Sunday, August 31, 2008

Medical Ethics and Health Policy - A Year in the Blogosphere

Here's what I wrote in my first posting when I started this blog a year ago today:
Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

Organizational ethics is what this blog is all about.

In the blog I will talk about how organizations engage with the ethical dimensions of their work. I will look for approaches we can learn from, not simply to wring my hands and rant. I hope the blog stimulates discussion and debate. I encourage readers to present their own perspectives.
One year and almost 150 posts later, I feel that I'm starting to get the hang of the blogosphere. It's new learning for me. My modality for writing has been journal articles and books, and I'm among the rare Neanderthals who do not carry a cellphone or a blackberry.

Here are four of the main lessons I've learned:

1. I feel even more strongly than a year ago that the fundamental premise of the blog is sound. Health care is personal. It ultimately comes down to interactions within dyads - patient/doctor, patient/nurse... But as important as the temperament and personal ethics of the individual clinician are, the ethical quality of the setting(s) - hospital, clinic, community, and the wider health system - are almost always in the room with the patient/clinician dyad. The organization and system determine a substantial component of what we as individuals experience in our health care.

2. I've found myself paying attention to a much wider range of phenomena than I'd anticipated. I expected to focus on the organizations we're familiar with - hospitals, group practices, health plans, and the like. But as I've thought more about the factors outside the dyad of care that shape the ethical quality of the patient's experience, I've found myself including media, politics, and the elusive topic of the public mind(s) as well. Health care is about human finitude and death. Our explicit and implicit philosophies of life shape the way we think about health care and deal with our cockeyed health care system.

3. When I started the blog I envisioned a virtual meeting place, where folks with a shared interest in the ethical dimensions of health organizations and the health system would meet and talk. That was naive. There are many excellent health blogs that touch on the area I marked out. People are too busy to focus on any one blog for a long time. I've appreciated the opportunity to talk on the blog with those who make comments, but comments have been sparser than I'd (naively) anticipated. A year ago I'd never heard the term "lurker." I know from the statistics I get that the blog has lots of lurkers. I'm no longer surprised by this - I'm a lurker myself at blogs I find interesting and read regularly. Life is short, and lurking is efficient!

4. Blogging has been psychotherapy for my perfectionism. In writing articles and books, I've agonized over getting things just right. That kind of obsessional dilly-dallying doesn't work in the blogosphere. Readers don't spend a lot of time on blogs. They want to be engaged and shown something - quickly. I'm the same when I read blogs. My daughter-in-law Emily Bazelon blogs on the XX factor blog. When we were watching Michelle Obama's talk on Monday night Emily was on line with her laptop, writing as we listened. When we debated some of the points she made she said "that's what makes the blog interesting - someone else will take up the argument." I haven't gotten that free yet, but maybe it will happen in year 2.

I want to celebrate the one year birthday of the blog by thanking those who have given feedback on the blog, by email, and in person. And I make a special request to readers to tell me what they'd like me to concentrate on next year, and how to make the blog more interesting and useful to them.

(In July the Kaiser Family Foundation hosted an interesting conference on "The Health Blogosphere: What it Means for Policy Debates and Journalism." A video and a transcript are available here.)