It's just an idea, really

0-30,000	0%
30-60000	10%
60001-90000	25%
90001-120000	33%
120001-183000	50%
183001 +	33%

No deductions, none.  I'm not attached to the brackets, I just kind of threw it together, but given that I paid a higher effective rate than Mitt Romney the year he ran for president, I would like to see it be fairer.

Email to Senator Heller, copied to Murkowski and Collins

Sir, having watched your statement on the current proposition I wanted to reach out.  I  live in Virginia, but spent most of my life in Maine.  I voted for a number of Republicans in the past, I voted for Senator Collins in 1996 and again in 2002.

The current republican party seems to be in service to the rich, the Russians and the racists.  To value smaller government does require this.  I have probably become a Roosevelt Democrat and will rarely again vote Republican, but there should be a dynamic tension between those who wish to expand government services and oversight and those who wish to constrain it.

I'm a supervising physician in a public health clinic and I tell the clinicians and the accountants, that if either group gets everything they want, we're doing something wrong.  I feel the same way about government.

If you believe that the goal of government is to serve the people, would you consider reaching out to Collins, Murkowski and a few of the others who seem like reasonable folks and forming a new party?  Caucus with the Republicans, but give yourselves a chance to set a new platform?

Fixing American healthcare requires regulation and price setting, I don't think single payer would suit us as a country, but I suspect that will be where we go if the Senate passes this bill.  After 10-20 years of misery for a lot of folks.  All payer rate setting (including pharma), a public option in rural areas and nation wide medicaid expansion would preserve the majority of the current system intact and probably cost less.  A few very rich people would make a bit less, but everyone would have more.

Respectfully,
W.W. Weaves, MD

Pro-choice and Pro-life

I describe myself as both pro-choice and pro-life. 

Sometimes I have described myself as anti-legislation, but that doesn‘t encompass the fullness of my position.  I am also anti-demonstrations out side of clinics, anti-shaming of women for the choices they make, anti-ignorance, anti-abstinence only education, and anti-forced birth.  I'm also very pro contraception.

Edward Snowden

This is not intended to be in anyway comprehensive, just quick thoughts:

1. As an American I would like to get Snowden out of Russia.  Both for his sake and ours.
2. I think he needs to do some jail time.  Not hardcore, but some.  
3. For absolutely no logical reason I've decide 3 years, low security is about right.
4. I wish he and Obama had worked out a deal before the election.  I'd rather have him back.

Always Relevant

https://imgs.xkcd.com/comics/free_speech.png

Work hours for Interns

There's a lot of uproar about the fact that the maximum shift for first year residents (interns) has been extended to 24 hours again.  I was an intern twice (don't ask) and worked first under no restrictions and then under the 80 hour work week.  I had a variety of chief residents who fiddled the schedule in various ways.

I did a number of 36 hour shifts, they suck.  Unless you are one of those people who is wired that way, they are complete misery.  I found out later that a lot of my fellow residents used adderall to get through.

Twenty-four hours, when you were done at morning sign out, was not that bad.  You had a whole day, often during the workweek, to use as you wanted.  I tended to spend the morning in the hospital finishing up paperwork, left at noon as directed and went home, did laundry and went to bed at 7 or 8  pm and slept through to the next morning.  If the night had been horrible, I would go straight home, shower, put on my jammies, sleep if I could and work on catching up medical records via a Virtual Private network in to the hospital computer system.  (I LOVED that, from my standpoint it was the best invention ever.)

What I hated was having call, and then being assigned the next morning do cover something, a surgery or the floor on patients I didn't know.  It is one thing to be dog tired and delivering a baby after getting to know the woman all night, another to have to hang around for a stranger because there's no one else.  It was being allowed to stay for something you wanted to do, versus being forced.

Hand-offs are their own kind of danger.  Hand-offs create more problems at the lower (less experienced) levels.  There was a study on this in JAMA, I'm not going to go find it.  I read it during my semi-annual CME binge.  For senior residents, sleep may be more important than familiarity.  For juniors, this may not be true.  As someone who does only office work now, my middle of the night phone calls are non-existent.  But for a few years I worked in a general clinic where I took the middle of the night calls from my patients.  These were relatively few, and always on point.  Because I knew the patients well I could triage between "go to the ER" and "Be at the office at 8am," pretty easily.

I found a certain amount of value in the learning I did when bone tired.  I learned that I prefer to do my thinking ahead of time and I develop routines and workflows that keep me from missing things.  This still serves me well, even as I get a full night sleep every night.

I think there is a possibility that period 24 hour shifts are NOT the problem.  That the problem is frequency of them, and the casual disregard of people's health the rest of the time.  I really enjoyed a Q6 call schedule, and still kind of miss it.

Sticking points for most ACA ideas:

Individual Mandate:  Everyone wants to repeal this, but they either don’t understand how insurance works, or they are willfully obstinate.

a.       I am a healthy middle-aged woman.  My health care costs me approximately $1000/year.  I pay $4800 in insurance premiums, I have a high deductible, so I get nothing out of it.

b.      That $4800 goes to take care folks with cancer, folks who had car accidents, type I diabetics who need kidney transplants, etc.

c.       I pay that $4800 in case I ever get cancer, have a car accident, etc.

d.      If folks like me opt out, there’s not enough money to take care of the sick folks.

2.       I have a Health Savings Account (HSA):

a.       I was able to fully fund it for the past two years so it has the full amount of my deductible in it. 

b.      However, if I were to be hit by a car in November, it is likely I would be looking at paying my deductible twice, at the same time my income would bottom out.

c.       If I can hold off getting hit by a car for the next decade I may have saved enough to fund two deductibles, pay my premiums and replace my income during my recovery.

d.      All this is null and void if I get something like Parkinson’s which robs me of my ability to work for the rest of my life.  And even if I get disability, Medicare doesn’t kick in for 2 years.

3.       Public Option: I have come to the conclusion that a public option is required for several reasons:

a.       Competition: As a true non-profit the public option will be the lowest cost in every market, which will require the for-profit industry to be “better” in some way to get people to pay for it.  I have no doubt they can do it.

b.      Areas of the country without enough population to sustain commercial programs.

4.       Minimum Essential Coverage:

a.       Before the ACA insurance companies could offer anything they wanted, and call it health insurance.

b.      The problem with à la carte insurance, is that it functions more like “pre-paid” health care. 

There may be edits to this.  

Nice to talk to you today, and REALLY?!?!

I called my Congressman's office today, and came home to find he'd voted for HR7. So I began this email to the staffer I talked to. I'm not sending it because I work for the state, and I like eating. But I am so tired of people who make life harder. They're never happy people. The text of the email so far:

It was nice to talk to you today and I suspect that for the next couple of years, we're going to get to know each other.


HR7 is the kind of dumbass pander to the nasties I expect from my representative.


You know what I hate most about you narrow-minded pro-birth proto-fascists?  That if your sixteen year old was pregnant , you'd drive her to the clinic.  Actually, she wouldn't have to go to the clinic, your private OB/GYN would do a D&C for "dysfunctional bleeding".

I also hate that you make me support abortion, which I fundamentally don't like. I believe that life begins at first cell division. But I also believe that there are crimes worse than murder, and if a woman is not ready to be a parent, ending that life before it fully starts may be the better choice.

Realize that my religion debates whether it is better to eat fish (dumb but small and thus many must be eaten) or cows (fairly smart but one death feeds many).

I hate these anti-choice measures for a number of reasons:

1. I've never met anyone happy having an abortion. 
2. All the restrictions do is push them later and more dangerous. 
3. If a woman were happy about having an abortion, would you want her to be a mother? 
4. I have seen narrow minded small souled bigots feel empowered to be ass-wipes to women suffering the loss of wanted pregnancies. 
5. Similarly, I have seen women carrying life threatening pregnancies of babies that will not survive treated badly for the decision to go ahead and induce at 30 weeks rather than risk orphaning her living child. 

When I was in training I asked everyone about abortion, and the old hippy dude who said, "They come here with enough of their own shit, I don't add mine" was the guy who felt like a saint. So I stick with that.