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The AMA And Congress: How To Cross The Cultural Divide

The AMA’s communications department kindly sent me a copy of a letter that they (and 9 other professional society CEOs or Presidents) recently sent to Barack Obama and 12 members of congress. I’ve been blogging about the fact that healthcare providers in general, and physicians in particular, do not seem to have much of a voice in healthcare policy. In fact, from what I can tell, Dr. Nancy Nielsen is carrying the torch almost exclusively. I don’t mean to belittle anyone’s efforts, it’s just that I’ve noticed that she is often the only physician at the highest level policy meetings.

So it was with great interest that I read the group letter to Obama et al., wondering what collective message our physician leaders were trying to get across. The writing was academic – using terminology familiar to those heavily steeped in medicine – and emphasized the creation of a patient-centered culture supported by evidence based medicine.

However, the letter raised an interesting question in my mind: Will members of congress read and understand it? I believe that the most effective letters to congress are likely to share three qualities: 1) they must be emotionally provocative 2) they must be written at about the 6th grade reading level 3) they must be brief.

Why Letters Must Appeal To Emotion (“Cultural Competency”)

Dr. Nielsen said at a recent Medicare Policy Summit that speaking with Senators can be “pure theatre.” That has been my observation as well. Decades of experience speaking in large committee meetings have taught them that amusing sound bites or emotional outbursts get attention. In fact, it may be the best way to get things done in congress. For example, did you know that the reason why kidney care is the only disease-based eligibility under Medicare is that Shep Glazer testified before congress during one of his dialysis sessions?

Washington , D.C. , Nov. 4, 1971 – In the most dramatic plea ever made on behalf of kidney patients, Shep Glazer, Vice-President of NAPH, testified before the House Ways and Means Committee while attached to a fully functioning artificial kidney machine.

Minutes before, in the corridor outside the hearing room, Shep told reporters from the AP, UPI, and the Washington Post, “Gentlemen, I am going to tell the Committee that if dialysis can be performed on the floor of Congress, it can be performed anywhere.” As his wife, Charlotte , connected him to the machine, he continued, “Kidney patients don’t have to be confined to hospitals, where expenses are $25,000 a year and more per patient. It’s much cheaper in a satellite unit or at home. I want to show the Committee what dialysis is really like. I want them to remember us.”

My point is that in congress, as opposed to medical meetings, emotion is king. Physicians have a hard time speaking from the gut, since we’re trained to speak from data – because we know that the gut can be misleading. However, my plea to physician groups is this: let’s collect our data, understand the science behind our point of view, and then present our advice in a way that is persuasive to congress. That means we’d probably benefit from a few theatre classes (can we get CME credit for them?) I’m not suggesting that we become undignified in any way – I’m just saying that personal stories, case studies, and appeals to emotion are the currency on the Hill. If we want attention, we’ll need to find a way to make our points in their own language.

For example, I was listening in to a recent Senate hearing on healthcare finance, when a Republican senator began his introductory remarks about “out of control spending” with this:

I must tell you that I have major concerns about our current approach to spending. We’ve already sunk billions of dollars into all kinds of bailouts and programs without any clear benefits. But every time I bring up the excessive spending issue, you’d think I was a skunk at a picnic…

An amusing analogy, and one that resonated with his peers. This Senator understood the culture to which he was speaking. In other words, he had a “culturally competent” message.

Why Letters Should Be Written At About The 6th Grade Reading Level (Health Literacy)

Dr. Richard Carmona told me that one of the first things he learned as Surgeon General was that the American people understand health information at a 6th grade reading level. Thus, there is no point in making a 100+ page medical report on the health hazards of smoking the corner stone of a public smoking cessation campaign.

Health information must be written in a clear, and actionable manner – but it must also be delivered in such a way that it resonates with diverse communities. Letters to congress are no different – many of our congressmen and women do not have advanced medical or science degrees. We must be sensitive to that and write to them in a way that makes it easy for them to understand what we’re hoping to accomplish.

Why Letters Must Be Very Brief

Much has been made of the fact that many people who signed the recent 1000+ page stimulus bill hadn’t actually reviewed it. In fact, it is estimated that 306 members of Congress voted for a bill they had not read.

Of the 535 members of the United States House and Senate,  246 House members and 60 members of the august Senate voted for the $787 billion  stimulus bill without having read a single one of the bill’s 1,071 pages or having any idea of where all of this money borrowed from our grandchildren is going to be spent.

So if our members of Congress don’t read the stimulus bill, will they take the time to read long letters from professional societies? I think you know the answer.

Conclusion

The AMA should be applauded for their lobbying efforts on the part of physicians in Washington. However, my personal view is that letters to congress may be more effective if they are written in a concise, jargon-free, compelling way that respects the “culture” of congress. We physicians hear a lot about “health literacy” and “cultural competency” – and must remember to apply those principles to letter-writing campaigns.

Will any letter influence congressional decision-making? It’s hard to measure the “ROI” of group letters to congress – and certainly they’re only one part of a larger strategy. However, it behooves us physicians to find ways to reach across the cultural divide to speak to congress about the issues that trouble us all: the fate of patients. Letters may be helpful, but an increased presence in Washington, along with some heartfelt reasoning, may be our best shot. Perhaps the Broadway actors affected by the economic recession could help us out?


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6 Responses to “The AMA And Congress: How To Cross The Cultural Divide”

  1. David MD says:

    You're absolutely right about the emotional argument/plea and it is a bit surprising to me that physicians writing these letters don't realize this. Also the presentation of the dialysis argument (a direct emotional please by a sufferer — I give an example later) is the way we should present things to others.

    With anti-smoking and Israel I mention that 10,000 Israelis die from smoking and second hand smoke which compares with 20,000 Israelis that have died in all of the war and terror since 1948. Also I mention (as is the case in America) that most people (80 to 90%) start smoking as minors when they are not legally supposed to be able to purchase cigarettes and that we need to enforce the law so that children don't get access. We need to be serious about protecting our children.

    Regarding infertility which I also work the RESOLVE fertility organization will send a team composed of a reproductive endocrinologist, a psychologist that deals with infertile patients and an infertile couple to speak directly to others including other doctors.

    My “joke” is that they don't teach us “Madison Avenue” (e.g. “sales and advertising”) in medical school. Yet, much of what we do (esp. in primary care) is trying to convince patients to quit smoking, lose weight, etc.
    For instance today I spoke with a smoker with two young children and I said to him that as a parent he doesn't want his children to start smoking and he agreed and I told him that they are going to follow your example because they look up to you. Similar arguments are used to get patients to remain compliant with anti-hypertensives (you want to see your grandchildren grow up don't you?).

    Look how effectively the drug companies are selling their wares on TV. That is what we should be doing in medicine as well when talking with political leadership. Simple, emotional messages.

    Thank you for making this point.

  2. David MD says:

    You're absolutely right about the emotional argument/plea and it is a bit surprising to me that physicians writing these letters don't realize this. Also the presentation of the dialysis argument (a direct emotional please by a sufferer — I give an example later) is the way we should present things to others.

    With anti-smoking and Israel I mention that 10,000 Israelis die from smoking and second hand smoke which compares with 20,000 Israelis that have died in all of the war and terror since 1948. Also I mention (as is the case in America) that most people (80 to 90%) start smoking as minors when they are not legally supposed to be able to purchase cigarettes and that we need to enforce the law so that children don't get access. We need to be serious about protecting our children.

    Regarding infertility which I also work the RESOLVE fertility organization will send a team composed of a reproductive endocrinologist, a psychologist that deals with infertile patients and an infertile couple to speak directly to others including other doctors.

    My “joke” is that they don't teach us “Madison Avenue” (e.g. “sales and advertising”) in medical school. Yet, much of what we do (esp. in primary care) is trying to convince patients to quit smoking, lose weight, etc.
    For instance today I spoke with a smoker with two young children and I said to him that as a parent he doesn't want his children to start smoking and he agreed and I told him that they are going to follow your example because they look up to you. Similar arguments are used to get patients to remain compliant with anti-hypertensives (you want to see your grandchildren grow up don't you?).

    Look how effectively the drug companies are selling their wares on TV. That is what we should be doing in medicine as well when talking with political leadership. Simple, emotional messages.

    Thank you for making this point.

  3. Jeffrey Segal says:

    The art of persuasion is actively taught in law schools. It's an acquired skill that physicians can master. Like anything else, it takes time.

    Have you heard the evolving iteration to the “skunk in the garden party” metaphor referenced above? I have heard it colorfully described as”bringing attention to the turd in the punch bowl.”

  4. Jeffrey Segal says:

    The art of persuasion is actively taught in law schools. It's an acquired skill that physicians can master. Like anything else, it takes time.

    Have you heard the evolving iteration to the “skunk in the garden party” metaphor referenced above? I have heard it colorfully described as”bringing attention to the turd in the punch bowl.”

  5. smoking says:

    This health issue is tremendously complex. We almost need to start over. It also should be a lot easier to identify the cost components that are rising so fast
    BK

  6. smoking says:

    This health issue is tremendously complex. We almost need to start over. It also should be a lot easier to identify the cost components that are rising so fast
    BK

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