In the piece, Addicted to Mammograms, Aronowitz (an internist) notes that the screening controversy is nothing new. “It’s the same debate that’s gone on in medicine since 1971, when the very first large-scale, randomized trial of screening mammography found that it saved the lives only of women aged 50 or older. Despite the evidence, doctors continued to screen women in their 40s.” He adds:

You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer, and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail. This doesn’t make sense

Still, he says, the reason so many women and doctors rejected the findings back in the 70s — and now — is that to accept them would be akin to “giving up the one means they had to exercise some control over cancer.”

The tech person, a lovely Russian woman from Brooklyn, said she thought everything looked fine. Then, a few days later, a nurse called to say there appeared to be a tiny calcification in one breast. “Fairly common,” she said. “I wouldn’t worry too much.” She scheduled me for more imaging. This Thursday, at Mt. Auburn Hospital.

It was my first mammogram in about 8 years, since the birth of my two children.

There is no breast cancer in my family history, so I was pretty lax about getting screened again. But my primary care doctor in Cambridge kept telling me to do it, citing the previous guidelines to get a mammogram annually after age 40. I am 45.

But during the years I nursed my daughters, I kept delaying the screening. Finally, when it was clear that my breastfeeding days were over, I scheduled the test (which, for those of you who haven’t had it, is really annoying, and involves stretching and flattening your breasts over a hard surface and then squeezing them down so they sit like sandwich meat between bread.)

Last night, after reading Gina Kolata’s story in the New York Times about the new guidelines that urge women to wait until they’re 50 before getting routine mammograms, I feel like canceling my appointment.

But of course, there is the issue of the small, “fairly common,” calcification. While I am healthy, excercise regularly, don’t smoke and eat well, you never know, right?

A good friend, a 39-year-old vegetarian marathon runner, died suddenly a few years ago, due to a rare heart condition, leaving two young daughters. Another healthy friend, whose mother died of breast cancer, got a radical mastectomy and hysterectomy after learning she had the gene for breast cancer. How can I, a journalist, a mother, a curious human being, not find out what is there in my body, guidelines, or not?

Today, I kept thinking about how, despite our knowledge about science and probability, we expect medicine to be so clear, to give us straight answers and immutable guidelines. I read all the coverage on the debate, trying to better understand what to do. I talked to my mother, my husband and my women friends. They were also confused. But here I am, between two mammograms, wanting reassurance and clarity, but also understanding that it would probably be ok to wait.

Or would it?

– Rachel Zimmerman

A post-script: I just got back from my follow-up mammogram. Everything is normal. The “calcification” they saw on the initial image turned out to be overlapping tissue. Still, the changing room was plastered with black and red signs announcing Mt. Auburn’s position on the new recommendations. The hospital, siding with the American Cancer Society, is sticking with the old guidelines — routine mammograms annually for women starting at age 40. As I left the imaging center, the technician who delivered the good news waved to me and said: “See you next year.”

The United States health care system cannot be fixed by legislation alone. No matter what the laws say, our societal expectations, if unchecked, will ensure that health care costs continue to soar.

As Americans, we want the best health care available. Of course we do. But there is a degree of entitlement and misuse of the system. We are uncomfortable with ambiguity and do not like what we cannot control. We want answers and we want a cure. We never accept death. To contain health care spending, a fundamental cultural shift is required.

While I firmly believe that access to high quality, compassionate health care should be a basic human right, there are limits to what we should expect and hard choices to make. I write this to convince myself as well as you. Consider the following scenerios:

A 47-year-old business executive, Mrs. S., comes in to see her primary care physician for her yearly physical. Her exam, including a pelvic, is normal. She feels well. She has no risk factors for ovarian cancer, but she requests that her CA-125 level be checked, noting that she is anxious about this disease despite her lack of symptoms. The doctor explains that CA-125, a protein biomarker that can found in elevated concentrations in the blood of individuals with ovarian cancer, is not recommended as a screening test because of inaccuracy. Many people who do not have cancer will have elevated levels, resulting in expensive and potentially harmful additional testing. She has read about the test on the Internet and feels she understands the risks. She wants it done, and she is adamant. The test is ordered.

A 35-year-old female, Ms. A., is seen in clinic complaining of fatigue and vague abdominal pain. She lives alone and works as a city bus driver. She is run down and has no energy. She is sleeping poorly, has no appetite and has lost weight, but she is not vomiting or having diarrhea, and there is no blood in her stool. Her exam is normal. Blood work is normal (a blood count, electrolytes, kidney function tests, liver function tests, thyroid function tests). She is reassured by the doctor that nothing of concern has been identified and is sent home. Her symptoms continue and she returns to the clinic on multiple occasions, and is seen in the emergency room twice as well. Along the way, she has additional blood work, an abdominal CT, an upper endoscopy and a colonscopy. She is seen by a gastroenterologist, and then a rheumatologist. She admits to feeling depressed and anxious “sometimes,” but refuses a referral to counseling and medications to address these symptoms. She continues to come to the clinic, seeking answers, but there are none to be had. She wants someone to make the pain go away.

Mrs. P was a 68-year-old happily married mother of four and grandmother of twelve who developed breast cancer and died. She had been healthy, and had always done what the doctor recommended, having her yearly physical and mammogram on schedule. In April of 2006 she noticed a breast lump and went to see her doctor. The lump had not been detected on physical exam or mammogram the previous June. The lump was cancer, and it had already spread to her lymph nodes and her liver. She had chemotherapy and lost her hair, vomited, and developed sores in her mouth. She became so thin her own grandchildren were afraid to look at her. The cancer won, and she died 18 months after diagnosis. Her family sued the doctor for malpractice, claiming that the lump had been “missed” at her June 2005 physical exam. A long court case ensued, and the doctor’s insurance company eventually settled with the family.

Mr. V. was a spunky, independent 94-year-old man who read the newspaper daily and did his own grocery shopping until he collapsed one day on the sidewalk in front of his apartment. He wasn’t breathing when the EMTs arrived, and a breathing tube was placed before he was transported to the hospital. He had suffered a massive stroke. Mr. V.’s only son, who lived in a different city, came to the hospital the following day. Mr. V. did not regain consciousness, and the doctors said the prognosis was poor, but Mr. V. had not made his end-of-life decisions known. The doctors raised the possibility of withdrawing care by removing the tube, but Mr. V.’s son was unwilling to do so. Mr. V. remained on a respirator for 3 months, until his heart stopped on its own and he was pronounced dead.

In none of these cases did the patient pay out-of-pocket. The costs were ours, as a society. But I can imagine being any one of these individuals. I would want the CA-125. I would want an explanation for my pain. I would be angry if my mother developed breast cancer despite appropriate preventive care. I would have trouble removing my father from a respirator. But we need to think hard about our expectations. To control health care spending, we all must be accountable.

I don’t have the answers, but here are my thoughts. We should find doctors that we trust and follow their recommendations. If a certain test is not standard of care, we should not demand that it be done. We cannot expect our medical system to heal all of our pain, emotional and physical. We, as a society, need to work harder to strengthen family and community supports. We have to accept ambiguity and loss of control. Sometimes doctors can’t fix the problem, no matter how hard they try. Though egregious medical errors do occur and litigation is at times justified, all too often lawsuits are fueled by anger, unresolved grief, and the need to blame someone. Lastly, we need to encourage end-of-life discussions to clarify patient wishes. We need to know when it is okay to let go of life.

As the nation held its breath, waiting for news about health care, violent acts were committed against a caregiver to the mentally ill and by a caregiver himself. The psychiatrist in Fort Hood who shot military men and women was preceded by a more intimate tragedy. At Massachusetts General Hospital a bi-polar man, at an outpatient appointment, attacked his psychiatrist, a female doctor and was killed by a security guard who happened on the scene.

The following day I sat in my office and wondered, not for the first time, if I might get killed by a patient or have a death on my hands. And I thought (unlike many) how amazing it is that these events do not happen daily.

Mental illness shows no prejudice: it is invisible and slippery. Progress is difficult to measure and the care is given by people who are tired, severely underpaid, suffer compassion fatique and vicarious traumatization. We live in two worlds — often at the boundary of madness. Then we walk back into the bright, well-lit rooms of our homes or our children’s school and try to forget what we know.

But at such an important moment of change, as we contemplate our American health care “system” we need to review the state of mental illness. Thirteen years ago I began treating young women who were dying from eating disorders. I was tremendously optimistic about change in my field. Taboos were lifted and therapy became widely acceptable as did new and effective psychotropic medication.

Yet, in fact, the opposite has happened. I see more and younger women succumb to eating disorders. We know what treatment is but there are fewer places for this treatment. I also see the power of our modern culture: we speed up our pace of achievement but are fed less nourishment. We have less free time, vacation time, time with our own children. Rarely do we have time to read and reflect upon what we do. We refuse ourselves the precise self-care which we insist is essential for our patients.

Mental illness — the invisble dark cloak of depression, the shaking hands of the anxious, the rude voices of schizophrenia — is one of America’s untouched frontiers. We believe that people with cancer are due every bit of bone marrow they can find. Yet we leave our ill to sit in squalor with demons in their heads. No one visits or calls. Loneliness is the chief complaint of most of my patients.

Something in us still dares not name mental illness when we see it. Others of us trust everyday that the relationship we have formed with our patients—the web of connection thrown over an abyss, will hold. The anxiety, depression, and psychosis caregivers metabolize is staggering. We do it because we are curious, compassionate and believe we are not doing hospice work. I remain deeply troubled as to why this profession goes undervalued when it is lifesaving and lifeaffirming.

Our country is still adolescent. We believe death will not happen to us. We believe that unattractive aging is optional. We believe there is an ‘us and a ‘them.’ Until that prejudice is dropped and we understand that mental illness is often a cruel accident of birth, we will never provide adequately for mental illness in those we care for or those who give care. The valedictorian of the class, the doctor’s wife who requires weekly restraints, the college roommate who kills himself while writing a book….all of these real people are just a few cracks in the pavement away from us. There is nothing especially ‘other’ about mental illness. Perhaps that is why it scares us so.

Harris (my former colleague at the WSJ), says that “Maine is the Charlie Brown of health care.” He continues:

The state’s legislators have tried for decades to fix its system, but their efforts have always fallen short: health insurance premiums are still among the least affordable in the nation, health care spending per person is among the highest and hospital emergency rooms are among the most crowded. Indeed, many overhauls to the system have done little more than squeeze a balloon — solving one problem while worsening another.

On Saturday Capuano, a Democrat who is running hard for the U.S. Senate seat previously held by the late Ted Kennedy, voted with the majority in the House to pass a health care overhaul plan that did include such restrictions. Massachusetts AG Martha Coakley, also running for the U.S. Senate, made news when she said she wouldn’t have voted for the health care bill because she objected to the abortion restrictions.

For more coverage on how abortion politics may play out as the U.S. Senate takes up health care reform, see this roundup from Kaiser Health News.

Maddie likes America because we have freedom here and Maddie believes in patient choice health care. She has come here to say she doesn’t want government to take over health care. She wants to keep her plan.

For coverage of the rest of the House debate, see NPR’s story.

And for an excellent piece on how to really overhaul health care, see David Leonhardt’s profile of Intermountain Healthcare and its chief quality officer, Brent James, in the New York Times Magazine.

The report by the Division of Health Care Finance and Policy shows that, on average, 30 cents of every premium dollar goes toward profits and administrative costs, compared with 12 cents for plans sold to the general public. The remainder of the premiums is what’s used to pay medical bills.

Students at state schools faced the greatest disparity: 45 cents of every insurance dollar they pay goes to profit and administrative costs, according to the report.

For more than a year, students at several campuses have pushed state regulators to investigate because, they said, the lower-cost insurance products marketed to them offer limited coverage, leaving many vulnerable to enormous medical debts after accidents or serious injuries.

Keeping health care affordable is the challenge facing all of us in the health care system and we recognize that rising health care costs have fallen particularly hard on small businesses and their employees. But as the chairs of the Health Care Financing Committee asked members of the Massachusetts Medical Society and other providers that testified at Monday’s hearing of Senate Bill 2170, “If not this, then what’s your solution?” We haven’t seen any proposal from the Mass. Medical Society to help small businesses. (See the MMS post on SB 2170 here.)

Last January, the Governor and members of his Administration called on the health care industry to come together to help control health care costs. Our association answered the call, by working with Sen. Moore, Rep. Stanley, Sen. Michael Moore and small business organizations on legislation – the Affordable Health Plan – that would provide immediate relief to small businesses, reducing premiums by as much as 22 percent. No other proposal has been able to offer those types of savings.

The proposal emphasizes the goal of shared responsibility, the key tenet of Health Care Reform. The Affordable Health Plan would establish in statute a new product for businesses with 50 or fewer employees and individuals. It would establish a rate cap on providers for just this product, which would be just one of hundreds of health benefit plans available in the small group market. Health plans also take on new responsibilities for limiting the cost of coverage: for all products offered to small groups and individual, health plans’ post-tax underwriting surpluses (or profits) would be limited to 2 percent and at least 85 percent of the premium would need to be applied to medical costs. More on the Affordable Health Plan is available here.

Reducing the premium by 22 percent would generate significant savings for small businesses. For example, the lowest-priced Bronze package for a family of four, with two 40-year-old parents and two children, is approximately $800. Cutting the premium by 22 percent would save $176 per month or more than $2,100 a year. For a business with 20 employees, those savings can really add up.

The cost of health care is the issue. The bulk of the premium dollar pays for medical care and other services that directly benefit consumers. Premium rates have been rising largely because medical services have become increasingly more expensive. According to the Division of Insurance’s September 2008 report, Trends in Health Claims for Fully-Insured, Health Maintenance Organizations in Massachusetts, between 2002 and 2006, the total cost for medical services increased by 55 percent per insured HMO member, which was attributed to significant annual increases in the cost of physician, hospital and pharmacy services. The Affordable Health Plan focuses squarely on the main driver of health care costs – the rates that providers and hospitals charge for their services – and seeks to reverse the trend of annual cost increases.

Massachusetts health care costs are the highest in the country and the continued increase in the cost of health care takes away resources small businesses can use to hire more workers, fund capital expenditures, and make other investments that could help boost the state’s economy. The Affordable Health Plan would give small businesses some much-needed help in addressing one of the largest expenses they face, providing them with the relief they need in the current economic crisis.

Reporters Tom Hamburger and Kim Geiger write:

The measure would put Christian Science prayer treatments — which substitute for or supplement medical treatments — on the same footing as clinical medicine. While not mentioning the church by name, it would prohibit discrimination against “religious and spiritual healthcare.”

It would have a minor effect on the overall cost of the bill — Christian Science is a small church, and the prayer treatments can cost as little as $20 a day. But it has nevertheless stirred an intense controversy over the constitutional separation of church and state, and the possibility that other churches might seek reimbursements for so-called spiritual healing.