposition to his foreign policy objectives.

With regard to most Democrats, again, their support is predictable. Most national Democrats will reflexively support any measure that results in increased numbers of low-income government dependent voters, as this bill will. Only the most left-wing radical Democrats would oppose this bill, and then on the grounds that it doesn't let in enough immigrants. Increased immigration fits well into their philosophy of "sharing" and redistributing wealth, and more immigrants means bigger budgets for entitlements such as Medicaid, Social Security, and children's services. Bigger budgets mean bigger taxes and bigger bureaucracy and bigger government--these are Democratic fundamentals.

I think the Chamber of Commerce, along with some other business interests, views this bill as a way to ensure a ready supply of lower-wage workers, especially in service sectors. I'm not in disagreement with much of their reasoning, but, on the other hand, these are the same guys advocating increasing ties with Communist China and who are building factories and business partnerships with the Chinese. Their aim is economic gain, but I can't shake the feeling that in dealing with folks like the Chinese, we are dealing with potential enemies. I fear that 50 years from now our children and grandchildren will face a Chinese threat that we helped fund. Forgive my roundabout process, but my point is that I'm not convinced the Chamber of Commerce has our national interest at heart--they have big business interests at heart, and those two interests are not always concordant.

Finally, there are the Republican supporters of the bill. A few, I think, are motivated by principle, but others are simply interested in favorable publicity or are appeasers always willing to compromise to "make a deal." Lindsey Graham of South Carolina, one of the Republican negotiators, has never met a camera he didn't like, and he is way too quick to sponsor compromises that sell out principles. John McCain typifies this group well. These, then, are the players in support of the immigration bill.

What about the opposition? Amongst the GOP Presidential candidates, most except McCain have come out against this compromise. This tells me that these guys have read the pulse of GOP primary voters and detected real concern. I was particularly interested to see Fred Thompson quickly come out in opposition with a well-reasoned article which can be found on the RealClearPolitics website. Countering the Chamber of Commerce support for the compromise is the National Federation of Independent Business. The NFIB might have been expected to represent the same interests as the Chamber of Commerce, but they have instead come out against the bill because of its punitive measures against small businesses and because of the regulatory burden it places on them.

On balance, just looking at the compromise's supporters and opponents, I'm pretty comfortable in opposing this bill. It seems to me that the merits of a guest-worker program ought to be subjugated to the imperative of securing our national border. Why can't the government come to the American people and say, " We've reduced illegal entry into this country by 80% over the last two years, and every illegal immigrant who commits a felony is being deported. Now that we've secured our borders and established the rule of law, here is our proposal for a guest worker program." This seems eminently more reasonable to me.

I hope conservatives can muster the groundswell necessary to stop this compromise. I'm optimistic that if we can, then perhaps progress can be made in enforcing our current immigration laws. If that happens, then I'm all for hashing out an agreement that allows for reasonable immigration. Right now, though, we're too busy getting the cart before we have a horse. And this is one ugly cart.

Debating the Debate

This week's GOP debate in South Carolina was another opportunity for the top tier guys (McCain, Romney, Giuliani) to distinguish themselves from one another, as well as an opportunity for the lesser-known candidates to kindle an identity for themselves in the public eye. Unlike the earlier GOP debate, I did not watch this one in its entirety, but I've reviewed partial transcripts and viewed snippets and digested some snap post-debate commentary, and, having done so, I feel reasonably confident in offering this analysis. By the way, the news of the day today has to do with the Senate's backroom bipartisan deal on immigration reform, and I'll certainly post on that once I know more details of the agreement. At first blush, I'm at best greatly conflicted, and I need to reflect for a few days on how this agreement purports to solve such a base failure as our government's failure to adequately secure our nation's borders. But I digress...

With regard to the GOP debate, Mitt Romney was clearly the biggest loser of the night, I think in part because he had done so very well in the previous MSNBC debate. This week Romney was not so sharp, seemed to struggle with some answers, and consequently suffered the letdown of unmet expectations. My impression of Romney from the first debate was that he looked Presidential and in command of the issues. That was not my impression this week.

The conventional wisdom is that Rudy Giuliani helped himself the most among the Big Three with his authoritative focus on national security and his seemingly spontaneous umbrage with Libertarian Ron Paul's blaming of 9/11 in part on American foreign policy. Nevertheless, I do not believe Giuliani can win the GOP nomination with his strategy of embracing his pro-choice views on abortion. I once thought he could possibly finesse the issue with his assurances about appointing strict constructionist judges, but I believe he has needlessly alienated too many social conservatives with what I perceive is a flippancy ("It'd be OK..." to reverse Roe) toward one of the foundational issues of our day. He once had the reserve of good will to handle this issue, but I believe his opportunity is lost.

The debates do not help John McCain. His answers remind me of Al Gore's--the canned responses of an insider. I'm convinced John McCain is pursuing a pipe dream but doesn't know it. He has banked on the tradition of Republicans to nominate "the next in line" (think Bob Dole, George H.W. Bush, even Ronald Reagan in 1980), but he underestimates his negatives. Conservatives remember his campaign finance reform which limits our free speech rights, his opposition to the Bush tax cuts, his coddling of the liberal media in 2000 in part by attacking religious conservatives, and his hamstringing of America's efforts to interrogate terrorists with his publicity-seeking opposition to "torture." McCain is learning the same lesson many other Republicans have learned the hard way--he was once a media darling by virtue of attacking conservatives, but now that the mainstream media has deserted him, he finds himself alienated from those conservatives. His base is now largely comprised of establishment inside-the-Beltway types who have no firm ideology. Support from such folks might normally be enough for a Republican to win the GOP nomination, but I suspect not for McCain, because I think he's made too many conservatives mad.

I've posted before of my support for Mike Huckabee, and I think his polished performances in both GOP debates may be enough to push him up from the mass of lower-tier candidates into his own lone position as a second tier alternative. He clearly had the line of the night with his John Edwards beauty shop one-liner, and his deft handling of questions and fresh yet polished candor is very appealing. National pundits don't appreciate what many of us know--Huckabee's background as a pastor of a large Baptist church is serving him very well right now. Huckabee has also quelled my concern that he might not be committed enough to limited government and lower taxes. He has a proposal for a consumption tax called the "Fair Tax" to replace income and corporate taxes, and his support for this indicates to me that he understands the economic imperative of a limited tax burden. Political consultant Dick Morris has called Huckabee's delivery a combination of Reagan's and Clinton's styles, and after a bit of a shudder at his linkage of these two icons, I can see Morris's point. Huckabee is Reaganesque in his ideology and optimism and his media savvy delivery, but he also emotes and engages the crowd like Clinton can.

We're about two months away from the campaign's second quarter fund-raising reporting, and Huckabee will have to have shown some movement by then if he is to have a chance. I suspect he will. I also predict McCain will muddle along while most media attention is devoted to Giuliani and perhaps a summertime Fred Thompson entry into the race. This is all very interesting to political junkies like me, but it's also critically important for our country as these candidates lay the groundwork for our nation's alternative to the Democratic vision of defeat, retreat, division, and economic and moral decay.

Who Will Write Our History?

My children and I traveled to Shiloh National Military Park this weekend for a family getaway and history lesson. It was a wonderful and fun trip for the kids and for me, as I remembered similar trips to Shiloh when I was their age. In a time when so many of the defining elements which shape our culture are not being passed to the next generation, it was a joy for me to be able to build memories with them.

As we wandered the beautiful and meticulously kept grounds of the cemetery, John Henry and Lydia were full of questions. Among them were questions about who was buried there, and which side were the "good guys" fighting on? It is hard to explain to seven year olds the concept of a civil war, with brother fighting against brother. Nor did they ever grasp that everyone buried in the cemetery in individual graves fought for the Union, while the Confederate soldiers were buried by the thousands in huge burial trenches. Indeed, according to family lore, my own great great grandfather is buried in one of those trenches, having himself left behind a seven year old daughter who would grow up to become my great grandmother.

The epiphany hit me while we were wandering in the cemetery. History is written by the victors, so it has always been, and so will it always be. We who live generations later can have little real understanding of the milieu which led these ancestors of ours to make the choices they made. We can study and read and educate ourselves, but the truth remains that in a major conflict such as The War Between the States, where basic philosophies are at odds, the victor conquers more than people or land. He vanquishes the losers' ability to frame the debate. I hasten to add that I do not speak of racial matters here, for there can be no reasoned debate on race in today's America.

I speak, instead, of victory in a society's battle of ideas: The South's belief, for example, that their government was the true inheritor of the principles of the Founding Fathers. That the individual states did have a sovereignty that superseded that of the Union. That many who fought for the South fought not for slavery but to defend their homes from what they viewed as armed invaders. Yet none of these truths, as Southerners saw them, has survived to the national identity of today, because the South lost the war. The United States after the Civil War was a very different country from the looser organization of states that existed before the war, and the Southern cultural perspective is now relegated to a quaint footnote, or worse.

My point is not to comment on the consequence of the Civil War on today's America, but rather is to recognize that our society's views are a product of those battles of ideas that have preceded us. Further, we as a people are engaged today in a multitude of battles whose outcome will determine what kind of world our children and our children's children will live in. The victor will tell the story. If you are apathetic about these battles, you shouldn't be. The stakes are high.

We face, among numerous other challenges, an implacable Islamic terrorist foe who believes that women are second class citizens, who denies freedom of speech and religion, and who does not share the traditional Judeo-Christian view of the worth of the individual. If we as a society do not steel ourselves to recognize and fight this enemy, it is hardly an exaggeration to believe that our progeny might grow up under sharia law, with no understanding or appreciation for the freedoms we now take for granted. It does not matter whether we acknowledge the threat we face---the threat is before us and threatens our very existence. We ignore it at our children's peril.

Scripture tells us in the Book of Judges that the Hebrew people did such a poor job of teaching their children that, " ... a generation grew up which knew neither the Lord nor the things He had done for Israel." (Judges 2:10) It is incredible that after all God had done for the Hebrews--delivering them from Pharoah and slavery, parting the Red Sea, delivering The Ten Commandments, parting the Jordan River, and delivering Jericho--that God's people did not teach their children about Him. Let us not make the mistake that those Hebrews made. Let us recognize and engage our foes, and teach our children to appreciate and defend the blessings of Western civilization, so that they can carry those blessings forward for themselves and our children's children.