Wednesday, January 23, 2019

Reflections on 40 Years of Advocacy for Internists


Yesterday was the 40th anniversary of my career in representing internal medicine doctors, first with the American Society of Internal Medicine, and then with the American College of Physicians after the ASIM-ACP merger in 1998.   My first day on the job for ASIM was January 22, 1979.

To understand how long ago it was when I started working for ASIM, in the month of January 1979:

Jimmy Carter was President. He proposed on 1/14 that Martin Luther King’s birthday become a national holiday.

The Village People's Y.M.C.A became their only UK No.1 single.

The Shah of Iran fled Iran during the cultural revolution. 1 million marched in Tehran in a show of support for the exiled Ayatollah Khomeini.

In Super Bowl XIII, the Pittsburgh Steelers beat Dallas Cowboys, 35-31; MVP: Terry Bradshaw, Pittsburgh, QB.

Tom Brady was only 17 months old.  Really.                               

The Dukes of Hazzards premiered on CBS.

The “Wiz" closed at Majestic Theater NYC after 1672 performances.

Pope John Paul II embarked on his first overseas trip.

Midnight Express, starring Jane Fonda and John Voight, won the Golden Gloves award for Best Picture.

I was 22, a few months out of college; my hair was brownish (not white), quite a bit longer, and parted in the middle; and I weighed quite a “few” pounds less than now.  Had you asked me then if I would still be advocating for internists four decades later, I’d have said you were crazy.

So how is it that I am still here 40 years later?

I work for internists—a special breed of doctor that almost without exception, has been caring, thoughtful, engaging, creative, supportive of me and others on the [ASIM, ACP] staff, and fun!  There is no better group of physicians to work with, or for, than internists.  Many of them are my friends.

I’ve had great mentors and supporters of my career, from every one of the bosses that I reported to, from Bill Ramsey (ASIM), Mark Leasure (ASIM), Joe Boyle, MD (ASIM), Alan Nelson, MD (ASIM, and ACP), Walt McDonald, MD (ACP), John Tooker, MD (ACP), John Mitas, MD (ACP), Steve Weinberger, MD (ACP), and now Darilyn Moyer, MD (ACP).  Their management styles couldn’t have been more different, yet I’ve learned so much from them, and I’m still learning.

I was able to contribute to the successful merger of ACP and ASIM in 1998, working with Alan Nelson, Mark Leasure, John Tooker, and Walt McDonald to bring together the staff from the then-ACP and then-ASIM Washington offices into a team of equals, after years of being rivals.  The result has been the most effective physician advocacy organization on the planet (IMHO).

I am privileged to work in an organization where there is mutual respect between our internist-members/leaders and their staff, recognizing that we each bring different skills to the organization. This organizational culture of staff and physicians being on the same team is rare in American medicine.

I’ve been to all 50 states on business trips, and seen the beauty and diversity of our country in ways few are able to experience.  I’ve talked to many thousands of internists in my travels, learning from them what can be done to make things better for them and their patients.

I’ve been able to write often about health care, feeding my inner journalist.

I’ve been invited to author/co-author some of ACP’s most influential policy papers, many published in the Annals of Internal Medicine, addressing topics from universal coverage to gun violence to reducing administrative burdens to improving payments for internists’ services, and many more.

I’ve had the best staff colleagues, and still do; many are among my closest friends.

And, at the top of my list, my career has allowed me to make a difference, improving health care for patients and improving the professional lives of internists.  Is there anything more defining than that for a successful career?

It’s been a great 40 years of being an advocate for internists and patients.  I plan to keep on doing it, until . . . well, I’ll know when it’s time.   But not yet, not too soon; there is still too much to accomplish and still too many good times ahead!

Thanks to all of you for your support and friendships over the past 4 decades.

Friday, December 7, 2018

How a single tweet from the NRA helped ACP reach millions of people on gun violence


On November 7, the National Rifle Association tweeted this about ACP’s new policy paper on firearms violence, published in the Annals of Internal Medicine:

Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.

As a co-author of the ACP paper, I immediately posted a reply to the NRA:

Passing laws to stop kids from getting shot by unsecured guns, reducing the lethality of mass shootings, keeping guns from domestic violence offenders who will use them to kill their intended victims—oh yes, these are all in doctor’s lanes.  Like any other public health threat. 

Within hours, thousands of physicians tweeted why gun violence was in their lane, accompanied by the hash tags #ThisIsOurLane and #ThisIsMyLane.  Many included graphic photos of the carnage and blood they’ve experienced in treating gunshot patients; I continued to tweet often on the topic, sharing their testimonials and information about ACP’s policy recommendations.

I just learned that in the past 4 weeks since I first replied to the NRA, my tweets on ACP’s behalf reached 8,300,000 people!  Think about that: 1 tweet from the NRA, resulted in more than 8 million people being exposed to ACP’s advocacy message on gun violence (and a few other topics sprinkled into my tweets) in just 30 days.  Never before has my efforts to spread the word on ACP advocacy garnered so much visibility.

Yet it’s hardly just me that helped get the word out.  As of this hour, there are over 23,000 responses to the NRA’s original tweet, overwhelmingly in support of physicians’ speaking out on gun violence. The backlash from physicians has received extraordinary coverage in the mainstream press, from the New York Times (Doctors Revolt After NRA Tells Them to ‘Stay in Their Lane on Gun Policy’), to the WallStreet Journal (After NRA Rebuke, Many Doctors Speak Louder on Gun Violence), to CNN (Doctors Start Movement in Response to the NRA, calling for more gun research), to NPR (After NRA Mocks Doctors, Physicians Reply: This Is Our Lane)—and hundreds more print, digital, cable and TV outlets.  That the NRA’s tweet appeared just hours before another mass shooting at a Florida night club, and just a few weeks before another one at a hospital in Chicago, no doubt contributed to physicians’ fervor to take them on, and the coverage that resulted. 

Altmetric, a firm that tracks how much attention published research is getting from the news and social media, found that Annals’ publication of ACP’s firearms policy paper is now one of the top attention-getters, all time, of the millions of research outlets it has tracked:

Altmetric has tracked 12,258,221 research outputs across all sources so far. Compared to these, this one has done particularly well and is in the 99th percentile: it's in the top 5% of all research outputs ever tracked by Altmetric.  [Ranked 224 out of more than 12 million research outputs, and #2 out of the over 10,000 research outputs published by Annals and tracked by the firm.]

The NRA’s attack on physician advocacy on gun violence has also spawned editorials from physicians in the most prestigious peer-reviewed medical journals, including in Annals (Firearm Injury Prevention: AFFIRMing That Doctors Are in Our Lane,  co-authored by Annals editors Drs. Christine Laine and Darren Taichman, and Dr. Sue Bornstein, chair of ACP’s Health and Public Policy Committee); and in  NEJM (#ThisIsOurLane — Firearm Safety as Health Care’s Highway, co-authored by Drs. Megan Ranney, Marian Betz, and Cedric Dark).

For too long, the NRA has dictated much of the debate over gun violence, bullying those who offered other ideas.  No longer: the NRA has awakened a sleeping giant, the hundreds of thousands of physicians and their professional societies who feel both obligated and emboldened to speak out on the dangers to the health of their patients of unrestricted access to firearms.  Now, the challenge and opportunity going forward is for ACP, and other professional societies that share our commitment to reducing gun violence, to make sure that This Is Our Lane becomes a sustained movement, not just a moment.

Today’s question: What do you think about physicians’ and ACP’s response to the NRA and the This Is Our Lane movement?

Wednesday, November 7, 2018

It’s health care, stupid



This seems to be the big take-home message from voters in the mid-term election held yesterday, which bodes well for preserving gains from the Affordable Care Act and expanding coverage.   Health care was the number 1 issue for voters according to several exit polls, beating out immigration, the economy, and gun violence, among others, with voters strongly favoring Democrats as the party more likely to protect patients with pre-existing conditions.  Preserving the ACA’s protections for pre-existing conditions arguably may have been the single greatest contributor to Democrats taking control of the House of Representatives from Republicans, gaining at least 30 seats. 

Yet Republicans not only kept control of the Senate, they also expanded the number of Senate seats they control, adding at least 3 seats to be held by members with strongly conservative views. This raises questions about how much of the electorate’s desire for Congress to act to make health care more affordable to them and their families will translate into action in Congress; preserving existing patient protections may be the most likely outcome.

The story at the state level is very different: more states seem poised to expand Medicaid coverage; yet on other health care issues, like women’s access to reproductive services or reducing gun violence, the prospects at the state level are more mixed.

Here’s my take on five health care issues likely to be affected by the mid-term election results:

1.  Obamacare repeal and replace is dead. The Democratic-controlled House of Representatives will not allow legislation to advance to repeal, or repeal and replace, the Affordable Care Act. 

Except . . .Congress will have to do something to preserve protections for preexisting conditions, if the courts ultimately rule in favor of a case brought by 20 GOP-led states and supported by the Trump administration that seeks to have the ACA’s protections for pre-existing conditions ruled unconstitutional.  A decision by a conservative Texas judge is imminent and should he rule for the plaintiffs, as many expect, it will assuredly be appealed to the higher courts; it may be up to the Supreme Court to ultimately decide.  Stripping pre-existing condition protections via a court decry will be hugely unpopular with the electorate, and almost all of those elected yesterday promised to protect them (even when their own voting records suggest otherwise). However, it’s by no means certain that a Democratic House, Republican Senate, and President Trump could agree on a path forward to reinstate them.  The best outcome would be for the courts to find that the case has no merit and rule against the plaintiffs.

And . . . while there may be interest in both political parties to advance bills to make the ACA more affordable for those who are not eligible for premium subsidies because they earn too much to qualify, it is hard to see a path forward that could bridge the ideological divide between Republicans and Democrats.  House Democrats will also try to advance bills to overturn the administration’s decisions to allow sale of short-term plans that do not cover essential benefits, yet such bills likely would die in the Senate, or face a veto from the president.  States that have elected Democrats as governors and to the statehouses may pass legislation on their own to ban or regulate sale of short-term plans.

2.  More low-income people will gain coverage from Medicaid expansion, upwards of half a million of them.  Voters approved Medicaid expansion via referenda in three GOP-leaning states: Idaho, Nebraska, and Utah. The election results in three other states, Maine, Wisconsin, and Kansas, also bode well for expansion.  Montana voters, however, voted down a referendum to continue to fund their version of Medicaid expansion via higher tobacco taxes, potentially placing coverage for their residents at risk.  Republicans elected or re-elected to the governorships in other states are unlikely to expand Medicaid, and/or will seek to include work requirements that may make it more difficult for people to qualify.

3.  Prospects for policies to address the high cost of prescription drugs may advance at both the state and federal levels.  In his initial remarks today on the midterm elections, President Trump suggested that common-ground could be found with Congress and the Democrats on lowering the cost of prescription drugs. Many Democrats newly elected to the governorships and state legislative seats favor policies to require transparency in drug pricing.

4.  Common-sense policies to reduce gun violence may be advanced in additional states, as voters elected candidates to governorships and legislatures who favor such policies; yet in other states, voters elected or re-elected candidates opposed to such policies.  Voters in Washington state approved a referendum to advance restrictions on firearms. NBC’s exit poll found that 60% of those who casted votes favored stricter gun control policies, including 46 percent of gun owners compared to 76% of those who don’t own firearms; just one-in-ten ranked it as the most important issue facing the country. Democrats are likely to advance gun violence policies in the House, yet it is unlikely that a more conservative Senate and the Trump administration will accept them.  On the other hand, the House will almost certainly reject concealed carry reciprocity, should it be taken up next year by the Senate.  (In the current Congress, such legislation passed the GOP-controlled House, but was not taken up by Senate).

5.  It’s a mixed bag for women’s health.  The House of Representative will not advance or accept legislation to defund Planned Parenthood and other women’s health clinics.  It may try to advance bills to overturn the administration’s efforts to allow broad “conscience exemptions” to contraception coverage, yet it’s hard to imagine those being accepted by the Senate.  With more states under partial or complete Democratic control (governors and statehouses), bills to ensure women’s access to reproductive services may fare better in those states than in the past; voters in several other states yesterday advanced measures to greatly restrict access to such services.  For many women, access to necessary services will depend on where they live. 

There are many other issues that are less partisan and may find common-ground in the new Congress, including improvements in the Medicare Quality Payment Program, payment for primary and comprehensive care, reducing barriers to chronic care, addressing the opioids epidemic, and reducing administrative tasks imposed on physicians and patients.

One thing is sure: voters yesterday ranked health care as the most important issue behind their votes, and politicians who ignore them, or let partisan divisions lead to inaction, will do so at their own risk.