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What Do You Want?

Here’s an excerpt from a project I’m working on about the choice between nursing and medicine.  I’d love to know what you think.

Barry Schwartz, in his book The Paradox of Choice, asserts that most good decisions involve the following steps:

Figure out what your goals are
Evaluate how important each goal is
Gather all your options
Evaluate how likely each option is to fulfill each goal
Pick a winning option
Re-evaluate

Reference here: Schwarz, Barry.  The Paradox of Choice: why more is less.  HarperCollins, NY, 2004.

These steps sound simple enough.  You know these steps.  You run these steps a thousand times a day in small ways.  Here’s the problem.  Step number 1 involves figuring out What You Want.  Step number 1 can take your whole life to complete.  Figuring out What You Want involves all your prior experiences with good and bad choices, how you expect future experiences to feel, and the experiences you’re having now.

Let’s take a simple example.  You go to the library to choose a book to read.  The decision to go to the library for your book is based on prior experience with the library and a glance at your overburdened bookshelves.  In the library, you can choose to go to the “new book” section or upstairs to older fiction.  But wait, maybe your prior experience with fiction was unpleasant.  Or maybe you like fiction but the work of fiction you’re currently reading is unpleasant.  So you decide to go to the biography section, for something different.  You don’t know if you will like biography, having had no experience with it.  You anticipate you will like it because you liked History 101 in college.  Once you’ve chosen biography, you still have no idea what you want because you have no experience with the different authors.  So you choose a book about Abraham Lincoln because you just saw the movie.  You leave the library, hoping you made a good choice, but not knowing for sure.  Your chances of having made a good decision for yourself are fifty-fifty at best.
Schwartz says that knowing What You Want means that you have to be able to anticipate how you will feel if you choose different options, which in the case of health care is very difficult to do.  And the ability to accurately predict how you will feel is even more important when the thing being chosen, as in medicine, is years away from actually happening.  Here are two seemingly contradictory conclusions drawn by people who do research into decision-making:

Most people don’t know what they want.
We have to see things in context and comparison.  What we see tends to change depending on what things are next to each other and how we judge each.  My car looks great next to that old jalopy but it looks like a bucket of bolts compared to the Jaguar on the other side.  Nursing looks great next to my high school friend working at Starbucks, but maybe doesn’t look so great next to your other friend who is transplanting hearts.
What other people think also has a great impact on what we think we want.  When somebody says “You’re so smart.  You should go to med school”, they are imposing their judgements, values, and stereotypes on the decision.  But you’ll care about what they think, and as I said above, it will influence how you decide.

Most people know what they want
This is why a simple list of pros and cons doesn’t work when it comes to these kinds of decisions.  Gut feeling is a powerful indicator of what we really want.  Most of the time our gut is drowned out by social structures and expectations, but it is a very important piece to pay attention to.  For example, if you are making a decision about whether or not to buy a new car you might make a list of all the good things and bad things about buying a new car vs. keeping the old one.  What you might not factor in is the gut feeling that says “I want a new car.  Now.”  So you end up buying one even if your list concluded it wasn’t a good idea.  We are not completely rational creatures.

It is clear that, using Barry Schwartz’s steps to good decision-making, you have to get step number one right.  No amount of information will help if you don’t know yourself and what you want.  Not just what you think you want, or what you think you should want, or what someone else tells you is the right thing to want.

No Comparison

Having been both a nurse and a doctor, most of the questions I get from readers have to do with making the decision between nursing and medicine.  Let’s lay aside for a moment the reality that the fields are totally different and that direct comparisons are useless.  But people ask me all the time, so as a little experiment, I turned to the US Department of Labor.  The USDOL, in it’s Employment and Training Administration arm, has an Occupational Information Network, or O*NET.  O*Net Online has a set of what it calls Summary Reports, that list the tasks, knowledge base, work styles, values, abilities, and interests for a wide variety of jobs.  I looked up the one for Registered Nurse and compared it to the one for General Internist.  Here’s what a comparison of the two reports reveals:

Under “Tasks” the doctor list uses authoritative words like
Treat
Prescribe
Explain
Manage
Analyze
Provide
Advise

The nurse list uses subordinate words like
Maintain
Administer
Record
Monitor
Consult
Coordinate
Prepare

This is the USDOL, not me.  Don’t shoot the messenger.  Virtually any member of either field would say that both nurses and doctors do all these things, to a greater or lesser degree, and depending on educational level and specialty.

The entry under “Technology” is virtually useless, except for it’s amusement value.  Apparently internists use splinter forceps while nurses use curved hemostats.  Who knew?

Here’s the “Knowledge” category:

1.  Both doctors and nurses need to know about medicine, dentistry, biology, psychology, and sociology.  Doctors need chemistry.  Nurses need math and computers.  I guess this suggests that the doctor does the experiments but the nurse tells us what it all means.  There could be some profound truth in there, but I doubt the DOL knows what it is.

2. Doctors need administration and management skills.  Nurses don’t.  I’m ducking now to avoid the rotten tomatoes coming my way from nurse managers and vice presidents for nursing, as well as any nurse who takes care of actual people.

3. Nurses need English language skills but doctors don’t.   Wow.  Truer, more hilarious words were never spoken.

Then we come to “Skills” and “Abilities”.  Here’s where the simplistic, incomplete nature of these Summary Reports really becomes clear, and potentially inflammatory, politically incorrect, and possibly felonious.  Right off the top, the internist needs science, complex problem solving, category flexibility, and active learning.   No laws of hemodynamics or pesky thinking involved in nursing, it seems; no need to “understand the implications of new information for oth current and future problem-solving”.  Ah, but nurses have their own skill set that doctors don’t need.  Things like service orientation, coordination, and monitoring.  Like, say, a waiter.  And finally, the kicker: both nurses and doctors need speech clarity but only nurses need speech recognition.  And if that doesn’t tell the whole story…

There’s a lot more categories with inclusions and omissions along the same vein, but you get the idea.  This post is all in good fun, and I have nothing against the Department of Labor or it’s misguided attempt to give us all Occupational Information.  But it does make my point that such comparisons are ludicrous and misleading, if not also occasionally humorous.  When someone asks me “Should I be a nurse or a doctor?” I don’t send them to O*Net.  I send them to their parents, their childhoods, their favorite authors and movies, their passions, what they dream about.  I send them back to their lives to ask the question of themselves.

I’m Famous!

No, not really.  Just a little piece I published over at NPR’s Cognoscenti – motherhood-related but you might find it entertaining…

http://cognoscenti.wbur.org/2014/07/09/disney-parenting-shirie-leng

The Employer Mandate

Let’s talk about the Employer Mandate.  Oh, now, don’t whine.  It can’t be all bubbles and roses and Supreme Court rants on this site.  I’m a respectable organization.  Here are the salient facts:

1. The Employer Mandate, part of the Affordable Care Act, is a requirement that all businesses with over 50 full-time employees provide health insurance to said full-time employees, OR

2. Pay what is called an Employer Shared Responsibility Payment (non-tax deductible) with the company’s federal tax return.  This annual fee is $2,000 per employee (first 30 exempt).

3. The Employer Shared Responsibility Provision is supposed to insure that the federal government, state governments, insurers, employers and individuals are given shared responsibility for the availability, quality and affordability of health insurance coverage.

4. If at least one full-time employee receives a premium tax credit because coverage is either unaffordable or does not cover 60 percent of total costs, the employer must pay the lesser of $3,000 for each of those employees receiving a credit or $750 for each of their full-time employees total.  This means, I think, that if the employee qualifies for government assistance with premiums because their company does not provide adequate, affordable health insurance, the company has to pay the government back. This is often called a “free-rider” penalty because it is triggered when an employer’s low-income employee “free-rides” on the federal government to obtain health care coverage.

5. For coverage to be “affordable”, the statute requires that for low-income employees—defined as those between 100-400% of federal poverty level—the employee’s portion of the premium for individual coverage cannot exceed 9.5% of his/her household income. Secondly, to meet the minimum value requirement, the plan must pay, on average, at least 60% of the costs of covered services.

6. Offering coverage that is affordable for the employee blocks all “related individuals” — generally, the spouse and tax dependent children — from accessing a government subsidy. And the bar hasn’t been set very high: if the employee would not have to pay more than 9.5% of his household income for his portion of the single (employee-only) premium on the employer’s plan, his entire family is firewalled off from getting the subsidy.

I know.  Yawn.  Blah, blah, blah.  But here’s the thing: according to Avik Roy of Forbes, “If the employer mandate were to ultimately be repealed, or never implemented, today’s news [regarding the delay in implementation to 2016] may turn out to be one of the most significant developments in health care policy in recent memory.”  Why does Mr. Roy say this?

Because the employer mandate reinforces the bizarre United States practice of having health insurance provided by employers in the first place.  The idea started in the 1880s when large mining, lumber, and railroad companies developed plans that covered medical services for their workers. The 1942 Stabilization Act, which restricted wage increases but ruled that health insurance didn’t count as a wage, combined with the failure of President Truman’s public health insurance proposal, set in motion the system we have today. Opponents of the employer mandate, whose numbers are rising according to Politico.com, have several concerns.  They say it drives up the cost of labor, that it discourages small business growth, that it encourages part-time hiring and out-sourcing, and in general increases the cost of doing business in the US, making it hard for us to compete with foreign companies.

Uwe Reinhardt, my favorite healthcare economist, said this in the New York Times last week: (http://www.nytimes.com/2014/07/03/upshot/the-illogic-of-employer-sponsored-health-insurance.html?module=Search&mabReward=relbias%3Ar%2C{%222%22%3A%22RI%3A15%22}&_r=0)

“The [Hobby Lobby] ruling raises the question of why, uniquely in the industrialized world, Americans have for so long favored an arrangement in health insurance that endows their employers with the quasi-parental power to choose the options that employees may be granted in the market for health insurance. For many smaller firms, that choice is narrowed to one or two alternatives – not much more choice than that afforded citizens under a single-payer health insurance system.Furthermore, the arrangement induces employers to intervene in many other ways in their employees’ personal life – for example, in wellness programs that can range from the benign to annoyingly intrusive, depending upon the employers’ wishes.  And what kind of health “insurance” have Americans gotten under this strange arrangement? Once again, uniquely in the industrialized world, it has been ephemeral coverage that is lost with the job or changed at the employer’s whim. Citizens in any other industrialized country have permanent, portable insurance not tied to a particular job in a particular country.”

And here’s Neil Irwin, also of the NYT:

“In truth, the American system of health care — in which most people get their private health insurance through their employer — has always been rather odd. Why should quitting a job also mean you have to get a new health insurance plan? Why should your boss get to decide what options you have and negotiate the cost of them? Employers don’t get to select our auto insurance or mortgage company, so why should health insurance be any different?”

Health policy experts are saying that, in effect, the ACA is working so well that people might decide they’re better off getting their own coverage through the exchanges than through their companies, in part because of item #6 above.  Companies would be glad to oblige, moving insurance away from employment.  Except for that pesky mandate.

Opium Wars

Doctors have a long and illustrious history of addicting people to narcotics.  In the 1800s this was largely because they didn’t know what else to do, they had no idea what was wrong with anyone, and they didn’t have any drugs that worked.  Apothecaries, pharmacists, and doctors made proprietary concoctions in which opium was always the active ingredient.  And it worked, right?  Morphine works for anxiety, works for pain, works for “fluxes”.  What else could really be wrong with people anyway?  This profligate use of narcotics had it’s expected effect.  Thomas Crothers, in 1902, wrote a book called “Morphinism and Narcomanias from Other Drugs.“ Morphinism,” Crothers explained,  “is a condition following the prolonged use of morphine by needle or mouth.  Women, especially, are affected by it.  Capriciousness, irritability, selfishness, and excitability are the natural characteristics of women who are morphinists.  Morphinomania is the condition of persons in which the impulse to use morphine is dominating.  Such a person is often a psychopath from heredity, and has a defective neurotic organization.  Morphinomania is a moral disorder.  Even if no immediate deleterious effect is in evidence, the will and moral forces suffer.”

Something had to be done about these amoral, mostly female degenerates, clearly.  In the 1860s states started passing laws that said that the potions being made at least had to have an ingredient label.  The Pure Food and Drugs Act of 1906 was the beginning of the FDA, so named in 1930, but even then narcotics were available, as long as they were labeled.  But it helped.  In an effort to regulate narcotics, the Controlled Substance Act was signed into law in 1970, creating the schedule system we know today.  Other early interventions basically amounted to warning labels.  In 2005 The DEA, in an effort to increase detox and treatment, allowed practitioners who were not formally in the drug treatment business to use other scheduled drugs to treat addiction.  In 2007 the FDA got a new tool, Risk Evaluation and Mitigation Strategies (REMS), that allowed them to put restrictions on certain substances.   In 2009 The FDA asked for recommendations on restricting prescribing which were met with opposition from drug companies and physicians’ lobbying groups.  Last year the FDA recommended changing Hydrocodone-containing drugs to Schedule II (highly addictive) and limiting refills and prescribing practices.  Still the epidemic goes on.

Dr. Thomas Frieden, director of the Centers for Disease Control, made the following comment about prescription drug abuse: (http://www.nytimes.com/2014/07/02/health/prescription-drug-deaths-in-florida-plunge-after-tougher-laws.html?ref=health):

“This is an epidemic that was caused largely by inappropriate prescribing, and it can be fixed to a significant extent by improving prescribing.”

I used to take umbrage at this kind of remark.  After all, doctors cannot be responsible for what people put in their mouths.  Then I read about Florida.  Did you know that doctors in Florida bought 89% of the Oxycodone sold in the entire country in 2010? 98 of the 100 highest prescribers of narcotics practiced in Florida. The pain clinics lined the streets.  No wonder trust in physicians is at an all-time low.  There is absolutely no excuse for the behavior of these physicians.  Here’s what Florida did, starting in 2010.  They made pain clinics register with the state.  They indicted “pill mill” owners and, in once case, accused a doctor of murder.  Doctors’ licenses got suspended.  A prescription drug monitoring system was put in place, privately funded since Florida Republicans blocked the measure in the state legislature.  And it worked.  Prescription drug overdose deaths are down 23%.  Doctors’ purchases of Oxycodone fell by 97%.

What is the problem here?  A few physicians violating the Hippocratic and every other oath I can think of?  Oh, Yes.  Doctors and pill mill owners should absolutely be prosecuted to the full extent of the law.  But, as I pointed out above, addiction is an old disease.  Some of the Florida patients who can’t get prescription narcs anymore will go to heroin or cocaine.  Some will get morphine instead.  Some will seek rehab treatment.  The larger issue, however, is addiction itself.  The social, genetic, behavioral, and neuro-chemical drives for drug use are powerful, persistent, and ancient.  We can choose to criminalize drug use, declare it a disease and treat it, ignore it, or feed it.  What we do with it, as a society, will be one of the things that defines us for future generations and civilizations.

 

 

Let Me Off!

I’m speechless.

Well, I’m as speechless as an opinionated blogger can be.  SCOTUS has got the country on some kind of time warp ride, and I really want to get off.  Campaign finance limits are gone.  The buffer zone is gone.  Church and State separation is gone.  It’s enough to make one want to move to Crimea.

The ruling by the Supreme Court striking down buffer zone around “abortion clinics” was bad enough.  Let’s forget about the fact that most abortion clinics, Planned Parenthood being the most prominent, are actually women’s clinics, and provide a lot of basic gynecological and other health services for women.  Let’s also forget about the privacy issues and human rights considerations being discounted by the courts.  The point, I guess, of SCOTUS was that the zone violated free speech.  They said that regular state law already provides protection for citizens from harassment.  But first, you have to be harassed.  Once you’ve been verbally assaulted, then you can call for help.  That’s a comfort.  The law assumes innocence until proven guilty, and you can’t get arrested for intent.  So essentially a crime has to occur before justice can be done.  Some would say that the area around the clinic is public property, and thus anyone should be able to do anything they want on it.  OK, that’s fair.  But my car is my private property and the law states I have to put my kids in 5-point restraints every time I leave the driveway.  That law protects children before something happens.  Women don’t get the same protections?

Then, to make a bad situation worse, the court then ruled in favor of Hobby Lobby, who really should get prosecuted for that ridiculous name.  Hobby Lobby, in case you’ve been in deep freeze, won the case in which it said that it should be exempt from the ACA rules about covering contraception because the owners had religious objections.  The owners did.  Have religious objections. To a federal law.  It turns out that people on the religious right can say whatever they want to a woman at the door to an abortion clinic, and they don’t have to pay for contraception.  Wow.  Oh, and we’re the only country in the world that doesn’t have paid maternity leave.  It doesn’t take Ruth Bader Ginsberg to figure out where this is going.

I guess the only recourse the poor, stupid, uterus-laden woman has is the court of public opinion.  The only way the Hobby Lobby decision won’t work for the owners is if people a) stop shopping there, and b) stop working there.  I almost wish I shopped there and worked there, so I could quit and never come back.

The Criminalization of Poverty

This post is only tangentially related to medicine, more directly related to parenting, and absolutely related to humanity.

There has been a recent spate of children-left-in-cars stories lately.  Some of these moms, and it’s always moms, like Christina Moon (http://www.today.com/parents/errand-crime-parents-now-face-hard-consequences-leaving-kids-car-6C10584642) and Kim Brooks (http://www.salon.com/2014/06/03/the_day_i_left_my_son_in_the_car/) were criminalized for leaving their children while running an errand.  Arguments can be made both ways on that.  Normal mothers trying to manage their children and their lives getting put in jail and getting visits from the Department of Children and Families seems a little extreme to me.  Especially in Massachusetts, given the safety record of children under the care of DCF.  But the story of Shanesha Taylor is different.  Taylor’s story is about the criminalization of poverty.

Shanesha Taylor, if you haven’t heard, is the unemployed, homeless mother who left her two very young boys in her car while she went for an hour-long job interview.  She is being charged with two counts of felony child abuse, each of which carries a 7-year prison sentence.  Her children have been taken away.

Now, the facts of the case are in some dispute, because Taylor’s story has been called into question.  Was she homeless or wasn’t she?  Was she unemployed or not?  Did she have any available funds or not?  Did she really arrange for childcare that fell through or not?  Ms. Taylor says that she had a good job as a loan officer until her mother died, at which point she quit her job to “regroup”.  Ok, bad decision.  She had two children with a man she is not married to, while underemployed and on shaky financial ground.   Ok, bad decision.  It doesn’t matter.  People make bad decisions every single day.  But, two counts of felony child abuse? 

A felony is defined as a crime sufficiently serious to be punishable by death or a term in state or federal prison, as distinguished from a misdemeanor which is only punishable by confinement to county or local jail and/or a fine.  Really?  Shanesha should be eligible for the death penalty? (The countries with the largest number of executions, by the way, are Iraq, Iran, China, Saudi Arabia, North Korea, Somalia, Sudan, Yemen, Japan, and us.  That’s an awesome list to be on.)  Historically, however, felonies were crimes involving moral turpitude, those which violated the moral standards of a community.  Ah.  Good old fashioned moral judgement of someone else’s actions without knowledge of their situation.

Someone must have called the police while Shanesha was in her job interview.  Someone also called the cops on Christina Moon and Kim Brooks.  The people who called 911 might have been well-meaning.  But no one knows anybody else’s story.  Those who call 911 made a snap judgement that results in the criminality of the mother.  But what are the real circumstances?  What if, instead of calling the cops, a truly concerned person had checked on the children, attempted to find the mother, and offered to help?  What if the person who called 911 on Shanesha had actually spoken to her?  “Gee, Ms. Taylor, that sounds terrible.  Why don’t I watch your kids for a little while while you go try to get a job?”  Or even a simple “How can I help?”.  If you call the police because a kid is in the car alone, you don’t know anything at all about the situation.  Maybe that mother has been driving around trying to get that kid to sleep for an hour and finally the kid is sleeping.  Maybe the kids are in the car because the house is on fire and the mother has run to the neighbors for help.  Maybe that father (yes, fathers do it too) has a sick kid at home and really needs to just drop in and fill that prescription.  It’s 60 degrees, the child in the car is engaged in a video game, it’s a low-crime neighborhood, and the perfectly good parent makes a choice based on the information available.  Isn’t that what parents do all the time?

What was the goal of the person making that call to the police?  Was it concern for the children?  Well, now the kids are in foster care and the mother is in jail.  How wonderful for the children.  Maybe the goal was more along the lines of the historical definition of felony.  Maybe the caller wanted to punish a Bad Mother, in which case, nice job.

Parenting is hard.  Parenting while broke is harder.  Being a mother while broke is not a crime.  It’s a social and public health problem created by the United States’ lack of support for working mothers.  Can’t we help each other?

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