When you're done getting dressed, take the rooster to the front desk

Sue Lowden is a Republican running to capture Sen. Harry Reid's seat in Nevada. Recently she suggested that we should go back to the days when people paid their doctors directly, whether in money, or you know, if they didn't have the money right then, then maybe, barter, with, you know, like, chickens and stuff. That back-to-the-old-days nonsense is so phenomenally stupid, it nearly begged for someone to set up this site:

Prices of medical procedures in number of chickens.

Make sure to read the fine print to properly adhere to the plan's rules.

For big procedures, the site suggests possibly converting to cows.

On the other hand, teaching hospitals might consider accepting chicks in order to subsidize medical education--and to pay residents with. Residents, being mere doctors-in-training, should be paid in chicks rather than in chickens. This will also allow them to invest in their future. Once the chicks grow up, they can be used to pay off student loans.



The Democratic Senatorial Campaign Committee has a different plan available.

Unbelievably, after taking a week of jokes (Jay Leno: "But what if your doctor isn't Amish?"), she continued to promote this idea, in the tone of making a helpful suggestion for the folks at home.

Jamie Oliver, ABC's pop Alinsky

Photo: Jamie Oliver in Britain, where he transformed national school lunch policy.


Ms. Dr. Hemodynamics and I were having a little bit of TV time the other night, and Jamie Oliver was trying to convince the lunch ladies of West Virginia that cooking from scratch was a good idea, and railing against some state bureaucrat's affection for chocolate- and strawberry-flavored milk.

Surprisingly, we kept watching.

OK, so, admittedly, I've only seen one episode thus far--but still, I found myself surprisingly compelled by the episode I saw, as a template for health-oriented community organizing.

I have mixed feelings about the moral panic in progress about obesity. The term "obesity" has become so loaded with moral judgment that I've taken to showing people in my clinic the NHLBI BMI calculator while holding my hand over the category labels. I always explain that this is a continuum, and that it's my view that the terms "overweight" and "obese" are better understood as "higher risk" (for 25 to 29.9) and "even higher risk" (for over 30). I don't think that calling someone "obese" is that useful. And absolute weight numbers, especially around the high 20s/low 30s fairly "overweight"/slightly "obese" range that so many of my patients and I occupy, may be at least as important as proxies for other things--like cardiovascular fitness and nutrition--as problems in and of themselves.

But my own struggles with weight and fitness, and those of my patients, are for a different day. The genius of Jamie Oliver's show, at least the episode I saw, is that he doesn't waste a lot of time trying to persuade individuals to change their individual diets. He knows that they'll drink the chocolate milk if it's in front of them and they have a choice between that and regular milk. Who wouldn't? And if the chocolate milk isn't there, they won't drink it, because how would they?

Here are some other aspects of why Jamie Oliver showed himself to be a smart community organizer in the 45 minutes I watched him:

1. Big change comes from changing big systems. He knows that the leverage is in the structural intervention. Children in this town all eat lunch at school, so don't try to get them to bring their lunches. Change the school lunches. People at a work place eat food that's close to work, so don't ask them to drive to some place that has a salad bar two miles away: drive a food truck that serves salads and bison burgers up to the work place. Like smoking, a lot of food choices are made because of availability, proximity, habit--all things that can be affected by altering the physical and economic environment at least as easily as changing individual minds.

2. Individual beliefs matter. Conversely, he knows that structural interventions can only work if a large enough number of individuals support them. People who think eating better food and avoiding obesity is a good idea will appreciate the support that a structural intervention gives their personal goals. But if people don't understand the rationale behind the changes, they'll just be mad that there's no chocolate milk or french fries--they'll register a change, understand it as out of their control and leading to a result they don't like, and demand a change back to the old system.

3. Every individual matters. Anyone at any point in the process, from state bureaucrat to food supplier to principal to cook to teacher, can either advance or sabotage a project for change. Because of this, he also lets everyone know that when they are supporting change, they are instrumental in doing so. He lavishes praise on the smallest change. "Fantastic!" he raves, as if the low-level administrator who removes the chocolate milk for a day should win a MacArthur "genius" award. Even non-committal shine-on answers get a "great, great" from Jamie, as long as they're not frankly obstructive--though he doesn't take "maybe" for an answer, and goes back to trying to close the deal.

4. Follow the money. He understands that the approach he's recommending will cost more. He targets the town's biggest employer, which nicely is a hospital. He shows that they should have an interest in supporting his changes and relentlessly hits them up for money. (That in fact they may not have any particular economic interest in the changes he proposes is a sign of the utter perversity of the healthcare system, but that's another reality TV show.)


These four ideas are the basis for a lot of successful community organizing.

I'm not sure Jamie Oliver has got it all figured it out--most importantly, I'm not seeing him build a corps of organizers who will stick around to keep the pressure on. But maybe at the end of the show, the real point is not the people in that particular town--but the corps of organizers he might build from the millions of people who are watching him on Friday nights.

Berwick to run Medicare/Medicaid

Unless Republicans in the Senate manage to somehow find a way to sink the nomination, it looks like Don Berwick will be the new Medicare/Medicaid chief. I think that is actually big news. It suggests that in the next phase of healthcare reform, Obama's emphasis will be quality improvement--and likely, linking payment to quality outcomes.

Medicare has already started moving in that direction. And healthcare reform quietly includes some important tools to help it move farther. But this may suggest that Obama is going all in on changing payment structures.

Why do I say that? Because Berwick is the person who has probably best popularized the quality improvement movement within healthcare. Though he runs an institute and has evidently done a good job of it, he is primarily an evangelist, not an administrator. So you wouldn't choose him for a big job unless you thought the job required evangelism.

Repub's vow: no snitchin'

Someone called Stupak a "baby killer" on the Senate floor. (But... isn't a baby killer a guy who votes against the Children's Health Insurance Program? I must be confused.)

Campbell, initially suspected as the lawmaker who shouted the phrase, told reporters that he didn't say it and believed that it came from a member sitting a row behind him, where the Texas Republicans usually sit. Campbell said he heard "a Southern accent".

"The people who know won't give it up," Campbell told reporters.

He said the remark was "clear as a bell."

On NPR.org: "Overshooting Obama's Health"

New writing of mine, posted elsewhere (and broadcast on All Things Considered on 3/4/10):
"It doesn't take a CT scan to know that President Obama should keep exercising, watch his diet, and quit smoking. So deciding not to do a test like a coronary artery calcium CT scan isn't just about avoiding the financial cost of the test. If the results of the test won’t change what we recommend, then the patient is taking risks for data that won’t make a difference."