Thursday, July 31, 2008

The Third Wave vs. Coverage for the Uninsured

What is the best way to insure that some folks won't be able to afford health coverage for their strokes, broken bones, and heart attacks?

Simply require insurance companies to cover particular pills and procedures, whether or not this is the patient's preference.

The women at "Feministing" are angry that insurance plans are required to cover Viagra, but not birth control, and are taking McCain to task for it (it is true that he could have constructed a better response to the challenge than embarrassed stammers). I understand their concern, but I don't believe either medication should be mandatory.

First of all, it's a matter of priorities. Yes, prevention is the best medicine, but no one in her right mind would choose a "prevention" plan over a "catastrophic" plan, provided she couldn't afford both. She can assess her family planning options, not her "susceptibility to cancer" options. When various goodies are added to insurance plans, the cost of coverage is unnecessarily increased, and the patient can no longer opt-in for an "I'm not quite as screwed if I get cancer" plan. Of course, a few bucks here or there won't suddenly price-out millions, but all of these consequences occur at the margins.

Second of all, it is questionable whether or not, even for the well-off consumer, it is preferable that her birth control be covered by insurance altogether. Insurance is best for situations that are unpredictable. We are fully aware that we will likely end up paying the insurance companies more than we will cost them, in the long run. Yet, we consider it worthwhile to have the piece of mind that we'll be able afford our treatment if something terrible happens to us. However, birth control pills are a non-emergency, continuous, relatively predictable expense. For such medications, wouldn't it be best to buy directly from the pharmacy, rather than invite an unnecessary middle-man, who arrives with a chock-load of bureaucratic expenses?

Thirdly, the feminist movement is not always consistent when it comes to the concept of "choice." If it is the woman's choice whether or not to have an abortion or take birth control, shouldn't the pharmacist, doctor, or insurance company get to decide whether or not to be complicit in this choice? (I would make an exception for emergency situations or instances where the provider does not inform the woman of all of her options. That could arguably considered professional neglect).

The women of "Feministing" would be wise to consider the unintended consequences of their cause. If they want to help women, they should allow for more affordable coverage for breast, ovarian, and cervical cancer, not birth control.

As an aside, I can never tell anymore when exaggeration of "ideal" women's bodies is considered, by the feminist establishment, as unacceptably sexist or simply ironic re-appropriation. Is it me or do the naked silhouettes on the banner of the Feministing webpage resemble those on the storefront of Orlando's strip club?

Lazy Thursday Gardening and Cooking

This is my herb garden on the balcony, which overlooks a parking lot. Today, I'm using the sweet basil for my favorite baked ziti recipe. The moral of this story is that I have way too much time on my hands when I'm not in school.

Tuesday, July 29, 2008

Lessons Learned at the L.A. Gun Club

1) The first 10 minutes in the booth are the most difficult, because it takes some time to avoid flinching at every "boom." However, after habituating to the sound, it's not too tough getting used to the basic mechanics of loading (I need to use a speedloader), pressing down the slide lock, holding the gun properly, pulling the trigger, and finally releasing the magazine. It's more like learning to play guitar, rather than violin, in that it's easy to pick up and do a decent job, yet difficult to master. I just hope that inserting a central venous catheter will also prove to be as unexpectedly straight-forward.

2) I was predicting that the place would be filled with burly men sporting mullets and neon green sleeveless shirts. However, it was a diverse group, with roughly equal numbers of men and women, and a few hipster boys with Buddy Holly glasses, argyle socks, and Keds. Perhaps NRA involvement is the up-and-coming strategy for bohemian non-conformity.

How Libertarian Doctors Think?

Now, I am not much of a "reductivist," in that I don't believe that people's personalities can be neatly decoded based on their political philosophies. What people feel about the proper role of government does not necessarily translate to how they may view private interactions. For example, although I am a libertarian, I am an ardent proponent of private charity and volunteerism, and I abhor the notion of "Social Darwinism." However, I do wonder whether or not libertarian doctors may tend to approach clinical situations a bit differently than do other physicians. I'll use an example from medical school.

In Los Angeles, we have tons of under-employed actors. When they aren't discussing the Stanislavsky method at Psychobabble, many come to our medical school to act as "standardized patients" or "SPs" They are given a scenario, in which they must pretend to be the dying/angry/unknowingly-HIV-infected patient, and we med student poindexters must learn how to speak with them properly. We usually have a tag-team approach, in that one student will start the "interview" until our professor calls "time-out." We then provide feedback to the student on how the interaction went, until the next student goes, taking over as the "same medical student."

One time we had an SP whose scenario is described as follows, (The patient does not really exist and is a caricature):

Paul Cassidy is a computer engineer, now off work on disability, who is coming to the orthopaedic clinic today for another opinion about his chronic low back pain. He has agreed to talk to a medical student about his history before seeing the attending physician. Two years ago, he was in a car accident in which 3 lumbar vertebrae were crushed (L2, L3, and L4). He underwent spinal fusion at that time and, following a lengthy hospital stay, extensive rehabilitation. He continues to have back pain that prevents him from returning to work. He is upset that his previous orthopedist has not been able to find any additional physical complications to explain his persistent and chronic pain. (He has had x-rays and CT scan recently which show no evidence of pathology beyond his post-surgical changes.) Your task is to elicit Mr. Cassidy's concerns and history. If you have some ideas about ways he can manage his pain, you may choose to explore that with him in the later part of your interview.

"Mr. Cassidy" entered indignantly, clutching his back in pain. He was clearly frustrated by his myriad previous physicians' inability to properly help him, and insistent that the doctor find the proper pathology and treatment. He tossed out his words with a bit of bitterness, but generally remained polite. He explained how, in the past few years since the injury, he has not worked, maintained any hobbies, nor visited any friends. He has since moved back in with his mother, and basically does nothing all day. He would really like to start work again, but he is just waiting for his pain to be fixed. His only source of income is his monthly disability check.

My peers treated Mr. Cassidy with respect and empathy. They said things like "that sounds really tough," "It must be so difficult to be going through such a hard time," and "we will do everything we can to try to fix this problem." They asked him about all of his symptoms, and took a detailed history of his long ordeal. I was genuinely impressed with my fellow med students, some of whom have shockingly good interviewing skills.

When it was my turn, I similarly expressed empathy for Mr. Cassidy. I understood he was angry, and didn't take it personally. I fortunately have never experienced the inconceivable misery of chronic pain. I am aware that I likely would have behaved no more congenially, had I been the one in the patient's seat. Thus, my problem with the situation was not Mr. Cassidy's anger, but his maintenance a life of chronic anticipation. He was waiting to engage in the world again after until he was healed, and everyone presumably considered it cruel to suggest to Mr. Cassidy could possibly end up living with his pain forever.

So I finally said to Mr. Cassidy,

"Sir, we are going to pore over your charts, and try to see if there's anything that may have been overlooked. We will make it a priority to find the best analgesic for your pain. However, I do want to address something that may be a bit difficult, yet necessary, as you seem to have put your life on hold since the accident. I want you to consider the possibility that the pain may never go away, and that, no matter how hard we try, we may not make any meaningful changes to reduce your pain. Pondering that possibility, do you think that you may approach life a bit differently, that you may feel motivated to resume any of your old activities?"

Anarchy struck. The patient stood up, shouting rapidly, "You're telling me, that I'm coming here, just to hear that I'm stuck with this? That I have to live like this for the rest of my life? You call yourselves doctors, and you're saying that you can't help me?"

Mr. Cassidy wasn't the only one disappointed by my performance. During feedback, My peers said that I was too harsh, that my bluntness shattered Mr. Cassidy's hope, and only further deepened his despair.

I don't disagree. But, given another chance, I would likely re-enact the scenario in the exact same way. I felt that I owed it to Mr. Cassidy to consider the full scope of potential outcomes. I don't want him to miss out on life. Without anticipating his unfortunate reaction, I would initially be more fearful of acting dishonestly with my patient, rather than allowing for unnecessary worry.

Similarly, in our scenario with the dying patient, while I mentioned that statistics can't be predictive of any individual case, I still said that I'd look up the average prognosis for someone with his condition. For the obese patient with Type II diabetes, I didn't blame the patient, but I also didn't blame industrial food manufacturers for his plight. Ultimately, I believe that empathy must be balanced with honesty, respect for the patient's autonomy, and a realistic belief in the role of personal responsibility. And I wonder if that makes me a particularly libertarian (almost) doctor.

Sunday, July 27, 2008

Religious Inspiration

Yesterday, I went to shul at the Pasadena Jewish Temple. The services were lovely. However, the Torah portion could be divided into roughly 3 sections, each a bit astonishing:

1) A woman's vows are only binding if her father or husband agrees to them, otherwise the vows are automatically annulled and the woman's "sin is forgiven."

2) The Israelites must go back and kill all the non-virgin women of Midian, because the Israelites only killed the men on the first round (virgin women are always spared).

3) Reuven and Gad ask Moshe if they could settle the land on the East of the Jordan, as they've discovered that the land is pretty darn good, and, to them, preferable to living in Israel. Moshe gives them the option of fighting with their brothers and getting the land outside of Canaan that they want, or opting out of fighting altogether, yet getting stuck with land inside Canaan for which their brothers still must fight.

Very strange deal. Very difficult Parsha to relate to. No wonder the Bat-Mitzvah girl decided to read from the Haftarah.

Thoughts on Cato University Lecture I: "Why Freedom Matters" by Tom Palmer

Tom Palmer gave an overview of the mission of Cato (which he calls "Central Atlantic Treaty Organization." Now I'm scared that the Democrats might abolish the think tank sometime soon, arguing that it harms workers). He makes an excellent point about the common criticism of Cato, in that it can't be trusted because it "has an agenda." For one, he mentions, "Everyone has an agenda, and every question you ask expresses your agenda." Reading studies from think tanks that claim to perform "objective social science research," to me, is at least more time consuming, because I always have to spend a few minutes figuring out what their ideology is. When Cato has a policy proposal, they've already done me the favor.

If any of you ever attend Cato presentations in D.C. and are annoyed by the first of two lecturers who might go on about market failures, the moral obligation of governments to help people, or how guns kill children, Palmer explained the reason for that. He mentioned that Cato likes to invite their "toughest and strongest" opponents on an issue, because the only way to demonstrate to themselves and to the audience that the institutes's ideas have merit is to answer to thoughtful, cogent criticism. This leads me to respect tremendously not just the institute, but also its guests. I couldn't imagine myself speaking in the lion's den of the Center for American Progress or People for the American way. Props to any populist or conservative willing to speak to a primarily libertarian audience.

At one point, Palmer explains that people often associate "libertarians," with their "genetic hybrid," "libertines," presumably referring to those people who would want small government, just so they could have access to call girls and cannabis. Most libertarians I know just want to choose their kids' schools or prevent some township from seizing their house- in other words, pretty mainstream. But, I do wonder if there is a cultural difference between libertarians and other folks, not so much in terms of their relative pursuits of wild lifestyles, but in terms of how they approach situations that have nothing to do with government interference. Today, I'll give a med school example of what I mean, in another post.

Saturday, July 26, 2008

Dead-blogging the Cato Conference

This past week, I attended "Cato University," at the Rancho Bernardo Inn in San Diego, California. It featured lots of free liquor, pool time, cute college boys (yes, dear husband, I'm trying to get you mad enough to go to the conference with me next year), and gourmet food served at a vineyard. (Oh yeah, and there were also some lectures about stuff).

Presumably, live-blogging is the best way to describe what's going on at an event, but all 2 of my readers will have to deal with my post-conference round-up, which I'll do over the course of this week.

All in all, wherever you are on the libertarian spectrum (purist to bargainer, anarcho-capitalist to "rule of law" devotee), I highly recommend the conference as a way to learn from distinguished researchers and writers, get energized about pro-liberty causes, and argue at the bar about "policy, policy, policy" (a phrase, often invoked by the Cato scholar, Gene Healy, is intended to silence any taboo-trangressor who couldn't think of "normal person" stuff to talk about at a social event).

Honestly, all of the presentations were excellent, and I actually stayed awake and attentive during the six hours of lecture each day (take that, med school). I met lots of cool attendees, including a feisty German senior-citizen who outswam me at the pool, of whom another (almost) med-student called the biggest babe at the conference. I met a vet from WWII, another from the Korean War, and lots of docs, armed with pamphlets and position papers, whose life mission seemed to be steering me away from medicine. Since this week is my last week of sweet freedom before school starts again, I figured that, over the next few days, I'd post snippets and thoughts from some of the lectures.

If the presenters think I'm giving away too much of their lectures, please email me, and I'd be happy to take down some posts. Or you could read this, and perhaps forgive me.

Sunday, July 13, 2008

Increasing Welfare: A Uniquely Republican Solution?

Here is an Op-Ed I submitted to a newspaper. It was rejected, and I am too lazy to work on it and resubmit it somewhere else. So enjoy it on my blog!

When imagining politicians clamoring for income redistribution, one may not think of Republicans. As proponents of small government, GOP members generally believe that the best method for helping the poor in the long-run is a free market economy that creates jobs and opportunities for entrepreneurship. Additionally, as Tom Coburn (R-OK) frankly stated in an Op-Ed for "The Wall Street Journal" last week, "Spending other people's money is not compassionate." While these beliefs have considerable merit, they fall flat to many Americans mesmerized by Barack Obama's hopeful, if unattainable, promise to provide every American with health care, housing, and a myriad of other benefits, all while improving our GDP. Furthermore, charts and figures that extol the long-term advantages of fiscal responsibility seem callous to Americans who, according to Pew Research Center polls, increasingly favor a "safety net" for the poorest Americans.

The key to a Republican solution is the fact that American sentiment is not "either-or." Most Americans also favor free-market capitalism, small government, and pro-growth policies. Thus, rather than simply dismissing all types of aid to the poor, Republicans have a unique opportunity to distinguish their version of government assistance from that of the Democrats. In this area, a Republican pro-market solution can come prevail, based on its simplicity and potential popularity: Republicans should legislate for the government give the poor more money.
One area where Republicans can implement this approach is in addressing the health care crisis. Faced 45 million uninsured Americans and stratospheric costs of care, the Democrats' solution is to control, regulate, and even socialize the pharmaceutical, hospital, and insurance industries. Their ideas involve mandating which medical conditions must be covered by insurance companies, controlling how eligibility may be determined, calculating "legitimate" compensation to health care providers, and even creating government-controlled insurance. To many fiscal conservatives, the cost of such bureaucratic meddling , in addition to outrageous legal settlements, are at least as economically burdensome as the actual costs of providing health care.

Republicans should not ignore the problem of the uninsured. But they can favor a policy that maximizes aid for the poor, while keeping an appropriate distance from people's insurance plans and medical records. John McCain's health plan is built on this principle. He believes that by simply deregulating the stifling insurance market, initiating tort reform, and, most of all, providing money for health coverage, many more people could receive the prevention and treatment care they need.

A similar approach can be taken to assist the homeless. Democrats opt for big-government solutions, including rent control, public housing, excessive zoning laws, and all-out bans of untrendy "corporate" stores from certain neighborhoods. These strategies have distorted and raised market rental prices, deterred landlords from improving or building new rental units, and increased neighborhood blight. Public housing is also inequitable, in that it provides low-cost housing to a select few, leaving thousands more to languish on wait lists. The most devastating manifestation of public housing is perhaps its social cost: public housing neighborhoods have contributed to "two Americas," placing low-income families in a de facto racial "ghettos," thus forcing Americans of different social classes to live parallel lives with minimal interaction.

A Republican solution to the housing crisis would be to provide homeless people more money for rent, while interfering minimally with the market. Thus, low income families could be empowered to choose their neighborhoods, after evaluating school districts, access to supermarkets, and relative safety. Additionally, the money would be allocated more fairly, with the amount of aid determined by income, rather than a winning housing lottery ticket.

The "simply give poor people more money" could also be the Republican approach to the education crisis, in that it would empower families, rather than union leaders or unaccountable administrators. Washington D.C. spends $24,000 for every pupil per year, which should be enough to cover enrollment at Horace Mann or Dalton. Instead, an untraceable money chain has resulted in physically dilapidated schools, dissatisfied teachers, and abysmal graduation rates. Distributing money (in the form of vouchers) to individual families would respect needy parents by allowing them to make their own decisions on behalf of their families. And we could be sure that they will use this power of the purse to hold their children's schools accountable.

Reports of Republican party's death have been greatly exaggerated. Yet, the party, faced with a populace demanding for the government to actively solve problems, must update their mantra of fewer taxes and less spending. If Republicans instead focus on moderate taxation, a balanced budget, and smart spending in the form of direct payments to the poor, perhaps they can win popular support, improve the economy, and truly help the poor. The Departments of Education, Housing and Urban Development, and Health and Human Services could be dramatically downsized. Meanwhile, the GOP's least favorite government agency, the IRS, would ironically extend its responsibility, through a renewed role of redistributing income. This strategy, similar to Milton Freidman's "negative income tax," or Martin Luther King's "guaranteed minimum income" could be a uniquely Republican way to reduce government bureaucracy, while ensuring a "safety net" for every American. Of course, guidelines for eligibility, such as a demonstrated willingness to work, could be implemented. But through a well developed, small government strategy for social mobility, we may find that today's aid recipients will be on tomorrow's giving end of diminishing welfare rolls.