Another new direction

I’ve been in medical school for almost three months now. It’s time to turn this thing into a proper med school blog.

That means three things. First, from now on, only the posts I’ve written during med school will be visible. Second, I will be attempting to hold to a regular update schedule (TBD, but probably biweekly). And finally, rather than flailing away without explicit goals, I will now be purposely attempting to:

1) Practice my writing.
2) Summarize and analyze the things I’m learning outside of class (through posts like this one). These will mostly be centered around health care improvement, a REALLY broad term which I’m using here to include everything from federal policy (like PPACA) to innovations in delivery on the ground (like PCMHs).
3) Track my personal and professional development (through posts like this one).

Hopefully, having an audience (even if it is just my poor Facebook friends) will be enough to keep me on track with these goals.

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Takeaways from the #CUMCforum

Last night, I attended my university’s Election Forum, a health policy discussion with Thomas Barker from the Romney presidential campaign, and Vivek Murthy from the Obama campaign (slightly more information about event and the speakers is here, sorry for the facebook link). You can see the live-tweeting of the event here, but I thought I’d try to use this mostly defunct blog to organize a few takeaways:

1. Republicans are much more in favor of payment reform than I thought. With all the rhetoric flying about repealing PPACA, I just assumed that the payment and practice reform provisions were on the chopping block as well. Not so, apparently: Mr. Barker had very positive things to say about patient-centered medical homes, ACOs, and capitated reimbursement.

2. Romney’s been pushing “repeal and replace the ACA” pretty heavily. While he could likely repeal/block large portions of it, it is highly unlikely that he’d have a cooperative Congress with which to implement his own reforms. Mr. Barker slammed Obama a bit for ramming through PPACA “in a very partisan fashion,” though I’m not sure it would be possible any other way. Perhaps a more bipartisan law, with Romney/Ryan’s premium-supported Medicare, and also all the popular parts of PPACA like the pre-existing conditions requirement (which Romney aims to keep!), would make it through the process, and would be stronger for the compromises. But I’m A) not that optimistic and B) think that such a thing would be pretty devastating for those who qualify for insurance subsidies and the Medicaid expansion (read: the poor).

3. For Republicans, fixing Medicare insolvency is the top priority (I didn’t catch an equally clear “top priority” from Dr. Murthy). According to Mr. Barker, this needs to happen by switching Medicare from a “defined benefits” entitlement to a “defined contribution” model (a decent, and really long, outline of that argument by a Romney health care advisor is here). Those terms, and that whole question, will require an entire post (or series) of their own.

4. Surprise! There’s disagreement about Medicare Advantage! Mr. Barker characterized it as “the future of Medicare,” while Dr. Murthy was less sanguine about its purported benefits. My memory of his actual words is foggy now, but a common Democrat position seems to be that Medicare Advantage costs the government (CMS) more than “regular” Medicare, without delivering more benefits. This is something I need to look into, clearly. (Care to educate me in the comments?)

5. Tort reform didn’t seem to be very high on either agenda. Not surprisingly, either: it’s not actually as large a driver of health care costs as people tend to think, and cost seems to be the major driver in health reform recently. But it’s still a very important issue, and it would be nice to see more coherent ideas articulated by both parties.

6. Confusion about graduate medical education (GME), the insufficiency of which is a large contributor to the physician shortage, especially in primary care. Mr. Barker’s take: repealing PPACA will restore the cuts Obama’s making to CMS (the infamous $700 billion), which includes funding for GME. Dr. Murthy’s answer was less clear-cut to me: it seems that the Prevention Fund allocates money to primary care GME, but this money is in danger if we go over the fiscal cliff. GME funding reform has been needed for ages, and it’s disappointing to see it getting largely overlooked in the health policy conversation.

7. Overall, the discussion was very amicable, and a good reminder that both Republican and Democrat health policymakers have the same “Triple Aim” in mind, namely: “improve the health of the population; enhance the patient experience of care (including quality, access, and reliability); and reduce, or at least control, the per capita cost of care.” While the effects of PPACA on Medicare and the federal budget make Republicans very critical of any comparisons to Massachusetts health reform, there is a large amount of overlap between the parties on this issue.

8. However, the very significant differences between Republican and Democrat approaches to health care also became clear several times during the event (no surprise here). Broadly, the most controversial part of health care reform seems to the parts of PPACA that seek to implement universal insurance coverage. According to Mr. Barker, adding a huge new entitlement without paying for it is a great threat to the solvency of Medicare/Medicaid (and, by extension, the federal government itself). However, that new entitlement, the expanded insurance coverage of low-income citizens (through the Medicaid expansion and subsidies available for use in the insurance exchanges), is an indispensable component of health care reform for Democrats, and for anyone who considers equitable access to health care a fundamental aspect of social justice (like me). On this issue, I doubt there will ever be bipartisan agreement.

9. It will be very interesting to see what happens in this election. No matter who is elected, major changes are coming our way.

Thanks for reading! This is something of an inaugural health policy post for this blog, so I could really use some feedback/correction if I’m misrepresenting any issues or positions here.

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Turning the pages

The countdown started on January 26th. Acceptance Day.

With great relief, one chapter of my life came to a close that afternoon. I was no longer a pre-med. Of course, I still had a full semester of Physical Biochemistry and other fun ahead of me, but the agonizing process that started in 2008, almost four years of undergrad with the application never fully out of mind, was over.

In many ways, it felt like the book wouldn’t open again until August 4th. The time between acceptance and orientation felt out of place, like a tangential plotline that wouldn’t really affect the story of my life, yet still needed to be listed somewhere in the table of contents. In an instant, part of me had checked out of college. I would continue to work hard in my classes for the joy of learning (in the interesting classes, like Environment and Development in the Third World, and Women of Color Feminism) and out of stubborn perfectionism (in the boring ones, like Organic Chemistry Lab). But pre-meds have the importance of perfect grades drilled into their heads so often that over time, the purpose of school becomes nothing more than the acquisition of those grades. And I was finally free of that unhealthy cycle.

All that mattered was counting the days. My last semester of undergrad did its best to distract me.

Summer brought its own distraction: a two-month whirlwind tour of Southeast Asia. Unlike studying abroad, this trip didn’t bring any revelations, or work any significant transformations in me. Instead, it was travel for travel’s sake, to be places and see things without higher objectives than seeking adventure. Exactly what I needed, on the edge of burnout, before starting the hardest four years of my life.

But such periods of adventure don’t fit easily into the personal narratives you tell at interviews. This summer feels like a section of pages that have come loose from the binding of an old paperback, sticking out slightly no matter how carefully you place them back in.

Today is August 4th. The countdown has switched from days to hours. In five of the latter, I will be on a plane to New York, opening up the brand new chapter entitled “Medical School.” Unable to sleep, I’ve come to realize something.

Med school won’t be a glamorous period that mystically transforms us into physicians. It won’t be drastically unlike our current lives, and we won’t find ourselves to be unrecognizable on the other side of these four years. Instead, it will become just another part of the same daily struggle with life in which we have engaged for 22(ish) years, along with everyone around us. The challenges will be unique in some ways, but challenges arise in all areas of life, and will continue once we’re done. And to draw on the wisdom of my childhood hockey coaches, we’ll get out of it what we put in; it’s up to us to take the skills and knowledge presented to us and transform them into action.

We build up such high expectations as pre-meds, but we shouldn’t overestimate med school. Yes, we got here. We earned it. The white coat ceremony will be a recognition of all the sacrifices we made to join the profession. But that will probably be the extent of the breathtaking, transformational feelings. Despite the ceremony of it all, we probably won’t feel like we’re actually changing.

And that’s okay. Professionalism means not that we will stop seeing ourselves as kids, but that we will learn to act according to the demands of medicine, despite our inner childishness. Life isn’t about grand personal narratives that you can compress into sound bytes for your interviewers and secondary essay readers. The journey of growth and self-discovery isn’t linear, and it doesn’t have to make sense to the outside observer. And it probably won’t make sense to ourselves, either. So we’ll start new chapters, drink from the firehose, encounter more problems than solutions, generate more questions than answers, and discover how open ended the story really is. Even as we find ourselves getting corralled into interest groups and specialties and seemingly esoteric research projects, each step in a new direction will be a step forward.

The days will blur into each other, as they always do. The chapters will fall into place behind us as we keep turning the pages.

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