And even when I sit and think about being a doctor, I don’t think about the last 7 years of being a faculty member here at IU.  I rarely think of clinic when I was a fellow before that.  When I think about being a doctor, I almost always go back to residency.

Look, I know many physicians who love caring for patients.  I even know those who remember fondly their days as residents, being in the trenches and completely immersed in clinical care.  I was not one of those people.  I hated residency.  It really didn’t agree with me.  Ask my wife; for that matter, ask any of my friends.  It was obvious to anyone who spent any time with me.

I didn’t hate residency because of the hours, although they were terrible.  I didn’t hate the pay.  I didn’t hate being overworked or underappreciated.  I didn’t hate patients or the people I worked with.  I hated the system.  More specifically, I hated being a doctor in the system.

I just finished Atul Gawande’s latest masterpiece.  I am rarely so jealous of anyone as I am of him and his skill right now.  He brought it all back for me.  I can tell you many horror stories of those three years in Seattle.  But ask me to rank the top few and this one inevitably comes to the top:

I was on a rotation in the Neonatal Intensive Care Unit (NICU), where babies who are born prematurely or really sick are cared for.  A couple came in with a midwife after a way-too-long and rather botched attempt at a home delivery.  As soon as they arrived, we knew things were not going to go well.  The baby was born in extreme distress.  It appeared to be septic, or massively infected.  Initial vital signs looked really bad.  And then things got worse.

One by one, the baby’s systems seemed to shut down.  He couldn’t breathe on his own, so we put in a breathing tube.  Then his heart started to fail, so we put lines into his umbilical cord to pump in medications.  His lungs collapsed, so we put in tubes into his chest to help them reinflate.

While another doctor and I struggled to keep all this going, I listened as, right behind me, the doctors in charge sounded downright optimistic to the parents, who were, understandably, a mess.  They could not imagine how things had gone wrong so fast.  They wanted to hear good news.  No one seemed to be able to tell them the truth.  They were given messages of hope and told us to do everything.  That’s what we do in medicine.  That’s especially what we do in the NICU.

They left to go home and get clothes and supplies.  Everyone dispersed.

So I was alone with this baby.  It was small, and blueish, and had an ungodly number of devices and tubes coming out of it.  I was 25, depressed, and I started to cry.

The baby never moved.  His heart would slow down, and I’d up his meds.  His heart rate would come back up until it didn’t and started to drop again.  So I upped the meds some more.  I don’t know how long this went on.  I didn’t eat, I didn’t go to the bathroom, I didn’t talk to anyone.  I just stood and watched.

Eventually, the ventilator stopped getting the job done, so we had to put the baby on an oscillator.  Basically, instead of giving normal breaths, this machine shoves tiny amounts of air in and out really fast.  It sometimes works when other things fail.  It was loud, noisy, and made the baby shake.  I don’t think he noticed.

Things slowly got worse.  Nothing was working, and every vital sign was heading downwards.  As instructed, I just kept adding stuff to keep him alive.  But deep down inside, I started to think that what I was doing was wrong.  Not incorrect – wrong.  I wondered if I was hurting the baby.  I just wanted him to be at peace.  And, for a moment, I wanted the baby to die.

I don’t like to think about it.  I try not to.  Ever.  But it happened.

Not long after, nothing I was doing was working.  I called in the doctors in charge, and they agreed.  They asked where the parents were.  It suddenly dawned on me that they hadn’t yet returned.  We called them, and they were shocked to hear how bad things were.  After all, those same doctors had told them things were going to be ok.

They rushed back as fast as they could.  They didn’t make it in time.

I thought I would post a piece of Gawande’s article and talk about how we completely screw up end of life care.  I thought I would make a comment about how we spend too much money or waste resources.  I thought I would talk about tradeoffs and better choices.  But I can’t.  Partly because I can’t do his work justice, and partly because this is an issue where deep down inside I think we are doing a ton of harm.  Full stop.

I went home that night and bawled uncontrollably.  This kind of thing happened all too often.  I toyed with the idea of getting out.  I even had resumes prepared to send off to companies outside of medicine.

But, some time later, I found myself back in the NICU.  A similar situation was occurring.  This time, though, the doctor in charge handled everything differently.  She spoke to the patients honestly and in a completely different tone.  She asked the parents what they wanted out of the short time they might have with their baby.

They cried at first.  And then they stopped.  They cleaned the baby up and dressed him in clothes his grandparents had bought.  And they took him out.

They were gone for a few hours, and then they came back.  They allowed us to give the baby drugs to comfort him.  They held him, as a family, as he quietly passed.

I remember quite clearly his sister was in the room.  She was about six.  I asked her how they had spent the day.  She told me how they had taken the baby to the park, to see the water.  They had brought him to family members so everyone could hold him.  They showed him the sun and let him lay in the grass and let a dog lick his face.  Her mother was listening in at the end, and somehow smiling.

Some months later, I ran into the mother in a different part of the hospital.  She remembered me, and thanked me for all I had done.  I remarked that I hadn’t done much; they had cared for the baby.

“No,” she replied.  “Without all of you, he never would have known what chocolate ice cream tastes like.”

I spent four years in medical school learning how the body works, how it can break down, and how to repair it.  I spent three more learning how to give the right drugs and do the right procedures to fight illness.  And in all the time I’ve been a doctor, I honestly don’t know if I’ve ever done any more good than helping to stop the system so that baby, and that family, could share some ice cream.

I have a hard time explaining what I do to people.  I’m not trying to discover a drug or cure a disease.  I want to fix the system.  That’s how I found peace.  That’s how I practice medicine.

That’s why I’m a health services researcher.

For some of us, improving the health care system is more than a passing fancy.  I’m a health services researcher.  It’s my job.  Those people on the TV pay attention to it when it gets ratings, and those people in Washington get into it every other decade or so, but it’s what I do every day.

I really with I could make you believe that I couldn’t care less about the politics of it all.  Seriously.  Yes, like everyone else I care about who is in the White House of Congress, and I do lean different ways on different issues, but – on this I swear – I just want a better health care system.  That’s all.  I don’t care if it’s labelled conservative or liberal.  I don’t care what names you call it.  I just want it to be better.

Specifically, I want it to have phenomenal outcomes, I want everyone to have access to it, and I want it to be cost-effective.

I hope you notice I didn’t say cheap.  I think good things DO cost money.  I just wouldn’t like to spend any more than we have to.

People may think I’m closed minded, but I swear I’m not.  I am persuaded by good research.  That’s all.  Evidence.  Data.  Science.  I really don’t have a stake in who “wins” this.  It’s only the final product that matters.

Which brings me back to the title of this post.  I’m heartened by some recent activity I’ve seen.  I watched a debate occur between Austin Frakt and Avik Roy without it degenerating into partisan hackery.  I somehow managed to say a few words on the topic without resorting to sarcasm.  And I believe (maybe I’m delusional) that someone following the whole thread may have seen that it is possible to discuss good, unbiased research in a civil manner.  I stand by this:

I don’t think there is necessarily a right or wrong here.  Research is, more often than not, baby steps.  Each study adds a small amount to our understanding; each study is only so generalizable.

And I’d add that by talking about the body of work that exists, and discussing what from it we can agree on, we could find a starting point for moving forward.  Wouldn’t it be nice if we could devise pilot programs in health care reform in different ways, and then study them?  Agree to the methodology beforehand and then see what happens?  How great would it be if we all agreed to stand by the results, no matter what they might be, no matter what our ideology?

For instance, Avik cites the Medicaid program in Indiana which set up health savings accounts for Medicaid recipients and then coupled them with high deductible health care plans.  Why oh why did they not agree to allow an independent third body to set up a study to see how it worked?  Maybe good research would have shown that reform to be a spectacular success, vindicating the consumer-driven approach.  Maybe good research would have shown that reform to be a spectacular failure, suggesting that such an approach cannot succeed in a high-risk population.

It sure would have been nice to find out.  Instead, too many are driven by a desire to see their pre-chosen method of reform succeed, and so prevent any chance of it being seen in a bad light.  These types of people deny any flaws in a single-payer approach, no matter if such flaws exist.  They refuse to examine the downside of increasing out-of-pocket costs because it might hurt their “side”. They are more interested in the ideology than the goal of improving the health care system.

No good can come of that.

Anyone who reads this blog knows I think highly of Austin.  And, I opened by email this weekend to receive a very nice note from Avik concerning my recent posts.  Those personal contacts really do matter.  They remind me that some of us do have a shared goal – a better health care system.  We may disagree on how best to get there, but we can at least discuss our differences, and – perhaps – look for similarities. This kind of post gives me hope.

I hope this type of debate continues.  For my part, I’m going to keep an eye out for the study that started this all.  When I can finally read the whole thing, I will, and I will make sure I tell you what I think.  I’ll tell you if I think it’s a good study (or not), and how I think it adds to our body of knowledge about Medicaid.  And maybe, if more people keep on doing that, we can shift the discussion of health care reform away from politics and back to what really matters.

The gloves are off in the fight for the Democratic nomination for governor. Former State Senator Matt Dunne is calling out Senator Peter Shumlin for what he says is a troubling misstatement.

Peter Shumlin first said it two weeks ago in an online questionnaire, then again this week in a mailing to voters: “I am the only candidate who sponsored a single-payer health care bill.” Dunne says that is simply not true.

“The facts are that I also sponsored a single-payer health care bill,” Dunne told reporters outside the Statehouse Wednesday.

He did. During the 1993-1994 legislative session when Dunne was serving as a State Representative he co-sponsored a bill that would have created a single-payer system. He wants a public retraction of Shumlin’s claim and is requesting that Shumlin send out another mailer with the correction.

Wait…  what?  Are you kidding me?

One Democratic candidate for governor, Matt Dunne, is upset at another Democratic candidate, Peter Shumlin, because he Shumlin claimed that Dunne did NOT support single-payer health care.  Did you get that?  They are fighting to show which of them is the more fervent supporter of single-payer health care reform.

Watch the TV, and you’d think that voicing anything less than total hatred for such reform would be the kiss of death in modern politics.  Not so in Vermont.

Vermont is still a state, right?

And you thought all talk of a public option health insurance plan was dead. But no, Rep. Pete Stark (D-Calif.) asked the Congressional Budget Office to crunch the numbers on a public plan, funded by premiums, not taxes, and they found the following:

“The Congressional Budget Office (CBO) estimates that the public plan’s premiums would be 5 percent to 7 percent lower, on average.”

Also:

“CBO and the staff of the Joint Committee on Taxation (JCT) estimate that the proposal would reduce federal budget deficits through 2019 by about $53 billion.”

The next year would probably save another $15 billion, for a total of $68 billion shaved off the deficit by 2020.

You can read the full CBO report here.

But look, what I said back then still applies:

It’s just not that important. It’s really not. Maybe there was a time it was, but no longer. Now it’s a withered appendage. No more people will be insured with a public option than without it. Nor will the quality of care differ. It may decrease the total cost of the bill by a few percent, but that’s it. It’s not a path to single payer. It’s not a secret government takeover of care. And I say that not caring whether you hope or fear if either of those things is true.

I’m all for saving another $53 billion a decade, but come on.  We’re spending $2.5 trillion a year on health care.  I applaud the idea of continuing to improve the system, but we need to make bigger changes than this.

One of the stories we’re watching in Washington this week has to do with something called “the doc fix.”

It has to do with how doctors are paid when they care for Medicare patients. It’s a problem that’s been around for years — without a permanent solution.

Healthcare-policy wonk Dr. Aaron Carroll provides his take on the latest developments in government health care reform.

This stuff is still relevant, regardless of the short attention span of the media.

The sun hasn’t exactly set on Solar Planet, but anxiety over the fate of the Arlington tanning salon has been running high ever since a “tan tax” took effect last Thursday.

One of the less-publicized measures in the new health-care law, the tax imposes a 10 percent surcharge on the use of ultraviolet indoor tanning beds.

Supporters — including the Obama administration, congressional Democrats and dermatologists — have argued that the tax will raise an estimated $2.7 billion toward the cost of expanding health coverage to the uninsured, while discouraging a practice that increases the risk of skin cancer by as much as threefold in frequent users, according to scientific research.

But outraged owners of tanning salons worry that the levy could deal a death blow to an industry already reeling from the recession.

Look, we tax cigarettes at a much higher rate than other things.  Alcohol, too.  And other stuff that’s unhealthy.  Tanning is really bad for you.  Plus, go out in the sun if you want to save money.

It’s not that I don’t understand why some of you are upset about this; it’s just that I can’t get that worked up about it.

It’s not all good news.

Let’s say you are a 60 year old divorcee in 2014.  You make $46,136, which is 401% of the poverty line.  You are therefore eligible for NO subsidy from the government.  Your premium will be $10,162.  Should you actually need care, your out of-pocket costs will be capped at $6250.

So in a best case scenario, your health insurance/care will cost you 22% of your income.  In a bad year (or a regular year if you have a chronic illness) your health insurance/care will cost you 36% of your income.  Um… that’s not affordable.

Granted, the cost is so high that you would likely not be subject to the mandate.  Great.  So you continue to have the option to be uninsured.

The people who are going to be hit hardest by this are those making just over 400% of the poverty line.  Because, ironically, if you make just a little bit less – say $45,906 (399% of the poverty line), then – due to subsidies – your premium will cost you $4361.  That’s less than 10% of your income.  And your out-of-pocket costs are capped at $4167.  So the most you could pay in a year would be 19% of income.

That’s still a lot.  But it’s WAY less than if you make just over the 400% line.

I have yet to see a good answer for what the government is going to do when people start asking for pay cuts to get under the 400% line.  I don’t see why it won’t happen.

Press Corps-pls do your job as Obama sneaks in Berwick appt;pls cover his mission:socialized healthcare&rationing based on”quality of life”

This kind of thing makes my head explode.  Look, I’m not going to get into the politics of the Berwick appointment.  But who oppose him see his “mission” to be twofold:

1. He’s for increasing government paid/run health care
2. He’s for decreasing spending on government paid/run health care

Ok.  You can’t be angry at him for both of these.  You can be angry at him because you believe he will increase the amount of money that government spends on health care or you can be angry at him because he will limit the amount of money that government spends on health care, but you can’t be angry at him for both.  For that matter, he really can’t do both.

Moreover, you, yourself, can hate one of these things, but you can’t hate both.

So, please, rail against increases in health care spending or against them.  Choose.  This is sort of silly.