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?

We have summer reading! Again! As BH, who is in math grad school (taking classes like "topological algebra" and "partial semi-differential hand-waving") said when I told her: "Buh?"

Last year's summer reading was on The Spirit Catches You and You Fall Down, a rather sad story of cultural clashes. It frustrated me no end, which I suppose was the point. We were supposed to discuss in small group but never actually got around to it, so my understanding of cultural competence, $60k later, is not really much better than what it was around this time last year. (I do, however, have a much better understanding of rotation of the gut, for what it's worth. Everyone has situs inversus.)

This year's summer reading is Mountain Beyond Mountains, Tracy Kidder's biography of Paul Farmer. I'm holding off judgment until I actually receive it (could be a while, given the Fourth of July shipping delays), but it should be an interesting read, if nothing else. I'd like to do international work eventually, and Dr. Farmer's kind of a Big Deal in the global health arena. It is gratifying to see that idealism can actually work.

Slow day at work?

I've settled into a bit of a summer routine by now. Up at 6:30, out of the house by 7:15. I carpool with my parents, who drop me off outside their office and I walk across to my own. I usually get there well before the office opens, so I duck into a Borders across the street and read till 9. (Currently working on Kate Atkinson's Behind the Scenes at the Museum; highly recommended to anyone who liked Middlesex.)

I go to a lot of Congressional hearings. They are becoming a commonplace now, but when I stop and think about them, it's really a remarkable experience. I always seem to arrive just after a tour group of obese Midwesterners; that's summer in DC for you. After I shuffle out of the oppressive humidity (the city retains the atmosphere of its swampy origins) through metal detectors, I head up a marble circular staircase to whatever committee room the hearing will be in. There's usually a long line for the public; often I have to stand in the back or along the sides. The committee sits at a large dais, Democrats and Republicans on either side of the chairman's throne. Witnesses sit facing the committee at a long table, with microphones and water glasses. After opening statements by committee members and testimony by witnesses, the fun part -- the questioning -- begins. I've seen committee members rip into witnesses, and you can really tell when someone loses their cool or has been "rehearsed." The whole thing takes an hour or six. Then I go back to the office and write up a summary for whoever is in charge of that issue.

What has struck me most about these hearings is the almost total lack of clinical representation. Since these are mostly Health subcommittee hearings, the witness panel usually includes a physician, but generally a researcher rather than a clinician. Lots of MPHs, lots of PhDs. It's a little surprising, given that members of Congress appear to respond better to "clinical vignettes" about anonymized children than statistics about disease prevalence. So why not bring in the people who actually care for these kids? Demands of the profession? Less experience with law? 'Tis unfortunate, because it means that Congress is dictating from on high with very little input from the people who would actually be affected by this legislation.

Grassroots stuff -- letter-writing and phone calls and petitioning -- can work, but there's nothing as effective as sitting in front of ten or fifteen Senators arguing your case.

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?

What just happened?

I am DONE with first year! It really doesn't feel like summer yet -- for one thing, it's freezing -- but it's Very Nice Indeed to take a break from studying. I went out to dinner with med school friends on Monday (the day of our last exam), and last night I finished off the leftovers in my defrosting minifridge while watching Bleak House on DVD -- guilt-free! It's awesome.

One really good thing about being done -- I get to spend more time with my friends who aren't in med school.

You know those anxiety dreams where you go to take an exam and as soon as you get the paper you blank out? That was me and the neuroanatomy exam yesterday. I was exhausted from a marathon study session the day before, and apparently I actually fell asleep during the exam. The parts where I was awake weren't much better.

Oh well! The other exams were alright, and I really am not stressed about anything. (Sleep-deprived, yes, but not stressed.) I took yesterday night off to recuperate and eat applesauce and watch a melodramatic costume drama on DVD. Good times. There's one more to go, and then I am done.

It's really shocking to think that the year is almost over. In a lot of ways, I feel like we just got here. I'm moving back home on Thursday; starting work the day after Memorial Day. Perhaps I should have looked into something international -- I'm very interested in global health as a possible career, and I'm exceedingly jealous of my friends who are going abroad (postcards, please!) -- but I think the job will be interesting, and I'm not going to deny that it'll be nice to be home and taken care of for a few months. (I'm grown up, really!)

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Now playing: Virginia Hullabahoos - Your Song
via FoxyTunes

Not that I loved trees less, but that I loved passing more

Yesterday I printed:

-a 22 page review guide for epidemiology
-a 14 page review guide for psych
-a 124 page review guide for neuro
-a 54 page review guide for endocrine

Also miscellaneous practice exams, one-off review sheets, etc. The goal for today is to quit slacking and get through at least the epi and psych.

Poor rainforest.

Anatomy

The anatomy memorial service was this afternoon. As far I could tell, there were no families there -- I don't know if that's a common occurrence or just because the date got switched around a lot this year. Several of my classmates read poems or short essays. One theme that came up over and over in the student readings was the difficulty of knowing the body so intimately and the person not at all. I understand the need for privacy, and knowing too much, especially at the beginning of the course, would have made it even harder to do what we had to do. Over the course of the year, as we got to know each other, we got to know her as well: she had severe scoliosis, blue eyes, pierced ears. Something of her past medical/surgical history as well: a hole in her skull for trepanning, a stent in her inferior vena cava, no gallbladder. But knowing the little things would have provided a little closure. What was her occupation? Did she have children? Grandchildren? How old was she? What language(s) did she speak? Did she live alone? What did she like to do in the evenings? I don't mean to sound sentimental, but the relationship with the cadaver is such a unique one -- intimate strangerhood -- that I can't help but compare her to my grandfather, who was a donor as well. Presumably, she had a family as well.

Looking back, I don't really know how I got through anatomy. I detested lab; dissection never came naturally to me, and the phenol made me tired and cranky. I still can't recall the goalpost labs without wanting to throw something at a wall. There were good moments, though. My group was perfectly amazing, and those friendships are the best thing to come out of lab -- better even than my actual knowledge of anatomy, which is tenuous at best.

Amazing! Things are happening here

Ever since I read Panda Bear's post about the futility of student governance in med school, I've been dying to write a rebuttal. I graduated from a university where student self-governance was practically a founding principle, like liberty in the Declaration of Independence. I had plenty of examples of students effecting change in undergrad, but med school's a very different system, so I decided to hold off until I had a more concrete success than "They modify lectures based on student feedback after each block."

You see, since about January, there have been rumblings of eliminating Honors from the second-year grading scheme. (We are pass/fail for first year, H/P/F for second, and actual grades for third and fourth.) We all felt honors was a carrot of competition they held in front of us, creating extra short-term stress with little long-term yield -- "everyone knows" residency directors don't really care about grades in the pre-clinical years. Anecdotally, there's also a lot of faculty support for the change. There is a big curriculum reorganization in the offing, and the Big People already decided to make the preclinical months honors-free. So why not for us?

A couple of weeks ago, we had a curriculum survey of the entire first year. On the question of honors, almost 80% of the class voted to remove it and go to a straight P/F system. In light of that result, we had an open meeting with the dean of students and the curriculum committee chair. It was remarkably well-attended, much better than lectures for sure. I got the impression that Dr. D, the chair of the curriculum committee and kind of an old-school guy, was very pro-honors and that he would be the one we'd have to win over if we wanted this change to occur.

After the meeting and question/answer session, we took another survey, which revealed that 86% of the class wanted to remove honors from the system. The results were presented at the curriculum committee meeting this morning, after which we received an email informing us that second-year, like first, would now be pass/fail.

So you see, the administration, at least at this august institution, can and does listen to student input.

Now, if we can just convince them to waive our tuition....

MSE

I've been back for a week now. Without anatomy (I passed!), I have copious amounts of free time, which I fill by watching videos on youtube and strolling around the city. It's wonderful.

We started psych med on Tuesday and have thus far learned about the Mental Status Exam. The examples given in the book are very novelistic ("She seductively sweeps her bangs away from her face....") and so I present for your amusement a quick game of Guess the Patient.

Patient X is a student (age debatable), about 5'10 and 160 pounds. His facial appearance is marked by distinct pallor, which contrasts sharply with the inky black of his open doublet and dirty socks that fall around his ankles. He enters the room in a distracted fashion, looking around him as though afraid of being followed. The knocking of his knees also suggests fear. As the interviewer rose to greet him, Patient X drews his right hand slowly to his forehead, then extended it in a flowing motion to meet the interviewer's outstretched hand. He then sank into a chair, where he remained for the duration of the interview.

The patient answers all the interviewer's questions readily. His speech pattern alternates between slow, monotonous responses and garrulous outbursts. When asked about his mood, he says that he is "very like a whale." On being asked to explain, he winked at the interviewer but did not elaborate.

He has a full range of affect, although occasionally a question about his family causes a shadow to pass over his face and shuts down his emotional response. This is brief, however. Thought process is circumstantial and tangential; long digression of the death of an older man who played with him as a child and appears to have been a surrogate father figure. Some loosening of associations. Thought content is obsessive, centering on the recent death of his father and his mother's subsequent remarriage. Grandiose delusions of his "destiny" as the savior of his family and friends. His girlfriend recently broke up with him, an event he attributes to the influence of her father, a friend of his stepfather.

Some evidence of visual and auditory hallucinations, primarily of his father. These hallucinations command him to avenge his father's death. Admits to passive suicidal ideations (longing for the "sleep of death") but has not made a plan due to fear of the afterlife he believes to exist. He also shows evidence of homicidal ideation against his mother, stepfather, and girlfriend's father.

Cognition: fair. Alert and oriented to self; described interviewer as "fishmonger." Recalls 3/3 objects in two minutes. Digit span 7 forward, 5 reverse. Does not know own age or age of father at death. Frequently confused two childhood friends. Fund of knowledge good on current events, somewhat shaky on chronology and dates of the past. Above average intelligence, reflected in sophisticated vocabulary. Occasionally invents words.

Poor insight. Patient is aware that his friends and family are "concerned" about his recent behavior. He insists that he is "but mad north by northwest."

Judgment: Patient does not appear to understand the need for treatment. Recommend hospitalization for suicidal and homicidal ideations.