I arrived in the briefing room early enough to watch technicians finishing the sound check. From the center aisle halfway back, I could weigh the balance of bodies ahead, behind, left, and right as people filed in. One researcher presenter and two discussants – a consumer advocate and one from the pharmaceutical manufacturers’ corner – went at it in classic confrontational theater. The topic was direct-to-consumer advertising of drugs. A couple of television cameras rolled on the side. During the question and answer period, tempers flared understatedly and eyes bounced back and forth between the protagonists, some of whom were in the audience and well recognized by those around them. We disbanded after two hours.
I want to be in that room, I told David over dinner. Who do you want to be in that room? he asked. I don’t know; I don’t care. It had everything – high stakes of billions in drug profits and health insurance dollars as well as public safety and well-being; a good guy, a bad guy, and confused people in the middle; data driving the conversation and important minds being changed. If the conversation actually affected decision-making, that would be the icing.
That was in my first year of training in health policy research. Three years later, I was comfortably nestled as the only physician in a well-respected research group in downtown Washington, with a wry economist boss who could remember and dissect the history of most consequential policy decisions made over the past two decades. From this comfortable and privileged seat, I grew a steady string of solid professional successes, publishing the kind of respectable research papers that were inarguably useful and did no harm to anyone’s reputation.
But four years in came a project that consumed me. It was an analysis born of observing a data flaw, a descriptive series of averages, sums, and ratios lacking any statistical sophistication that graphically illustrated that the world of medical care delivery was not as we believed; that it was far more fragmented and indefensibly irrational than previously thought. Each patient saw an outrageous number of different doctors, and each doctor shared patients with an overwhelming number of their peers. Such chaos, we tried to quantitatively demonstrate, would hobble some prominent policies intended to improve the quality and efficiency of health care.
The paper was controversial. Many academics, policymakers, and interest groups were heavily invested in the success or failure of a model called ‘pay-for-performance,’ in which health insurers give physicians bonus payments for delivering higher quality care than their peers or for meeting preset standards. Just as many people were skeptical of it. It was this model that the paper took head-on. The response to our pre-publication presentations of the data to was stridently positive or negative, rarely moderate.
Through multiple revisions in response to caustic journal reviewers, it was easy to develop a sense of beleaguerment. It was a battle not to make a splash, but to claim what seemed a fair share of the policy oxygen for this modest little idea. The journal acceptance finally came just after Christmas Day, a year and a half since the project began. I edited the final revisions after the kids finished opening Christmas presents and before we clumped all the wrapping paper into recycling. That the paper was to appear in the most selective medical journal was sweet, but exhausting and somewhat anti-climactic. What more impact could this thing have by the time it’s released?
No, no, my senior co-author Peter corrected me, Your life is about to change dramatically; for the better. Out the paper went into the ether in late March and then…..nothing. We had been careful to air our findings early to the main stakeholders. As I predicted, it was calm after publication; there was nothing left for anyone to say. Peter was wrong.
Three months later, I presented a related but, I thought, far less dramatic set of results at an invitational meeting. Then more invitations came. Could I give a speech next time, not just a slide show? I did as told, to impact that seemed disproportionate. I communicated the way I feel compelled to, by telling stories and asking questions. I was often the youngest person in the room. Could you write a white paper for this next meeting? Maybe, let me think….Could you join us on this funding proposal? The deadline is next week. Not having ever had to say ‘no’ to such offers and therefore not knowing how, I didn’t.
Someone in management came and sat down in my office to ask what my ambitions were. One head hunter called, then another. Universities and some competing firms wanted to recruit me. Wherever the policy conversation turned, it seemed, I had what was relevant to say. Isn’t this fun? Peter asked over the telephone. I glared at the receiver. My neck and shoulders tingled more and more persistently until they burned and would only unflex when I was unconscious. I became skittish at every ring of the telephone, and started to close my office door out of habit, afraid there wouldn’t be adequate lead time to do that when the palpitations began and I needed to lie down on the floor with the lights off.
Palpitations came from the left and the right and in my sleep. No one had prepared me. No one was offering to help. Help with what? The circular conversation spun at the base of my brain and in my throat, winding the neck muscles tighter. Poor sleep fractured into no sleep, which only grew worse after several months of Lunestra, little pills the promising color of a blue moon that forced my eyes closed but did nothing to snuff out the synapses gone wild. Five days of low dose Ativan, I thought, or maybe Klonopin, that’s all I need to readjust. What do you think? I asked a physician friend at my dinner table. She watched me bounce from exhilaration to despondency and switch direction three more times before dessert, and pursed her lips. Maybe you should try talk therapy first?
I looked desperately for any sign of the staircase to climb back down to anonymity, but it had disappeared. I ricocheted, I thought, between the wide-eyed ingénue other people were comfortable with and the aggressive, opinionated personality that surely put everyone on edge. Each night, my reserve of control ran out a few minutes earlier than the night before. It became a race against the adrenaline time bomb. Then one October Thursday, I arrived at our back gate just as the meltdown came. Blood vessels constricted in my temples, my gut, my wrists and the top of my neck, so that the fingers shook and the eyes slid in and out of focus.
I sent the kids down to the basement for a video and sat on the steps one floor above, in the dark, clinging to the spindled wood railing, my nails digging into the center of my palm. With the other hand I dialed the first number I could remember. Phoebe, I think I’m going to die. Call David now, and then call me right back.
I went to informational interviews with two highly recommended therapists. The first one listened patiently and reflected a reasonable summary of my distress. Calming, I thought, I can do this with her.
The second one made my forehead furrow because he did not just listen.
Really, you’re doing this to me on the first meeting? I thought.
His questions left an impression of the tiny, repetitive dissecting strokes of a scalpel. He was young, and Jewish. I picked him.
Please, I begged him, give me a toolkit. I really need a toolkit to get through the day before we fix anything else.
He signaled with the look of a first responder facing an accident victim who asks for a cup of tea as blood gushes from her head wound. Sure, he promised, we can do that.
I call him Blue.