The voters of the state of Michigan approved a law last year that allows the governor to appoint an “emergency manager” for cities he deems in financial distress. He did this for Detroit this year, effectively disenfranchising 3/4 million residents. Yesterday the EM said he would not rule out selling off some or all of the collection of the Detroit Institute for the Arts, one of the nations finest art museums. Suddenly, after voting for the law and watching the Detroit city government lose its power, the suburbs are enraged. Seriously, if you tell your poorer, darker-hued neighbors that you’re taking over the town and then complain when the cuts might actually inconvenience the lighter-hued citizens, you’ve got to re-examine your thinking.

Re-examine Your Thinking

The good people of the State of Oklahoma are no strangers to tornadoes, and can smell them from a mile away. Norman-based experts track dangerous storms and word gets out as quickly as possible for folks to take shelter. Only, most Okies (? PC) don’t have tornado shelters. They don’t have basements, safe rooms, or other places that might keep them from getting impaled by a two-by-four. But Oklahomans are an independent bunch:

“we are a pretty independent free people who don’t like being told what to do” ….

That’s great, but seriously, seriously misguided. If your ideology requires you to put you and your children at risk because of your ideology, it’s time to stop asking “why me?” and start digging. Yeah, there’s money involved, but this is a perfect situation for a little federal support.

Speaking of Federal Funds

A bridge collapsed in Washington State today. The bridge was, by all reports, a geriatric pile of stressed steel waiting for any excuse to collapse. And lots of our bridges are like that. Travel to any western European country and take a look. All those crazy taxes are doing something—they actually look like modern nations. Our infrastructure would look great to pre-DeLorean Doc Brown, but damn, how stupid are we?

Have a nice weekend. Watch where you drive.

So many of them I hadn’t thought about for years, people from my early years as a doctor. I certainly remembered Syd, because I still cared for his wife. I also cared for his adult his children, who would also have to be struck off. I made a note of it. There was Mary, who was old, toothless and wonderful. She had grown up picking tobacco and cotton and didn’t much like it, but would still go south to visit her sisters and brothers every year at the family home. There was a Holocaust survivor who watched her greatest tormenter executed by an American soldier. There were so many names.

It’s easy to be forgotten when you’re dead, at least by those who weren’t used to your daily presence. I saw these people in sickness and in health, caring for them in the office and the hospital, but went home every day to my own family, putting as much of work out of my mind as was possible. But here they were, on a computer screen, glowing memories, daring me.

So I read each one, tried as hard as I could to remember them, remember the living things about them, remember that Jack liked to play tennis and make love, that Carole hated her kids. I pictured the lives they led while not in my exam room, lives full of the dull facts that make up a day, a life: making tea, having beer with friends at the corner bar, playing golf. Or worse, holding young children, saying long goodbyes to people who would have to grow up without you.

I struck off each name, the bytes disappearing from the list, shortening it significantly. I hoped that people remembered them all, the good, the bad, the silly. I would do my part; I would try. But I will strike them off just the same, making room for the living who need me more.

So are gun deaths. Cigarettes don’t kill people—unless people pick them up and smoke them. Guns also don’t tend to pick themselves up, point themselves and fire. Guns are simply tools that people use, tools that are responsible for more than 30,000 deaths in the US each year. Every one of those deaths were preventable. Suicide made up a large part of these deaths. Not all suicide attempts are successful, but the immediate lethality and ready availability of firearms makes it easier to try and succeed.

People can certainly disagree about the meaning of the Second Amendment, but facts don’t lie: our adherence to one particular interpretation is allowing tens of thousands of preventable deaths every year.

Whatever lawmakers may say, I will continue to ask my patients about gun ownership because it’s important to their health. I don’t tell them not to have guns, but I do ask them about their hobbies, hunting habits, and gun safety knowledge. I also let them know about the statistics that say that owning guns makes you more likely to suffer a firearms injury or death (obviously, really).

As with cigarettes and auto accidents, it’s likely that gun deaths can be prevented by regulation, but to take that step we ned to at least agree as a society that dead children make the question worth debating, examining, and voting on.

It sounds a bit like morning, the same bird calls I expect will wake me. During the heat of the day, there were more woodpeckers knocking, red-winged blackbirds trilling, and black-capped chickadees, my local favorite, making me feel as if I were farther north.

Even with eyes closed, though, I’ll soon hear the evening. Spring peepers will slash through the relative peace, rivaling the cicadas I expect on a warmer week.

I learned a new flower on my walk last week: bloodroot. Despite all my time outdoors, I’ve never noticed it, preferring to keep my eyes out for trillium. The daisy-like flowers were nearly enfolded by a palmate leaf, seemingly birthing them into the spring.

The poison ivy’s not far behind though. The hardiest of hardy’s I’d say. They always look healthy and do not like to be removed. As soon as a bed has been cleared, they appear on a tree trunk, obscuring the bark, daring us to touch.

A cardinal a little ways away seems as happy as I am, enjoying the cool, dry spring air (although I suppose he’s a bit lonely).

The ducks though—the ducks. We have a pair in the backyard, but today, the female was surrounded by a group of drakes—a large group. They splashed, flapped, scooted, and eventually, two of them trapped the female long enough, I suppose, to make suspect the next generation’s paternity.

They can’t ruin this though. It’s perfect, and when I tuck in my daughter, I expect she’ll agree. I’ll never take spring for granted.

One of the complaints I most often get is from patients who want me to help them out but don’t want to come to the office. This is understandable. Doctor’s visits aren’t free, and with high-deductible plans becoming the norm, more of the cost is the responsibility of the patient.

But there are two very good reasons to practice medicine face-to-face. The first is simply practical: doctors, unlike lawyers and other professionals, cannot bill for time on the phone, email or other sorts of interactions. We simply cannot keep the lights on if people don’t pay for the services we provide. It’s also morally wrong to expect me to work for free. In our culture, payment shows you understand the value of a service.

I do provide free care through a local charity. They send me patients, but not so many that I can’t deal with it financially. Sometimes doctors will work out arrangements with uninsured folks, but when a patient is insured, discounting a visit can lead to legal trouble with insurance companies.

The most important reason to avoid phone-it-in medicine is that it’s “phoning it in”. If a patient needs a long-standing prescription refilled, it can almost always be handled over the phone. But nearly anything else is asking me to use my professional judgement to help a patient. Medically it’s a bad idea.

If you have long-standing hypertension, this needs regular monitoring. Hypertension often worsens over time and treatments need to be adjusted. Asking me to simply prescribe something indefinitely is asking me to practice bad medicine. A visit in person allows me to look for the signs of damage done by hypertension, and to spend the time talking to you about obvious and subtle symptoms.

It’s hard to tell the difference between bronchitis and pneumonia over the phone. Bronchitis doesn’t require antibiotics; pneumonia does. In the office I can listen to the chest and if needed get an x-ray. Sometimes just looking at someone helps tell me how sick they really are.

When your doctor puts off treating you over the phone, she’s doing it for a reason, one that is usually in your best interest.

Today I received an email from the Board—the board which just gave me a 10 year certification—that it ain’t over. After having been assured that my two year of preparation and examination, costing me about $2000 and endless hours, I will now be required to pay the board $200/year and engage in even more busy-work, such as taking quizzes and collecting patient data (oh, and BTW, is there some sort of IRB approval for all this data-gathering? DrugMonkey?)

When the Board implemented the 10 year certification process it grandfathered in members who had been certified by a certain date. This new process has no such provision: after having spent thousands of dollars and hundreds of hours with the understanding that I won’t have to do this again for several years, I’m now told that I will need to keep going.

This will take away from patient time and from other educational activities. Instead of choosing my own educational programs, I’ll have to use that time and money to do modules from the Board.

I know it’s not all that dignified, but I must tell the ABIM: you’ve jumped the shark with this one. Practicing internists don’t have time or money for your bullshit. Please fuck off.

Saturday night she slept over at a friend’s house. When I picked her up, she said, “It’s a really nice spring day. Let’s do something outside. Can we go to the zoo?”

Yes. Yes we can. We went home, had a little lunch, packed a bag with snacks and took off. The zoo is a gorgeous piece of land, with long esplanades, gardens, and of course, animals. She wanted me to use the map, but it was much more fun to wander and let the animals surprise us.

She’s old enough to read the signs and learn about the animals and their habitats, and enjoyed teaching me. More important, she walked. A kid who prefers to sit walked for hours. Near the end of the day she did wear out. I gave her a piggy back ride, and she kissed the back of my head, saying, “I love you Daddy.”

I’m glad she slept in, but I’m ready for her to come down to breakfast.

The last few mornings, the birds have sounded like spring. Cardinal songs are lovely but their incessant, randy singing can get a bit annoying. Blue jays’ musical tones are wonderful little surprises. But my favorite is the black capped chickadee. Its song always reminds me of the wilderness, so I took off onto the trail this morning for my return to running, and with the hope that the birds would provide a sound track.

I didn’t make it very far, but beside a pond I saw a movement in the bush. There it was, a small bird, perhaps just a random little brown thing. Then its small beak opened and out came the remarkably clear “yoo hoo” of my chickadee. Its camouflage is remarkable. Look how its brown body blends into the background, its black and white head mimics the light-dark of the branches and the spaces between.

Cry havoc and let spring the new season!

If doctors stop taking medicare patients should they pay back 500k+ CMS http://www.aafp.org/online/en/home/policy/federal/issues/workforce/education.html … invested in training them?

Now, I’m not saying the tweeter thinks this is what should be done, but the premise is so completely wrong that…well, it’s not completely wrong, it’s just mostly wrong.

First, let’s chat about Medicare, the program that insures people over sixty five (and many disabled people). Medicare sets prices paid to doctors based on all sorts of formulas, but due to Congress’s inability to make financial decisions, these fees are unstable, requiring last minute fixes each year. This means that doctors that treat Medicare patients have considerable trouble planning salaries, hiring, capital improvements, and other expenses. Because of this instability and the generally lower fees paid by Medicare, it might make sense for some to simply opt out and stop participating. Medicare patients would still be able to go to the office, but they would have to pay out of pocket.

The interesting question raised by the tweet is this: since Medicare funds graduate medical education (residencies and fellowships) do doctors owe Medicare some sort of obligation?

Work has a value, and ideally the value is assigned at the time someone is hired for their work. If the worker doesn’t agree with the fee, they move on and management is denied her production. Ideally.

The ethic here is analogous to informed consent: contracts should explicitly state the obligations and benefits for both parties. Doctors pay for medical school, and exit with a debt averaging $200,000. They enter residency with the expectation that they will receive a modest stipend, one that usually doesn’t allow for loan repayment but at least pays room and board. To maintain a residency program, hospitals receive money from Medicare, and some of this money is used to pay this stipend (or salary, depending on whom you ask).

Residency is not a benefit given to young doctors: it is an obligation. In return for being taught and supervised, they take care of patient, working long hours and sacrificing years of potential earning and often family life. There has never been an expectation that they owe anyone anything.

This, then, is why I call “bullshit” on anyone who would suggest the system has other hidden obligations. To impoverish young doctors through debt, and then further impoverish them by having them pay for their training not only in service but in dollars is not consistent with how we create doctors in this country.

If we as a society decide that residency and fellowship are really tuition-based services rather than work, that would need to be explicitly agreed upon long before high schoolers enter college and decide to torture graduate students with questions about their organic chem grade.

If doctors are required to become indentured servants to Medicare, it should not be without an explicit understanding.

Hey, whassup!

Welcome back. I’m dusting off the furniture and moving back in—sort of. I’m having a great time writing over at Forbes (and I sincerely hope you’re reading!), but let’s face it: Forbes is a news outlet, and not a great place to put on the personal touches.

So, I’m re-opening WCU here at WordPress for my non-medical bits: family anecdotes, poetic musings, fiction, political rants, whatever. I invite you to follow both blogs for a complete look under the white coat.

Grand Traverse Bay. Yes, it’s that cold.

OK, that came out wrong, but you get what I’m saying.

So the other night my dad and I were talking about the latest cosmology story in the papers. PalKid, always the eavesdropper, asked what we were talking about. How the hell can I explain cosmology—something I barely understand—to a third grader? The first step, I figured, was ‘c’. Without understanding that light has a finite velocity, there’s no way to understand anything else.

As it turns out, third graders are capable of getting it. I started out with explaining how when we turn on the lights, it seems instantaneous but it’s not. Then we moved up to the sun. “It takes eight minutes?”

Then we moved up to nearby stars, and finally the edges of time. It was amazing. The kid soaked it up like a sponge. And then she went back to watching re-runs of Full House.

Anyway, spring is on the way. The blacked-capped chickadees are getting noisy, the robins fat. If the thermometer would just cooperate…

The whitecoatunderground.com domain will from this point forward direct here, and to get to Forbes, plug in my addy there, and thanks for reading.

I’ve written this blog in it’s many forms for a number of years now, at a number of venues. It’s moving day again.

I’ll give details at the new place, but please note that you will so find new posts appearing at the new White Coat Underground at Forbes.com.

Those of you from the north know the non-sound of snow falling, the “indoors” feeling of sounds after a heavy snowfall. When we do get enough snow around here (my area is in a bit of a snow shadow) I head out on snowshoes a find my self alone in a large metro area, able to enjoy the sounds. The other night I heard howling and yipping, and had no idea whether it was dogs or coyotes (or both).

The frigid weather this past week gave our local landfill-associated ski areas to make a ton of snow. I dragged PalKid out of bed and we’re heading out soon for a day of brief runs on grainy snow. It’s gonna be a blast.

I’ve written a number of times about how a physician must be careful not impose his or her personal beliefs on patients.

Another interesting case has hit the news. The decision of the California Supreme Court hinged on interpretation of state non-discrimination law. I’m not a lawyer, but I do know a bit about medicine and medical ethics. Regardless of law, this doctor’s behavior was wrong. The details are a little sketchy, but an unmarried lesbian woman was denied fertility treatments by a California doctor because the treatment conflicted with the doctor’s faith.
Conflicted with the doctor’s faith. There’s the rub.

This is a particularly perverse form of proselytizing. It doesn’t involve having coffee with an acquaintance and teaching them the Word. It involves a vulnerable individual, who comes to a qualified professional for help, and is turned away because of “improper” living and thinking. In this case, it is disputed whether the patient was denied care because of being gay or because of being unmarried. It doesn’t really matter. Either reason for discrimination is wrong. What matters is that the doctor felt that treating the patient would violate her own religious beliefs.

The measure of whether a treatment is appropriate is whether it conforms to standard of care, is safe, effective, and ethical (non-coercive, etc.). If a patient presents for infertility treatment, and is medically qualified, she should receive the treatment (assuming she doesn’t breed babies for snack food). The American Society for Reproductive Medicine recognizes this in several position statements. One specifically addresses unmarried and homosexual patients:

–Unmarried persons and gays and lesbians have interests in
having and rearing children.
– There is no persuasive evidence that children raised by
single parents or by gays and lesbians are harmed or
disadvantaged by that fact alone.
–Programs should treat all requests for assisted reproduction
equally without regard to marital status or sexual
orientation.

When you decide to become a doctor, you immerse yourself to the neck in ethical problems for the rest of your career. Patients make bad decisions. Other doctors make bad decisions. Ethically grey conundrums pop up on a daily basis. Standards set by professional organizations help to sort some of these out, but not always. The “most wrong” decision in an ethical debate is the cop-out. For a physician to deny a patient care based on their own beliefs is a cop-out, and is a coercive use of their paternalistic powers. This decision doesn’t just deny them your personal services. It may cause permanent psychological harm to the patient. And that’s not what doctoring is all about.

Another doctor in our area specializes in so-called “holistic” medicine. He runs expensive tests that aren’t covered by insurance. Many of these tests are either of questionable significance and utility, or are run in labs widely known for their “variable” quality. He puts his patients on unconventional mixes of medications and supplements, many of which he apparently sells. He and many doctors like him send their patients to “real” doctors to take care of the rest of the patient’s healthcare.

In the first case, the cops caught up with the guy. The fallout for patients will last for a while as the scramble to find new primary care physicians (there’s a shortage, you know), or have to suddenly deal with a narcotic problem after their source dries up.

In the second case, the doctor will continue to collect cash from patient to whom is is very kind, and who get the answers they want from a kind man.

The second doctor isn’t doing anything illegal. He’s practicing bad medicine, outside of the standard of care, but as far as I can tell, he’s not breaking any laws. And his patients love him. He listens, spends time, and tells them what they want to hear. I looked into ways to get this guy investigated, to have some sort of third party look over his practices, but I couldn’t find one. Complaints against healthcare professionals have to be lodged by patients or their agent. As far as I can tell, in this state there is no way for anyone other than a patient to complain about bad doctors.

This makes some sense. If someone opens a practice across the street from me and my patients start fleeing there, who says I wouldn’t call in a complaint just to hurt my competition? (I wouldn’t obviously, and there’s no incentive even if I were a bad guy. There are plenty of patients for all of us.)

But while doctors clearly breaking the law can get caught and prosecuted, doctors practicing obviously bad medicine are pretty safe. Their patients often love them and wouldn’t think of lodging a complaint. Even if every other doctor in the community knows another doctor is bad news, there’s nothing they can really do.

I may not be completely right. Maybe there’s a way to complain to the medical board in this state. Maybe not. I couldn’t find one, and I’ve never heard of it happening.

Doctors get disciplined if patients complain, maybe get busted for breaking the law, maybe get sued if a patient is unsatisfied, but they don’t get investigated for being quacks.

I don’t have a solution to propose that wouldn’t create layers of bureaucracy and put good doctors at risk of false allegations. But there must be some way to deal with quacks. Their work harms patients and makes my job difficult as I try to tease apart what they’ve done to my patients.

I think there is something else that must be said because it is a magnificent demonstration of discipline. With all of the thousands and hundreds of thousands of people engaged in this demonstration today, there has not been one reported incident of violence. I think this is a magnificent demonstration of our commitment to nonviolence in this struggle for freedom all over the United States, and I want to commend the leadership of this community for making this great event possible and making such a great event possible through such disciplined channels.

Almost one hundred and one years ago, on September the 22nd, 1862, to be exact, a great and noble American, Abraham Lincoln, signed an executive order, which was to take effect on January the first, 1863. This executive order was called the Emancipation Proclamation and it served to free the Negro from the bondage of physical slavery. But one hundred years later, the Negro in the United States of America still isn’t free.

But now more than ever before, America is forced to grapple with this problem, for the shape of the world today does not afford us the luxury of an anemic democracy. The price that this nation must pay for the continued oppression and exploitation of the Negro or any other minority group is the price of its own destruction. For the hour is late. The clock of destiny is ticking out, and we must act now before it is too late. 

The events of Birmingham, Alabama, and the more than sixty communities that have started protest movements since Birmingham, are indicative of the fact that the Negro is now determined to be free. For Birmingham tells us something in glaring terms. It says first that the Negro is no longer willing to accept racial segregation in any of its dimensions.For we have come to see that segregation is not only sociologically untenable, it is not only politically unsound, it is morally wrong and sinful. Segregation is a cancer in the body politic, which must be removed before our democratic health can be realized.  Segregation is wrong because it is nothing but a new form of slavery covered up with certain niceties of complexity. Segregation is wrong because it is a system of adultery perpetuated by an illicit intercourse between injustice and immorality.  And in Birmingham, Alabama, and all over the South and all over the nation, we are simply saying that we will no longer sell our birthright of freedom for a mess of segregated pottage.  In a real sense, we are through with segregation now, henceforth, and forevermore.

Now Birmingham and the freedom struggle tell us something else. They reveal to us that the Negro has a new sense of dignity and a new sense of self-respect. For years— I think we all will agree that probably the most damaging effect of segregation has been what it has done to the soul of the segregated as well as the segregator.It has given the segregator a false sense of superiority and it has left the segregated with a false sense of inferiority.  And so because of the legacy of slavery and segregation, many Negroes lost faith in themselves and many felt that they were inferior.

But then something happened to the Negro. Circumstances made it possible and necessary for him to travel more: the coming of the automobile, the upheavals of two world wars, the Great Depression. And so his rural, plantation background gradually gave way to urban, industrial life. And even his economic life was rising through the growth of industry, the influence of organized labor, expanded educational opportunities. And even his cultural life was rising through the steady decline of crippling illiteracy. And all of these forces conjoined to cause the Negro to take a new look at himself. Negro masses,  Negro masses all over began to re-evaluate themselves, and the Negro came to feel that he was somebody. His religion revealed to him, his religion revealed to him that God loves all of his children, and that all men are made in His image, and that figuratively speaking, every man from a bass-black to a treble-white is significant on God’s keyboard.

So, the Negro can now unconsciously cry out with the eloquent poet,

Fleecy locks and black complexion

Cannot forfeit nature’s claim.

Skin may differ, but affection

Dwells in black and white the same.

Were I so tall as to reach the pole

Or to grasp at the ocean at a span,

I must be measured by my soul

The mind is the standard of the man.

But these events that are taking place in our nation tell us something else. They tell us that the Negro and his allies in the white community now recognize the urgency of the moment. I know we have heard a lot of cries saying, “Slow up and cool off.”  We still hear these cries. They are telling us over and over again that you’re pushing things too fast, and so they’re saying, “Cool off.” Well, the only answer that we can give to that is that we’ve cooled off all too long, and that is the danger.  There’s always the danger if you cool off too much that you will end up in a deep freeze.  ”Well,” they’re saying, “you need to put on brakes.” The only answer that we can give to that is that the motor’s now cranked up and we’re moving up the highway of freedom toward the city of equality,  and we can’t afford to stop now because our nation has a date with destiny. We must keep moving.

Then there is another cry. They say, “Why don’t you do it in a gradual manner?” Well, gradualism is little more than escapism and do-nothingism, which ends up in stand-stillism.  We know that our brothers and sisters in Africa and Asia are moving with jet-like speed toward the goal of political independence. And in some communities we are still moving at horse-and-buggy pace toward the gaining of a hamburger and a cup of coffee at a lunch counter.

And so we must say, now is the time to make real the promises of democracy. Now is the time to transform this pending national elegy into a creative psalm of brotherhood. Now is the time to lift our nation. Now is the time to lift our nation from the quicksands of racial injustice to the solid rock of racial justice. Now is the time to get rid of segregation and discrimination. Now is the time.

And so this social revolution taking place can be summarized in three little words. They are not big words. One does not need an extensive vocabulary to understand them. They are the words “all,” “here,” and “now.” We wantall of our rights, we want them here, and we want them now.

Now the other thing that we must see about this struggle is that by and large it has been a nonviolent struggle. Let nobody make you feel that those who are engaged or who are engaging in the demonstrations in communities all across the South are resorting to violence; these are few in number. For we’ve come to see the power of nonviolence. We’ve come to see that this method is not a weak method, for it’s the strong man who can stand up amid opposition, who can stand up amid violence being inflicted upon him and not retaliate with violence.

You see, this method has a way of disarming the opponent. It exposes his moral defenses. It weakens his morale, and at the same time it works on his conscience, and he just doesn’t know what to do. If he doesn’t beat you, wonderful. If he beats you, you develop the quiet courage of accepting blows without retaliating. If he doesn’t put you in jail, wonderful. Nobody with any sense likes to go to jail. But if he puts you in jail, you go in that jail and transform it from a dungeon of shame to a haven of freedom and human dignity.And even if he tries to kill you, (He can’t kill you) you’ll develop the inner conviction that there are some things so dear, some things so precious, some things so eternally true, that they are worth dying for.  And I submit to you that if a man has not discovered something that he will die for, he isn’t fit to live.

This method has wrought wonders. As a result of the nonviolent Freedom Ride movement, segregation in public transportation has almost passed away absolutely in the South. As a result of the sit-in movement at lunch counters, more than 285 cities have now integrated their lunch counters in the South. I say to you, there is power in this method.

And I think by following this approach it will also help us to go into the new age that is emerging with the right attitude. For nonviolence not only calls upon its adherents to avoid external physical violence, but it calls upon them to avoid internal violence of spirit. It calls on them to engage in that something called love. And I know it is difficult sometimes. When I say “love” at this point, I’m not talking about an affectionate emotion. (All right) It’s nonsense to urge people, oppressed people, to love their oppressors in an affectionate sense. I’m talking about something much deeper. I’m talking about a sort of understanding, creative, redemptive goodwill for all men.

We are coming to see now, the psychiatrists are saying to us, that many of the strange things that happen in the subconscience, many of the inner conflicts, are rooted in hate. And so they are saying, “Love or perish.” But Jesus told us this a long time ago. And I can still hear that voice crying through the vista of time, saying, “Love your enemies, bless them that curse you, pray for them that despitefully use you.” And there is still a voice saying to every potential Peter, “Put up your sword.” History is replete with the bleached bones of nations, history is cluttered with the wreckage of communities that failed to follow this command. And isn’t it marvelous to have a method of struggle where it is possible to stand up against an unjust system, fight it with all of your might, never accept it, and yet not stoop to violence and hatred in the process? This is what we have.

Now there is a magnificent new militancy within the Negro community all across this nation. And I welcome this as a marvelous development. The Negro of America is saying he’s determined to be free and he is militant enough to stand up. But this new militancy must not lead us to the position of distrusting every white person who lives in the United States. There are some white people in this country who are as determined to see the Negro free as we are to be free. This new militancy must be kept within understanding boundaries.

And then another thing I can understand. We’ve been pushed around so long; we’ve been the victims of lynching mobs so long; we’ve been the victims of economic injustice so long—still the last hired and the first fired all over this nation. And I know the temptation. I can understand from a psychological point of view why some caught up in the clutches of the injustices surrounding them almost respond with bitterness and come to the conclusion that the problem can’t be solved within, and they talk about getting away from it in terms of racial separation. But even though I can understand it psychologically, I must say to you this afternoon that this isn’t the way. Black supremacy is as dangerous as white supremacy. No, I hope you will allow me to say to you this afternoon that God is not interested merely in the freedom of black men and brown men and yellow men. God is interested in the freedom of the whole human race.And I believe that with this philosophy and this determined struggle we will be able to go on in the days ahead and transform the jangling discords of our nation into a beautiful symphony of brotherhood.

As I move toward my conclusion, you’re asking, I’m sure, “What can we do here in Detroit to help in the struggle in the South?” Well, there are several things that you can do. One of them you’ve done already, and I hope you will do it in even greater dimensions before we leave this meeting.

Now the second thing that you can do to help us down in Alabama and Mississippi and all over the South is to work with determination to get rid of any segregation and discrimination in Detroit,realizing that injustice anywhere is a threat to justice everywhere. And we’ve got to come to see that the problem of racial injustice is a national problem. No community in this country can boast of clean hands in the area of brotherhood. Now in the North it’s different in that it doesn’t have the legal sanction that it has in the South. But it has its subtle and hidden forms and it exists in three areas: in the area of employment discrimination, in the area of housing discrimination, and in the area of de facto segregation in the public schools. And we must come to see that de facto segregation in the North is just as injurious as the actual segregation in the South.  And so if you want to help us in Alabama and Mississippi and over the South, do all that you can to get rid of the problem here.

And then we also need your support in order to get the civil rights bill that the President is offering passed. And there’s a reality, let’s not fool ourselves: this bill isn’t going to get through if we don’t put some work in it and some determined pressure. And this is why I’ve said that in order to get this bill through, we’ve got to arouse the conscience of the nation, and we ought to march to Washington more than 100,000 in order to say,  in order to say that we are determined, and in order to engage in a nonviolent protest to keep this issue before the conscience of the nation.

And if we will do this we will be able to bring that new day of freedom into being. If we will do this we will be able to make the American dream a reality. And I do not want to give you the impression that it’s going to be easy. There can be no great social gain without individual pain. And before the victory for brotherhood is won, some will have to get scarred up a bit. Before the victory is won, some more will be thrown into jail. Before the victory is won, some, like Medgar Evers, may have to face physical death. But if physical death is the price that some must pay to free their children and their white brothers from an eternal psychological death, then nothing can be more redemptive. Before the victory is won, some will be misunderstood and called bad names, but we must go on with a determination and with a faith that this problem can be solved. 

And so I go back to the South not in despair. I go back to the South not with a feeling that we are caught in a dark dungeon that will never lead to a way out. I go back believing that the new day is coming. And so this afternoon, I have a dream.  It is a dream deeply rooted in the American dream.

I have a dream that one day, right down in Georgia and Mississippi and Alabama, the sons of former slaves and the sons of former slave owners will be able to live together as brothers.

I have a dream this afternoon (I have a dream) that one day, one day little white children and little Negro children will be able to join hands as brothers and sisters.

I have a dream this afternoon that one day,  that one day men will no longer burn down houses and the church of God simply because people want to be free.

I have a dream this afternoon (I have a dream) that there will be a day that we will no longer face the atrocities that Emmett Till had to face or Medgar Evers had to face, that all men can live with dignity.

I have a dream this afternoon (Yeah) that my four little children, that my four little children will not come up in the same young days that I came up within, but they will be judged on the basis of the content of their character, not the color of their skin.

I have a dream this afternoon that one day right here in Detroit, Negroes will be able to buy a house or rent a house anywhere that their money will carry them and they will be able to get a job.

Yes, I have a dream this afternoon that one day in this land the words of Amos will become real and “justice will roll down like waters, and righteousness like a mighty stream.”

I have a dream this evening that one day we will recognize the words of Jefferson that “all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” I have a dream this afternoon.

I have a dream that one day every valley shall be exalted, and “every valley shall be exalted, and every hill shall be made low; the crooked places shall be made straight, and the rough places plain; and the glory of the Lord shall be revealed, and all flesh shall see it together.”

I have a dream this afternoon that the brotherhood of man will become a reality in this day.

And with this faith I will go out and carve a tunnel of hope through the mountain of despair. With this faith, I will go out with you and transform dark yesterdays into bright tomorrows. With this faith, we will be able to achieve this new day when all of God’s children, black men and white men, Jews and Gentiles, Protestants and Catholics, will be able to join hands and sing with the Negroes in the spiritual of old:

Free at last! Free at last!

Thank God almighty, we are free at last!