Doctors' Job Choices Have Political Consequences

The New York Times ran an interesting article today about the political consequences of the job choices that doctors are making. Historically, many doctors have owned their practices, explained journalist Gardiner Harris ("As Physicians' Jobs Change, So Do Their Politics"). As business owners, they fought for fewer restrictions on practices that they felt were hampered by business expenses such as taxes and high malpractice insurance premiums. They tended to vote Republican.

Today, however, more and more doctors are joining hospital staffs in order to avoid many of the business headaches of running a practice and to have a better work/life balance, Harris explained. "As more doctors move from business owner to shift worker," wrote Harris, "their historical alliance with the Republican Party is weakening...."

With the hospitals running the business side of medicine, these doctors have become more focused on wider social issues in medicine such as covering the uninsured. They are also more likely to vote Democratic. Harris wrote that this shift has helped Obama pass the health care reform bill.

This focus on social issues is not exactly altruistic. Hospitals benefit when more people are insured, because then the hospital does not have to absorb the cost of treating the uninsured. Doctors employed by hospitals who advocate for expanding insurance coverage benefit their employers, just as doctors with their own practices who advocate for limiting liability claims hope to benefit their own businesses.

The bottom line? Being an entrepreneur is not very appealing to many doctors these days. Many are choosing to exchange the freedom of self-employment for the stability of a staff job.

As I read the New York Times article, though, I realized that the patients that doctors treat have a very different experience of the workplace. The recession has forced many people into self-employment - whether they want to do it or not. As jobs with good salaries and benefits have gone away, people who have been downsized or laid off, or who recently graduated from college, have reinvented themselves as freelancers, independent contractors, or entrepreneurs in order to pay the bills.

Without employer-provided benefits, one thing that these accidental entrepreneurs really need is the affordable, comprehensive health insurance coverage that health care reform is trying to deliver. When more doctors were entrepreneurs themselves, they looked at health care reform through a business lens and fought it as a threat to their own livelihood. With more doctors employed as staff members, and protected from some of the vicissitudes of the marketplace, many are now more sympathetic to those who are forced to take on the risks of entrepreneurship.

Lessons from Zombies

I've spent many, many hours on the CDC website researching different health topics over the years. But this week they provided advice on a health hazard that I'd never considered before: a zombie invasion.

"The rise of zombies in pop culture has given credence to the idea that  a zombie apocalypse could happen," wrote Assistant Surgeon General Ali S. Khan in a May 16th Public Health Matters blog post. "The proliferation of this idea has led many people to wonder 'How do I prepare for a zombie apocalypse?'"

It turns out that preparing for an invasion of the undead involves the same steps as preparing for any other disaster: make a disaster kit, and create a family emergency plan. While citizens of zombie-infested areas flee town through escape routes they'd wisely planned out in advance, Khan assures us that "CDC would conduct an investigation much like any other disease outbreak. CDC would provide technical assistance to cities, states, or international partners dealing with a zombie infestation."

By framing disaster preparedness in terms of zombie preparedness, the CDC brought media attention to the issue. The clever blog post has been mentioned in a wide range of media outlets, such as ABC News, The Atlantic, and Fox News. Zombie preparedness is a humorous antidote to the hurricanes, earthquakes, and other disasters regularly covered in the news, for which, of course, we really should be prepared.

Humor - and zombies - convey the message of disaster preparedness much better than a carefully crafted CDC press release ever would. Health information is often conveyed by drawing on our fear of disease or injury: get this screening test now to catch cancer in its earliest and most curable stage! Childproof your house to protect your baby! It's exhausting to worry about so many health issues. Maybe more people would follow health advice if some of it were conveyed with a lighter touch or a more positive spin. Bring on the zombies, I say.

Goodbye, Firehouses

Many years ago, a neighborhood firehouse in San Francisco was quietly converted to a battered women's shelter. If you have to take a firehouse out of commission, at least turning it into a shelter keeps the building's function in the realm of public service. But that type of firehouse conversion is not the norm here. I was dismayed to read a profile in the San Francisco Chronicle today of a converted firehouse in San Francisco that has been recently renovated into two multi-million-dollar townhouses.

Real estate in the Bay Area has become much more valuable over the past few decades, while California's Proposition 13, passed in 1978, continues to limit the amount of property taxes that can be collected from these properties. Property taxes help pay for emergency services, among other things, and without adequate funds, many smaller fire stations have closed - and often renovated into luxury properties. Currently, 51 fire stations in San Francisco serve a population of roughly 815,000 people.

San Francisco was destroyed by the earthquake and subsequent fire of 1906, and the fire did far more damage than the earthquake. Fire returned after 1989's Loma Prieta earthquake, fueled by a broken gas line, destroying parts of San Francisco's Marina District. This video compilation from the San Francisco Chronicle shows some of the extensive damage caused by the 1989 earthquake, such as the partial collapse of the Bay Bridge:

There is no large earthquake here without a fire, it seems, and many people wonder how well the fire department could handle another earthquake. To help bridge this gap, the San Francisco Fire Department now trains citizen groups in basic disaster skills, including rescue and disaster medicine. Because if you need fire fighters or paramedics, it's no use banging on the door of a townhouse that contains a fire station's original fire pole but cannot help anyone in need.

Drug Shortages: Blame Policies, Not Agencies

A recent article in the Washington Post by Rob Stein pointed out shortages of 211 medications in 2010, including lifesaving drugs used in emergency rooms and oncology wards ("Shortages of key drugs endanger patients"). What is causing this shortage? "Experts cite a confluence of factors," writes Stein:

Consolidation in the pharmaceutical industry has left only a few manufacturers for many older, less profitable products, meaning that when raw material runs short, equipment breaks down or government regulators crack down, the snags can quickly spiral into shortages.

Stein points out that there are especially acute shortages of generic medications (which aren't very profitable for manufacturers), especially sterile injectable medications (whose manufacturing processes are complicated and error-prone). There are also shortages of raw materials (often imported from abroad).

Stein cites the shortage of the leukemia and lymphoma drug cytarabine due to problems obtaining raw materials and manufacturing the drug. Cytarabine is a vital cancer drug that many hospitals have been forced to ration to patients. Inadequate medication substitutions have also lead to patient deaths, he said.

It's easy to blame the FDA for some of the problems with the drug supply. As Stein explains, "some industry representatives blame part of the problem on increased oversight by the FDA, which has made drug safety a higher priority after coming under intense criticism for being too lax." If the FDA would just skip a few manufacturing facility inspections, the supply pipeline would be smoother?

Drug supply problems don't originate with the FDA, however. Pharmaceutical manufacturers, eager to turn a healthy profit for their investors, would rather chase the next blockbuster drug (earning $1 billion or more in profits yearly) than thanklessly churn out low-profit items such as generic drugs and vaccines. Increasingly, venture capital firms that might fund new drug development would rather fund profitable new technologies than invest in better treatments for diseases.

The financial market, while it plays a role in drug development, should not drive public health decisions. The antidote to this problem is thoughtful legislation. Laws such as the Orphan Drug Act, which I've written about before, have successfully helped pharmaceutical companies refocus some of their energies on patient needs rather than profits.

Maybe the FDA could require that a company whose FDA-approved drug reached blockbuster status must ramp up its generic manufacturing to a certain level - building more manufacturing plants for a needed drug, or adding a popular vaccine to its roster -  before any more drugs are approved. Why not? Stronger regulations and incentives can encourage pharmaceutical manufacturers to diversify their assets and create a safer and more stable supply of drugs for everyone who might need them some day.