Not So Fast, Schwartz

By  |  January 21, 2010 | 

Every family has a favorite joke or two. One of ours went this way – unsurprisingly, given my dad’s interests and pedigree, it is Borscht Belt meets US Army. Here goes:

An army drill sergeant receives word that both parents of one of his enlisted men have died tragically in an accident. Although the sergeant is tough as nails, he struggles with how to break the news to the fragile Private Schwartz. Finally, just before the morning mail call, he seizes on an idea.

At mail call, his troops assembled, the sergeant bellows, “OK, everybody with parents, take one step forward.”

“Not so fast, Schwartz.”

Every year, I give a keynote address to close the Society of Hospital Medicine’s annual meeting. Larry Wellikson, SHM’s president, flatters me by saying that my talk helps keep people from leaving early. I believe that my placement helps ensure that I annoy the fewest possible attendees. Whatever.

This year, I decided to entitle my address for the upcoming meeting, “How Health Care Reform Changes the Hospitalist Field…And Vice Versa.”

Not so fast.

I won’t add to the Massachusetts post-mortems filling our collective in-boxes (I particularly like the stuff on The Healthcare Blog, such as this and this). I’ll focus instead on what the Fenway Flabbergaster means for the healthcare bill, and in turn for America.

My guess is that reform is dead for this year – it is hard to believe that the Dems can get 60 votes for anything more complex than a referendum on whether the sky is blue (and even that would get politicized). Adding to the headaches, they’re teetering on a classic legislative tightrope – if they veer any more right in a (probably futile) effort to pick off a stray Republican, they’re sure to lose somebody on the left.

Moreover, the lesson the Republicans must be taking from the experience of the last year is that hard-line, unblinking nay saying is a political winner. After the Boston Massacre, why would they even think about altering their playbook?

Of course, the bill’s failure (I’ll use the singular “bill” here, recognizing that the Senate and House versions needed to be reconciled) to truly address the cost/quality conundrum (notwithstanding Atul Gawande’s surprisingly positive spin in last month’s New Yorker), its sidestepping of the malpractice mess, its too-wimpy efforts to bolster primary care, and the Nebraska Purchase (of Senator Nelson’s vote) were particularly disappointing and unsavory.

That said, the bill did address some of the most heinous aspects of our present insurance system, and did so without colliding with America’s antipathy for Big Government or busting the budget. Flawed, sure, but the bill deserved to pass, and then to be improved over time.

Life will go on. The problems in healthcare will worsen and ultimately need to be addressed, somehow. What scares me about this is what it says about our political process. If things do stall out, I believe that the bill will have been brought down by two major forces: the growing distrust of experts and elites, and a series of lies that gained purchase because they are fundamentally more interesting than the truth. These are two powerful, and dangerous, trends.

David Brooks recently observed that the defining characteristic of today’s political age is the mistrust of elites – a populist surge that elevates morons like Sarah Palin and Glenn Beck while tarring the Obamites as being out of touch with the concerns of real people. Noting that the Tea Party now polls better than either Democrats or Republicans, he writes:

The tea party movement is a large, fractious confederation of Americans who are defined by what they are against. They are against the concentrated power of the educated class. They believe big government, big business, big media and the affluent professionals are merging to form self-serving oligarchy — with bloated government, unsustainable deficits, high taxes and intrusive regulation…
The Obama administration is premised on the conviction that pragmatic federal leaders with professional expertise should have the power to implement programs to solve the country’s problems. Many Americans do not have faith in that sort of centralized expertise or in the political class generally.

Of course, those of us who live in San Francisco recognize that we live in a bubble, the rest of the country far redder in both face and politics than we are, but now it turns out that Massachusetts – a place we thought was ensconced in The Bubble with us – more closely resembles the rest of America. I don’t get it. Seething about Wall Street bonuses and arrogance – fine, I understand (and agree). But getting angry about a healthcare bill that is generally moderate, sensible, and incremental. Huh?

Which brings me to the second issue. The only way to get truly pissed about this bill – if, in fact, that is what the Massachusetts vote was really about (and you can’t convince me that it was simply about a weak candidate; hell, in normal times, Paris Hilton could have held Ted Kennedy’s seat) – is to accept the lies and spin of the right: Death Panels, Obama the Socialist, Government Take-Over. Whether you like the bill or hate it, these labels don’t just torture the truth, they waterboard it. Yet, for a sizeable portion of the public, they stuck. Why? Because, let’s face it, they have more sizzle than the truth. They attract eyeballs, and hits, and Tweets. In a nation with an insatiable thirst for News-ertainment, a battle between Rush Limbaugh and Washington Week in Review is not a fair food fight.

The hope for the Dems is that the Massachusetts vote is Obama’s ‘94 – a wake up call like the one that shook, and ultimately energized, Clinton when Gingrich’s army took the Congress by storm. It’s clear that Cool, Balanced, and Professorial is no match for Shameless, Nasty, and Self-Certain. The Prez is going to need to take it up a notch.

Ultimately, Massachusetts was a victory for “none of the above” – for “I’m Mad As Hell and I’m Not Going to Take This Anymore!” Thoughtful folks, on both sides of the aisle, realize that, while cathartic, this answer doesn’t help us tackle our nation’s growing list of really sticky problems. But I guess we’ll just have to deal with those tomorrow.

Speaking of problems: What the hell am I going to talk about at the SHM meeting? Anybody with a topic for his keynote speech, take a big step forward.


  1. Daddy January 21, 2010 at 3:06 pm - Reply

    This is a great article, despite the fact that your politics doesn’t exactly match mine. Although Mom forced me to vote for Obama, using a modified version of the 500 mile rule.  That is we cannot have sex if any of the children are within 500 miles of us.  The modification was that I also have to vote the way she does, particularly when my three kids are also voting the same way.

    Anyway, the article is beautifully and reasonably written and I am proud to say you are my son the “Big Doctor”.

    Luv Ya – Dad

  2. Daddy January 21, 2010 at 3:06 pm - Reply

    This is a great article. I am glad you don’t take after me. Although Mom forced me to vote for Obama, using the 500 mile rule. That is we cannot have sex if any of the children are within 500 miles of us. The article is beautifully and reasonably written and I am proud to say your are my son the “Big Doctor”.

    Luv Ya-Dad

  3. SandralpsRN January 22, 2010 at 1:51 am - Reply

    While I enjoyed and agreed with many parts of your article, I grow weary of the self-appointed intellectual elite calling others who happen to disagree morons. I am by no means an idiot or moron. In fact I possess an IQ of 135. I was not in a position to attend an “elite” university where I could be taught how much better I am than those lowly serfs who attended a state school.
    In my 30 years of voting, I’ve never registered as anything other than Independent because I choose to vote for the person not the party. I research candidates positions and records on the issues rather than party affiliation or whether or not they obtained an Ivy League education.
    Why does no one ever point out how poorly Medicaid serves the public? Have you investigated the Self-Administered Drug legislation or seen how it is effecting patients? Medicaid will not pay for these SAD drugs when given in an outpatient setting including Emergency Rooms but will not allow us to give them to patients for free. I’ve seen event reports where patients have refused premedications because they don’t want to pay for them who have then had allergic reactions. Or the hoops we must jump through to document start and stop times of IV medications even if it is a few seconds to push morphine so that Medicare will pay for the charges. Who implements these rules which reduce reimbursement first? Medicare does, then other insurance companies follow. Insurance reform is great but clean the government house too.

  4. Brian Clay, MD January 22, 2010 at 10:34 am - Reply

    A minor adjustment to your topic: “How Health Care Reform Would Have Changed the Hospitalist Field…And Vice Versa.”

    All of the major issues are still in play: the near-term insolvency of Medicare, the vast millions of Americans without insurance, the need to bring primary care back to the foreground, medical malpractice, medical student debt, Dartmouth Atlas vs. McAllen, Texas, the moral hazard problem of going without insurance vs. the legality of an individual mandate to purchase said insurance, health care cost inflation, and so on.

    (Maybe you could spend the hour just LISTING the issues involved.)

    Because all of the above issues still need to be address, the next legislative crack at a comprehensive solution (however far away that may be) is likely to be similar in structure; it simply will have become mission-critical for national solvency to pass legislation by then, rather than the mere urgent pressing need it was in 2010.

    Alternatively, we could all submit jokes for presentation. I’ve got one along the same lines of “breaking bad news”:

    Two brothers took some time off from their jobs to pay an extended visit to their mother, an elderly woman in failing health. The older brother brought with him a most cherished pet, a cat that he had had for over ten years. A few days into the visit, this older brother, an upper-level executive in his company, learned of a crisis that demanded his presence back at work for several days.

    Before leaving, the older brother asked the younger brother to look after his cat, giving precise instructions on feeding and other issues. Unfortunately, soon after the older brother’s departure, the cat escaped outside through an open door, ran into the street, and was fatally hit by a car.

    The younger brother realized he couldn’t flat out tell his older brother about the incident; he loved the cat so much that the news could be devastating if delivered the wrong way. After some thought, he came up with a way to gradually break the news.

    The next day, the older brother called, asking after the cat. The younger brother said, “Well, the cat got outside. She’s up on the roof and we can’t get her down.” He promised he would call the fire department if the cat didn’t come down by herself.

    The following day, the older brother called again. The younger brother said, “The cat tried to jump down by herself, but she ended up breaking her leg. We’re taking her to the vet.”

    The older brother called again the next day, asking for the latest information. Empathetically, the younger brother informed him that the injuries were too severe, and that she passed away at the vet’s office.

    The older brother became very emotional, was able to accept what had happened. “Thanks for doing everything possible to help my cat. By the way, how is Mom doing?”

    “Mom? Well, she’s up on the roof and we can’t get her down.”

  5. James January 22, 2010 at 4:59 pm - Reply

    The one time I took an IQ test it indicated I was in the top 7/10th of a percent of intelligence. As such, I suppose I could also refer to anyone I happened to disagree with as a “moron”. However, I don’t choose to do so. My intelligence tells me that to do so is to come off as arrogant and coarse. It also tells me that it is those who lack the ability to refute an argument that must resort to personal attacks and insults.

    You also need to look more closely at the financial underpinnings of these bills. They were a collection of budget gimmicks designed to create an illusion of being affordable.

  6. JackLounge January 24, 2010 at 6:18 pm - Reply

    I often remark to patients who put off thier colonoscopy that denial is a workable health care strategy. It works right up to the very end.
    Your position as a thought leader is undermined when you insist on denying what occurred last week in Massachusettes. Yes , the elitists are smarter than most Americans. They scored well in the big tests for academic advancement and we benefit greatly from thier hard work and discoveries,etc. Unfortunately , they are not the whole fabric of what we call the American experience. As a matter of definition, they need to be a minority, hence elite. We should all respect the minority opinion of the elitists. By respect I mean to say “listen to understand” rather than the “listen to respond”. The ability of the elitists to lead will require a message that captures the hearts and minds of the majoriity of Americans who sometime have a hard time understanding the big words and difficult concepts of Life , Liberty , and the Pursuit of Happiness. Teabaggers and morons abound! Maybe the lesson from Massachusettes is listening to understand. The failure of Air America was not in its message. It was in its cynicism of dissenting opinion.
    The opportunity is clear. You can be a thought leader or a thoughtful one. Choose wisely.

  7. Bob Wachter January 24, 2010 at 11:21 pm - Reply

    The following comment comes from Bob Centor, Associate Dean at the University of Alabama (and author of an excellent blog, at )  Apparently my site wasn’t accepting his comment (as you see from some of the above, it isn’t because I’m blocking comments that don’t agree with my point of view!) — we’re working on the technical glitch, but in the meantime, here, with Dr. Centor’s permission, is his comment:


    While I agree that we need health care reform and that the bills were acceptable, I would argue that they are not good. The Democrats have done a miserable job of “making sausage” and of explaining their bills. They have not acted quickly enough, and they have not had discipline.

    The result are 2 bills (House and Senate) that one could describe as large Xmas trees with many broken branches and ornaments. This makes it too easy to criticize the bills. Critics can avoid the strengths of the bills and highlight weaknesses.

    Massachusetts shows that all politics are local. The Democrats had a weak candidate and the Republican ran without ever using the label, rather claiming the independent label. He successfully focused on the weaknesses in the bill and in the administration’s approach to terrorism.

    The Democrats unfortunately do not understand how to develop a “sticky message” about health care (see Chip and Dan Heath’s great book – Made to Stick), rather they suffer the Curse of Knowledge.

    If I were you, I would focus on how Hospital Medicine can improve health care, and would highlight the safety movement – root cause analysis and checklists. I would talk about the dangers of transitions.

    Good luck.

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About the Author: Bob Wachter

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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