back to school

I've enjoyed seeing everyone's back to school photos of social media these past few weeks, though they make me realize that I must be either one click off age-wise or else totally disconnected from current parenting trends, as I have never in my life taken a picture of my kid holding a sign (or if you want to get real fancy, a blackboard) broadcasting what grade they were going into. (Another trend that either came later or else that I just totally ignored was that thing where you put a giant sticker on the front of your kids' onesie telling everyone how many months old they are.) I mean, not that I don't take a picture of my kids on approximately the first day of school, because I do...kind of. But it just seems like there are so many things and rituals and accoutrement now. Like the child-rearing industry is slowly becoming the bridal industry.

But speaking of back to school...

Around the end of last year (right around, oh, say...Wednesday November 9th), I started thinking about how I could get more involved in healthcare on a broader level. I love my job and have no plans to stop being an anesthesiologist, but I also wanted to do something...else. Something more. Something less zoomed in, something a little more macro, something more policy and population-based. A broader way to help out. So what I decided to do was to go back to school and get a Masters of Public Health.

This was not an easy decision. Getting this degree is going to take a lot of time. It comes with a not-inconsequential monetary cost. I don't "need" to do it, and in most ways it's going to make my life a lot harder. It's not linked to any particular path for upward mobility or higher earning power, and I'm not looking to switch jobs. Almost no one that I'm close to understands why I want to do this, or thinks its remotely a good idea. (My parents seemed initially excited at the news, but then rapidly realized that I said I was getting an MPH, not an MBA, as they misheard. They were much less excited after that.) Oh, and also, I don't really have a really good specific idea of what exactly I want to do with this degree when (or if) I finally complete it. If I'm going to be totally honest, the only real reason I want to go back to school is because I want to learn more about public health, and can only hope that in the process of going through the coursework I'm going to find a useful, real-life way to marry this knowledge with my current career and find a good, real-world application for it. But I don't know what that's going to look like yet.

So anyway, that's happening. I've been accepted to the Mailman School of Public Health at Columbia, and will be starting their part-time executive MPH program next week. "Part-time" means I still will working my normal job, exactly the same as before. It also means a lot of remote work and an online curriculum, though once a month, for one long weekend (Thursday through Sunday, all day long), I will be flying into New York and completing my in-person classroom requirement. This, every month, for two years. We had an on-campus orientation in August. The first official day of classes is next week on September 14th. If I can get through this all without losing my mind, I'll be slated to graduate in August of 2019.

The time investment. The time investment is...a lot. I take it seriously. I work part-time at the hospital, but I have three kids (which is why I went part-time in the first place), and kids don't just go on auto-pilot. Doing this program necessarily translates into less time for me for them. It means more time in the evening spent in front of books, more than twice as many weekends I will be out of the picture, less flexibility for everyone all around. This was Joe's main objection to me starting this program. I don't think I'm airing any dirty laundry by talking about this, because he'd tell you just as easily: he doesn't think this is such a great idea. He's nominally supportive, and by that I guess I just mean he would never tell me explicitly not to do it. But for our family, I know he'd really rather I just...didn't. He doesn't see why we spent so many years getting to a point where our life was finally getting easier only to deliberately make it harder again.

But that was my exact thinking, only in reverse. We have three kids. Our youngest, Nina, just started kindergarten this year. I'm not saying our kids still aren't youngish (they are), or that they don't need me as much (they do, though the ways in which they need me are less about immediate survival and more about presence and guidance and...well, I guess I do all the food shopping and cooking, so, yes, maybe a little bit of survival). But it's a bit easier now. We have some breathing room. We have margins. What do you do with that elasticity? What else do you want to do? What's important to you? Is it about the luxury of empty space, or is it about the luxury to take on more? To do more with your life? What comes next?

Also. I finished residency nine years ago. Nine years into private practice. I love my current job, I love taking care of patients. It's the most rewarding, immediate, and intimate type of service I could ever hope to provide. (I know I'm supposed to say, "outside of parenthood" right here, but I won't. It's not that I don't think parenthood is important, I just feel it's a completely different thing.) But I feel like there's more I want to do. I just don't know how yet, so I want to learn. Because life is not lived in order to be easy. Life is lived to be worthwhile.

And honestly, once I decided to go ahead and do this thing, part of me was really tickled and excited about the idea of going back to school. It's been a long time. And I like school. I like learning. I like knowing things. I especially like knowing things that I feel I should know already. I've been doing some pre-reading for some of my classes, and there are so many things I'm learning now--about healthcare economics, policy, the history of Medicare and Medicaid--that I can't believe I hadn't been explicitly taught before. And the fact that I'll be back at school right where I started, at Columbia, on the health science campus...I just get a kick out of returning "home." (Columbia friends: the School of Public Health is located in the old Psych Institute, next door to the new Psych Institute, two doors down from our first year prison dorm rooms in Bard Hall. That was a grim little block wasn't it?)

So anyway. That's what's new with me. How have you been doing?

credible threat

Probably one of the ways to not fall into a funk of not writing is just to keep on writing. So with that in mind...this thing!

I'm on call at the hospital today, which—OK, look, no one likes being on call, right? Given the choice between walking the halls of the hospital at 6:30am on a Sunday morning and, I don’t know, having French toast with your kids at home, I think most people would choose the French toast. (Plus or minus on the kids.) But there’s something about being part of the bigger machinery that makes things work. There are unglamorous, less fun, more onerous parts to every job. But you spread them out and everyone takes a turn at it and that’s how you keep things moving forward. This weekend just happens to be my turn. So in that sense, no, I don’t mind it that much.

The other day, when I got home from work, I received this email from the administrators at Cal’s school. Here is the body of the text, excerpted in part:

Last Friday afternoon, we were alerted to the presence of some graffiti in our 7th grade boys’ restroom. It read, “I’m shooting up the school on last day of January.” Some students took a picture of the message and shared it before we learned about it. […] We began an investigation with our administration and school police officer and continue to follow various leads. As of this time, no other graffiti has occurred. The threat references the last day of January as the date that something would take place. While we are always concerned about any threat to students’ safety, we are not alarmed. Although we have nothing to suggest any credible threat, we have reached out to the […] Police Department for additional follow-up and to provide a larger law enforcement presence than normal.

Now, you’ll recall from yesterday's post that Cal is 11 years old now, and in the 7th grade. My God, the 7th grade. I don’t know if this makes me egocentric or what, but the most remarkable thing about having a kid that age is that I truly, vividly remember being that age myself. Not in the way you recall being six or seven—at that age, some memories stick out, but the edges are fuzzy, timelines occasionally discontinuous, characters fungible. No, I mean I really remember being in the seventh grade. I remember where my locker was, and who had the locker above me. I remember the classes I took—not just what books we read and projects we worked on, but I remember the thoughts I had during the classes; about my classmates, about what I was going to have for lunch, about the unfortunate macramé-d sweater vest my French teacher insisted on wearing week after week. Remembering yourself as a preteen is different from remembering yourself as a young child, because after a certain point, though you still had room to grow and mature, that was you in there already, soft but fully formed, the person you were set to be all along.

Cal and I are similar in a lot of ways. He’s smarter than I was, but the way we think about things—the way I thought about things when I was his age—are the same. Sometimes when he tells me things about school, I think about it in the shoes of my own self in that same situation at his age. I don’t know, maybe that’s unhealthy? I’m not projecting myself onto him or anything, and I don’t insist that he does things my way (or the highway, boy). It’s just hard not to associate yourself strongly with your children, particularly as they get older and that parent-child gap starts to shrink ever so slightly.

That said, I have no experiential knowledge of how it would feel to truly worry that one day, some kid might come into the seventh grade hallway, fully armed, and start shooting at people.

The world, as we all know, is a different place these days. Those of us with young kids in certain parts of the country (maybe all parts of the country? I’m actually not sure) know that we don’t just run fire drills anymore. We run disaster drills. We run “active shooter” drills. I don’t think they’re explicitly stated as such—particularly in the younger grades, I they try to keep the scenarios as vague as possible—but this is the world we live in, that we need to rehearse what to do in the event that someone comes into the school with a duffle bag full of guns and just opens fire. It’s so common we have a whole language around it. “Active shooter situation.” “Another school shooting.” Did you know that the columbine is a flower? Maybe you did, but many probably don’t, because it’s not “a columbine” anymore. It’s: “Columbine.”

Part of the problem with the Trump ascension is not so much that we don’t know what to fight against, it’s that there’s so much to fight against that we all get overwhelmed. Which fight do we take on? Which atrocity should we protest first? Which rights should we prioritize to defend? Healthcare access? Reproductive freedoms? Immigrant and refugee protections? Gun control? Environmental protection? The basic human tenet of not acting like a total dickhead at all times? There are so many things that people can’t even pick just one or two, and I think, for me at least, it started to feel like too much. Like: IT’S OFFICIAL NOW, EVERYTHING IS THE WORST, TIME TO LEAVE THIS EARTH AND EJECT MYSELF STRAIGHT INTO OUTER SPACE, BECAUSE THIS WHOLE THING IS SO BROKEN IT’S BASICALLY UNFIXABLE.

So, back to the email. Do I think that this bathroom graffiti threat is real? No, I don’t. I think it’s probably some little punk-ass shithead doing what he does best, which is being a little punk-ass shithead. (We all were, to some degree, at that age, because one of the important tasks of adolescents is learning how to be a human being, and even the best 7th graders aren’t quiiiiiite there yet.) But just the fact of any of it. The fact that he (I’m just presuming “he” because it was written in the boys bathroom) thought to write that particular message. The fact that some kids saw it and got scared and took a picture. The fact that the administration had to investigate. The fact that the police are involved. The fact of the “increased law enforcement presence” as a result. All of it.

It’s not the fact of what is ultimately an adolescent prank in poor taste, so much as the fact that we’ve lost the privilege of truly being able to view it as such. Say what you will about gun rights (and, again, I live in the South—I’ve had this conversation before), but in the end, the resultant culture is one where there is a little less freedom for all of us. I don’t have the freedom to send my kid to school tomorrow and be able to get through my day without worrying, in some dark back corner of my mind where all these types of thoughts collude, that he’s going to get shot. That’s a big concession. These are huge societal losses that we’ve borne.

But when I get overwhelmed with all the things that are wrong and getting wronger by the day, I think: OK. Stop for a second. Slow down. There’s a lot we need to work on, but it’s not going to all happen at once, and it’s not going to all be just on a few of us. There are lots and lots of good people out there who want to help. So I pick things that I want to work on right now. It’s not always the same thing, sometimes it changes week to week, depending on what’s coming up and what seems more urgent in the moment. But I pick a thing, or a few things, to focus on. Other people will pick other things and focus on those. And in that way, it’s like taking weekend call. We spread out the work. We each do a little bit and in that way, eventually, we get to take care of everyone.

I think being overwhelmed at the scale of the job before us shouldn't make us shut down and disengage. I think it’s a reminder of how deeply we care about so many different things. And in the end, that's never going to be a bad thing.

The Little Thing I Did Today: Called my two state senators and left voicemails opposing the immigration ban imposed by President Trump. (Wow, it never stops being weird. "President Trump.") If you live in Georgia, it's interesting to note that neither of our Senators have actually spoken up in favor of such a ban (to my knowledge), so a vocal opposition to the executive order from their constituency might make a difference. 

To help, here: a list of all the U.S. Senators, and their positions on the immigration ban if ever publicly stated. Contact info included, along with social media handles. 

ch-ch-ch-changes

This blog, from the beginning, has been a journal about change. I started writing here in the year 2000 (though some of the older Homestead archives have since been eaten, believe me, they went alllll the way back, and yes, there was an Internet then) and from the beginning, it’s been a chronicle of ∆x/∆y. Medical school. Marriage. Residency. A different residency. Parenthood. Moving to the South. Every year was something big and something new and oh hell, how are we going to do this now and the constant, underlying theme through it all was change.

At the time I kind of petered out on the blog (and know that I never really intended to step away entirely, but the slow fade just kind of…happened) part of it was that the rate of change had slowed. Things were calming down, and we were settling into our lives in a way we’d never had a chance to before. Joe and I were both attendings and in stable jobs. Our kids were getting older. We bought a home and lived in it for a while. There were days with patients and nights on call and parent teacher conferences and summer camps and carpool lanes. And while things continued to be busy, they also became shockingly normal. Calm. Maybe even a little bit boring, though I mean that in the best possible way. It just felt, though, that in this journal about change, there wasn’t much left to write about.

I don’t think I feel that way anymore. There are a lot of ways to view this post-Trump ascension world we live in now, but I don’t think I can say anymore that life ceases to change. But neither can I continue to insist that it is boring, so...there's that. I think a lot of people—regular people, normal people, people like me—have a lot of energy and a renewed sense of civic responsibility in the face of this new administration, but often if feels difficult to know where to channel all that energy, you know? What do we do now? Where do I put all this? How can I help? How do you do stuff?

Look, I’m just a dumb doctor. I do what I know how to do. I work with patients. I help people individually in sometimes big but usually small, concrete ways. I speak the language of medicine and science and research and data. My campaigns are waged at the bedside, or in the operating room. I’m not a politician. I’m not a legislator. I’m not a lobbyist. I’m not a judge. I don’t know how that world works, or the avenues into it. But I want to change that. I want to learn. Then I want to do it. And I don’t want to do it alone.

I’ve done a few things since Election Day. These are just very small things, things I know how to do, in order to chip in, help shore things up, fix things, and teach my kids how to do the same. But it’s not enough. These things are important, but they are also too small. I know it takes thousands of little drops to fill a bucket, and I want to keep on adding those drops, but I’m ready to start doing more, and I just need to figure out how. So now we’re going to start, and we’re going to do it together.

Here’s a small list of some of the things my family and I have done since November 9th. It’s not a complete list (there are probably some things I don’t quite remember, I didn’t write them down or anything), but I also didn’t talk about it much on social media either, because my instinct was always that anonymous good works are the best kinds of good works. However, now I think the need for collective action and coalition building supersedes those instincts, and also, more than ever, we deserve to know that we’re not alone on this. So, an incomplete list.

• Donated money to Planned Parenthood.
• Donated money to National Public Radio and the Public Broadcasting Station.
• Donated money to the National Parks Service.
• Volunteered at Hands on Atlanta making holiday gifts for veterans at the VA. (The kids helped with that one.)
• Sponsored a needy family for the holidays through Families First Atlanta—a mom, kid, and grandparents. The dad had been deported earlier in the year.
• Signed up with the Clinician Action Network.
• Signed this petition to fight the repeal of the Affordable Care Act.
• Donated to the DNC.

But these are tiny actions, and not nearly enough. Lately it has been suggested to me that one means of political action is, quite simply, talking out loud. I mean, after a fashion. Via the Internet, on social media, ways in which ideas can be shared widely and communities built broadly. I know this is not a new idea at all—it's pretty much Twitter's entire modus operandi, at this point—but I never felt that it was as satisfying talking about doing stuff as actually just shutting your mouth and doing the stuff. But I think what I'm learning now is this. Sharing ideas is activism. Talking to people is activism. Starting the conversations and keeping them going is activism. And then we'll get to what comes next.

Anyway, this blog. I'm still just a doctor. This has always been a small platform focused on the minutiae of daily life, and will continue to be for as long as I can remember my Blogger password. (Hey, shut up, it's hard sometimes.) But the world is bigger than any one of us, and it's also up to us to take responsibility for all of it.

Now, to what you've all actually been interested in.

Cal is eleven now, and in the seventh grade. I know many of the people who have been following this blog since time immemorial remember when Cal was just born, and it's impossible for you to believe that he's in middle school. Don't worry, I feel exactly the same way.

Mack just turned eight a few weeks ago, and is in the second grade. He only recently stopped making a weird face every time I tried to take a picture of him. This photo was taken before that particular skill was mastered.

Nina, she will insist on telling you and everyone in earshot, is A Big Girl. She also insists on dressing herself sometimes, as you can clearly see, but has luckily tried to cut her own hair only once. She is four and a half years old, and in Pre-K.

Joe is 42 now and in the one millionth grade. No, but really, he's doing well. I'm not going to talk too much about his work, because that's probably pretty boring, but he's great at what he does, and it's an honor being on his team. Probably the most important thing you can do in life is choosing the right co-pilot, and somehow I lucked into a good one. I'm not a perfect person, and I have more flaws than I can reasonably enumerate. But whatever good I've done, and continue to do, is due to and in the service of these guys right here.

Anyway, this is just a brief mic check, and a post it note on the wall to say...I'm here. I hope you are too. So let's start talking. Let's get to work. Let's do this thing.

Discuss: What social or political actions you and your family taken, if any, since the election, and why? I understand that we don't all have the same political leanings, and I respect those differences. I live in the South, after all, I am accustomed at this point to having smart people disagree with my political views and having it descend into a slap fight only 50% of the time. (60% tops.) But the goal is the conversation, after all. In the end, the campaign of change has to be one of hearts and minds. So let's start here.

because disasters are apolitical but choices aren't

One of the things Joe and I were discussing (because we are SO ERUDITE--in between making a series of fart noises, both faked and authentic, and then blaming them on the dog) is the impact that Hurricane Sandy and its aftermath is going to have on the election. It's difficult to calculate, I think.

First, the regions hit hardest by the storm (that is to say: the Northeast) are traditionally firmly Democratic, and logistically, it may be difficult for people to turn out and vote come Tuesday. But will this actually make any difference in the electoral college, or will it just impact the popular vote?

Secondly, people inside and out of the affected regions may respond differently based on their perception of storm readiness, reaction and aftermath. I think that overall the reaction has been largely positive (at least compared to the level of preparedness for Katrina, "heckuva job Brownie" and all), but it's clearly a difficult time for everyone impacted. Will that change anything come election day? Again, difficult to say.

Campaigning for both parties has obviously been put somewhat on the back burner, or at least a burner off to the side--for the president firstly because he's busy, you know, leading the country during a crisis; and somewhat for the Romney camp as well, to (rightly) avoid politicizing and tragedy and, perhaps more importantly, avoiding the opportunity to say anything completely offensive of tone-deaf to those suffering losses. What did these two campaigns have planned for the final two weeks of the campaign? Would that have made a difference either way?

And on and on and on. Like I said, the political effects are incalculable, and though I think the post-mortems at the end of next week will pick apart this and that trying to frame whatever the outcome ends up being in the light of inevitability, but that's all Monday morning quarterbacking to me. Regardless of whichever presidential candidate wins the election, the effect of an unprecedented natural disaster of this scale is as unexpected as it is difficult to predict.

But there's one thing I do know that everyone can take away from the stories of Hurricane Sandy, and which is: you are not immune. Terrible things happen, and they can happen to any one of us. The single mom in Staten Island and the hedge fund manager in Tribeca. The elderly couple in New Jersey and the CEO in the Hamptons. Terrible things can happen, and they can happen quickly, unexpectedly, without prejudice. And all of us, whether we think we will or not, will occasionally be grateful for some help.

I think back to my own reaction to the aftermath of Hurricane Katrina in the days and weeks that followed that particular storm. I was shocked and horrified and of course I pledged my support and dollars to help the survivors, but still, even though it happened in my own country, it all still felt a little removed for me. I admit that fully. The words and the situation: Lake Pontchartrain? Levees? Superdome? It seemed so foreign from the everyday life of a dyed-in-the-wool New Yorker that my empathy, and my ability to relate, while present, still felt a little bit distant.

But this? Oh, this.

I walked here, on my way back from a late night out in med school after finals, from restaurant to dive bar to seedy club, trying to find my way back to the subway station to take me home.

Over the course of high school I got off at this subway station hundreds and hundreds of times.  We'd take the 6 train one stop down and switch here to catch the express, or maybe venture above ground to get something to eat, or browse through the new CDs at HMV (remember when we used to do that?), or just walk around and people watch.  Do you know how vast, and how deep those tunnels are?  Do you know how much water it must take to fill them up?  I don't.  I can't even imagine.

The cutoff for power outages on Manhattan was at 25th street and south.  I used to live on 25th Street and Second Avenue, on the 19th floor of our building.  Most likely we would not have had power.  Now, with three kids, in the chill of November, it's difficult to imagine how we would have handled it, though I can say for sure we would not have done it with the grace of those in New York the even more seriously affected outlying communities.  Probably I would have just cried.  Well, cried and eaten all the ice cream, like we did after that big power outage in 2003.  (IT WAS GOING TO MELT ANYWAY YOU GUYS.)

We lived just a few blocks away from NYU Medical Center (it is, in fact, the hospital at which I was born), which of course was evacuated after the storm when the power went out and the backup generators failed.  I can't even imagine what it must have been like for those staff working that night.  I read accounts of patients, fresh CABG post-ops and others, being walked down 10 flights of stairs or more to evacuate after the elevators failed, NICU babies being carried out one by one, nurses and housestaff and techs and everyone forming lines up the stairs passing buckets of fuel up the fire escape to the emergency generators after the fuel tanks in the basement of the hospital became overwhelmed with water.  I think: what if I had been in the OR at that time with a patient when all the power went out?  What would I have done?  I see myself reaching for the ambu-bag, sending someone to run for more IV induction meds, and holding up the flashlight we keep in the bottom drawer of our anesthesia cart so that the surgeon could see enough to sew faster.  I can kind of imagine it.  But also, of course, I totally can't.  Not really.

In the final days before the election it's hard to conceive of people who are still undecided about who to vote for, but I know they must be out there because the news and the polls say its true.  And I ask these people to think not just about jobs or the economy or foreign policy (though these are, of course, also crucially important issues) but to also think about the role of government in the face of crisis.  In the face of bad things happening, indiscriminately and free of political bias.  And think not just of how the candidates are reacting now, but of what they've said in the past.  About the role of government.  About "dependency" and "entitlements."  About the size of government and how some might propose both a smaller government with a diminished role and ability in providing help to its citizens in deep trouble, but also concurrently one that paradoxically insists of legislating and restricting our personal lives.  Think about these things.  And then go vote.

It's easy to accuse and tell people what they should have done or what you would have done when bad things don't tend to happen to you, but Hurricane Sandy reminds us in the most explosive and shocking way possible: bad things can happen to us all.  And everyone needs help sometimes, and sometimes the help we need is bigger than that which individuals or private institutions are able to provide.  And it's a credit to our civilization when we as people, and yes indeed as a government, are able to help those least among us.  Because next time, it could be you, too.  And where do you want to be living, and under what kind of leadership, do you want the next time something does?

My family are all OK, thankfully.  Much love to my friends in New York and the surrounding areas devastated by the storm--I'm with you in spirit if not in person.  If you need help, just ask.  And if you're looking for ways to help, two good starts are here and here.

warning

I've got to say, once I finally figured out how to make a mouse-over image change (and granted, it wasn't that hard to do but you'd never be able to tell from how long it took me to figure out how to get it right), I just want to make a mouse-over image change for everything.  EVERYTHING.

But I guess I'll just quit while I'm ahead.

one of these things is not like the other

I was driving the other day when I got stopped behind this car, which was, in the fashion of the times, bedecked with many an opinionated bumper sticker.





Now, this is not a knock on the politics expressed via bumper sticker. People certainly have the right to express themselves via rear window decal, just so long as it isn't with a "Calvin peeing" logo. However, it occurred to me that one of these bumper stickers was not quite in line with the others. See if you can spot it.








(Note also, that the hood of my car was covered in a fine dusting of yellow pollen. Welcome to springtime in Atlanta. I can't tell if everything is yellow because it is coated in pollen, or if it is actually my eyeballs themselves that are coated.)

so, health care reform




I've been staying away from this for a while because it's just such a divisive topic around these parts that I felt the better part of valor would be just to keep my head down and thoughts to myself. I would probably feel differently if I still lived in Manhattan (aka Liberal World *) but the fact of it is that I work in Georgia where I often feel that my political views are in the minority and thus in the interest of fitting in and not getting into crazy scream fights with people, I'd best just go about doing my job without the political side-conversation. But then the health care reform bill passed yesterday, and I've been writing this blog entry in my head all night. So here it is, apologies if it's rough, but this is not a multiple-draft proofread missive, I'm just spooling it out here.

The healthcare system needs reform, and I cheer the passing of the bill. There is tons that I could talk about, see here for more wonkish details (I am not the expert on this topic by any means, nor do I pretend to be), but the reason I stand behind the idea of healthcare reform is a simple philosophy, perhaps too jejune for most, is this idea: "The essence of civilization is that the strong have a duty to protect the weak." ** (In fact, I think that's part of what I was trying to say about the issue of vaccinating, which brings up very similarly contentious issues about personal freedoms and taking responsibility for others--not to stir that pot again.) "The essence of civilization is that the strong have a duty to protect the weak." Do I believe that? Yes I do. Working in medicine, this is a version of what we do every day.

This bill affects me personally, of course, though not in the same was as many people. For instance, I have health insurance. I make an income above what would qualify me for the expanded Medicare benefits proposed. In many ways, the passage of this bill into law will be detrimental to me personally, at least when it comes to my bottom line. When Joe starts making his attending salary and adds to our household income, our taxes will go up quite a bit. Decreased compensation for the work that I do under the Medicare reimbursement scale will mean that I make less money. (Anesthesia practice as whole is particularly vulnerable to this beyond most other specialties, see: "The 33% problem." For more, read this or other memos from the president of the ASA.) As the most junior member of a private practice anesthesia group, do I worry that such financial implications could endanger the very fact of my job? Yes, I do. I have two young kids at home, how could I not worry about it?

But--and again, I can feel that this is going to come off as irrepressibly naive, but to hell with it, as a young doctor, don't I deserve to play Pollyanna for a little bit longer?--there are bigger issues at play here. The world is bigger than just me and my family. Or even from a more selfish standpoint: it could be me. If there's one thing that Joe's bout with myocarditis this past summer taught me, even more than working with patients all day, is that as young and healthy and invulnerable as we may feel, we are all just one breath away from catastrophe. And if catastrophe landed in my front yard, wouldn't I be glad to live in a society that didn't just champion the notion of "every man for himself"? The essence of civilization is that the strong have a duty to protect the weak. Call it socialism, call it communism, whatever you like. I may be strong now, but I know that could all change at any point, and it gives me comfort to know that if and when it does, this is not a society that will turn its back on me.

Do I have reservations about parts of the bill? Of course I do, it's far from perfect. In particular, I am very nervous about any move towards cost-containment in healthcare (and of course it is undeniable that healthcare costs are, everyone's favorite verb, "skyrocketing") without addressing the incredible cost of practicing defensive medicine. The cost of malpractice insurance, performing procedures that tests that in all honesty do not need to be performed, the Cover Your Ass style of defensive medicine, all because anyone who has ever watched any form of daytime television can tell you that there are hoardes of slavering law firms out there ready and willing to sue your doctor for any old thing.

I am nervous about the prospect of undervaluing the work and expertise of doctors in the name of cost-containment, and the judgments made that paraprofessionals of all stripes can readily step into the roles that doctors once occupied for the simple fact that mid-level providers are cheaper. I don't like the idea that non-medical people may be making judgments on the importance or value of certain aspects of care, and I don't like the idea that hospitals and doctors may be penalized (general practitioners nonwithstanding) and devalued while being expected to accommodate the huge influx of sicker patients that this new law may avail of healthcare. And, of course, the size of federal deficit makes me nervous. I didn't even get a credit card until halfway through med school, because the idea of debt made me so uneasy. So there's that, too.

From a more detached point of view, though, it's really an interesting time to be starting out in my medical practice. Watching some of my more senior colleagues reacting to these imminent changes, part of me is glad that, as a rookie who just stepped into the ring, all I really know is how to do my job. (And even that, at times, is questionable. Kidding! Sort of.) But seriously, there are obviously going to be changes coming down the pike. What these changes will be and how they impact our lives remains to be seen, but I'll be here, and I guess we'll all figure it out together.

So the bill. It's not perfect. I don't love everything about it. But societally, it's a huge first step, and overall a good one. Not everyone agrees with me, particularly in this neck of the woods, but that's OK, we can disagree and listen and try to convince each other and then talk about it some more. And in the end, isn't that one of the key things about living in a democracy?


* "Don't you see the rest of the country looks upon New York like we're left-wing, communist, Jewish, homosexual pornographers? I think of us that way sometimes and I live here." -- Woody Allen, in Annie Hall

** This quote was taken from a speech by George W. Bush. Yes, you read that right. Of course, he was talking about something else, but still, the sentiment is generalizable.

one last thing about this and i promise i will stop

I was posting this in the comments section, but it was starting to get rather long, and in any event, my browser ate it, so I thought I would just post it here as a follow-up to the post yesterday.

First off, I want to extend an invitation to those people who are reading who are anti-vaccine to talk about why they don't vaccinate. I think we are overall very civil here, and if the concern is not about the so-called link to autism (as one of our commenters noted), then what is the concern? Some vague unease about "chemicals"? Concerns about "overwhelming" baby's immune system? Seriously, I want to know, not being snotty. It is hard to have a conversation about this without coming to (virtual) blows, so I would love to be able to talk about it rationally here, not even just to try to convince one side or the other, but just to visit the other side's perspective. (Obviously this need not be said, since we are all grown-ups here, but if anyone is brave enough to present their personal concerns about vaccines in what seems to be a very pro-vaccine forum, we all should play nice.)

The second thing I wanted to address was the fact this topic never fails to make me as both a mother and physician so enraged--not annoyed, not puzzled but actually angry, like I'm taking people's anti-vaccination sentiments as a personal affront--and I wonder why. After some thought, I have come up with this: I am taking it personally. And here is why.

As someone who works in healthcare, with sick patients, I see every day the injustice and horror that is illness. Preventative healthcare is a wonderful thing, perhaps the best kind of medicine that we can practice. Along with a healthy lifestyle, protecting against preventable illness is a big part of that. As a doctor, it's quite simply the very best that we know how to do.

When I go go onto these internet parenting boards, to read this anti-vaccination literature and hear the rhetoric, we see people who are not only rejecting we have to offer, but who vilify doctors and other healthcare workers--people who have devoted decades of their lives to caring for children and families--for working their hardest and giving the very best of what modern science has to offer, it quite frankly hurts my feelings. It's not paternalism, it's not about me wanting to tell patients what to do and for them to comply mindlessly, it's about me wanting to do my job and provide the best; and then feeling like people reject my efforts and recast my motives as somehow evil, greedy, or just plain ignorant. It hurts my feelings.

So yeah, I take it personally. I respect a parent's intuition and I respect the fact that no one feels great, myself included, about bringing their baby in, making them cry by jamming them with needles filled with seemingly mysterious antigens and preservatives. I know first hand that the desire to protect your children from all real or potential harm is beyond conscious thought, it is instinct.

But I respect science, too, and I have based my life around that. In lieu of religion, I have science. And the impulse to prosthelytise is equally strong. And just like people who prosthelytise about religious faith, I am doing so not to force you to be like me, not to scorn or humiliate you for possibly being of a different faith, but because I care about you and your children and families, and I want what all best evidence I have points to being the most effective way to stay out of my hospital.

The other thing that would have enraged me, by the way, with all the fury of a mother bear protecting her cubs, would be if Mack had somehow gotten the measles from an un-immunized kid before he was old enough to get his own vaccine. Luckily we he got his first MMR last week, so at least that's one less thing to worry about.