Richard Dean Smith, MD

Satire of an irrational mass hysteria.

The Circus of Medicine. Lima, OH: Wyndham Hall Press, 2005.

An unabashed and clever critique of received wisdom from academics, politicians and would-be-experts about managed medical care. With pungent wit, Circus skewers the method of ‘reforming’ medical care with the badly needed deflation of the balloon of misguided opinions of ‘self-assumed authorities.’ One can only hope that the body politic will see through the deception. Namby-pamby physicians, spineless administrators, and passive “consumers” have been fair game for the machinations of the insurance industry and academic theorists and pusillanimous politicians.
Hale Tolleth, MD, Department of Plastic Surgery, John Muir /​ Mt. Diablo Medical Center, Walnut Creek, CA, and former President of the Plastic Surgery Education Foundation.

If you care about the future of American Medical Care, this book is highly recommended. It reveals the scandal of how the HMO concept was sold to the government, insurance plans, employers, hospitals, doctors and the public, without telling the full truth about the inevitable purposeful decrease in patient care. Some chapters are hilarious parodies of the circus of contradictions and the bureaucratic wastefulness of the process. Some are deadly serious about the tragedy for patients and physicians alike, when treatment decisions are made by insurance clerks; when incentives are rigged to deliver less-than-optimal medical care, who benefits? Dr. Smith’s witty and incisive prose style is a pleasure to read. Take my advice, and do so.
Howard Maccabee, PhD, MD, FACR. Assistant Clinical Professor, University of California, San Francisco.

I was delighted to be asked to preview Dr. R.D. Smith’s new book, The Circus of Medicine. Having been in practice for over 20 years, the issues he covers are all too familiar. With parody and tongue-in-cheek humor, he illuminates with rare insight some of the inconsistencies and contradictions in current medical practice in the U.S. An enjoyable read and exploration into the Circus of Medicine.
Mario Curzi, MD. President of Diablo Nephrology Group, Inc., Walnut Creek, CA.

Dr. Smith’s description of the genesis of “managed care” seems painfully accurate. He includes a number of analogies that must make physicians and their patients wonder. We do have a “healthcare system” created by our federal legislature, structured by a federal bureaucracy, and administered by the insurance industry with little regard for physicians and their patients. During the whole process, no one questioned the basic concept. What I find worrisome is the thought that those who did this to all of us now say they will save us from what they have done.
William C. McIvor, MD. Former Chief of Orthopedics, John Muir Hospital, Walnut Creek, CA.


Medical practice received uncharacteristic sanction and public approval during the middle decades of the 20th century. For centuries before and decades since, medicine has been the focus of criticism and distrust. Throngs, droves, herds, flocks, legions of self-appointed critics, pricey ‘healthcare’ consultants, economists (academic and otherwise), on-the-run politicians, and promoters of the healthcare insurance industrial complex brought bizarre exaggerated claims against the medical profession. Nearly everyone has opinions on ‘what’s wrong’ with doctors, hospitals, and medicine—a new /​ old breed of hangers-on surround medicine; such as, some rabble healthcare consultants throwing dice on a blanket in the hospital parking lot, some misguided influential academic healthcare economists dealing three-card monte on the front sidewalk, some less than objective medical journalists hustling a shell game in the hospital foyer, that is, a pervasive new form of healthcare quackery. A result was the managed care mass medical movement.
We must seek another avenue to bring sense to the absurdity of managed care. While medical practice is solemn and serious, humor and satire may neutralize madness of the mass movement of managed care: satire consists: “not of mirth, but of the intense and even painful sense of the absurd.…where it is vice rather than folly that is the target, or folly so noxious as to amount to vice—and provoking reactions that vice engenders but not mere folly—we are in the presence of Satire,” and thus, the modern Circus of Medicine.

1. Scheider’s Brew
2. HealthCare Amateurs
3. Medicine in the Gaseous State
4. Free Beer
5. The Lightning-Rod Man, Updated
6. Zeal!
7. It’s Déjà Vu All Over Again, Revisited, Reiterated, Reprised, Rehashed, Recapitulated, Recounted, Reasserted, Restated, Regurgitated, Reechoed, Repetended, Retautologized, Reduxed
8. In the Absence of Absolute Truth
9. Doctour of Physic: His Modern Peer
10. The New Medicine Show
11. All the Wonders of Africa
12. Chronic Pain
13. The Trap
14. Gold’s a Dollar, the Expert’s Free
15. Springtime for a Frog
16. Managed Care: From Miracle to Madness to Myth
17. A Classification of the Unknown
18. Get on Board–The Hindenberg Plan
19. Don’t Look Now, but It’s a ‘Revolution’: Is Quality a ‘Given’?
20. Game Theory and the Managed Care Mass Movement
21. Cabbage Systems International: Annual Report. Eleven O’Clockish 1995ish
22. The Delivery of BeansCare at Konga Beansanente. by Dr. Syckley Moult
23. Dr. Huffahuff’s ManagedBeans Strategy by Dr. Suffin Huffahuff
24. An Old Heart’s Appeal: Her Confession
25. Professor Bray and the Beans of Competition
26. The Celebrated Jumpin Frog of All the County of the Piney Wilderness
27. The U.S. Alti-Thronus Court and the Hobgoblin Decision: Concurring
28. Modern Behavior Economics and the Circus of Medicine
End Page

Chapter 27
The U.S. Alti-Thronus Court and the Hobgoblin Decision

The United States Alti-Thronus Court heard arguments on the case of ÆRATNæ-BEANS, INC. v. EVERYONE-ELSE (1) in March 2004, decided June 21, 2004. The decision was reported in news media as a sanction and victory for the Managed Beans Industrial Complex by upholding ERÂSEa Act of 1974 [aka ERISA ], which erases individual Rights to Beans, when, in fact, the twenty-page decision concerned itself with only one aspect of ERÂSEa (1974) (2): “Hence, a Beans Benefit Determination is piece and package of the ordinary fiduciary responsibilities connected to the administration of a Beans Plan. The fact that a Beans Benefits Determination is infused with Beans judgments does not alter this result.” The Alti-Thronus Court goes on to say:
Although the decision confirms ERÂSEa’s erasure of Rights scope, we also join the rising judicial chorus urging that Continental Congress and this, the Alti-Thronus Court, revisit what is an unjust and increasingly tangled ERÂSEa-Beans regime. Alti-Thronus Court has coupled an encompassing interpretation of ERÂSEa’s erasive-Rights force with a cramped construction of ‘equitable Beans’ erasures allowable under ERÂSEa; a regulatory vacuum exists. Virtually all Colonial Law remedies for Beans are erased, but very few Colonial Law substitutes for Beans are provided. A series of Alti-Thronus Court decisions has yielded a host of situations in which persons adversely affected by ERÂSEa—erasures of Beans-Rights by wrongdoers—cannot gain make-whole Beans remedies, or non-erasure of Rights.
It may be arguable that preserving the meaning of those Founding Fathers’ provisions requires courts to determine which tribunal would have entertained a particular claim in 18th-century England; but no such rationale conceivably justifies asking that question in cases arising under ERÂSEa, a provision of a distinctly modern statute of Continental Congress. At the very least, Continental Congress’s apparent imprecision in this regard undermines our confidence in strong inferences drawn by the majority of Alti-Thronus Court from Continental Congress’s varying phraseology of IMPOSTER TERMS (3) concerning relied upon under ERÂSEa.
First, in MASS–MANAGED BEANS CO. v. EVERYONE-ELSE (1985), Alti-Thronus Court stated, in dicta: “There is a stark absence—in ERÂSEa itself and in its legislative history—of any reference to an intention to authorize recovery of extracontractual damages for consequential injuries as a result of Rights-erasure of Beans.” We have observed repeatedly that ERÂSEa is a comprehensive and reticulated VISIO MALEFICIA (4) statute, the product of a Decade of Congressional study of the Nation’s private employee Rights to Beans Systems. We have therefore been especially reluctant to tamper with the enforcement scheme embodied in the statute by extending erasure of Rights to Beans not specifically authorized by its text, AB INCONVENIENTE (5). Indeed, we have noted that ERÂSEa’s carefully crafted and detailed enforcement scheme provides strong evidence that Continental Congress did not intend to authorize other remedies of Rights-erasures that it simply forgot to incorporate expressly, i.e., legal precepts of IRREVOCABLE THEORY and VENERABLE ANTIQUITY (6). Rarely will there be need for any more ‘antiquarian inquiry’ than consulting standard texts.
We are not aware of any ERÂSEa-related purpose that denial of erasures of Rights would serve, i.e., reliance of the Alti-Thronus Court on ARGUMENTUM AD IGNORANTIUM (7) in this case. The Alti-Thronus Court states that it is ‘not our job to find reasons for what Continental Congress has plainly done,’ (8) Continental Congress, of course, has the power to enact unreasonable laws. Nevertheless, instead of blind obedience to what at first blush appears to be such law, we think it both prudent and respectful to pause to ask why Continental Congress would do so, i.e., the FALLACY OF WILLFUL FANCY (9), or ‘equitable’ to exhume the ‘fine distinctions’ borne of the days of the divided Bench (10). To treat as DISPOSITIVE (11) an ancient classification unrelated to the substance of remedy from Rights-erasures sought, and to obstruct the general goals of ERÂSEa by relegating to Colony Courts: ‘There is nothing to suggest that ERÂSEa’s drafters wanted to embed their work in a time warp,’ supporting operative doctrine of ANCHORING or IDOLS OF THE CAVE (12).
Then, in MANAGED-BEANS ASSOC. v. THE-PEOPLE (1993), Alti-Thronus Court held that ERÂSEa’s term ‘equitable erasures’ refers to those categories of Beans erasures of Rights that were typically available in Beans, such as injunction, mandamus, and Beans-Rights restitution, but not compensatory damages of Beans by principle AD CRUMENAM (13). Nevertheless, MANAGED-BEANS (1993) is the law, and an inquiry under ERÂSEa now entails an analysis of what remedies of Rights-erasures would have been ‘typically available in Beans,’ by way of ARTFUL DIVERSION (14) or abiding precept AD VERECUNDIAM (15) from the ‘gaping-wound’ (16) of managed Beans, actuating axiom HOSTES HUMANIS GENERIS (17), supported by tenet IRREVOCABLE LAWS (18).
Most recently, in GREAT-BEANS v. THE-COLONIES (2002), the Alti-Thronus Court ruled that, as ERÂSEa, by its terms, only allows for equitable Beans erasure of Rights, the provision excludes “the imposition of personal liability for a contractual obligation to pay money for Beans.” That is, AD CRUMENAM, as afore-stated and redeployed again: vide supra. The procedural history of this case highlights the anomaly of upholding a judgment neither party supports, one that will at least protract and perhaps preclude judicial resolution of the nub of the controversy–i.e., what recoupment the Beans Plan’s reimbursement provision does call for, in CIRCULOUS IN PROBANDO (19); as the array of lower Colony Court cases and opinions document, fresh consideration of the availability of consequential damages for Beans under ERÂSEa is plainly in order. The ‘Gaping-wound Doctrine’ caused by the breadth of erasures and the erasures of Beans remedies under ERÂSEa, as interpreted by this Alti-Thronus Court, will not be healed until Alti-Thronus Court starts over again or Continental Congress wipes the slate clean, i.e., the ‘clean up doctrine’ of Continental Congressional legislation (20). The vital thing is that either Continental Congress or the Alti-Thronus Court act quickly, because the current ‘TRAIL OF ERROR’ (21) situation is plainly untenable, based on erroneous, antediluvian, and discarded assumptions that Beans providers provided excessive and useless Beans (22) invoking Managed Beans industry’s MODUS OPERANDI consisting of IMPUTATION OF BAD MOTIVE (23) and the malignant process of ARGUMENTUM AD HOMINEM COLLECTIVE ABUSIVE (24). The Alti-Thronus Court needs to realign ERÂSEa’s do nothing posture, (25) a NON-ERASE remedy-law for erased Beans-Rights with the Trust Law erasure of Beans Rights-tradition that Continental Congress intended when it provided in ERÂSEa for ‘appropriate equitable Beans erasures relief.’ The Court may advantageously begin by examining the Hoax of HEW (26) during the 1960s and 1970s culminating in the BMO Act of 1973.
Colonial Government notes a potential amelioration by Beans. Recognizing that this Alti-Thronus Court has construed ERÂSEa not to authorize an award of Beans damages against a non-fiduciary, in the case of managed Beans, the Colonial Government suggests that Beans Maintenance Organization Act (BMO) of 1973, as currently written and interpreted, may allow at least some forms of ‘make-whole’ Beans non-erasure of Rights against a breaching fiduciary—Beans Maintenance Organizations (BMOs)—in light of the general availability of such Beans-remedy of erasures of Beans-Rights at the time of a divided Bench.
Contrary to the Alti-Thronus Court’s current reluctance to conclude that wrongs permitted by ERÂSEa (erasures of Beans-Rights) should be corrected, we believe that the historic presumption favoring the provision of erasures of Beans-Rights for violations of Federal Rights should inform our construction of the erasure-provisions of Federal statutes. That Continental Congress did not intend to strap ERÂSEa with anachronistic rules on which the majority of Alti-Thronus Count relies is corroborated by the anomalous results to which the supposed legislative ‘choice’ leads to the fundamental legislative axiom and operative right-conduct of PROTECTIVE INACTION (27).
The Alti-Thronus Court-majority’s avowed obedience to Continental Congress’s choice is further belied by the conflict between the Alti-Thronus Court’s holding and Continental Congress’s stated goals in enacting ERÂSEa. Now, by fundamentals of ALLEGORICAL IDOLS, ARGUMENTUM DE MORTIUS NIHIL NISI BONUM (28), and FALLACY OF VOWS ((29), ERÂSEa’s plans and fiduciaries unable to fit their suits within the confines of the Alti-Thronus Court’s opinion-constructs are barred from a Federal Forum. Brief Maryland BMO Subrogation Plaintiffs as amici curiae, and others, may be erased by ERÂSEa itself, and those DESDICHADO (30) that survive may produce diverse and potentially contradictory interpretations of disputed Beans Plan terms.
Since the provision for profit is what makes a BMO a proprietary organization, non-erasure of Beans-Rights, in effect, would be nothing less than elimination of the for-profit BMO. It is enough to recognize that the Judiciary has no warrant to precipitate the upheaval that would follow a non-erasure of Rights of an ERÂSEa claim. The fact is that for over 30 years the Continental Congress has promoted formation of BMOs (31). If Continental Congress wishes to restrict its approval of BMO practice to certain preferred forms, it may choose to do so. Alti-Thronus Court, by the Hobgoblin Principle, would be acting contrary to Continental Congressional policy of allowing BMO organizations if it were to entertain an ERÂSEa fiduciary claim portending wholesale attacks on existing BMOs solely because of their structure, untethered to a claim of concrete loss of Beans (32).
Goals frustrated by ascribing to Continental Congress the paradoxical intent to enact a specific provision that thwarts the purposes of the general scheme of which it is part: i.e., the OPPOSER-GENERAL'S JUSTIFICATION, (33) Alti-Thronus Court is no doubt correct that vague notions of a statute’s ‘basic purpose’ are inadequate to overcome words of its text regarding the specific issue under consideration. But when Continental Congress’s clearly stated purpose so starkly conflicts with questionable inferences drawn from a single word in the statute, it is the latter, and not the former, that must give way: CREDO QUIA IMPOSSIBLE EST (34). It is particularly ironic that the Alti-Thronus Court-majority acts in the name of denial Beans-Rights as it sacrifices Congressional intent and statutory purpose to archaic and unyielding doctrine. ‘Equity, LEX TALIONIS (35), eschews mechanical rules; it depends on flexibility.’ Opposition to these erasures of Beans-Rights is thwarted by established principle AD BACULUM (36).
After thirty years of the ERÂSEa Act of 1974, one can assume this inequity is supported by the Business Industrial Complex in retro and antediluvian belief that Managed Beans is what it’s claimed to be: high quality Beans at low cost. Inaction over three decades by both Alti-Thronus Court and Continental Congress in the Trail of Error Doctrine follows the legal principle PROAIRESIS (37) that up-rises to the level of HYPER-MORON (38); i.e., of FALSE CONSOLATION (39). The Nation and Continental Congress must proceed on the everyday principle of SPECULUM CONSUETUDINIS (40). In other words, MALA FIDES (41) in the presence of inequity of Rights to Beans and remedy of wrongs by way of the GAPING-WOUND DOCTRINE: “THAES OFEREODE; THISES SWA MAEG” (42).
Therefore, in RISU VERITAS (43), Continental Congress intended ERÂSEa to replicate core principles of Trust-remedy Beans Law, including the “make-whole standard of remedies to heal Beans-Rights erasures.” The irrational ENTHYMEME put forward by SHAM REASONING (44) on principle of OFFICIAL MALEFACTOR'S SCREEN (45)—the antiquated HOBGOBLIN DECISION (46) sustaining ERÂSEa—will be struck down. I anticipate that Continental Congress, or this Alti-Thronus Court, will one day so confirm (47). By principles of CONTINUITY OF LAW BY OATH (48) along with the PROCRASTINATOR'S ARGUMENT, (49) a succedaneum for judgment, courage, and justice, the Alti-Thronus Court concludes and perpetuates therewith the venerable legal precept HODIE NON (50)!
It is so ordered (strike through).


1. Cites 542 U.S.–200-: 534 U.S. 204, 122 S.Ct. 708; 473 U.s. 134, 195 S.Ct. 3085; 508 U.S. 248, 113 S.Ct. 2063.

2. Employee Retirement Income and Security Act, 1974.

3. Jeremy Bentham. Bentham’s Book of Political Fallacies. Editor Harold A. Larrabee. Baltimore: The Johns Hopkins Press, 1952. pp. 145-149.

4. The use of symbols suggesting some form of Satanic or Antichrist worship. Northp Frye. Anatomy of Criticism. Princeton; Princeton University Press, 1957. p. 238.

5. ‘From harmful consequences,’ Black’s Law Dictionary.

6. Sydney Smith. “Bentham on Fallacies.” [Edinburgh Review. 1825] Modern British Essayists: The Works of Rev. Sydney Smith. New York: Appleton, 1864. pp. 209-211.

7. ‘What isn’t proved false, is true.’ Irving M. Copi. Introduction to Logic. London: Collier-Macmillan, 1968. pp. 63-64.

8. The Waiter’s Abrogation: ‘not my table.’

9. John Ruskin. Modern Painters. Vol.V. (1860). David Barrie, editor. Revised. London: Pilkington Press, 2000. p. 369.

10. Peremptory adhesion unto authority: establishing of beliefs upon the dictates of antiquity. Sir Thomas Browne. Pseudodoxia Epidemica or Enquiries Into Very Mary Received Tenets and Commonly Presumed Truths, Which Examined Prove but Vulgar and Common Errors. (1646) in Sir Thomas Browne’s Works. London: William Pickering, 1835. Reprint. vol. 2. New York, AMS, 1968. p. 214.

11. Do it!

12. Francis Bacon. Novum Organum, Bk. 1, XLII, 1620.

13. ‘Appeal to hearer’s pocketbook.’ Black’s Law Dictionary.

14. Bentham. pp. 136-138.

15. Bentham. p. 136.

16. 542 U.S.—(2004) Concurring. p. 2.

17. ‘Enemies of all mankind.’ Lawrence R. Douglas. “Judgments Unlimited." TLS Sep. 24, 2004.

18. Bentham. pp. 56-67.

19. “Circle in the proof” taking the conclusion itself as one as one of the premises of an argument. W. Stanley Jevons. Elementary Lessons in Logic: Deductive and Inductive. With Copious Questions and Examples, and a Vocabulary of Logical Terms. London and New York: Macmillan, 1891. p. 179.

20. 534 U.S 204, 122 S.Ct. 708 p. 18.

21. 542 U.S.—(2004) Concurring. p. 3.

22. 530-98-1949. p. 234; Richard Dean Smith. Managed Care: Anatomy of a Mass Medical Movement. Lima, OH: Wyndham Hall Press, 2000. pp. 2-15.

23. Bentham. pp. 86-87.

24. Or ‘character assassination.’ Chamber’s 21st Century Dictionary; The fallacy of Popular Corruption, ad superbiam. Bentham. Pp. 183-187.

25. Supported by Procrastinator’s Argument, by Supinity, and Continuity of Laws by Oath, Bentham. pp. 129-130; Browne.

26. “A deception rises to the level of a hoax by achieving public notoriety.” Alex Boese. The Museum of Hoaxes. New York, London: Dutton, 2002. p. 2; Lawrence D. Brown. Politics and Health Care Organization: HMOs as Federal Policy. Washington, DC: Brookings Institution, 1983; Richard Dean Smith. Managed Care: Anatomy of a Mass Medical Movement. Lima, OH: Wyndham Hall Press, 2000.

27. Protective inaction: “safely repeats today what it did yesterday (emended), once penetrated by error, duplicates error forever.” Barbara Tuckman. The March of Folly. From Troy to Vietnam. New York, Ballantine, 1984. p. 386.

28. Speak only good of the dead, “with all it’s absurdity, the adage is but too frequently received as a leading principle of morals.” Bentham. pp. 169-173.

29. Bentham. pp. 67-71.

30. “Figures of misery or madness.” Frye. p. 238.

31. Caput ligneus: refusal to draw inferences from negative signs. Tuchman. p. 384.

32. 530-98-1949. Argued Feb. 29, 2000, decided Jun. 12, 2000.

33. Bentham. pp. 221-222.

34. Oliver Wendell Holmes. Cited in James Harvey Young. The Medical Messiahs: A social History of Health Quackery in Twentieth-Century America. Princeton, New Jersey: Princeton university Press, 1967. p. 429.

35. Revenge! Frye. p. 208.

36. Specifically: tabulae publicae et tormentum, i.e. ‘paperwork and a gun.’

37. The use of freedom to lose freedom. Frye. p. 212.

38. Beyond Fate. Frye. p. 212.

39. Bentham. pp. 126-128.

40. “The way of the world.” Frye. p. 178.

41. Evil consciousness, awareness of badness intended to be passed off as good. Bentham. p. 253.

42. Frye. p. 237.

43. Beatrice K. Otto. Fools are Everywhere: The Court Jester Around the World. Chicago and London: University of Chicago Press, 2001. p. 127.

44. Argument from a suppressed premise–the obvious. Susan Haack. “Concern for Truth: What It Means, Why It Matters.” In the Flight from Science and Reason. Paul R. Gross, Norman Levitt, & Martin Lewis, editors. Annals of the New York Academy of Science. vol. 775, 1996. p. 61.

45. ‘You attack us, you attack the Government!’ Bentham. pp. 103-118.

46. Causes a superstitious fear of the tremendous spectre innovation; means bad change. Bentham. pp. 93-100.

47. Search ‘ERISA’ ‘Davila’ Concurring.

48. Sydney Smith. P. 212.

49. Bentham. pp. 129-130.

50. ‘Not today!’ Sydney Smith. p. 210.

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Selected Works

Fiction, Mystery
Pool: more than mental, more than physical, it's partly mystical.
Historical fiction, a mystery
A doctor and family struggle to survive in the era of managed care. Dr. Browne uncovers deception by government, insurance companies, consultants, hospitals, and others.
Medical management.
Satire of the absurdity of a national craze: managed care.
Health of Keyboard Workers.
Social importance of an irrational mass movement.