So much drama on C-SPAN!

On a bill to give the FDA regulatory authority over tobacco, especially to ban flavored cigarettes (kids' favorites).

Rep. Boehner (R-OH): This is a boneheaded piece of legislation. *handwaving and rant about big government*
Rep. Dingell (D-MI): I yield myself 15 seconds of time to respond to my beloved friend. Mr. Boehner, tobacco kills. And you will be the next to die.
Entire AAP Office: Whoaaaaaa!

(I wish I were making this up.)

I've spent most of the last few weeks at work on the phone, trying to scheduling meetings on Capitol Hill but mostly getting transferred from voicemail to voicemail. An awful lot of Congressional staffers are away from their desks, all the time. I have this vision of them wandering the Halls of Power, like zombies in a a 1950s scifi flick, searching for the Mother Ship.

Big news today: the leaked HHS proposal that seeks to redefine "abortion" to include contraception. (Ummm... Griswold v. Connecticut, anyone?) The so-called "conscience" clauses grant financial (and possibly legal) immunity to those who deny services based on religious beliefs. What I can't seem to find is the HHS definition of contraception. Is this just Plan B, which prevents implantation of a fertilized embryo? Or shall we include barrier contraception, which prevents fertilization? What about hormonal contraception, which prevents ovulation itself? (Apologies if I got any of this wrong. I went to a school district that had abstinence-only sex ed, and despite passing both Human Development and Endocrinology/Reproduction in med school, never had a lecture about pregnancy.) If women and men don't have access to basic contraception, and education about its use, abortion rates ("real" abortion, that is) will just climb.

What I find especially interesting (disturbing?) is that the proposal cites a NEJM study that found that 86% of physicians feel they should present all available options to a patient (and 71% would refer the patient to another physician in the case of religious/moral conflict), yet promptly rejects that overwhelming professional opinion in favor of a 2001 Zogby poll that found that 49% of respondents believed "abortion destroys a human life and is manslaughter." Dunno how the Zogby people feel about contraception, but given that 40% of American women use hormonal birth control, I think I can guess.

As a future physician, I'm aware that my personal beliefs may, at times, conflict with those of my hypothetical patients. But, like 86% of physicians, I think that patient need is superior to provider religion. Hey, HHS? What's your definition of paternalism?

The objections of the President of the United States to the contrary notwithstanding

Raise your hand if you thought "Congressional action" was an oxymoron.

Yeah, me too. The system was, of course, designed to move as sloooooowly as possible. Between committee referrals and hearings and filibusters, it's a procrastinator's dream come true up there on Capitol Hill.

Which makes today's events all the more surprising. After just 4 of his allotted 10 days of consideration, Bush vetoed the Medicare bill this morning. After lunch, the AARP held a rally on the West Lawn of the Capitol. Two hours later, the House voted to override the veto; the Senate vote took place about two hours after that. This is the equivalent of hyperspeed for Congress! Good for them! (Even more surprising: more people voted to override the veto than voted in favor of the bill in the first place. Buh?)

My other task today was attending a Global Health and Poverty luncheon. Irony is eating ham and havarti on rye and drinking raspberry white tea while copying down statistics on how many sub-Saharan African children suffer from malnutrition.

High drama on the Senate floor!

While I was in New York, stressing over where I'm going to live next year, the Senate was tackling a sliiiiightly more important issue: the Medicare vote.

Act I: The Exposition, or Let's Screw Doctors
For those of you who didn't hear, Medicare was set to have a 10.6% reimbursement cut, effective July 1. CMS, which handles claims, said they'd put a hold on processing claims for two weeks until Congress decided whether to delay the cuts, as they have done every year since Time Immemorial. (I learned today that CMS doesn't process claims for 14 days anyway, so the hold was more semantic than real.)

Act II: The Rising Action, or Let's Put on a Band-Aid (TM)
The House rushed through a bill on June 24 to delay the cuts. (355-59; definitely veto-proof; See how your guy/gal voted.) Following the procedures outlined in Schoolhouse Rock (and, you know, the Constitution), the bill went to the Senate. Given the time crunch, Sen. Reid of Nevada moved to invoke cloture, which meant that the Senate would skip committee, debate, amendment, and the inevitable compromise-with-the-House quagmire and pass or reject the bill in its House form. That motion fell 2 votes short of passage. Not voting were Sens. Kennedy of Massachussetts (understandably) and McCain of Arizona (not so understandably). Here's the roll call.

Intermission
Then Congress went on a ten-day picnic and the American Medical Association went beserk.

Act III: The Climax, or Let's Applaud for Two Minutes
On Wednesday, more than a week after the cuts were scheduled to go into effect, the Senate reconsidered cloture. In possibly the most dramatic moment in Senate history since Preston Brooks caned Charles Sumner, Sen. Kennedy arrived, specifically to vote in favor of cloture. He flew back to MA for more chemo directly afterwards. But thanks to his appearance, the hard work of the AMA and AARP, and plenty of grassroots pushing, the motion passed, 69-30. Again, a veto-proof majority. Again, Sen. McCain did not vote.

Act IV: ?, or What You Will
Bush has repeatedly threatened to veto the bill. Schoolhouse Rock (I mean, the Constitution!) says the president can sit on the bill for 10 business days before deciding what to do. Probably he will veto it after all, so the veto-proof majority in both houses is an important fact. So important that I spent most of the day today writing to my senators to thank them for their votes in favor of cloture and urging them to continue to support access to care. You should too! There's a cool new online system accessible at [lastname].senate.gov, so you don't even have to spend on stamps! And you get automated replies:

Senator Warner is snuggly
Thank you for your email. It is my goal to reply in a timely fashion to every email that I directly receive from a fellow Virginian. I appreciate your views and look forward to responding to you.

Senator Webb is not
Your comments have been submitted.

In any case, it's all very restorative in the Power of Democracy: Congress CAN do things, grassroots letter-writing and phone calls DO make a difference, legislation DOES affect you, me, and that old guy who sits outside the Metro station and plays the pan pipes.

I think I'll go home now and watch Mr. Smith Goes to Washington. Sappy enough for you?

Today for work, I went to scope out the "Green Our Vaccines" autism awareness rally on the steps of the Capitol. A little background: In spite of repeated scientific evidence disproving the purported link between autism and vaccinations, many parents still blame the vaccines for the devastating condition their family has to live with. Thimerosal, a mercury-containing preservative in MMR and other vaccines, has been targeted in the past. Thimerosal was removed as of 2001; autism incidence rates continued to rise. (Now it appears that aluminum is the fashionable suspect, but that's another story entirely.) As I am interning at the American Academy of Pediatrics, they asked me to go over and see just what was going on.

I expected a lot of rhetoric and a lot of emotion at this rally; that was kind of the point, after all. The speeches took a two-pronged approach: "We are not anti-vaccines, we just want to spread them out more" and "There is a big government cover-up."

The cover-up allegation was really not so surprising -- as the saying goes, you can't spit in DC without hitting either a lobbyist or a conspiracy theorist -- but what really struck me was that they had expanded their conspiracy net to include Big Pharma, the media, and physicians.

Here's the clincher: Robert Kennedy, Jr. stepped up the microphone and rehashed a Salon.com article of his, in which he completely misrepresents a CDC conference in 2000. Skeptico does a solid analysis of the article. In his speech today, RFK Jr went over the same old points: that everyone is sleeping with everyone else and the pillow talk is all about how best to screw over the American public. He then "quoted" from the transcript of the CDC conference with one of the participants, whose name I didn't catch, saying "There is no way to massage the data to eliminate the link [between vaccination and autism]."

Whoa! I thought. That's some damn serious accusation, Senator. That's fraud. So when I got back to the office, I did what any self-respecting scientist would do: went back to the source. In this case, the transcript of the Simpsonwood conference. It's massively long, so after the first ten or so pages, I took advantage of the Handy-Dandy Finder in Adobe Reader and looked for "massage."

No hits. So how's that for fraud?

Surgeon's Blog has an excellent post on all that health economics/politics stuff that keeps coming up in connection with the election.

I would contribute actual content, but I'm tired, and sick, and studying for exams (just genetics to go!). My headaches have been getting more regular and more severe, which is really no fun. I consulted the wise and wonderful WebMD yesterday, which told me that I might have a subarachnoid hemorrhage. I love the internet.

First, my big news: I got the summer internship I applied for at the American Academy of Pediatrics! It's mainly child health advocacy stuff, things like insurance and immunization, and apparently involves going to Congressional hearings. Woot! It's such a relief to have my summer taken care of, so I can start planning a short vacation. (Last summer? *sigh*)

Three exams next week, but no anatomy. So I'm sitting here twiddling my thumbs, wondering what more I can do. I've gone over my notes, taken ten exams from previous years (overkill? but they reuse questions like mad); I've even made flashcards for things that they specifically told us won't be on the exam.

Anatomy is just such a time drain for me -- it's not intuitive at all, and the exams test ridiculous (and often incorrect) detail from a book whose last edition was printed when I was in elementary school. Even after five months, I still find cadaveric dissection emotionally challenging. (Unfortunately, I appear to be a sap. Damn.) So usually, anatomy dominates my study time to the point where I fall behind in everything else. I know that's what's going to happen in March, when we have our last anatomy exam.

Interestingly, the last time we had an exam block that did not include anatomy, I felt the same way -- like I had adequate time to prepare for the other classes. The difficulty of classes, at least at this school, is all over the map. On one hand, you have Anatomy of Doom; on the other, human development, which is the biggest joke in the world. (If you show up to take the exam, you pass. I know someone last block who bubbled in C for every answer. And passed.) Most of our other courses fall somewhere in the middle.

Is this what life after anatomy will be like? Free time?

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Thoughts on economic theory

Thanks to recent lectures, I've been thinking a lot recently about the role that economics plays in our health care system hodge-podge. I've found that economists tend to have an extremely narrow worldview. For them, it's all about the money. To some degree, this is pervasive in our country. Measures of success or failure are, almost entirely, monetary.

I disagree. Sure, money is important, but it is by no means the most important factor in health care, even in a country where costs are spiraling out of control. Money's useful as a means to an end, but as Kaufman and Hart so hilariously reminded us in the 1930s, you can't take it with you. Monetary measures of success make even less sense in a health care context, where so many people are driven by intellectual curiosity and a desire to be useful. As newbies on SDN are regularly advised, medicine provides some job security, but if you're in it for the money, get out now.

Here's the thing. Beyond a certain personally-determined point (say, 30k, 50k, 80k -- whatever), income doesn't really matter any more. Obviously, everyone's balance point is different and depends on things like educational background, career choice, personal goals, family situation, etc. My own limit, based on my educational debt and the fact that I'm not going to have a real job until about 10 years after many of my peers, is somewhere in the region of 50k; much less than that and I might consider leaving medicine (and doing what else? writing?) Once your basic needs are met, the rest is just fluff.

I took a fantastic literary theory class in college, which made me by turns a structuralist, a psychoanalyst, a deconstructionist, and a Marxist. (I remember when I told my parents that one.) Literary Marxism, which is quite different from its economic cousin, is the view that money and class are the most important motivators. I suppose that I am therefore now an anti-Marxist. (Theory-wise, I'd peg myself for a deconstructionist at the moment. The reader brings more to the text than many other theories allow for. But that's a story for another blog.)

To recap: economics isn't everything. In fact, it may well have been an over-reliance on economic theories that got our health care system in the current mess. As Lange's excellent Understanding Health Policy states, health care is not a good in the same way that DVD players are a good -- it's too unpredictable, for one. Economics has been the driving ideology of health care at least since the turn of the last century, when charitable almshouses began consolidating into hospitals. Perhaps the debate on universal health care should turn to a different model, one that addresses both the motivations of physicians and the needs of patients.

Stare into the (economic) abyss

Last Friday, I went to a lunch talk, run by my advisor, who always invites guest speakers to her biweekly shindigs. I attend religiously, partly for the free food (starving med student here) and partly for the opportunity to learn a little more about this crazy crazy world I belong to now.

Friday's speaker was a health administrator from a major hospital system out in the 'burbs. She was very well-prepared -- even had a massive long powerpoint handout -- and spoke quite articulately about what drew her into health administration.

I have to say, though, the content of her talk frightened me. Her job is essentially to track the physicians employed by [Major Hospital System Out In The 'Burbs] and call out the ones that are too expensive. I paraphrase: "Dr. Jones, as you can see in the spreadsheet on page 6, represents a net loss to hospital of $6,000 a month. This is because he treats Medicare patients like private payers."

Now, having spent hours on the phone with Medicaid my clerkship, I'm well aware that Medicaid is terrible insurance that pays for hardly anything. (I wasn't aware, till that talk, that Medicaid pays the hospital a lump-sum per patient/diagnosis rather than a per diem.) But the idea that one should treat Medicaid patients differently -- that is, employ a different, presumably lower, standard of care -- is morally repulsive to me. If the quality differential between antibiotic A and B does not make up for the fact that B is twice as expensive, then we should be prescribing A to both the illegal immigrant in 285-2 and Bill Gates over in the fancy-pants wing.

One other way that the administrator suggested lowering costs was by setting up follow-up appointments for whatever "other" (i.e. non-emergent) tests need to be run. Fair enough, but as one of my classmates pointed out, "What if the patient has a history of not showing up?" There's really no good answer to that, at least from the save-a-dime perspective.*

The rationale for all this cost-cutting is that the hospital can invest in better technology, etc. Great. I just don't see why the poor patients have to get shafted while the private ones sit in rooms fancier than most hotels. (I saw that on the tour at one of the schools I interviewed at. Kind of a shock, to see full-length mahogany mirrors and a window-seat/pullout bed for guests, and a wardrobe in a hospital room.)

This reminds me of a modern definition of chivalry I heard at some point. Treat all men as gentlemen, and all women as ladies.

Unfortunately, I'm not idealistic enough to believe (though I hope) that the system of health care in this country is going to change overnight, or even by the time I graduate. I don't even know if universal health care is a panacea -- probably not. Either way, it's going to be a long slough through politics and government (which are not the same thing, as Yes Minister taught me). But it's something that I fervently believe that everyone in medicine does need to think about, and hopefully do something about.

*I'd just like to point out that I'm probably one of the most frugal people I know. I detest waste of any sort (monetary, mental, or recyclables). I once went into Filene's and was shocked at the shoe prices; that's how frugal I am. But I also happen to think that the dude at the bagel cart deserves the same quality of care as the dude at the White House. Yeah, yeah, filthy pinko commie.

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