Time for another edition of Q&A. Comments are flowing in, especially on the malpractice problem. We have some heated exchanges, which I will touch on. Keep those comments coming!!!

Yes, a lack of activity and a plethora of calories leads to unhealthy weight. This is a simple equation. However, I find that the articles I read on the subject of obesity in North American society consistantly oversimplify the issue. Okay, so teenagers are eating high calorie, low nutrition foods and are less active (as is the rest of the population). Well, why don’t we ask the next logical question: “Why?”

With so many socio-economic factors contributing to this “epidemic of obesity,” stating that a better diet and “get[ting] off our butts” is not going to make any difference in obesity rates. I acknowledge the importance of taking some personal responsibility for physical health, but when you dig deeper into obesity rates in America, you find a) a very strong link between poverty and obesity; and b) that our culture sends constant messages to consume. We have created an environment that produces obesity, and yet we seem confused when it occurs. Ignoring the social factors of obesity and placing the focus exclusively on a lack of personal responsibility only marginalizes an evergrowing portion of the population, when in fact they are simply a product of the society we’ve created.

This important comment highlights an important social and political issue. Should we blame society, and then sit back, waiting for society to fix the problem? Or rather should we acknowledge society’s role, and offer solutions? I prefer the latter.

When dealing with individuals (which is my main role as a physician), I must focus on individual responsibility. We work to get patients more active and modifying their eating habits.

As a blogger, I have often highlighted efforts to positively impact society. We should support and demand changes to physical education programs in the schools. We should support and demand safe areas for outdoor exercise – running and bike paths for example. We should support programs to introduce more fruits and vegatables to poor areas (especially at reasonable prices).

While we strive to alter society, we still must give advice to individual patients. There we can only stress individual responsibility. If, through this blog, I convince one person to exercise and eat intelligently, then I have a success.

I am not so sure I would give the trial bar such an easy pass on their role in the crisis. They are the most significant force in the tort business, soliciting aggressively and portraying the filing of suits as an easy, cost-free, risk-free and consequence-free enterprise. That, of course, is a deception, and it successfully perverts and corrupts the public into believing there are no consequences to this kind of jackpot-seeking litigation. The fact is we all pay, and not just for medically-related litigation.

If a doctor operates unnecessarily or for inappropriate reasons, there are mechanisms that can stop that doctor: in hospitals, surgery centers, medical associations and state licensing boards. No, these mechanisms are not perfect. They can be resisted (by lawyers!) but they exist. Where is the similar mechanism for lawyers who abuse their professional privileges? When, short of criminal conviction, is it imposed? Our legislatures and much of our national political leadership is populated by attorneys. Is it any surprise the laws are lawyer-friendly?

This comment refers to a long rant from Friday. I focused on the tort laws rather than the lawyers. CHenry challenges me here, and specifically blames the lawyers.

This issue leaves me confused. One can almost make this a chicken and egg question. With proper tort reform, we would stymie the lawyers.

I argued that the lawyers see a way to make big bucks, and take advantage of the opportunity. While I would like to see lawyers consider the great societal good, I have a difficult time arguing that that is their responsibility.

As physicians we focus primarily on our individual patients. If our patient needs something, we are willing to have someone spend whatever it takes (AICD, IVIG, the latest greatest antiretroviral). While our patients advocacy may not aid the nation’s health, we feel (appropriately) a moral obligation to advocate for our patient.

Thus, I have critiqued the tort system that allows lawyers to produce the current malpractice crisis. The tort system is the disease (admittedly one that lawyers produced). The individual lawyers see a financial opportunity and take it. They couch their client advocacy in flowery terms, but their goals seem financial. But we should not focus on changing them. They will only sue us if the laws allow. We must change our paradigm and educate everyone about the tort crisis and propose solutions which protect patients and the health care system.

“Most cases that actually go to trial are lost by the defendant” – true, because only the valid cases will ever go to trial. The others are dropped or settled. However, that doesn’t mean that the frivolous attempts are cost-free – they aren’t. Whether or not a case ever goes to trial, every attempt made at a lawsuit has to be investigated by the physician’s insurance carrier. This takes time and money. Enough of these attempts and the physician’s insurance premiums will go up, even if the physician is never actually sued.

This is an excellent comment from a fellow physician blogger – Feet First.

This is heartrending. And, unfortunately, not an unusual story by any means. I wish patients and their families could better understand what is meant by “extending their lives” most of the time.

Recently, a patient of mine with Alzheimer’s deteriorated to the point that she was no longer eating because she could not remember how to swallow. The food merely sat in her mouth. I had multiple conversations with her granddaughter about placing a feeding tube. I made it clear that I did not recommend this procedure, that it would lengthen her life but that she would continue in the nursing home intensely demented and crippled by a stroke.

The granddaughter, of course, elected to have the tube placed. She’s still with us today. Sometimes I think we ought to ask family members: “If YOU were in this situation, would you want your family to do this for you?” I think a sizable number of them would say no.

This is another post from Alice of Feet First. I have included it to highlight a problem, and suggest a solution. Alice’s story happens frequently. We see these patients in the hospital and wonder – “what were they thinking”.

Personally, as a ward attending, I have a rule about feeding tubes and PEG tubes (a PEG tube is a feeding tube which goes directly through the skin into the stomach). My rule – we should never place a feeding tube which does not have the probability of improving the patient’s quality of life. When the patient can no longer participate in the decision making process, I do not feel an obligation to offer a feeding tube to a patient if he/she does not meet the above stated rule.

We are fortunate at our VA hospital to have an outstanding palliative care service. I often involve them in such decision making. Through many discussions, I have learned to only offer this option sparingly. I also resist this option with the argument that we would only prolong suffering (unless the patient meets the rule of the feeding tube improving the quality of life).

We (physicians) should become more paternalistic in these situations. Patient centered decision making works in most circumstances. This circumstance may require a more persuasive paternalistic approach.

At the end of the day all effective medical malpractice reform reduces to three options:

(1) Reduce the amount of compensation paid to the victims.

(2) Transfer the cost of the compensation from doctors to the taxpayer. Or spread the cost among all doctors equally so risky specialties such as obstetrics aren’t hit especially hard.

(3) Make the practice of medicine less risky.

Option number three seems the obvious choice. I don’t hear chiropracters complaining about their malpractice rates, because their practice has a smaller risk and their premiums are correspondingly less, despite having to face the same “greedy” trial lawyers. Now obviously making the practice of medicine less risky is easier said than done. But I think the real crisis in medicine is not the rising malpractice rates, it’s the amount of risk in medical practice.

Bernie (of The Careless Hand) has posted often this week. We obviously see the world differently. He misses the point completely, especially in this post.

The costs of malpractice are spread. That is one of the problems! If I practice excellent medicine, and never get sued, my malpractice rates still skyrocket.

Please explain his third point to anyone (including me). Sick patients come to us hoping to improve. They would like a cure (and sometimes we can provide that). They want us to help them improve their quality of life (and often we can provide that).

As I have ranted often, each action we take to help the patient has a probability of success. It also has a probability of failure. It also has a probability of side effects. And the patient has a probability of getting another problem.

We can minimize risk only if we minimize the chance for benefit. We must work to balance risk and benefit, but ultimately we (the patient and the physician) must accept some risk to get some benefit.

If this makes my profession risky, then I accept that risk. We cannot make medicine less risky and more beneficial. These are the yin and yang of our work. Perhaps we need to do a better job of explaining this dilemma to society and to individual patients.

We get sued often because sometimes the risk materializes and the benefit does not occur. We may help 90 of 100 patients, but 10 patients have a poor outcome. We consider that a success. Lawyers consider that an opportunity. The 10 patients think we have failed. The 90 consider us wonderful.

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So ends another Q&A. As usual each Sunday I rant on those issues which strike me as controversial or otherwise interesting. I do read every comment, but do not always respond because of time pressures (I have this other job). Thnaks for writing and making the blog more interesting!