You Get the President You Deserve.
I’m going to say this quick because I don’t have a lot of time.
Is Barack Obama really motivated by a bone-deep statist agenda? Is he most motivated by his own political survival? By a psychological need to reconcile conflicting viewpoints? By idealism? Or some combination of all of the above?
We don’t really know. What we do know is that he’s the democratically elected President of the United States and we’ve got a minimum of three and a third more years of him. (I hope that those of us who are still sane can all agree that a violent end to his presidency would be a catastrophe for this country we profess to love.) Rather than fantasizing about paralyzing him, or on the other hand, denying that he needs any improvement, how do we the people minimize the harm and maximize the benefit that we can get from these years?
It’s a truism of operant conditioning — a science of animal training that was applied to people in dolphin trainer Karen Pryor’s book Don’t Shoot the Dog, about which I once wrote a magazine article — that you get the best results by negatively reinforcing behavior you don’t want and positively reinforcing behavior you do. (Another good tactic in some situations is “extinction” — getting rid of behavior by ignoring it, because some behavior is designed to get attention and is fed by even negative attention. This might be the tactic of choice to apply to crazies at both extremes.)
Let’s be cynical and assume that Barack Obama’s deepest motive is his own political survival (although I don’t think that’s his only motive). If that’s the case, he is teachable. Never mind whether his coming to his senses about the Nancy Pelosi and Hugo Chavez agendas is motivated by a moment of illumination, a profound change of heart — we’re guessing his ideology is not much deeper than a chameleon’s skin anyway — or by a desire to stay in office (and we’ll cross that bridge in 2012). Motivations don’t matter nearly as much as actions — doing the right thing for the wrong reasons is better than doing the wrong thing, and in fact motivations often fall in line with actions, because we don’t like cognitive dissonance.
My point is that we can get something closer to the president we want for the next 3.33 years, and the way to do it is, yes, by loudly shaming the behavior we don’t like (Van Jones is gone!), and also rewarding with praise the behavior we do — such as exhorting fathers to be fathers and kids to stay in school. That may be part of what clever Newt, possibly because he knows a lot about animals, is up to, as he tweets about the text of the education speech:
newtgingrich Just read President Obamas speech to students.white House posted it. it is a good speech and will be good for students to hear
newtgingrich Remember that Presidents Reagan and Bush also talked to students nationwide. As long as it is non political and pro education it is good
By contrast, there are many on the right for whom this president can do nothing right from the get-go. And distortion is the stock in trade of partisans of both sides, for whom their side defeating the other side is more important than the health of the country. Cap’n Ed Morrissey at Hot Air does a word count on the text of the school speech and tries to paint it as an exercise in narcissistic self-promotion:
Update II: I’ve run the speech through a word frequency counter and found the following results:
- 56 iterations of “I”
- 19 iterations of “school”
- 10 iterations of “education”
- 8 iterations of “responsibility”
- 7 iterations of “country”
- 5 iterations each of “parents”, “teachers”
- 3 iterations of “nation”
In other words, Barack Obama referenced himself more than school, education, responsibility, country/nation, parents, and teachers combined. And to think that people accused Obama of self-promotion!
One assumes that many people will not read the speech but will take Rush’s word for it when he inevitably picks up this meme. However, many of the “I”s in the speech occur in such innocuous contexts as “I know that for many of you, today is the first day of school,” or “I’m here with students at Wakefield High School in Arlington, Virginia.” In a 44-short-paragraph speech, there are 5 short paragraphs about Obama’s own story, focusing mostly on his single mother and absent father and how such circumstances don’t have to stop you. Finally, there’s a little word that Cap’n Ed disingenuously “forgot” to include on his list: “you,” and its variants “your” and “yourself.” You find a word-count engine and apply it; I did a rough hand count. It’s over 160.
So do you want the demon socialist president of your political fever dreams — because he’ll be easier to defeat in 2012 — or do you want a president we can live with till then?
Preferring Seasons to Reasons
I’m filled with remorse now for uttering on Twitter the blasphemy that I was bored with the seasons — always the same ones, in predictable order, year after year after year. “Couldn’t the planet tilt another way for a change?” I tweeted. In the movie, presto! Midas gets his wish, we all go flying into space, or icecaps clang down on Ecuador, or the weather just goes bonkers — hell, we already have cause to be nostalgic for predictability (insofar as the weather ever was predictable; nostalgia lies).
Maybe I was really just lamenting how fast the seasons revolve by now (like the sun and moon in the classic George Pal/Rod Taylor movie of H.G. Wells’s The Time Machine, which we watched on TCM last night), or protesting my own sensory remove from them, indoors most of the time and bent over J or the computer. Because no sooner had I said that stupid thing than I got all excited because for the first time all summer, cold water came out of the cold water tap. Then I had the first really crisp apple in six months. I fell for our planet’s temperate trick all over again.
When I was in high school we did a “voice-speaking choir” performance of Stephen Vincent Benet’s John Brown’s Body. Someone had cut that wonderful book-length poem (you can get a good old copy for pennies) about the Civil War down to a spoken and sung chamber piece (there used to be a recording of it). I still remember a lot of it, including this:
Autumn is filling his harvest bins with red and yellow grain,
The fire begins and the frost begins
and the floors are cold again.
The floors are cold again.
When you’re a child, the seasons are a huge sensory drama, so much bigger than you — like the acts of a really grand opera. The revolving transformation of the scenery alone makes you gasp with awe. And it’s total immersion, not just visual: the smoke smell and fire color of leaves, the sugary burn of snow. Seasons make synaesthetes out of everyone; each one is an inextricable complex of color, texture, sound, and smell — you can taste cold, smell color, be smothered in humidity’s sweaty-breasted embrace. And each season is topped by a holiday, the cherry on the sundae, that concentrates it to its conscious essence: if fall is an apple, Hallowe’en is apple brandy. I adored holidays for the way each one summed its season up and made it consumable, a communion.
Habit, responsibility, introspection, and “development” — the razing of woods and selling of fields to build malls and suburbs — are all great estrangers from the senses. All four may have something to do with the way time has speeded up as we’ve gotten older. (I can’t even imagine what it’s like to be a kid now — what marks the seasons? Corporate fruitings like the release of the new American Girl or Wii? You don’t even wait for the floors to be cold again to go back to school. You go back in brusque violation of the laziest, sleepiest, most mindless days of summer. That’s symptomatic of some way the human world has spurned nature.)
The senses are roots: they tether you to the earth and keep you turning in time with it, inexorable but unhurried. La vida es corta, pero ancha. Life is short, but it’s wide.
Gang Sign of the Times
I mentioned that I worked out with Icepick the salutation for the times: “Glad to hear things could be worse!”
Ron then said, “We need a gang sign, too.”
So now we have one. Icepick:
I see Ron wants a gang sign to go with the salutation. I suggest an outstretched middle finger pointed at ones own temple, shorthand for “Still fucked.”
Does the VA Nudge Seniors Toward Death?
I didn’t buy the “death panels” rhetoric, but based on this, I’m reconsidering.
Note that neither Hot Air nor the WSJ actually links to the VA booklet. When you do, the first thing you get is this disclaimer:
Your Life, Your Choices was officially retired from use in VA in 2007, and an expert panel was convened to review and comment on an online module version of this document that was under development at that time.
Ha! So there are “panels.” Expert panels. Doesn’t that make you feel better?? God, I’m so sick of the fucking “experts.” What does that word cover anyway? Psychologists? Economists? Are there any combat-disabled veterans on the panels? The only “experts” on this subject are the patients and families who’ve been there, and the good doctors and nurses who’ve been in the trenches with them.
The Your Life, Your Choices online module is currently being revised based on suggestions from the expert panel members and from chaplains representing eight different faith groups. The revised online module is scheduled to be released on the My HealtheVet Web site in the spring of 2010.
Please note that portions of this document have been interpreted by some to be negative in tone and insufficiently balanced. The revision process is addressing these concerns. Also note that some of the links contained in the document are no longer active.
Hey, wait, I found the Expert of Experts! His name is Robert A. Pearlman, he’s the author of the VA booklet, and in this photo at least he bears an uncanny resemblance to Tim Geithner. (Purely rational Vulcans all?) He studied ethics at Harvard. How much more expert does it get?
He received post-residency training as a Robert Wood Johnson Clinical Scholar, a Fellow in the Ethics and the Professions Program at Harvard University, and a Faculty Scholar in the Project on Death in America. He joined the [National] Center [for Ethics in Health Care, apparently part of the VA] in the summer of 2000. His interests and expertise pertain to empirical research in clinical ethics (especially end-of-life care) and organizational ethics. His research has explored euthanasia, the role of quality of life in decision-making, the validity of life-sustaining treatment preferences, medical futility, advance care planning, physician-assisted suicide, and relief of patient suffering. He is the author of two books and over 100 publications in medical journals and book chapters. His most recent book, entitled Your Life, Your Choices, is an interactive workbook to help patients and family members with advance care planning. Your Life, Your Choices will be available to veterans through MyHealtheVet in 2007.
Forget Ezekiel Emmanuel: is this the government’s Dr. Death?
But now I’m really confused. The preface to the online booklet now says “Your Life, Your Choices was officially retired from use in VA in 2007.” Made available and retired in the same year?? Or am I misunderstanding?
Here’s Jim Towey, creator of what he calls “the most widely used living will in America,” “Five Wishes” (not unlike Your Life, Your Choices, “introduced in 1997 and originally distributed with support from a grant by The Robert Wood Johnson Foundation”), being vague about exactly when the workbook was instated (I’m trying to figure out whether the dates need to be jiggered to make Democratic administrations solely to blame for the thing and Republican administrations the blameless heroes who questioned it):
Last year, bureaucrats at the VA’s National Center for Ethics in Health Care advocated a 52-page end-of-life planning document, “Your Life, Your Choices.” It was first published in 1997 and later promoted as the VA’s preferred living will [VA “Fact Sheet” rejoinders that it is “not an advance directive or a living will.”] throughout its vast network of hospitals and nursing homes. After the Bush White House took a look at how this document was treating complex health and moral issues, the VA suspended its use. [VA “Statement” says “The document was developed under a federally funded research grant over a decade ago and in 2007, the Veterans Health Administration convened an outside panel of experts to review the tool and assess its merits. Overwhelmingly, the panel of experts, which included a diverse group from the faith based and medical communities, praised ‘Your Life, Your Choices’ and endorsed its use.”] Unfortunately, under President Obama, the VA has now resuscitated “Your Life, Your Choices.”
Who is the primary author of this workbook? Dr. Robert Pearlman, chief of ethics evaluation for the center, a man who in 1996 advocated for physician-assisted suicide in Vacco v. Quill before the U.S. Supreme Court and is known for his support of health-care rationing.
Here’s a perfectly decent handout on advance directives which, however, refers people to Your Life, Your Choices at the end.
So the booklet was “developed” with federal money during the Clinton years; it’s unclear when the VA began using it; and it’s unclear what happened to it in 2007 and whether its use has now been reinstated without input from “faith panels.” (The booklet encourages its users to consult religious advisers.)
Looking at the booklet, it certainly hits you right between the eyes with some gruesome though not unrealistic scenarios, and there is certainly a none-too-subtle bias in the discussions against taking heroic measures — or even antibiotics — to prolong a life clearly near its natural end:
Chris Larsen [age unspecified] never told his family what kind of medical measures he’d want if he became critically ill. He is in a nursing home after having suffered a severe stroke 9 months ago. He is paralyzed and unable to take care of himself or communicate in any way. Now he has pneumonia and will probably die unless he goes to the hospital to receive intravenous antibiotics. He also may need to be on a breathing machine for a week or so. The doctor says that his chances of returning to normal are remote, but that he has a fair chance of getting over the pneumonia. His family members disagree about what they should do. His son Bill says, “Dad was never a quitter. He’d want to fight to the very end, as long as there was the slightest hope.” His daughter Trudy disagrees. “Sure, Dad wasn’t a quitter, but he wanted to die naturally—he would be horrified to be kept alive this way.”
In fact, Trudy’s views were the closest to Mr. Larsen’s true opinion. But the family never had a way to find this out. They treated his pneumonia and he lived another year in the nursing home without recovering his ability to communicate or care for himself.
This is on page 5. It’s offered as an example of why you need to think and talk about these issues while you can. The trouble with such hypothetical scenarios is that not only do people differ in their values and beliefs, but each case is unique and often unpredictable in its particulars. After we got to Chapel Hill just about exactly three years ago, J declined both mentally and physically, until in December 2006 he ended up being taken to the hospital with pneumonia. He certainly would have died if he hadn’t been treated. His doctors and I agreed that a DNR order (do not resuscitate, i.e. no ventilator or defibrillator) at least was appropriate, and a woman resident asked me if I didn’t think it was time for “placement outside the home.” However, IV antibiotics was all it took to resurrect J — in a matter of hours, he went from virtually comatose to sitting up in bed talking coherently on the phone to my mother — and it turned out that most of his steep mental decline over the autumn had been due to incipient pneumonia, not accelerating dementia. The rest is history. If he were in a late stage of neurological disease, contracted in a fetal position, uncommunicative, and uncomfortable, IV antibiotics would not be appropriate.
(No, he doesn’t have a living will. Probably the best course for him is to ask him to sign a health care power of attorney. Though actually, I just learned from this very booklet that if you trust your spouse, that’s who will be consulted in the absence of a POA. Either way, it will someday be up to me, who knows J best, to decide whether, based on his mental status, responsiveness and awareness, he who loves food so much would want to be kept alive by a feeding tube. J is also the kind who might well look me in the eye someday and say lucidly, “Let me die.” But if something happens to me first?)
Naturally, the VA booklet is being quoted selectively by conservative culture warriors. (The exercise on “What makes your life worth living?” on p. 21, however, doesn’t need selective quoting to be every bit as bad as they say it is.) Towey in the WSJ notes that “There is a section which provocatively asks, ‘Have you ever heard anyone say, “If I’m a vegetable, pull the plug”?'” In full, that section merely notes that people sometimes do actually say things like that without being very clear about what they’re talking about:
Have you ever heard anyone say, “If I’m a vegetable, pull the plug”? What does this mean to you? What’s a vegetable? What’s a plug? Even people who live together can have very different ideas about what the same words mean without knowing it. When you say, “pull the plug” it could mean a variety of things:
•Stop the breathing machine
•Remove the feeding tube
•Don’t give me antibiotics
•Stop everything
The booklet’s central question is, “For you, is there such a thing as unacceptable quality of life? Where would you draw the line?”
It’s not that these are bad questions. It’s, why is the government asking them? (A far more important question than “Did a Democrat or a Republican administration ask them?”) Or, for that matter, why is an insurance company asking them, or a nursing facility which makes money when patients’ lives are prolonged? All of these parties have classic conflicts of interest — as, for that matter, can family members eager to be rid of a burden or to collect an inheritance. Families are not always havens in a heartless world — as Your Life, Your Choices rather ghoulishly acknowledges when it invites you to check “Yes,” “Not Sure,” or “No”:
I believe that my loved ones should take their own interests into consideration, as well as mine, when making health care decisions on my behalf.
I believe that it is acceptable to consider the financial burden of treatment on my loved ones when making health care decisions on my behalf.
The ultimate question is rather like that about sex education: is this a private matter, even if it inevitably means some kids will be kept in barbaric ignorance or misinformed? Do you really want some nanny bureaucracy with a “rational” agenda to impose its one-size-fits-all values on the intimate lives of your kids? Can the transmission of information about such issues ever be value-free?
It’s doctors who should be educated, in the most humane possible way (I mean they should read the humanities, philosophy and literature, as well as psychologists and other “experts”), on these issues, and doctors, together with trusted family members and chosen religious advisers, who should be working out the decisions. Family doctors used to do this, and no doubt plenty still do. Yes, it’s a priestly function. People do look up to their doctors that way in life-and-death situations, so doctors might as well live up to it.
Bake Sale Achieves Goal, And Then Some!
OKAY!! WE CAN STOP!! A couple of very generous contributions have put us well over the line! Bless you, my gang! Long live Ron’s computer! :D
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A vital member of our community is about to fall silent for a really stupid reason. We can help.
Ron, of Fluffy Stuffin’ and frequent commenter consolation and laughter, has been hit simultaneously with a dying hard drive and a drought of business. (FYI, the official unemployment rate in Detroit is 29.7 percent.) I overheard him telling Ruth Anne on Twitter that he would probably soon drop out of sight. The prospect of no Ron scared me, so I chased him down and asked him what was up and what it would take to keep him online. I would not take “never mind” for an answer.
Bottom line, it would take about $300 that he can’t spare now and can’t predict when he’ll be able to. For that, he can replace his ailing system with a reconditioned machine.
That’s a small amount of money to make such a big difference. I’m not being paid just now myself (when I reminded Ron that Icepick and I had worked out the salutation for the times — “Glad to hear things could be worse!” — Ron shot back, “We need a gang sign, too.” See what I mean?), but I can certainly manage $30. If ten of us can do that, we can keep that good stuff coming.
So if things could be worse for you just now, go to the hat down the left sidebar at AmbivaBlog (linking to it from here didn’t work) to pitch in. I’ll put it all together and pass it along.
And if you’re indignant that this isn’t an actual bake sale, just let me know and I’ll make you a batch of Mom’s World War II brownies.
UPDATE: We have $60. A fifth of the way there.
UPDATE II: Up to $120.
Repair America!
If only.
If only we could do nationwide what an unlikely coalition of Californians are determined to do, and actually can, thanks to the oddities of their constitution:
California’s nemesis [the initiative-and-referendum provision that has led to metastasis of its constitution and loss of control of its budget] could soon become its salvation. […]
Jim Wunderman […] wrote [in an SF Chronicle op-ed]. “It is our duty to declare that our California government is not only broken, it has become destructive to our future. Therefore, are we not obligated to nullify our government and institute a new one?” He then called for a “citizens’ constitutional convention” to do the nullifying and the instituting. […]
[The movement that op-ed inspired], called Repair California, is trying to put two initiatives on next year’s ballot. One would amend the California constitution to allow the voters to call a constitutional convention by initiative. (As it is, while specific amendments can be passed that way, it takes two-thirds of the legislature to call a convention. That will never happen.) The other would actually call the convention and specify its scope: governance, including the structure of the legislative and executive branches; elections, including the electoral system and the initiative process itself; the budget-making process; and the state’s revenue relationship with local government.
The genius of Repair California’s approach is twofold. First, it steers clear of “social issues”: no gay marriage, no abortion, no affirmative action.
And here comes the best part:
Second, the delegates would be chosen randomly from the adult population.
It’s the dream of a citizen legislature! It calls the bluff of William F. Buckley’s marvelous statement that he’d rather be governed by the first 100 people in the phone book than by “the best and the brightest”! Don’t you love it?!
Read more to find out what unlikely bedfellows are supporting Repair California, and exactly how this new constitutional convention would work. And here’s the Repair California website. Read it and weep. And cheer.
If only!
“We argue that depression is in fact an adaptation, a state of mind which brings real costs, but also brings real benefits.”
Otherwise, how to explain its universal prevalence? It has been found in just about every culture studied, of all states of social complexity. So it is not a discontent of civilization, nor is it a dysfunction of older age: the first episode tends to strike in adolescence or young adulthood, if not even earlier. And studies show that “between 30 to 50 percent of people have met current psychiatric diagnostic criteria for major depressive disorder sometime in their lives.”
There’s a serotonin receptor in mammalian brains, implicated in depression, that has been highly conserved by evolution: it is 99 percent similar in rats and humans. “The ability to ‘turn on’ depression would seem to be important, then, not an accident.”
So given how impairing and even dangerous depression is, what could it be good for? What could “drive the evolution of such a costly emotion”? Can you guess? Read and find out.
These authors think that rather than a malfunction, “depression seems more like the vertebrate eye—an intricate, highly organized piece of machinery that performs a specific function.”
Makes sense to me.
A Doctor in the Trenches: A Guest Post on the Healthcare Mess [UPDATED]
My sister, a specialized internist at a major university medical center and a professor in its med school, has told me more than once that from her position on the front lines, as a physician seeing clinic patients, she would much prefer a government-run, single-payer healthcare system, or short of that a public option, to the chaotic mix we have now. I’ll post her thoughts, from several e-mails over time, without comment except for the questions that preceded some of her answers.
The conversation began when I wrote my sister about the predicament of an online friend in her city who had been unable to get needed joint-replacement surgery (surely not a waste of money in the case of someone my age, or even in that of our healthy 85-year-old mom who’s walking blissfully all over Chicago on her 3-year-old artificial knee) because she fell into that “too rich for Medicaid – too poor to buy insurance” gap.
So sad. And such a common story. It infuriates me that people have to spend so much energy/time trying to get the bus fixed (I just LOVE that metaphor) when this should be a given. I feel so strongly that health care is a basic human right. It’s hard enough having to deal with your body falling apart but to have to endure the indignities of having to apply for indigent care compounds the awfulness. She’s right…you have to be destitute to get Medicaid here. . . . I’m helpless in the face of the great bureaucracy. Plenty of people figure out ways to get around things—put property in a spouse’s name and then divorce on paper. What bullshit that people have to go through such things!! . . . [My institution] is usually good about setting up payment plans for people with huge bills—reasonable plans that don’t demand 50% of your monthly income.
A: Yeah . . . but would you like working in a govt. bureaucracy??
I work in a fucking bureaucracy now!! from my end it’s SO much easier to deal with Medicaid and Medicare than with private insurance. I’m RELIEVED when I have a patient with Federal or State insurance…actually less bullshit to negotiate in this day and age. I’m not just talking about HIV…I’m on the inpatient gen med service now dealing with everything (heart failure, liver failure, cardiac arrhythmias, pancreatitis, suicidal drug OD, obstructive uropathy from cancer, pneumonia with ARDS, pulmonary edema etc etc). You don’t understand what it’s like on the front line.
correction. you know what it’s like being on the front line as a patient in the system but not as a provider.
A: What is ARDS?
Adult (sometimes acute) respiratory distress syndrome. i hope i didn’t come on too strong…being on the inpatient service is kind of like being in the medical equivalent of combat.
A: How come you are there? Was it an assignment or a choice? Or is it a rotation everybody feels obligated to take, like being department chair?
It’s kind of depressing to me that everyone views the same chaos and comes to the conclusions they were brought up to come to. I bet you know conservative docs who believe the solution is MORE free enterprise, just ’cause that’s “where they’re coming from.” The conservatives say that government medicine offers more universal low-level coverage but expensive, high-level, high-quality procedures and treatments become scarce and harder to obtain if you need them.
I’m just in between . . . don’t know what to think. I too was raised to see government as tending to be “good,” big business as tending to be “bad,” and now I’m exposed to this barrage of the exact opposite. I suspect only people who ARE on the front lines as providers know enough to have this debate.
What a mess it is!! It must also be frustrating to have to clean up after people’s shitty life choices all the time.
we (all the attendings in medicine) have to do it [inpatient service] 1-2 times/yr. It’s actually “fun” in an insane, all encompassing way. But you’re so right SO many of the people we see are fat/smoke/drink too much/use bad drugs/don’t take their meds. pick from the choices. it’s extremely frustrating, especially when they expect us to fix it and get angry if we can’t. And there’s so much passivity and entitlement!!
We don’t need more access to expensive, high level high quality procedures. We need good patient centered primary care, less reliance on testing to rule out everything so we don’t get sued, less financial incentive for doing procedures (yes, including colonoscopy), more studies on the cost effectiveness of procedures on a population scale (are we REALLY saving $ by doing screening colons on everyone. Yes, you occasionally find cancers in young people and save them. but at what cost? or stenting every single stenotic coronary artery?) and some serious discussions about end of life care. we’re keeping [people] with miserable quality of life alive to torture some more! It makes me feel like a cat!
* * *
Today I had to make a decision about a therapy in a patient with a bad disease and the decision point was determined totally by economics instead of what was best for her. (She has very bad pyoderma gangrenosum that I could treat with infliximab (has worked well for her in the past) but this is considered an outpatient med so it wouldn’t be paid for by her insurance (and it’s $$$). So I could either discharge her and give it to her as an outpatient (she’s on a PCA (patient controlled analgesia) pump so I didn’t want to do that) or pick something else. So we’re trying IVIG…also $$$ but I can give it inpatient. What kind of bullshit way is that to have to practice medicine? This is only one of so many daily occurrences. We just incorporate it into our daily decision making like it’s normal.
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[AMA came out against public option] A: Conservative friends on Twitter are ecstatic. One (Catholic, pro-life, mother of preemie twins) says “Go A.M.A! I would have two dead children if it weren’t for private insurance and the top-notch neonatologists in the U.S. circa 2003.” These people are fervently pro-capitalist. They decry making an idol of Obama, yesterday I told them I thought they were making an idol of capitalism. But I haven’t got a clue what to think.]
Totally predictable that the AMA would take this position…the potential is there for incomes to go down. It’s scary how many people we’re seeing who aren’t poor or disabled but don’t have health insurance. They don’t qualify for Medicare, Medicaid or our indigent care. One hospitalization could wipe out everything they own…it’s insane!!
I totally agree with your blog-friend about late in life care. Look what I’ve helped stave off for a patient in his 90s with arterial disease! More testing, more procedures, when he was functioning decently well…I’m thinking of the Podiatrist who was freaked out by his absent pulses and wanted dopplers then Vascular Surgery to do angioplasty when he didn’t have pain or obvious ischemia. The potential complications in him could be devastating. We (Dr’s) don’t think downstream–it’s all about fixing what’s broken (or looking for what might break) because that way we a) avoid lawsuits and b) are financially rewarded. And she’s so right about how there needs to be a shift in expectations on the patients’ side.
One thing I am worried about. There’s so much talk about outcome measurements–a good thing IF the measurements are good/accurate/meaningful. Based on one flawed study about giving antibiotics in a timely fashion to pts in the ED with pneumonia the big Joint Commission that does hospital accreditation now uses administration of abx [antibiotics] w/in 6 hrs of coming to the ED for any infection (or suspected infxn) as a quality measure. As a result some pts get abx before cultures are done (the waiting times in big public hospital ED’s can be incredible) which complicates and often prolongs hospitalization. Shitty quality measurement based on shitty science resulting in increased health care costs. This is only one of many such idiocies.
I quoted to her a comment by Ennui:
On the overall question of healthcare costs, if, as I suspect, the biggest factor input (especially for an aging population) is labor, and domestic labor costs cannot be simply reduced, the only way to reduce healthcare costs in a meaningful way is to reduce the quantity of healthcare delivered. The most effective way to do this, I think, is something like what Bruce B described. Here’s a concrete instance: when I was a TA I had a student who managed to slice the palm side of his fingers with his new knife (which he was proudly showing me – what can I say, it’s Texas). I took him to the emergency room where he was presented with 2 options.
- Option 1: Stitch up the skin and hope that the knicked (but not severed) tendons would heal (he was told that it would probably be fine). Price ~$750
- Option 2: Call in the specialist to stitch up the tendons as well. Price ~$5,000
He had no insurance. But he wasn’t broke. He mulled it over and chose option 1. As it happens, his hand was fine. This, harsh though it may seem, is cost cutting by means of market economics in the health care field. This is what I am for.
Agree that the reduction in quantity of healthcare is a critical component…ways to do this include tort reform (amazing how much testing is driven by lawsuit fears), decreasing payments for procedures (decreases incentive), also some way of regulating/eliminating physician ownership of testing services they get paid for. For example, many Heme-Onc practices have their own CT scanners and they do frequent CT’s…often more often than is recommended based on evidence based studies. It’s not pure evil greed (although that’s in the equation) since the patients love it because it gives them a (often false) sense of security. But if you’re the MD and you own the CT scanner and private insurance will pay you $800 for a scan of course you’re going to do a lot of them! And sometimes you’ll do them when watchful waiting or some blood work could give you similar info. [Her husband, a gastroenterologist]’s group owns their own endoscopy center so they get the facility fee instead of the hospital. They charge less than the hospital but it’s still (according to him) an amount disproportionate to the time/difficulty/expense to the practice. Do they do more endoscopies because they get paid directly? I’m guessing yes.
My admissions today so far…1) a homeless woman with horrible lice and a huge abscess on her butt. also 2 boyfriends who don’t know about each other converging on the hospital 2) a nice lady with an axillary abscess and a UTI with a kidney stone 3) a 24 y.o. Haitian woman who only speaks French with severe abdominal pain that started suddenly while she was on an airplane. The plane was diverted here. Her CT scan showed an abnormal spleen. When we finally found a French speaking med student we discovered she has sickle cell dz (she got splenic infarcts from the low O2 sats on the plane. leading to sickling). The sad thing was she was traveling with her 9 m.o. old baby. CPS had to take the baby (she can’t keep him in the hospital) and her sister is racing here from Connecticut to try to intercept. If she gets here before 5 they’ll give her the baby, if not then the baby goes into foster care for the weekend and she’ll have to go to court to get him back (WTF?????). 5 more (admissions) to go. just thought you might to know what my days are like. I honestly love it a lot of the time.
[On a cartoon I sent her about doctors’ callouw black humor] A: I’m not sure it’s something to deplore — it’s probably necessary for survival — but it can probably go too far, too.
it is kind of sad and inevitable at the same time. i see it happening and probably feed into it some myself…but you can’t help but generalize from your experiences. so when I feel/act all jaded about the 5th heroin/crack/meth/alcohol addict that’s being admitted to my team and the medical students see it i try to remember to tell them a story about the time i made assumptions about somebody and was wrong. it’s actually good for us to have students around because they make you behave. you have to at least fake being a role model.
in response to a 2008 Pajamas Media article I sent her, by the unpseudonymous Anchoress, “Socialized Medicine Looks Inevitable“:
not bad. maybe Obama’s such a great chess player that he saw all these moves in advance–the private sector will have to scramble to make huge changes to try to head this off and the need for a govt plan will be moot. I guess because I’m a visceral liberal (it was our [family] religion after all) i don’t get the terror that the specter of a government plan strikes in the hearts of conservatives. especially since we don’t even know what it would consist of!
* * *
I’m getting sick of all the squawking and the relentless posturing. How about you? From my in the trenches position I can tell you that the current private system is an inequitable mess that interferes with my ability to practice medicine on a daily basis. We have a large population of patients on Medicare and/or Medicaid and it’s a relief to deal with them! How ironic that there’s less red tape or obstructions to service with government-subsidized plans. We also have a substantial population of patients who aren’t impoverished enough or sick enough or old enough to get Medicare/caid. Some of them qualify for our indigent care funds and are responsible for some percentage of their costs. Many of these work but have no insurance or inadequate insurance. So they ration their own health care—if you have to pay for 40% of your screening colonoscopy, PAP smear, mammogram, routine blood work etc you wouldn’t be taking such great care of yourself either! Not to mention the folks with HIV who are working and earning more than $20K/yr so they don’t qualify for ADAP (AIDS Drug Assistance Program)—they’ll have to figure out how to pay for their HIV meds which cost 10-15K/yr! Or they can ration their care and wait until they get sick. I don’t see private insurance being an answer to these access problems–they’re in the health care business after all. I feel strongly that a public government-run option is part of the answer. Measures of quality of care are important but it’s critical that they be meaningful.
A: Why do you think it is that some doctors in the same trenches are adamantly opposed to the public option? Do they think they’ll make less money? Or is it just a question of how one is raised? Do we just see through the eyes we inherited? I saw a web page about how the hassles and time-wasting with Medicare were making some doctors refuse to take Medicare patients, so obviously some don’t find it refreshing, but maybe they’re going in with a bias against it? It seems there is no objective reality. You can go to Britain or Canada and find someone who thinks the world of their national health service and someone who hates it, based not even on their experience but on their demographics and preconceptions. It sometimes really does seem that believing is seeing.
I’m not sure why some docs hate medicare so much. maybe it’s older docs who remember the days of total carte blanche. or private practice types who are used to raking in the dough with no impdiments. The problem is that we’ve created a two-tier system that really impacts the uninsured—the folks with “good” insurance (i.e. no-holds-barred, OK to see your GI doc when you fart, your neurologist for your HA, have a CT because you’re worried you might have cancer etc) have absurd expectations about what care they’re entitled to and don’t want anything to change. The uninsured can’t even get the basics and “ration” themselves until they’re really sick, then have to declare bankruptcy to pay the hospital bill. How fucked up is that system??? And docs can be greedy pigs too. What about all these oncology practices that have their own CT scanners now, often with an in-house radiologist. They say the patients like it better–but they do an absurd number of scans and get paid fortunes by the insurance company. Oh I could rave on and on. Americans can be so selfish and shortsighted about their health care (“I’ve got mine so fuck you”). And as to the Canadian model–it’s done really well by [another of our sisters and her husband who had a detached retina], just for a personal example. When she had alarming symptoms last year she got bumped to the head of the line. and he got his eye fixed (or at least worked on) right away AND he doesn’t have to worry about how to pay for it. People get mad at docs because we ask what kind of insurance they have–for me at least it’s because i need to know how much shit i’m going to have to wade through to get done what needs to be done! And it’s not the government that’s providing the shit!
UPDATE: The author responds to the comments.
Cool! Love the comments. Realpc is a smart dude. So true that we do WAY too much in situations of futility (just put a demented 89 yo on dialysis ’cause his family wouldn’t hear of letting him go. How awful for him and how costly for us). When I say health care is a basic human right I absolutely am responding to the inequities of the current system. “Rich” people can get their diabetes and high BP
treated and “poor” people sometimes can’t. What’s up with that?? So I have to take care of the fat alcoholic and drug addicted smokers who drive too fast and when they’re impaired, don’t use condoms and sleep around? You bet. Since when is society allowed to pick and choose who gets services based on their lifestyle choices? There’s too much of the “I’ve got mine so too bad for you” in these conversations about health care. And re another comment…I can’t remember the last time anybody worshipped me as a doctor. where do people get these ideas?? Too much Grey’s Anatomy and “House”??
The Worst Thing We Do
— is make up a story that explains, for us, how life is and how it should be, a story the logic and form of which so captivates and convinces us, so satisfies and seduces us, that we prefer it to actual life. (Is this why we seem to prefer a screen to the real world in front of our eyes?) These stories become the greatest obstacles to living. Forlorn fidelity to them makes us miss many a chance and kill many a spontaneous response. Through their coarse grid much of life escapes; draped in their fine mesh we drown. A mind is a terrible thing.
At Ground Zero, Coffee and Jokes. [UPDATED AGAIN]
I wake up from vague political nightmares and turn on Twitter and find everyone cheerful, as if nothing happened.
Actually, I guess the Obama admin’s reversal and threat to ram through public-option health care with 51 votes (by the tactic called “reconciliation”) makes a lot of people happy. It merely confirms alarmism on the right about O’s and dems’ “tyrant” instincts — that inflammatory argument will no longer have to be rammed through, it’ll slide right in — while it has immensely cheered up the moping warriors of the left, who’ve wanted him to seize this opportunity to do just that all along.
Here I was stupid enough to think things were actually working as they should and that the minority had managed to slow the majority juggernaut almost to a standstill, forcing everyone to think and talk and work out a compromise that incorporated the best of a range of views. It looks to me as if the administration is reacting with wounded pride — urged on by its “base” — rather than trusting its own second thoughts or its flimsy (as it turns out) reconciler fantasies.
Didn’t they learn anything from the Hillarycare fiasco? They have handled this SO badly. Inconsistent, incoherent, chaotic, driven, it seems, by vanity and petulance rather than chastened sobriety and eagerness to learn. Nothing new will be allowed to emerge.
The Democrats may have a political majority, but that can’t paper over the deep crack almost right down the middle of the body politic. To force a solution on the country that close to half of it doesn’t want will give a fatal blow to the splitting wedge. We’re going to be a crippled country. When it’s all over we’ll be remembered for being so spoiled by success that we squandered our strength on the luxury of fighting each other, turning our birthright into the spoils of a political Super Bowl.
I’ll admit my own myopia. When you have a hammer everything looks like a nail, and when you’re a centrist partisanship, not “socialism” or “wingnuts,” looks like the force destroying the country. It goes back to the Republicans trying to destroy Bill Clinton (who, after the stumbles of his first year, is looking better and better, though rogue’s luck played a part) for no better reason than that he was a successful Democrat who’d “stolen” some of their ideas about fiscal prudence and welfare reform. (Granted that Bill put the weapon in their hands — and it was in his own pants — but it was wanton and self-indulgent of the Republicans to grab it.) It goes back before that to Democrats, including myself at the time, despising Ronald Reagan because he was a hawk and not an environmentalist, failing to appreciate how much the freedom we ourselves enjoyed depended on living in a strong country.
I think we’re in terrible trouble, and I’m really scared for the first time. I must have been naïve: hardly anyone seems concerned or even surprised this morning. It’s just another day for you and me in paradise.
UPDATE: From the other side, Philip A. Klein agrees with Maxwell that using reconciliation to pass healthcare reform is an empty threat — and little more than a bluff.
UPDATE II: Randy finds the best links! If I’d seen this by Clive Crook in the Atlantic sooner, I’d have just quoted it instead of trying to write about the issue myself.
This struck me as a non-story if I ever saw one.
Given hardening Republican opposition to Congressional health care proposals, Democrats now say they see little chance of the minority’s co-operation in approving any overhaul, and are increasingly focused on drawing support for a final plan from within their own ranks.
Oh please. It isn’t Republican support they lack, it’s public support. And this is not the way to go about getting it. Democrats are technically right that they can get a bill through the senate even with one or two defections on their own side, using a special procedure to prevent a Republican filibuster. But with public opinion, previously well-disposed to reform, now leaning against the Democrats’ proposals–a result of the White House’s dismal failure of leadership on the issue–it would be political recklessness of a high order to pass reform by means of a ruse. Not least because the purpose would be to disempower dissenting Democratic senators, not just Republicans. What would centrist voters make of that? The go-it-alone threat surfaces every few weeks. Though complaints about Republican obstructionism are justified, the idea looks less credible now than before.
It goes on. Key passage, in my view:
The administration should drop the public option. Politically, the disappointment of the Democrats’ hard-liners would be a plus for the administration, not a minus: their protests would reassure moderate opinion. Substantively, it would subtract little or nothing from the considerable virtues of the other aspects of the reform proposals, around which a broad popular consensus can still be built.
And from the Financial Times editorial Crook links to:
The sooner he ditches [the public option], the better. … In signalling that he might be ready to do so, Mr Obama has said that comprehensive reform is still possible without it. He is right. A broad consensus supports new rules that would stop insurers from denying coverage because of pre-existing conditions, cap out-of-pocket expenses (so that illness would no longer mean bankruptcy), and make affordable insurance (with public subsidy where necessary) available to all. Those changes are transformative in themselves. Dropping the public option in order to get that done would be a triumph by any sensible standard, not a defeat.
Ambiance 