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Grand Rounds

A matter of policy

By Seddon Savage, M.D.

My first appearance as a physician before the New Hampshire legislature was, from all reasonable perspectives, bizarre. As a young anesthesiology resident testifying against the death penalty, I described the crisp and painless death that can occur with a perfectly executed hanging and compared it to the potential agony of a botched lethal injection. Members of the House Criminal Justice and Public Safety Committee listened, mouths open, in obvious incredulity. My point, however—that all methods of execution are inhumane and New Hampshire should not make the death penalty more palatable—was more or less made. And (almost certainly due to the more elegant, seasoned, thoughtful testimony of others) facilitation of executions in the state was deferred for another year. I felt exhilarated.

My second foray into the public policy arena a few years later may have been more cogent but was equally naive. A 45-year-old accountant had come to the DHMC Pain Clinic requestingmethadone treatment for his addiction to opioids. He had relocated to New Hampshire from England, where he had been successfully treated withmethadone for more than 20 years. But U.S. federal law prohibited physicians outside a licensed methadone clinic from prescribing methadone for addiction. And there were no methadone clinics in New Hampshire. So we had to refer him to a clinic in Massachusetts—a life-disrupting commute for a busy professional.

Draft: I immediately set out to establish a licensed methadone clinic, only to discover that four months earlier the state had passed legislation banning methadone treatment of addiction. I was stunned: legislation that prohibited an evidence-based, highly effective, pharmacologic treatment for a life-threatening chronic illness?! My outrage propelled me to draft legislation—and to convince a legislator to submit it—that would permit methadone maintenance in the state and require it to be integrated into ordinary medical practices.

Alone, but confident that my view of right would conquer all, I marched into the legislature to testify in support of the bill. I was bewildered by the many opponents present, including representatives from the New Hampshire Department of Health and Human Services and various addictions advocacy organizations. The bill failed, and I learned that changing policy often requires not only passion, but also careful planning and collaboration. Two years later, under the leadership of more policy-savvy addictions advocates, a law was finally passed to allow methadone treatment programs in the state.

Throughout most of medical history, physicians, together with our nursing colleagues and patients, have been the heart of the health-care system, driving decisions and infusing the system with the core values of service and care. Today, however, we physicians find ourselves disempowered and marginalized, while administrators and politicians, often driven by financial and regulatory concerns, make critical decisions that shape our ability to care for patients.

Policy activism is a powerful antidote to disempowerment and to the demoralization that often accompanies it. Physicians have extraordinary influence when we speak from our hearts on behalf of our patients. Legislators listen carefully, especially to stories that illuminate the real-life impact that their policies have on our patients. Whether we work for incremental changes or more sweeping reforms, we can make a difference. And the energy generated from having open discussions, finding resonance with others, and learning from those with opposing views is revitalizing.

Victories: State medical societies provide powerful collaborative venues that bring physicians from all specialties together to work for policy changes in both public health and clinical practice. A society's experienced staff can facilitate coordinated actions by providing guidance as well as access to networks of other organizations. State medical societies generally welcome policy newcomers as well as seasoned wonks. Physicians working with the New Hampshire Medical Society (NHMS) have helped to achieve many public-health victories in recent years—including banning smoking in the state's bars and restaurants, mandating that family insurance policies provide coverage for children through age 26, reducing environmental pollution by heavy-metal emissions, and decreasing pharmaceutical industry influences on prescribing practices.

In addition, a 2007 NHMS survey found that New Hampshire physicians strongly support the concept of a publicly funded, simplified- payor health-care system. This finding will inform future discussions and actions on health-care reform. Whatever the cause, one's chance of effecting change is amplified by working with others.

Passion: Medical students can be potent policy advocates, too. At DMS, an active student group works on public health and health policy issues. The NHMS encourages and coaches students to play a role at the state level and has helped them testify before the legislature. Their passionate, unconflicted voices ring clearly and effectively in advocacy. For these emerging professionals, the interdependency of clinical practice and policy activism is becoming axiomatic.

In fact, engaging physicians—whatever their level of practice—in health policy activism can be an important element in both reempowering them and reinfusing the health-care system with a commitment to service. It can be heartening to recapture the sense that progress toward the common good is indeed possible.

The Grand Rounds essay covers a topic of interest to the Dartmouth medical faculty. Seddon Savage, a 1980 graduate of DMS, is the director of the Dartmouth Center on Addiction, Recovery, and Education and an adjunct associate professor of anesthesiology. She served as the president of the New Hampshire Medical Society in 2007.

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