Friday, August 5, 2011

Medical Advocacy and Star Wars

I’m not afraid to admit that the Star Wars trilogy, the original trilogy, was my favorite three movies when I was young. As a younger boy I didn’t understand one of the key moments of the first movie, though, and it always bothered me. I didn’t understand why Obi-Wan Kenobi would turn off his light saber and let Darth Vader strike him down. For those unaware of the movie plot, I’ll make the scene very simple. Obi-Wan Kenobi represents everything good in the world and Darth Vader represents everything bad. They had fought before and, to put it lightly, Obi-Wan demolished Vader in a previous battle. Yet when it comes time to have a real battle, and perhaps destroy Vader for good, Obi-Wan simply puts his weapon away, admits defeat, and lets Vader kill him.

To a 7 year old boy who wandered around in an oversized hoodie, hitting things with a cardboard paper towel tube, and generally trying to be like Kenobi, this moment was somewhat traumatizing. For a long time I believed that Kenobi held all the power and simply gave up because he thought he erroneously thought the fight was too hard to overcome. He put his lightsaber away because he didn’t believe in himself and he died rather than fight. I want to now acknowledge all the Star Wars fans frothing at the mouth; yes, I later realized he stopped fighting because in defeat he became both an immortal in the force and a martyr to drive Luke to his own heroics, but that doesn’t change how important my initial misunderstanding was.

When I talk to people about advocacy, especially at the student level, all I hear is defeatism. I can see them all pulling an Obi-Wan on me and simply saying that nothing they can do matters so they might as well just let the ‘inevitable’ happen and continue on with their lives without any resistance. When I hear someone tell me that ‘they can’t change anything’ or that ‘they need to focus totally on their studies’ I want to shake them and explain how crazy they sound to me.

On the former, experience has shown me that when debates become entrenched it tends to become ‘physicians’ versus another monolithic, entity without any face or soul as far as the common person cares. Today its doctors and trial lawyers, yesterday it was doctors and insurance companies, tomorrow its doctors and the IRS. I actually think doctors can win that last one. But I digress, when the debate becomes stale politicians, and other political movers and shakers, seek out the fresh faces that aren’t sworn to party lines. Students are seen as a fresh and innocent source of opinions. Generally speaking, we truly want what is best for the health of the whole society, and have shown willingness to make sacrifices in our future in order to create a health society that we feel is more “enlightened.” Students who speak up become central in the debate, our comments get the presidents to respond, the politicians to meet us in person, and the debate to shift dramatically. All we need is the courage to not give up before the fight even begins.

When I hear that a student wishes to focus more on education than advocacy I have a bit more understanding. Don’t get me wrong, I still believe they are being penny wise and pound foolish, but they are making an intelligent decision in their immediate future. Despite this, no amount of great grades will change that the health landscape, where we will almost all end up, is rapidly turning against physicians as the advocates for physicians often cannot match up to the vocal defenders of other vested interests. We study to be great physicians, but it would take so little time to act on behalf of the profession we hope to become so that organizations outside of the hospitals don’t recreate the world inside of it before we even get there. Sometimes just physicians suffer; sometimes decisions are made that hurt physicians and patients. The former is bad, the latter is a national tragedy that keeps happening over and over; all while students study diligently, completely oblivious to the detriment these changes will have on them.

I’ll give you a theoretical example from my own school. In late March and early April I was contacting every single school in NY to try to organize a united front to support a suggested NY State budget that would include many pro-physician changes along with a few compromises.  One of the greatest changes was an indemnity fund that, among other things, would lead to an estimated 25% cut in the malpractice insurance costs for obstetricians. In my home institution we were studying OB/GYN right as the debate on the medical-related portions of the budget was raging. A student I approached to take a few seconds of her time to sign a form letter for me, or write her own letter if she felt so compelled, rebuffed me coldly and refused to sign. Her reasoning for not signing was that she wanted to be an obstetrician and couldn’t do anything for me this close to test time, as she had time to read nothing else but her textbooks for the next 3 days and had to have a perfect score on her OB/GYN exam. I tried to explain the irony of not wanting to support current and future obstetricians because she was too busy studying to become one, but she had already tuned me out. Her lightsaber was down and she had accepted her defeat, whether she consciously knew it or not.

Recently the medical students of New York State participated in a study on their opinions on advocacy, among other issues. The study showed 68% of students want to be more involved with advocacy and legislative issues involving medicine, and 78% felt that their actions could have a positive impact on patients and colleagues. Despite the apparent willingness to participate, the study also showed that only 21% of students have ever participated in any way in such issues.  I can’t help but look at those numbers and assume there is a disconnect between what we students feel like we can and should be doing, and what we are willing to do when actually faced with the opportunity. The sense that we’re under qualified, the fear of time commitment, and the idea that we’re facing insurmountable odds are all fallacies that we tell ourselves when acting just isn’t what we want to do today. If I am going to do one thing in my term as your Chair of the Legislative Awareness Committee for MSSNY, it’s that I’m going to make sure every time a student thinks “someone should stop that” or “I don’t like that,” I’ll be there to give them the tools to make sure their opinion is well-informed, heard by those in power, and valued. No student should ever feel hesitant to broadcast their ideas publicly on these matters.

Now that I’m older I see there was another lesson Obi-Wan, and all of Star Wars, was trying to teach when he let a singular force strike him down. No one person can do it alone. This was true when Obi-Wan realized he was more powerful as a ghostly mentor to Luke than as a human warrior. This is true when you look at the entire trilogy. When it was time for Luke, the hero, to save the day in the first movie he fails. He misses time and time again when he tries to win by himself because there is too much pressure on him the enemies to line up a good shot. It’s not until Han Solo comes to his aid and Obi-Wan encourages him to trust in himself that he saves the day. This is even true in the other movies. Who defeats the bad guys? Not the hero acting alone. Luke loses. It’s Darth Vader, realizing what is being forced on Luke (death in this case) is reprehensible and joins forces to stop the Evil. Out in space there is another battle where you expect some major character to be the one to blow up the New Death Star. Who does blow up the Death Star? Lando Calrissian, a relatively small but very memorable supporting character, is the guy who saves the day in the end. For those who don’t know, Lando is basically the epitome of a medical student. He is charismatic, brave, intelligent, and fatally flawed by complacency. Lando chooses early in the trilogy to aid the villains rather than rock the boat and try to resist. He only becomes a hero once the protagonists convince him that it is possible to make a difference and change the universe.

So, maybe we can be a bit more like Lando Calrissian and Obi-Wan and realize that we can effect massive change if we support each other, rather than acting alone or simply submitting to a future we do not approve of without a fight. In the mean time, I’m going to watch the Star Wars trilogy again; and yes, I’ll be on my couch dressed up as Obi-Wan Kenobi, cardboard tube and all.

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