Below are the 20 most recent journal entries recorded in CMR: Chief Middle-management Resident's LiveJournal:

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Tuesday, November 10th, 2009
6:52 pm	Summary of HR 3962 for patients [The below is a draft summary of the House legislation that I've created. Please feel free to add comments, clarifications, or additional questions] What does this legislation do? - It reforms the insurance industry to forbid basing premiums on pre-existing conditions or health status. Premiums may vary based on age, but only to a maximum 2:1 ratio between the highest and lowest premiums. Plans may no longer have lifetime or annual limits on spending, and out of pocket costs are capped. These rules apply to all plans, with time allowed for them to come into compliance. Currently existing plans will not need to meet these requirements. - Creates a Health Insurance Exchange for individuals not covered by employers, Medicare or Medicaid. Businesses may also participate in the Exchange, starting with small firms in 2013. States may also create their own Exchanges. A Public Option will exist in the Exchange, funded entirely by its premiums (not through tax dollars). Who is required to obtain health insurance? - Individuals are required to have health insurance coverage. Failing to do so results in a fine equal to the lesser of 1) 2.5% of their adjusted gross income or 2) the average premium in the Exchange. Veterans and Native Americans are exempted. - Employers must cover 72.5% of the cost of premiums for employees (65% for families), or pay into the Exchange to subsidize low-income individuals and families. Employers who do not provide qualified plans will pay 8% of payroll to subsidize employees seeking coverage in the Exchange. How can I afford to purchase insurance through the Exchange? - Affordability credits are provided to individuals and families with incomes less than 400% of the Federal Poverty Level ($88,200 for a family of 4 in 2009). Annual out of pocket costs for these individuals are also capped. Credits are not available to individuals who qualify for Medicare or Medicaid. - Medicaid is expanded to 150% FPL ($33,075 for a family of 4). Will I have to pay more in taxes? - Taxpayers earning more than $1,000,000 (joint) or $500,000 (single) will pay 5.4% rate. There is also a 2.5% excise tax on medical devices. Contributions to health savings accounts are limited to $2,500. There are several other minor funding provisions. - Employers must cover 72.5% of the cost of premiums for employees (65% for families), or pay into the Exchange to subsidize low-income individuals and families. Employers who do not provide qualified plans will pay 8% of payroll to subsidize employees seeking coverage in the Exchange. - Small businesses (payroll less than $500,000) are exempt from 8% payroll contribution. Businesses with payrolls between $500,000 and $750,000 pay less than 8% on a graduated scale. Will my Medicare coverage be affected? - Medicare Part C (Medicare Advantage) plans will be required to limit cost-sharing (what you pay out of pocket for care) to be equal or less than traditional Medicare. What about prescription drug coverage (Medicare Part D)? - The Donut Hole in Medicare Part D is eliminated over several years. Will a “death panel” pull the plug on Grandma? - No. - Qualified insurers are required to provide information about end-of-life planning to individuals. However, there is no obligation for a patient to establish advance directives or comfort care orders. The information cannot “promote suicide, assisted suicide, euthanasia, or mercy killing.” - Comparative Effectiveness Research (CER) cannot be used to “mandate coverage, reimbursement, or other policies for any public or private payer.” (1 Comment |Comment on this)
Friday, October 9th, 2009
9:20 pm	An ethical argument for the public option As we enter the final stretch of the legislative process for health care reform, we are beginning to get an idea of what the final bill will look like based on the five existing bills: definitely regulation of the insurance industry (no more "pre-existing conditions"), most probably an individual mandate to obtain insurance (enforced by a fine or a tax), and maybe (?) a government-run public option to compete with the private insurers. Is there any other place in our lives where the government mandates that we purchase a good which is only available from private vendors? Car insurance is similar, but there is no mandate to purchase car insurance unless you wish to be licensed to drive -- and many people are not licensed because they don't drive. Businesses often have requirements to carry certain kinds of insurance, but businesses aren't endowed with individual rights. We do have laws in this country that compel mandatory attendance in school (with exceptions for home-schooling, etc). However in this case, the government also provides the means to meet that mandate: the public school system. (We are so lucky that Horace Mann lived in a different era ... in today's world, we'd have bitter partisan fights about creating a public school system and a "right" to a basic education, and we'd probably end up with a multitude of profit-seeking private schools who used their political influence to stop the creation of public schools.) Is it ethical to institute a mandate for everyone, but not provide the means for filling that mandate? I'd argue no ... if we believe as a society that everyone should have health insurance (which is what the legislation does, via a democratic process), then it is also our obligation as a society to ensure that health insurance is obtainable. And the only way to *guarantee* the availability of insurance is to have a public-sponsored program. Private companies are not permanent, nor are they necessarily stable. It's not a far stretch of the imagination to see a world where due to, say, a fiscal meltdown, all private health insurance companies suddenly go insolvent and are unable to offer new policies. Suddenly, we have a law that requires coverage, but the marketplace is unable to offer a product to satisfy that law. The failure is with the insurance companies mismanagement, but the penalty is enforced on the consumer. Through no choice of their own, Americans are penalized by the law. I'd argue that it would be unethical to write a law that allows citizens to be put in such a bind. That's why I'd argue that a public-sponsored insurance option is a necessary part of any health care reform that also includes an individual mandate. I realize that a focus on the individual mandate opens up libertarian arguments against it. However, I believe we have a right as a society to determine that some things are social goods, and that the state can use its power to tax and/or fine in order to enforce that social good. Again, education is similar. And so are the police and fire departments -- people are required to pay taxes (under penalty of imprisonment) to support those endeavors because there is a public good generated by having those services available to everyone. And it is much more efficient to have everyone paying into the system to support those departments than to have, say, a "fee for service" police department. ("Welcome to Cops 4 Less: Filing a robbery claim will cost $500, charging someone with assault will cost $350 and don't even ask about investigating white-collar crime -- that'll cost you an arm and a leg.") Finally, turning to the perpetual argument against the public option: it'll drive private companies out of business. First, I doubt it -- private firms will find markets where they can deliver value to customers (perceived or real), and people will pay for that additional service above what the public option offers (see: MediGap policies). Secondly, even if it did, that would be only because the public option was more efficient than private firms (they couldn't offer additional value, so they went out of business), so we'd be doing that same task of providing insurance to the population at a lower overall cost to society. What isn't to like about being more efficient in 16% of our economy? Oh, that's right, there's less room for profit-seeking enterprises to capture profit without providing additional value. Which brings me to my concluding point: health insurance reform with an individual mandate but without a public option is nothing more than the "Health Insurer Bail-Out Act of 2009" -- we'd be giving tax dollars straight to the private firms, who have a market guaranteed by law. Shouldn't we demand that they at least compete for our tax dollars? (4 Comments |Comment on this)
Sunday, August 16th, 2009
9:17 pm	Conservatives and Lies The heat of August has settled in, and the Congress has fled the swamp of Washington, DC. After the townhall forums this month, I suppose a few wished they had never left. We knew the debate would get ugly and heated, but what I think has truly caught me off guard is the degree at which the discussion is occurring about topics completely disconnected from reality. There are no "death panels" in the legislation (or even effectiveness review boards, which could become "death panels"). There is no plan to socialize the health care system (let's recall the definition of socialize: place it under government control, like GM or banks that are taken over by the FDIC). The public health insurance option, which isn't even expected to be in the Senate Finance legislation, wouldn't have the support of the government and would have to function like a private insurer in the private market (minus the profit-seeking). And even that is about to be abandoned. (Apparently, winning an election and a majority of Congress, while running on the domestic issue of health care reform, isn't enough of a mandate to actually pass the ideas that were talked about during the campaign.) I understand the political process, and how winning in the public relations battle can be more important than the actual legislation (Harper's has an article about how the PR battle has replaced the actual wording of the Durban Accords on race in many minds). But our public servants (elected officials like Senators, former Alaska governors, etc) are not correcting out and out lies being circulated about the legislation by the conservative commentariat. That is highly disappointing, and I'm having a hard time coming up with similar examples of liberal politicians promoting demonstrably false statements for political gain. Liberals lie about sex scandals, but so do conservatives. I would actually expect liberals to have multiple "truths" -- they are the ones of "relative truth" after all, where no culture, society or group has a monopoly on the Truth. But I am disappointed in the conservatives: they are the ones of "absolute truth" -- and what is written in legislative language is pretty much absolute, provable and undeniable. Where are their principles? (You know, those things you stand by even when it isn't immediately to your own self interest to do so?) Despite my personal political leanings, I tend to respect conservatives for the role they play in ensuring that liberals don't go off the deep end with their "brilliant" ideas. You know, a sounding board, a cooling chamber, a parental voice of reason when the kids want to have candy for dinner. I think this was expressed well by a founding father of the modern conservative movement, William F. Buckley, when he founded the National Review: "It stands athwart history, yelling Stop, at a time when no one is inclined to do so, or to have much patience with those who so urge it." (Full disclosure: I have subscribed to NR for a dozen years - I'm often amazed that it hasn't undergone spontaneous combustion when it has been placed in my mailbox next to Harpers, Atlantic Month, New Republic, the Nation, etc.) Buckley made the Republican party respectable by ousting the influence of the John Birch Society and bringing it back to reality. But recently, there was an insight into the Buckley family that I did not expect at all. Christopher Buckley, William's son, recently wrote about his life in the Buckley household. Now, it stands to reason that he did not have a wonderful childhood (he did, after all, endorse Barack Obama for President), but his description of his mother stunned me: "Over the years, I heard Mum utter whoppers that would make Pinocchio look button-nosed .... I remember the time I first caught Mum in some preposterous untruth, as she called it... I looked at Mum and realized — twang! — that she was telling an untruth. A big untruth. And I remember thinking in that instant how thrilling and grown-up it must be to say something so completely untrue — as opposed to the little amateur fibs I was already practiced at, horrid little apprentice sinner that I was, like the ones about how you’d already said your prayers or washed under the fingernails. Yes, I was impressed. This was my introduction to a lifetime of mendacity. I, too, must learn to say these gorgeous untruths. When Mum was in full prevarication, Pup would assume an expression somewhere between a Jack Benny stare and the stoic grimace of a 13th-century saint being burned at the stake. He knew very well that King George VI and Queen Elizabeth did not routinely decamp at Shannon. The funny thing was that he rarely challenged her when she was in the midst of one of her glorious confections. For that matter, no one did. They wouldn’t have dared. Mum had a regal way about her that did not brook contradiction. So, the founder of modern conservativism, who launched a magazine - and a movement - to stop history from running over the facts, lived with a serial speaker of "untruths" and had given up trying to stop it. I think I'm beginning to understand conservatives, after all... But why does it work for conservatives to completely make things up? On one hand, we go back to the fact that their opponents are the believers in multiple truths: there is always some piece of truth in a statement, right? Even if that "truth" is only the fact that the person saying it thinks what they are saying is true, despite all evidence to the contrary. It is important to acknowledge that truth, or else we might hurt someone's feelings and self-esteem. Secondly, we are witnessing the failings of the profession that sees itself as the seekers of truth in our lives: journalists. As a commentator in the Washington Post wrote today: Conservatives have become adept at playing the media for suckers, getting inside the heads of editors and reporters, haunting them with the thought that maybe they are out-of-touch cosmopolitans and that their duty as tribunes of the people's voices means they should treat Obama's creation of "death panels" as just another justiciable political claim. ...It used to be different. You never heard the late Walter Cronkite taking time on the evening news to "debunk" claims that a proposed mental health clinic in Alaska is actually a dumping ground for right-wing critics of the president's program, or giving the people who made those claims time to explain themselves on the air. The media didn't adjudicate the ever-present underbrush of American paranoia as a set of "conservative claims" to weigh, horse-race-style, against liberal claims. Back then, a more confident media unequivocally labeled the civic outrage represented by such discourse as "extremist" -- out of bounds. (Side note: that mental health clinic in Alaska was one of the things that WFB brought up as an issue with the Birch Society ... see, conservatives used to actually care about the truth.) One of the reasons I pay such close attention to the travails of the profession of journalism is that they are another profession that have their role in society undermined when profits are the sole pursuit (in their case, via the pursuit of sensational stories to drive up viewers rather than a discussion of facts and issues of the day). Actually, the very definition of a "profession" implies that as a class, the group provides a service to society that cannot be fully marketized; same goes for lawyers, clergy, police, etc. Democracy needs a profession to seek the truth of what is happening to real people, not to spout talking points generated by those who are currently in power. You know, the whole "Power to the powerless and afflict the comfortable." I am worried that journalism as a profession will not survive our adoration of "the marketplace". And I'm worried that my profession will be next. (1 Comment |Comment on this)
Sunday, July 19th, 2009
10:21 pm	Reviewing the House Bill I skimmed through a 41-page summary (PDF) of the House version of the Affordable Health Choices Act (PDF, 1018 pages) looking for the sections most relevant to physicians. There are lots of details that will be of interest to physicians in various areas of medicine, but I tried to capture the key portions. Below is that provider-specific summary of that summary. I've tried to ensure accuracy, but if there's something that isn't right, please let me know. I encourage you to read the original sources if you have any questions about the details. The House Tri-Committee bill expands health insurance coverage primarily through two mechanisms: the creation of a Health Exchange and expansion of Medicaid. Plans that are sold through the Exchange will be required to meet minimum standards, and can offer more benefits to obtain one of several higher benefit levels. An advisory committee chaired by the Surgeon General would be responsible for making recommendations to HHS about the coverage required to meet the various levels of plans in the Exchange. Companies will still be able to offer packages outside of the Exchange that do not meet the Exchange standards (but would have to meet the appropriate state regulations, as is currently the law). The Exchange will have a step-wise availability to the population. It will initially be open to those currently in the individual market, as well as employees of firms with less than 10 employees. In subsequent years, the Exchange will become available to more employees at larger firms until everyone has the option in year 5. Medicaid-eligible families would be enrolled only in Medicaid rather than the Exchange for the first five years, then would be able to enroll through the Exchange. There will be credits available to families up to 400% Federal Poverty Level for plans purchased through the Exchange. These credits will not be available to families currently offered insurance through an employer unless that plan costs more than 10% of their income. The Public Health Insurance Option would start in 2013, to be available through the Exchange. It would be under the same regulations as the private insurance. Premiums will be geographically-adjusted and must cover the cost of the program (ie, no tax dollar support). Payment rates for the first three years (2013-15) will be based on Medicare rates plus 5%. After three years, the HHS can change the rates as necessary to ensure access, affordability and efficient delivery of care. The payment system can further be changed to develop new ways to reimburse for care to enhance health outcomes, reduce health disparities, manage chronic illnesses and encourage care-integration. The Public Health Insurance Option can negotiate for drug prices. The Medicare Part D Donut is phased out by 2023. Part D beneficiaries can change plans mid-year if a formulary change adversely affects them. Providers currently participating in Medicare would be automatically enrolled in the Public Health Insurance Option unless they opt out. “Balance billing” would be limited. The Sustainable Growth Rate is repealed. Medicare will increase payment for primary care services and psychiatry. Primary care reimbursement will be allowed to increase at a faster rate than other providers. It also provides incentives to physicians practicing in areas that provide cost-efficient care (lowest quintile of per-capita costs nationally). Payment to hospitals will be linked to re-admission rates for three conditions (to be named later) starting in 2011. Integrates post-acute care providers into the payment system in the following years. Medicare will have an alternative payment system through Accountable Care Organizations, which are physician grouped around a common delivery system (hospital or integrated practice). Spending will be benchmarked; quality care delivered at reduced costs will be rewarded. Demonstration projects for language services, which will be studied by IOM. Eliminates cost-sharing for preventive services in Medicare and Medicaid. Requires smoking cessation to be covered as prevention by State Medicaid programs. Cost effectiveness research center in AHRQ to be guided by public/private stakeholder commission. The commission cannot mandate coverage for public or private plans (advisory role only). Physician Payment Sunshine Provisions requires disclosure of any payment from a device or pharmaceutical company to a provider of value above $5. (1 Comment |Comment on this)
Thursday, June 11th, 2009
10:32 pm	Let's get this health reform started! I am touched and honored that my letter to the AMA resonated with so many other health care providers, and even more with patients. It was humbling to read through the comments on the HuffingtonPost and see how many people want desperately to restore the integrity of the profession, and to see physicians practice on behalf of their patients. I must admit that I was also amused by the number of Star Trek references (I actually get very few of those in my daily practice). The best was "Dammit, Jim! I'm a doctor, not a profit-center!" I was also honored to be recommended for the Nobel Peace Prize, but I think that's a bit premature -- we need to get health care reformed passed (with a public health insurance option) before I'll entertain thoughts of a Nobel. :-) In just one day, we saw an incredible impact: the AMA retracted its opposition to the public health insurance option. This just shows how we are on the right side of history. We know that we must do what is in the best interest of our patients if we are ever to have a health care system that works. There was one theme in the comments to my letter that occurred time and time again - something that I know is not true: patients and the public believe that I am a unique physician in my desire for a patient-centered health care system; one without profits, salary or income as my first concern. Quite to the contrary, I know there are thousands of doctors who believe that we can be the professionals that we dreamed of being when we applied to medical school. If you are a physician who shares this vision of health care, please sign the petition to support the public health insurance option, join the National Physicians Alliance, and talk about these issues with your colleagues. If you are not a physician, you can send the above links to your friends in health care, as well as your own health care provider. You can also support our campaign to advocate on behalf of patients first. I know I am not alone in my belief that physicians have a duty to ensure that the health care system works for our patients. But we need to work together to ensure that our policy leaders hear our voices, because we know the opposition will be strong, will be organized, and will attempt to scare our patients into believing the current dysfunction system is the best that America can do. That is not true. We can have affordable, high quality health care in the United States, and we can do it while still offering the choice to our patients of keeping their current insurance plan if they like it, selecting another private plan, or choosing a quality public health insurance plan. Health care reform will happen this year. We will make the health care system work for our patients. (4 Comments |Comment on this)
Wednesday, June 10th, 2009
10:17 pm	Dear AMA: I quit! Dear American Medical Association, I recently had the opportunity to read your response to the Senate Finance Committee proposal for health care reform, and it is clear to me that I cannot remain a member in your organization. Please remove my name from your membership rolls, effective immediately. In reading the response, I was frustrated and disheartened by the fact that you couldn't get through the second paragraph before bringing up the issue of physician reimbursement. This merely highlights how the AMA represents a physician-centered and self-interested perspective rather than honoring the altruistic nature of my profession. As a physician, I advocate first for what is best for my patients and believe that as a physician, as long as I continue to maintain the trust and integrity of the profession, I will earn the respect of my community. The appropriate financial compensation for my endeavors will follow in kind. I encourage the AMA leadership to read Atul Gawande's recent article describing how physician culture drives up the cost of health care without benefiting patient outcomes. At the heart of this problem are physicians who have a vision of themselves as money-generating profit centers rather than professionals serving the public good. The AMA represents, and encourages, this mindset with its single-focus on physician reimbursement over all other health care reform issues. However, the most disappointing aspect of the AMA's response to the proposed health care reforms was the opposition to the public health insurance option. I simply cannot support an organization that opposes the public health insurance plan for my patients. Instead of advocating for patients, the AMA is supporting the private insurance industry, which has been a driving force in creating the dysfunction health care system we have today. But this should not have surprised me: when health care reform has been necessary, the AMA has always stood on the wrong side of history. The AMA opposed the creation of Medicare in the 1930s, when it was first proposed as part of Social Security. The AMA opposed Medicare again in the 1960s, going as far as to hire an actor named Ronald Reagan to read a script to the AMA Auxiliary declaring Medicare as the first step toward socialism, and concluding with the statement that if Medicare were to become law, "One day, we will awake to find that we have socialism.... One of these days, you and I will to spend our sunset years telling our children, and our children's children, what it was once like in America when men were free." That was 50 years ago ... and none of that has come to pass. And yet this year, the AMA argues that a public health insurance plan will destroy the private insurance market. I challenge the AMA leadership to cite a single example of an industry where involvement by the government has lead to the elimination of private enterprise. This has not been the case with the creation of public police forces in the second half of the 1800's (private security companies still exist), we have a robust system of public and private colleges existing the same market, and bookstores still sell books despite the presence of public libraries. A mix of public and private enterprises in the market is a truly American solution to ensuring equal access, as well as competition to drive quality improvement. In fact, the creation of the public health insurance option will *increase* competition, as demonstrated by the AMA's own studies showing that 94% of health insurance markets only have 1 or 2 providers in the market. It would appear that the AMA's position against the public health insurance market is driven by out-dated political ideology that blindly supports private industry rather than a careful examination of the facts of the current situation. The AMA seems to be fixated on the fact that Medicare and Medicaid payments are lower than other payers. Let's go back to the history again: because the AMA opposed the creation of Medicare, physicians were not represented at the table when the system was designed. As a great policy wonk once said, "If you're not at the table, you're on the menu." And thanks to the dismal leadership and short-sightedness of the AMA in the 1960s, physicians were not a full partner in the creation of Medicare. And we're still feeling the reprocussions of that today. And yet now in 2009, the AMA is going to repeat that mistake by opposing the public plan. The health care system is broken, and physician leadership is needed now more than ever to help direct the reforms that are desperately needed. However, the AMA has not shown itself to be the organization to provide that leadership in restoring the profession of medicine. New physician leadership is needed to fully achieve a reformed health care system that works for our patients and for our country. Sincerely, Chris McCoy, MD (6 Comments |Comment on this)
Saturday, May 30th, 2009
7:07 pm	Residency, by the numbers 444: Number of inpatient admissions worked up 109: Nights on call 1: Call nights in which I got absolutely no sleep 11: Number of admissions to the MICU during that no-sleep night 0: Call nights in which I admitted no patients 0: Patients admitted over a call night on oncology covered by a colleague when I was away for a conference 3: number of times I biked home in the rain 1: number of times caught by a rain storm on the way to work 5: Codes run 0: Peripheral IVs placed 0: Urinary catheters placed 5: Central lines placed 1: Pap smears performed 2: Patients treated with adenosine for SVT 97: Most number of hours worked in a 7-day period (on Gen Med as a senior) 5:15: earliest time in the morning I arrived for a shift (in the MICU as an intern) 8: most hours of sleep on a call night (on 10-3) 6,413: Hours spent in the hospital on inpatient services; add another 1,600 hours for the ten months of electives and outpatient clinic for about 8,000 hours total (3 Comments |Comment on this)
Wednesday, April 22nd, 2009
10:57 pm	Can we find compromise on the public health insurance option? Should we? (Cross-posted at the National Physicians Alliance Blog.) The major battle lines in the upcoming debate about health care reform will likely be drawn around the idea of creating a choice of a public health insurance plan to compete in the market with regulated insurance companies. Republicans have made it clear they will not support such a plan, and many Democrats have announced they will oppose reform that lacks this option. Compromise is as American as motherhood, apple pie and the creation of the US Senate. Undoubtably, our political leaders will attempt to find compromise on this issue as well. While it is less important for the House (where the majority party has near total control), it will be necessary to obtain the 60 votes that may be needed in the Senate. However, the two positions appear mutually exclusive at the moment. But I think there will be proposals that will attempt to find a middle ground. I anticipate they will be focused on the area of competition, since that is a linch-pin of modern GOP talking points. In particular, they are many places in the country with only one or two private health insurance providers, so the creation of a public health insurance plan would engender competition in those markets. (These areas also tend to be rural, which may attract the votes of Senators from important states such as Iowa and Maine.) One approach that has been suggested for similar debates in the past is to create a public plan only for people who live in areas that lack competition among private plans. Thus, the public health insurance option would create competition and choice for those who currently don't have it. Is this a compromise we could live with? Or should every American have the option of enrolling in a public-sponsored insurance plan, regardless of how many private options they also have? Now, consider the alternative proposal that will be suggested to stimulate competition: allow Americans to purchase health insurance across state lines. Currently, health insurance is regulated at the state level. Some states have passed laws requiring health insurance to be quite comprehensive; other states have only minimal requirements. However, if people could choose insurance from any carrier in any state, it would create more options for everyone to choose from. I would call this type of proposal the "UnderInsure America Act". It would lead to many more people purchasing inexpensive and, too late for them to realize, inadequate coverage. Now, how does that first compromise look in comparison? Maybe it is something worth considering ... it would create public plans for some people, allow us to work out the details, have a model to expand to other markets as insurance companies exit, etc. On the other hand, the public insurance plans would likely exist only in rural areas, which have a much different population than urban centers. It may be harder for those plans to build the numbers necessary to demonstrate efficiencies over private insurers. Is this a compromise we could consider? (Comment on this)
Monday, December 1st, 2008
8:35 pm	I'll be keeping my day job So, Obama has nominated Hillary for Secretary of State. Umm, I guess my political musings haven't been particularly prescient. Hillary for SoS? I didn't think so. And now it seems Sarah Palin is the face of the GOP, as opposed to a one-hit wonder who would drop off the ticket within two weeks. Yeah, I'll keep my day job. Hopefully, I'm slightly better at it. Current Mood: Humbled (Comment on this)
Friday, November 14th, 2008
9:18 pm	Transition: From Hope to ? Indiana? And Nebraska's second district? Wow ... I thought I was going on a limb when I called North Carolina for Obama. But now the warm, fuzzy, post-election feeling is starting to fade. And reality sets in. This country is in a deep, deep hole. And we're still sinking deeper by the day. President Obama has his work cut out for him. (As an historical aside, President Reagan also started his first time in a deep recession, but as I recall, things had turned better by the time the '84 election around. Will Alaska be the only remaining red state on the 2012 map?) The hot gossip of the moment is whether Hillary will be part of Obama's Cabinet. Don't count on it. There is no place in the Cabinet that would meet her goals and agenda. And Hillary subordinate to Obama? I can't imagine it. I suspect their clandestine meeting in Chicago was to allow Obama to talk with Hillary about who she would suggest for Cabinet positions. As Bill did many years ago, Obama will fill his Administration with the best-qualified, not just the best-friends. But even if Hillary were the most qualified person for Secretary of State (and I don't think she is), I don't think she'd want the position. No, Hillary's seat in the Senate is a nice place to be. As a member of the Senate HELP Committee, Obama's health care plan has to go through her. Plus, she's on the Armed Forces Committee and the Environment and Public Works Committee. She has a lot of power just where she is now. And unless she's the Decider, I can't see her working in the Executive Branch. There's another issue that is beginning to come up from the left-wing of the Democratic Party: what to do about Bush and torture. This is the single issue that most disturbs me about the Bush Administration and his legacy. He has immensely damaged the image of America as a nation of laws and justice. We must forcefully condemn those actions as antithetical to everything America stands for. However, how to do that? Put Americans on trial? When they were instructed that their actions were legal ... by the Justice Department itself? That doesn't seem right, and in fact, violates the ex post facto clause of the Constitution. I think the best response is to clearly state that the rules have changed, and we will never allow Americans to torture again. This change in policy could in theory be reversed by a future administration (since it appears the current administration is impervious to laws passed by Congress), but I hope that no administration would ever go into that dark place again. We need to move on and move forward. We should relegate the Bush administration to the dustbin of history, where it belongs. Current Mood: Hopeful (Comment on this)
Sunday, November 2nd, 2008
8:30 pm	Final Election Thoughts I'll be on call tomorrow, on the eve of the election, so I won't be going to a Bruce Springstein concert this time. (Apparently, though it didn't work for Kerry in Ohio in 2004, he's doing it again for Obama.) Instead, I'll be doing emergent pre-operative evaluations on the elderly who fall and break their hips on Election Eve. There are worse things to be doing in my distracted state of mind (MICU?). But before I disappear into the hospital for 30 hours, I wanted to toss out a few disconnected pre-election thoughts. Election Day is way better than Christmas: Not only is it for everyone (except felons), but it only comes once every 4 years. And unlike Christmas, when you are likely to get nice gifts from friends and family, on Election Day there is always a possibility that you'll really get a lump of coal. And not just any chunk ... one that will stick around for 4 (or 8!) years. It's like fruitcake! Only your fruitcake doesn't show up on the front page of the national papers on a regular basis reminding you how you didn't get that cool thing you really wanted instead. Sarah Palin - the gift that keeps giving? Sarah in 2012? Please, pretty please, don't throw us in that briar patch! Let's see, she would be a second term Alaska governor running against ... an incumbent Barack Obama. (Or, more disturbingly, Joe Biden carrying forth with the legacy of an Obama Presidency.) By then, Barack will have solidified his national security credentials, and Sarah will have ... invaded Russia? Do you remember what happened with Dan Quayle after his ticket lost the election in 1992. Neither do I .... Hillary done in by a non-issue: It's amazing to think that Hillary's biggest flaw in the eyes of the Democratic primary electorate was her vote to approve the use of force in Iraq in 2002. That irritated the left-wing of the party, and gave Obama an issue to use to peel away idealistic voters. And now? Iraq is a complete non-issue. Barack's signature issue that defined him from Hillary ... is a nonplayer. How would Hillary do against McCain in the context of the economic turndown that has dominated the election since September? Quite well, I suspect. So yes, she could have been President. If I were her, that thought would keep me up at night. I wonder if she'll support a movement to shift the primary season so it is closer to the general election, as to lessen the chance of the issues changing so dramatically from the primaries to November? Atheists: don't bother running in North Carolina. Though the country was founded by a group of Christians, they had good sense to explicitly state in the Constitution that there should be no religious test for public office. Sure, it's tacked on near the end in Article VI, but it's there. Perhaps Senator Dole should be reminded of the wisdom of the Founders. Fortuitous Five? While door-knocking this afternoon, I found a five dollar bill on the sidewalk. No one was around, no clear owner. So I donated it to the cause. The spectrum of Obama's supporters: amazing. Today, I talked with naturalized citizens from Africa, Mexico, and Eastern Europe. But the best moment was when an older Vietnamese man told me (through his teenage daughter, who was translating) that he would be voting for Obama. His face lit up when I responded with the only Vietnamese that I know: cam on. My wildest prediction: Obama takes North Carolina. He'll also take VA, PA, OH, FL, CO, and NV. We'll know the election is over when they call NC for him. Or Colorado. Or Florida. Or Ohio. But he won't take Missouri. McCain's (only) path to victory: he manages to win Pennsylvania. And Ohio. And Florida. And Nevada. I suspect, however, that McCain's ritual early bedtime won't be disrupted by the need to wait for late results to come in before making the phone call to Obama. Current Mood: Hopeful (Comment on this)
Thursday, October 30th, 2008
8:28 pm	Let's hear it for early voting Here's a crazy notion: how about a democracy where everyone who wants to vote, gets to vote. (Once.) It seems like an obvious way to run a representative democracy, but 2008 is looking like one of the first years where that is actually happening. But not in every state. Just the 30-some with early voting. Early voting appears to be the solution to the historical mistake of voting on Tuesdays. Lots of people, you know, "real Americans" have jobs (sometimes two or three) on weekdays (and weekends). They often can't make it to a polling place between 7am and 7pm on the first Tuesday after the first Monday of November. In 2000, I asked one of the cafeteria workers at my dorm if she had voted. She hadn't because she had been swiping our meal cards from 6:45 am until 7 pm. Sure, she had breaks, but probably not enough time for her to go back to her precinct and vote. Apparently, her vote wasn't important enough to count. (Actually, since it was Chicago, there's a chance that she did "vote", but that's another story I'll touch upon below.) Previously, people like her were told: too bad -- you should have planned ahead and jumped through three hoops to get an absentee ballot. But now states are providing early voting. What a concept: Vote when it is convenient for you! There are necessary limitations (a week, or a month, and not after Election Day), but this seems to implement the ideals of our democracy: The People Decide. Not just some of the people, or those with jobs that allow time to vote (or those now without jobs). Everyone. (Except ... foreign nationals, people under 18 and those incarcerated. But those are appropriate limitations.) Remember photographs of polling places in South Africa during its first open election? I get goosebumps looking at similar pictures from here in the US. And this is during the *early voting*! Will there be anyone left to vote on Tuesday? I hope so, I hope so. The concern for voter fraud is, well, a fraud. And here's why: yes, there have been fraudulent registrations turned in by voter drives. And while that creates a hassle for the county to verify or invalidate dead fish, live puppies, or cartoon characters, the vote itself is not disturbed. Unless said dead fish shows up to vote. What about people voting multiple times? Yes, it could (and probably does happen ... rarely). Yet, to have a significant effect on the outcome of the election, it would have to be a coordinated effort with lots of people. And by that very nature of having to be large to be effective, it would be easy to detect -- those kinds of efforts tend to leave a paper trail, disgruntled participants, people with loose lips, etc. It would be exceedingly difficult to secretly tip an election by a coordinated effort of multiple voting. No, the better way to sway an election is to purge the voter rolls of people with names similar to felons. To supply inadequate quantities of ballots to certain voting locations. To use machines and ballots that are confusing to the average voter. Turn off the "overvote" detection in some precincts but not others. Do you get my drift? Everyone who wants to vote, should vote. Period. Current Mood: Patriotic (Comment on this)
Saturday, October 25th, 2008
5:51 pm	Counting Calories and Carbon Between May 1st and November 1st, I estimate that I will have biked to work about 120 times (out of a possible 130 opportunities). At about 10 miles round-trip, that's 1200 miles that I haven't driven. My car gets about 25 miles per gallon in the city, so that's 48 gallons of gas I haven't burned. Gas averaged about $3.60 this summer, so that's about $170 in gas savings. On the environmental side, a gallon of gas produces 19 pounds of CO2, so I've reduced my emissions by 930 pounds of carbon dioxide. However ... I don't hold my breath while biking to work. How much CO2 does biking produce? A quick Google search shows that most estimates say that a person exhales about 2.2 pounds of carbon dioxide daily. That CO2 comes from the food we eat, so if we assume 2200 calorie diet, then for every 1000 calories burned, about a pound of CO2 is produced. Biking consumes about 500 calories per hour. It takes me 45 minutes to bike to and from work each day (20 minutes in and 25 minutes home -- it's downhill going in and I'm usually tired from rounds when going home). So 120 trips lasting 45 minutes amounts to 90 hours of biking. That's 45,000 additional calories consumed to propel myself to work. (For reference, a single gallon of gas has about 31,000 calories.) At 1 pound of CO2 per 1000 calories, it looks like I'm exhaling about 45 pounds of CO2 on my way to work. My primary source of those additional calories is the slice of toast that I add to my breakfast during the summer. A slice of bread has about 100 calories, and there are 24 slices in a loaf, so I eat about 19 loaves of bread to power myself. At $2 per loaf, that's $40 that I spend in groceries for those additional calories. So, to summary the savings and expenditures for biking to work: Savings Carbon Dioxide: 930 pounds Dollars: $170 Expenditures Carbon Dioxide: 45 pounds Dollars: $40 Net savings by biking to work during the summer: Carbon dioxide: 885 pounds Dollars: $130 The opportunity to watch the sunrise (and often the sunset) each day as I enjoy the fresh air, the morning quiet and the occasional sighting of deer, foxes and other animals: Priceless. Current Mood: contemplative (Comment on this)
Thursday, October 2nd, 2008
9:48 pm	That Reagan Quote Sarah Palin ended the debate by including a quote from Reagan: "Someday, we will be telling our children, and our children's children, what it was once like in America when men were free." I know that quote. In fact, it was a highlight of my Failure of the American Health Care System that I gave as AMSA Legislative Affairs Director. Want the full context? Listen to it. Reagan was speaking out against Medicare in the 1960s, paid by the AMA. It gets good starting at about the 7th minute. The quote comes at about 10:50. Current Mood: Flabberghasted (Comment on this)
Wednesday, October 1st, 2008
9:48 pm	Waiting Eagerly for the Veeps I'm excited for the Veep Debate tomorrow night. Much in the way that NASCAR fans are excited about the weekly races - sure the competition can be good, but the spectacular crashes are the real entertainment. And oh do we have some potential disasters awaiting us in St. Louis ... The expectations for the debate have been dramatically heightened (or lowered) by what seems like the longest interview ever: the Katie Couric interview of Sarah Palin that has come out ... drip, drip, drip ... slowly this week, each installment more flaberghasting than the prior. I need not link to them -- I'm sure you've already seen Gov. Palin meander through catch-phrases on her way to not answering a question, how she was unable to name a single newspaper and/or magazine that she reads, how other than Roe v Wade she can't think of a Supreme Court decision she disagrees with ... all of leads to exceedingly low expectations for her tomorrow night. I don't think we're going to have any explosions tomorrow night. Nor any meltdowns. (Question: if Sarah Palin breaks down into tears, would it actually help her?) Anyway, I'd like to see a real policy discussion (which I know won't happen), but here are some questions that I'd like to see answered: Dick Cheney has expanded the role of the Vice President in the past 8 years. What is your vision for the Office of the Vice President? The Vice President often visits foreign countries as an emissary of the Administration. What area of the world would you visit first, and what issues would you raise? Do you believe Guantanamo should be closed? If so, what would you do with the detainees currently held there? One of Dick Cheney's first acts as Vice President was to chair a meeting with energy leaders. He refused to make public the names of those he met with, a trend of secrecy which he continued through his terms. Do you think Cheney has been too secretive? Aside from military secrets, what information should be kept secret, and what kinds of information would you release to the public to maintain transparency and trust in the government? If Al Qaeda detonated a non-nuclear bomb in Washington, DC, what would be your administration's first course of action? China currently holds billions of dollars of US Treasury bonds. What would you do to ensure that they do not sell those bonds precipitously, causing the dollar to crash, especially during our current economic crisis? As President of the Senate, what would you do to restore bipartisanship and a sense of working for a common good in the Legislative Branch, and in the government as a whole? The Justice Department is in turmoil over politicized hiring and firing. What would your administration do to restore the Department? I look forward to hearing at least some of those issues discussed tomorrow and in the upcoming Presidential debates. If not, maybe we'll be entertained by some spectacular high-speed collisions and gigantic fireballs. Current Mood: anticipatory (Comment on this)
Saturday, September 27th, 2008
7:55 pm	An area for personal improvement I've been running for half of my life. Started at the age of 15 with high school cross country. Figured I'd stop when I got too busy in college, but I kept at it (though only recreationally, as Northwestern did not have a men's cross country team due to a common misunderstanding of Title IX). When I started medical school, I thought I'd not have time for running ... only to discover that I had plenty of time for running during the first two years. (It was a little harder to find the time in the M3 and M4 years.) Residency didn't put a stop to it (though I've notice my times have slowed a touch since medical school -- running when post-call is not conducive to fast times). This year I turned 30 and I decided to try something new: a combination of running and biking. It makes sense -- I started biking while in medical school, and I continue to run. Why not combine the two in one event? Like a 5K race, followed by a 19-mile bike ride, followed by a 5K race. There happens to be one such race right next to where I live, so it's crazy not to give it a try. Well, it turns out that I have a bit of a deficiency when it comes to this sort of competition. In the first 5K, I quickly found myself near the front -- 4th place after about 1/2 mile. I clocked the first mile in 5:55 -- just under my goal of a 6 minute first mile. I hit the second mile mark at 12:30 -- right on target. I did slow up a touch at the end of the 5K, finishing in about 20:00. However, I was still in 11th place overall. And then the bike portion started. About the only place on the entire route where I was able to keep up with those around me was on the steep incline near the beginning. On flat areas and downhills? I was being passed like I was out for a stroll. I like to think this was an equipment problem -- my bike isn't a racing bike. It's not even a street bike. It's my commuting bike, with upright handle bars and a rear fender. It is most definitely not a racing bike. During the entire 19 mile biking portion, I passed all of one competitor - someone who had passed me earlier in the biking route. I felt like a lead weight sinking to the bottom of a fast-moving stream. Even when we turned the corner for home, with a nice tailwind, I couldn't keep up. I was in 24th gear (of my 24 gears), pedaling as fast as I could, and people just pulled away from me on their high-end speedsters. Alas, the biking portion came to a close, and I parked my bike (one of the few with a kick-stand) and hopped back on the running course. As I did so, I thought popped into my head: "What are Earth are you doing?!?! You've already run a 5K today, you just finished nearly 20 miles of biking, and now you're running again?!" However, I was able to make up some ground on the bikers once we were back on solid ground. And in the end, I finished 30th after clocking a 22:00 5K. One of my slowest competitive races ever -- but given that I have never run a competitive 10K, I thought 42:00 minutes for a 10K of running was pretty good. But, about that biking part ... well, I checked the results this evening and discovered that while I was 11th in the first 5K, and had the 18th fastest time in the second 5K, I was ... wait for it ... 61st in the biking portion. That's right -- I wasn't even in the top half when it came to biking. Hmmm ... that appears to be an area for personal improvement. But the results yielded an even more entertaining find: I'm pretty fast at the run, not fast on the bike, but I'm really fast in the transition: I was the 3rd fastest transition from running to biking, and the 2nd fastest from biking to running. (I love the fact that they even keep track of that.) There's a simple reason for my transition speed: you see, my bike is so pedestrian that it doesn't even have clip pedals. That meant I did the entire race in my running shoes. By not switching shoes, I probably saved an entire minute. Tomorrow, I have a feeling I'm going to be pretty sore. But now I have a goal for improvement in next year's race: transition times under 30 seconds! Current Mood: diffuse myalgias (1 Comment |Comment on this)
Saturday, September 13th, 2008
9:16 pm	Palin's Personal Politics In contrast to the blathering drivel about cosmetics on farm animals, the New York Times has published a detailed review of Sarah Palin's political leadership style based on her experience in Alaska. Finally, some in-depth research and analysis of how she has approached her role as Mayor and Governor. It is worth a read. The article takes a critical tact, but that is appropriate. It would have been nice if it had been done concerning the leadership style of our current Veep ... before he took office. Governor Palin takes a similar approach to leadership to what we've seen from the Bush administration: loyalty is favored over expertise, disloyalty is punished harshly, and secrecy is paramount. We have seen what that approach does to good governance over the past 8 years. Four more years will lead to further fraying of our social covenant with our government. The New York Times does have a journalistic bias: in general, they favor openness and transparency because those are important values to journalists (it makes their jobs easier). And there are occasional sentences that belie a secular bias ("The new mayor also tended carefully to her evangelical base. She appointed a pastor to the town planning board." -- so? Ministers are often also leaders in the community). But overall, the piece is well-written and well-researched. And it shows that a Palin Administration would be loaded with friends and loyalists who use political power to exert personal goals (and not just obtaining sexual favors from interns). I hope this article stimulates a discussion about what kind of leadership we want from our next administration. We deserve better than another four years of leaders who use political power to advance personal issues. Our government works for us. As a young politician from Illinois once put it, "Government of the people, by the people, for the people." (1 Comment |Comment on this)
Friday, August 29th, 2008
9:28 pm	Vice President who? Sarah Palin? Really? John McCain's selection for Vice President certainly will re-enforce his maverick status. But, really? I'm not the first to point out that having her on the ticket completely undercuts the argument that Obama is too inexperienced to be President. The sole purpose of the Veep is to be President at a moment's notice. So, if Governor of the smallest state, and former mayor of a town with as many people as the building I work in - if she's qualified to be President on Jan 22, 2009, then so must Barack. The choice just seems so ... appropriate. For a college dorm room bull session with too many PoliSci majors. Sure, she's a woman, but she's not exactly going to win over the moderate and liberal women who supported Hillary during the Democratic primary. Yes, she's a working mother with five kids, including one under 6 months of age, but did people really vote for the person who looks most like them in a mirror, regardless of their politics? Here's a scenario I'd like to lay out: after one day, there is a touch of backlash from the conservative pundits. Initially, there was praise for the way Palin changed the discussion, but now there's the morning after. And some folks, like David Frum, are having second thoughts. We've seen this story play out before, when President Bush nominated Harriet "Who?" Myers for the Supreme Court. There was surprise, tepid acceptance, but then an overwhelming wave of disapproval from the insiders. In the case of Ms. Palin, I anticipate that a brewing scandal (either known or soon to be discovered) will explode. The GOP and conservative opinion leaders will decide whether to support McCain's choice, or quietly abandon her, leading her to step aside for the betterment of the party. And then McCain will choose a more conventional choice (read: Romney), but will get points for being a maverick first. In the meantime, we'll get an onslaught of discussions about whether a mother of a toddler is the appropriate person to be mere asystole away from the Oval Office. Let the disparaging sexist undertones resume! (You've missed them since Hillary conceded, haven't you?) Current Mood: surprised (1 Comment |Comment on this)
Sunday, August 17th, 2008
11:10 pm	Olympic Thoughts After a week of watching the Olympics (a bit of a challenge without cable, or even a television), a few thoughts come to mind: Michael Phelps: Wow. Shooting is an Olympic sport? I thought the Olympics were supposed to bring about peace and harmony among nations by bringing the young athletes together every 4 years. And yet, the first medal is awarded by someone's ability to use a weapon. Come to think of it, why are their separate men's and women's shooting events? Shouldn't this be an arena where gender differences are mute? Whether you have a Y chromosome or not doesn't really affect your ability to aim and pull a trigger, right? Though, it occurs to me that the small bore, 3 position competition sounds like it belongs in a porn movie rather than the Olympics. Gymnastics - incredibly athletic, requiring insane amounts of strength and control, but not a sport in my book. Let's call it what it (and it's winter cousin, figure skate) truly is: competitive art. Sure, there are required components, and penalties for falls and stepping out of bounds, but there's also a purely subjective component. What if one judge thinks dancing like a robot is more artistic than smooth, flowing moves? Why is that opinion wrong? Why is another correct? Opinions and style preferences can change. Sports should have objective measures: who scored the most goals? Who crossed the finish line first? Who touched the wall first? These are easily recorded, documented and agreed upon. Yes, there are always subjective components (was that a foul?), but the final measure of competition is objective, not subjective and subject to debate. We know Michael Phelps touched the wall first because we can all see it on the replay. Track should use a start system like drag racing with a series of lights. They use something similar in bicycle racing (in the velodrome portions), so why not on the track? It would be better than penalizing those with slow reaction times, and would eliminate the bizarre fact that a runner can be deemed to have a false start even if they leave the blocks after the gun (but sooner than 0.1 seconds after the gun). Beach volleyball? Come on ... how is putting one sport on sand make it a different sport? Beach soccer, anyone? And don't get me started on trampoline (see gymnastics, above). Synchronized diving doesn't come close, either, but it would be more interesting if the divers had to make contact with each other during the dive. (What next, couples trampoline?) That's enough for one night. Now back to watching some incredible athletes in action .... (Comment on this)
Saturday, August 2nd, 2008
7:30 pm	Leadership There are many definitions of a leader, and many different qualities that people expect to see in their leaders. One aspect of being a leader is encouraging and enabling those around you to become better people. Think of the lionized leaders in American history: Lincoln, Jefferson, Martin Luther King, JFK -- of the many things that they did as leaders, they all challenged Americans to be better people. On the flip-side, we generally don't have statues and schools named for people who encouraged bickering, pettiness and squabbling (unless the particular person strong-armed the funding for the project and had it named after them - see Stroger Hospital). At the moment, one Presidential candidate has struck a tone that has resonated with the American people, and the people of the world, in a way that has caused millions to engage in the political process and social endeavors. And the other guy is just cranky. Even if the former has a thin resume, and doesn't have solidified policy statements on every issue, I am hopeful that his mere presence and energy will encourage and enable the American people to move into the 21st century. (And stop fighting Vietnam. Please, just stop fighting that war -- we've normalized relations with the former enemy at this point!) Obama represents a new generation, one with a different understanding of race, poverty, homosexuality, the information age, and how success should be defined. Are we going to keep driving toward enriching the bank accounts of a few at the cost of the environment, social strife and the destruction of the family? Or is there a role for community and coming together for a bigger, better cause than ourselves? I think the biggest challenge Obama will face is that which brings down all great, inspirational leaders: failing to live up to the expectations of their followers. Great leaders have a tendency to encourage others to be better people -- all the while masking their own personal flaws. And while Jefferson, JFK and MLK may have been able to hide their flaws until after their death, in this era of intense media coverage, any speck in the character of Obama will be magnified. Can he manage the expectations of the masses? That may be President Obama's greatest challenge. Recently, commentators have pondered why Obama doesn't have a bigger lead in the polls. Americans want change, and he is the candidate of change. So why isn't he farther ahead in the polls? Gosh, could it be because he is a black man with a Muslim name? This election environment clearly favors the Democrats. I'm glad that we had the opportunity to choose between two Democratic candidates who would each be breaking a barrier as President. This was the ideal year for a non-white man to run for President -- it will take a substantial tailwind for either a woman or a minority to win the White House because there is a steep hill of prejudice to climb. But that is the case this year, and now is a prime opportunity to break the monopoly that pale penis people have had on the Executive mansion. So yes, Obama isn't winning as dramatically as he would be if he were a conventional Democratic candidate. But I believe that if the American people select him as our leader, he will inspire us - and the world - to new heights. Current Mood: Inspired (Comment on this)