Reflections of a forensic psychiatrist in Washington: politics and policy.

I walked into the lobby of the Hart Senate Office Building and looked up at the imposing black metal Alexander Calder sculpture that extended from the lobby to the eighth floor of the building. I was about to begin a seven-month health policy fellowship with the goals of participating in the political process and gaining an insider’s perspective about how government really works. I entered the seventh-floor office where my designated small cubicle was located. I sat down at my desk with my computer and small television set with mainly C-Span channels. I met all the bright, energetic people who worked as legislative assistants (LAs), fellows, and press secretaries. I was soon to realize that these individuals, who were mostly in their 20s and 30s, were responsible for developing policy for the United States. Each LA and fellow specializes in one or more areas, such as environment, defense, economy, health, social policy, and foreign policy. Constituents, advocacy groups, and lobbyists come to Congress hoping to meet with senators or representatives. Usually, they meet with the relevant LA or fellow, instead of the member of Congress. During my first two weeks, I met with groups of people from home health equipment companies, child sexual abuse response teams, and health maintenance organizations. Each group promoted the value of its services and lobbied for more funds or for minimizing cuts in funding of its services. The groups distributed material that described how effective their programs were. For example, the home health equipment group lobbied against the notion of competitive bidding and used the analogy that if one’s mother needed an appendectomy, one would not choose a hospital or a particular physician because he or she was the cheapest. The LAs also write opinion editorials (op-eds) on behalf of members of Congress. One day, a particularly effective op-ed concerning the role of the United States in Iraq was published in the Washington Post and signed by a senator. Everyone in the senator’s office stopped by the cubicle of the fellow who worked on foreign policy issues and congratulated him on writing an excellent op-ed piece. All the staff members knew that the fellow, and not the senator, had written the article. I learned that when a member of Congress or a candidate for office tells a joke or uses a pithy phrase in a speech, the words were most likely written by the press secretary or the speech writer in his or her office. Together with staff members, I was watching a televised speech given by a senator in which he told a joke that did not elicit any laughter from the crowd. Some of the staff members turned to the senator’s press secretary and jokingly said, “Did you write that? It just went flat!” The press secretary shrugged his shoulders as if to say that he had done his best. Staff members work long hours, including evenings and weekends, depending on the needs of the senator. An LA who worked in a Senate office almost missed her sister’s wedding because it occurred at a time when there was much activity on the Senate floor. Staff members also address a variety of other needs of legislators. When Senator Mikulski (who is Dr. Binder is Professor of Psychiatry and Director, Psychiatry and the Law Program, University of California, San Francisco, CA. Address correspondence to: Renee L. Binder, MD, Psychiatry and the Law Program, 401 Parnassus Avenue, San Francisco, CA 94143-0984. Email: renee@itsa.ucsf.edu