Clarifying my thoughts

Wow! This blog has had an almost exponential increase in commentary from readers. This is a great thing.

When I first started this blog, I had no idea what it would become. I knew that blogging would affect how I thought about medicine, and hoped that I would develop an audience which would both cheer and jeer. That has happened.

Generally the comments remain civil (although occasionally passions do rise). If you do not regularly read the comments, I recommend them as an interesting way to hear other sides of an issue. When you find a rant that you find interesting, return to it and follow the discussion.

Today I want to mention a couple of commentary issues.

First, regularly someone will post the details of their or their loved ones experience with malpractice. These stories are poignant yet should not change the discussion. We all recognize that malpractice occurs. We all believe that patients should receive appropriate compensation in these cases. We may disagree on the definition of appropriate. The debate (at least as I understand it) should not focus on whether malpractice occurs, but rather how best to find it and distinguish it from bad outcomes not due to malpractice. I will continue to argue that expert panels (as recommend by Common Good) would do a better job of increasing both sensitivity and specificity (fancy medical decision making talk for identifying a higher percentage of true malpractice while decreasing the percentage of bad outcomes labelled as malpractice). I believe that such a system would better protect both patients who suffer consequences of malpractice and future patients (by having a system for disciplining physicians).

Enough malpractice – although I know that it will remain a major issue on this blog because it does cause so much passion.

Now malpractice insurance – once again I must challenge our lawyer friend Aaron. He writes:

Malpractice costs should be part of office overhead.

In this comment he implies that physicians asking for fees to cover malpractice are being silly (his words not mine). He also implies (but does not say) that one can recover overhead costs by increasing income. But that is the problem. Physicians do not work in a free market. We have almost no control over fees. These fees are set by CMS, managed care organizations, Blue Cross and commercial carriers. Thus, when our overhead increases, our “profits” decrease. Unlike almost all businesses in this country, we cannot pass increased overhead costs on to our “customers”.

Now to the pharmaceutical industry. We continue to have spirited debate on how evil the pharmaceutical industry is. I have often attacked that industry, and will probably continue to do so. However, any attempts to blame high drug costs solely on the pharmaceutical industry are disingenuous. Physicians are a major part of the problem, and thus we should be the solution.

I act out my philosophy. I have not accepted visits from pharmaceutical reps for around 15 years. I have a $10 rule – I will eat lunch at a noon conference (as long as they did not choose the speaker), and that remains the extent of what I will accept.

Physicians should divorce themselves from pharmaceutical influence. We must take responsibility, and quit whining about the “drug companies”. We can influence them if we would only make rational cost-effective decisions.

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I expect more commentary – and welcome it. My email now receives large numbers each day just from this blog.

If you have ideas of issues that I should cover – please make suggestions. I use some, and ignore some. Afterall this is my ranting post, and I will rant about whatever catches my fancy. I hope that some of my rants intrigue you, and even drive you to passion. If I do that, then I am contributing to the debate. As we debate, we clarify our thought, and that must be good.