Turning Points in Medicine

Sherwin Nuland lists top 5 books that were turning points in medicine in this weekend's Wall Street Journal:

1. Interpretation of Dreams by Freud
2. The Double Helix by James Watson
3. The Silent World of Doctor and Patient by Jay Katz
4. Microbe Hunters by Paul de Kruif
5. The Merck Manual of Medical Information: Home Edition

To that list I would add On Doctoring, an anthology of writings about the art of medicine commonly given out to US medical students at the beginning of their training.

H/t Med Pundit

The Ecology of Polarization

Centrists are so often frustrated with the black-and-white thinking of the political Left and Right that I think it's worth reflecting on the useful role each political pole plays in the ecology of our political system.

Perhaps most importantly, the Left and Right wings supply much of the energy into the political system. While solutions may come about from compromise and persuasion, the movement toward resolution of problems is often sustained by pressure from one or the other political pole. It is much like the relationship between the Id and the Ego--the extremes supply the drive, the centrists find the solutions.

That formulation makes sense in terms of the routine operation of the government, but the more dramatic functions of the extremes are seen when societal paradigm shifts happen. Without a Left and a Right, we never would have seen either the civil rights movement of the 60s or the arrest in growth of the welfare state of the 80s-90s. The poles often supply the Big Ideas, or champion them before they have a chance to win general acceptance.

Finally, even if centrists had all the answers to the social and political problems of the day, unfortunately much of their impetus to action comes from a need to counter what they see as harmful initiatives by the political poles, and replace them with their own intitiatives. In this way, the Left and the Right prompt those in the Center to become politically active when they might otherwise not be.

So next time you're discussing abortion or Iraq with a liberal or conservative who just digs in his heels, try not to get too frustrated. He's chosen his role in the political ecology, and it's all just the circle of life.

The Peter Pans of Generation Y

Are the young men of Generation Y (today's 20-somethings) more listless than their forebears? Alan Stewart Carl comments on a Leonard Sax Wa Po column:

Within the last 30 years, marriage rates have been sinking and those getting married are doing so later in life. So, whereas young men in their 20s used to get married and then need a good job to support their family, now they don’t get married and thus don’t need a good job. Young men today simply do not have the responsibilities young men used to have.

But why hasn’t the decline in marriage also led to many more woman living at home? I think this has to do with the continuing effects of the feminist movement. Men who are not married are permitted by our culture to be boyish and directionless. But unmarried women are expected to rise above and claim their independence.

This cultural incongruity is readily seen within our modern movies. Actors like Will Ferrell, Vince Vaughan, Owen and Luke Wilson, Steve Carell and others make movie-after-movie that portray grown men as nothing more than overgrown children who find happiness in their boyishness. But actresses like Sarah Jessica Parker, Chalize Theron, Reese Witherspoon and most other popular Hollywood actresses are not playing roles that celebrate girlishness. Instead, they take on roles that demonstrate the virtuousness of independent women who either don’t need a man to be complete or are the rock in a directionless man’s life.

A TV advertisement that stands out in my memory showed an SUV that was seen packaged in a box as a toy, with a fully grown man agape like a child. It makes sense for advertisers to evoke child-like states of mind; child-men are more likely to make impulse purchases than mature men.

Youth has been glorified in various forms since antiquity, but in times of widespread material prosperity it is possible for people to 'live the dream' of prolonged childhood. I expect that extending the Imperial Self (to use Robert Kegan's psychological development theory) for men into their twenties, while women become more free to develop beyond the Institutional Self, will have profound implications on the institution of marriage in years to come. I see it in my own patients already. The difference between the situation now and 25 years ago is that it is common for such child-men to be economically and academically successful in their careers. This contrasts with Vaillant's work that found that achieving successful intimacy (with a spouse or mentor) was necessary to really succeed at work, because it catalyzed one's ability to connect with people, build trust, and work smoothly in organizations. In today's email workplace, it is possible to accomplish much without emotional maturity being noticed in many jobs.

But while you can fake sincerity, you can't fake emotional maturity, and tomarrow's families will need husbands and fathers who can fill the bill.

Mental Health Parity: New Evidence

The current New England Journal reports a study comparing federal employee health benefit plans with and without mental health parity (full coverage for mental health services on par with coverage for other medical services). They found that:

The implementation of parity was associated with a statistically significant increase in use in one plan (+0.78 percent, P<0.05) a significant decrease in use in one plan (–0.96 percent, P<0.05), and no significant difference in use in the other five plans (range, –0.38 percent to +0.23 percent; P>0.05 for each comparison). For beneficiaries who used mental health and substance-abuse services, spending attributable to the implementation of parity decreased significantly for three plans (range, –$201.99 to –$68.97; P<0.05 for each comparison) and did not change significantly for four plans (range, –$42.13 to +$27.11; P>0.05 for each comparison). The implementation of parity was associated with significant reductions in out-of-pocket spending in five of seven plans.

The NEJM editorial opines:

Although parity did not lead to increases in the use of services relative to a comparison group, it did lead to systematic reductions in out-of-pocket spending for mental health services. Parity coverage performed just as insurance coverage should. It shifted costs from out-of-pocket payments to the insurance company (and eventually to very small increases in insurance premiums) without leading to an increase in the use of services. This shift means that, in today's mental health environment, parity coverage unambiguously improves the value of health insurance. It moves risk away from individual patients without changing the incentives that they face.

The evidence is stacking up, and policymakers will not be able to ignore it much longer. Treating psychiatric care as a separate service from general medical care means that the organization that sees the costs--the mental health insurer--does not reap the reduction in general medical costs that occurs when good mental health care is provided, so there is no incentive to provide adequate mental health coverage. Parity ensures that the same insurance company has a stake in both psychiatric and general medical care, and providing a system that handles both types of problems well. Parity makes sense for patient care, and now the data shows it is good, or at least not bad, for the bottom line.

Because integrated mental health care can decrease general medical costs, it should be a key part of a comprehensive national plan to control the growth of health care costs. However, if one company implements parity, it would fear patients with mental health problems flocking to its plan from others, so parity must be implemented simultaneously across the insurance industry. That's where federal action is necessary.


Let your senator or representative know if you think that mental health parity is important.

The Fall of Red America

I was an online denizen, reasonably frequent commenter, and occasional diarist at Red State for about 6 months after the 2004 elections (my diary). Ben Domenech (aka Augustine) was a fair-handed editor of the site, and agree or not with his posts, he always did his homework.

Last year, the atmosphere at Red State became decidedly less friendly to good-faith dissent, and along with many other commenters, I left the site--and started my own blog.

Meanwhile, this year Augustine was rewarded for his excellent online writing with a job as the Wa Po conservative blogger. His supporters at Red State stalwartly defended him when he was attacked from all sides. Yesterday, Domenech was conclusively shown to have plagiarized throughout his writing career. Michael Dougherty summarizes the story nicely. He concludes:

No one can fault the reflexive defense mounted by RedState for their co-founder, especially when Domenech's original critics gave no indication of being fair or decent. They succumbed to a pressure unique to the blogosphere -- to publish faster than the speed of thought. They acted on instinct for everyone to see. But as the facts came out, RedState's editors were surprisingly unfazed. Mike Krempasky had the last word, announcing Domenech's leave of absence and prophesying his walk down the road of redemption. The harshest words were not for the colleague that had only a few hours ago refused to own up to his intellectual theft, and used RedState to lash out at his critics and spin the story in his favor, but for that man's critics. "Loathesome (sic), vile, and disgusting -- their contempt for civil behavior surpassed only by the emptiness of their own souls."

Meanwhile, now that the truth is clear, those defenders are as quick to forgive him as Domenech was to lie in his own defense this week. They are as quick to excuse him as they are to condemn Jayson Blair or Jill Carroll.

Here's the question for centrists like myself: are the reflexive defenders left at Red State the conservatives that can be productive in dialogue with liberals and moderates, or are those conservatives somewhere else? If not, where are they?