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Outlook: 10 Things I Hate About Health-Care Reform

Arthur Feldman
Arthur Feldman (Jefferson Medical College )

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Arthur Feldman
Cardiologist and Chair of the Dept of Medicine, Jefferson Medical College
Tuesday, September 8, 2009; 2:00 PM

Arthur Feldman, cardiologist and chair of the Department of Medicine at Jefferson Medical College in Philadelphia, was online Tuesday, Sept. 8, at 2 p.m. ET to discuss his Outlook article titled "10 Things I Hate About Health-Care Reform."

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Feldman is the author of "Pursuing Excellence in Healthcare: Preserving America's Academic Medical Centers."

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Arthur Feldman: Good afternoon. This is Arthur Feldman. I appreciate your joining me to talk about health care reform and my recent article in the Washington Post Outlook section.

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Frostburg, Md.: Will quality of care decline with universal health care and will individuals have to wait longer to see a physician?

Arthur Feldman: This is a difficult question to answer. I think physicians are concerned that care might decline if hospitals don't have the necessary support for infrastructure.

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Washington, D.C.: Dr. Feldman,

What kinds of regulations would you like to see for the insurance industry?

Are the problems with private insurers comparable to those with Medicare? Does Medicare have fewer, more, or different problems with respect to patient care and administrative paperwork?

If you could financially sustain your practice on exclusively Medicare patients or exclusively private insurance patients, which would you choose?

Arthur Feldman: For one thing I would like to see people be able to buy insurance across state lines. I would like to know what the administrative costs are for the insurance industry and not just what the costs for care are. And, I would like to understand why the insurance industry reimburses hospitals in different states and even in the same city at substantially different levels for the same service. Private insurers pay more than Medicare - but are more difficult to deal with because they are more likely to deny a patient coverage.

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Athens, Greece: You still don't explain how they can deliver care in Europe, for less, with better results on longevity and with about comparable satisfaction (complaints exist but are just as bad as in the U.S.). One observation I have from having been a consumer of state care in a place as poor as Greece is that for instance hospitals are not the palaces that I found in the U.S. Mind you if you want a palace type hospital you can still find it. The public option in Europe still allows the well off to afford the luxury treatments they want at 10 times the cost. One does not exclude the other.

Arthur Feldman: Europe is very different. For one thing, European governments have certificate of need laws which many states in the US do not. As a result high technology and expensive care is centered at central hospitals. As a result these hospitals do more and are better at doing it. An example is bypass surgery. In the US there are numerous small hospitals that perform bypass surgery at high cost because their level of reimbursement can't meet fixed costs of equipment nurses, etc. In Europe, bypass surgery is done in centralized centers of excellence.

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Rockville, Md.: The Post has a terrific article today about "recission," which I think is really the most important issue. How do we keep the incentives of a capitalistic-based system, without denying coverage to the money-losers:

1. Those who can't afford insurance 2. Those with pre-existing or chronic conditions

Is there any foreign model that does this well, without resorting to Canadian/British-style rationing?

washingtonpost.com: When Your Insurer Says You're No Longer Covered (Post, Sept. 8)

Arthur Feldman: Your question raises the really tough issue. I think we need to put the best minds in the country together to figure out the economics of health care - keeping in mind that the patient comes first. There are a thousand moving parts that unfortunately have been studied in the back halls of congress and behind closed doors in the White House without the opportunity for anyone except lobbyists to weigh in

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Tucson, Ariz.: Can tort reform help solve the escalating cost of health care? Why haven't the AMA spend the money necessary to put controls or caps on malpractice suits?

Arthur Feldman: We must have tort reform Doctors have become cynical because everyone is asking them to reign in costs - but no one is looking at the costs of an absence of tort reform. In Pennsylvania 93% of graduating trainees leave the state to seek employment in states with tort reform. Today everyone is pointing to Texas where they have tort reform. I agree that Texas needs to decrease its culture of over-utilization - but that doesn't mean that the ridiculous judgments of capricious juries needs to continue everywhere else

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Rockville, Md.: Is there a form that I can sign to send to Maryland's senators and representatives showing my concerns (exactly as you have expressed them)?

Arthur Feldman: I wish there was. Why not just send them the link to my Washington Post article!

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Gaithersburg, Md.: I agree with many of the points made in your article. Why I agree with health reform, is that health care cannot continue the way it is. Isn't some reform better than health care continuing as is?

Arthur Feldman: I agree - we have to have health care reform. We just have to do it carefully and thoughtfully, with transparency, and with input from the individuals who are in the trenches. We also need more data and less anecdotes.

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Washington, D.C.: I find the negative publicity surrounding the Canadian health-care system unproductive at best and patently false at worst. My husband is Canadian. His entire family resides in Alberta to include our son-in-law, a small business man. Without exception, no one would trade their health care (taxes and all) for ours. That's not to say their delivery system is perfect or that it could be transferred without revisions to the U.S. But there is not a wholesale exodus of Canadians to this country to access our health care.

Arthur Feldman: You ought to speak with hospital administrators in Detroit - they see a lot of business from Canada! That having been said there are pieces of the Canadian system that are good - but care is clearly rationed. You can't get an MRI in two days or bypass surgery the following week - and like in Europe - the wealthy can bypass the system by seeing their "private doctors"

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washingtonpost.com: 10 Things I Hate About Health-Care Reform (Post, Sept. 6)

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Asheville, N.C.: At what speed and in what increments would you revise or enhance health care?

Arthur Feldman: I think its a step by step process. I would begin with tort reform because it is low hanging fruit - and then move on to controlling health insurance companies - making them accountable for their expenses, ensuring true competition by allowing individuals to purchase insurance from other states, insuring that they support research into cost effectiveness, and mandating that they not cancel patients when they become sick.

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Baltimore, Md.: As a 2nd year medical student, I am very invested in this debate and this health-care bill. Do you know if the things that you and scores of people are saying are making a difference? It seems there is great, substance input out there about this bill coming from the private sector, but are Congress and President Obama even listening?

Arthur Feldman: Regrettably I'm not sure that anyone in Washington is listening to us physicians - they are certainly listening to the lobbyists from industry and the legal profession.

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Washington, D.C.: Reading your Op-Ed piece, one might get the impression physicians are underpaid. However, aren't American physicians the highest paid in the world? Given outcomes are largely no better, or in some cases worse, than outcomes in countries that pay doctors less, how can you demand citizens (via taxes and premiums) fork over more $ to pay doctors?

Arthur Feldman: I don't think that any of us believe that we are overpaid - I certainly don't. However, you must understand that Europe is very different from the U.S. Medical school is free so students don't graduate with six figure debt (average US debt for a medical student is $120,000 excluding any debt for their undergrad education), doctors do not go to undergraduate school - but go right to medical school, and post-graduate trainees are paid higher than American trainees. Thus, in Europe there is not the pressure to pursue high-paying positions at the expense of lower paying positions such as primary care as students do not have to think about how to pay off their debts.

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Darnestown, Md.: Dr. Feldman - You say that tort reform needs to be included in the health-care reform process, and I agree. Are you talking about comprehensive reforms, including caps on pain and suffering (non-economic) damages such as passed in CA and TX, or other reforms? If other reforms, what are they?

Arthur Feldman: caps are one piece but I think there are other important reforms. First, cases should be reviewed by panels of judges and physicians to insure that frivolous cases don't move forward. Second, there must be federal laws that protect the ability of physicians to review their mistakes without those reviews coming in to the public domain. And, third, their must be "whistle blower" type protections from physicians who attempt to deal with impaired or unprofessional physicians.

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Gaithersburg, Md.: Personally, I have a lot of trouble thinking a bunch of lawyers are going to support tort reform. You forgot to mention the numbers of Ob/Gyns who have left Ob because of the exorbitant cost of malpractice insurance.

Arthur Feldman: Your absolutely right. In our area there are only four or five hospitals that still have maternity wards. Remember that the #1 support for the DNC comes from the trial lawyers.

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Dallas, Tex.: Dr. Feldman, In America no one should go broke because they got sick. I am employed full time with health coverage, however if I get sick I hope I die without hospitalization, excessive copays and deductibles -- I'll be bankrupt.

Arthur Feldman: I agree. As I said in the article I believe that every American has the right to health insurance. My concern is that we need more than just universal coverage - many parts of the system are broken and no one is focused on fixing them raising the specter that health care will get worse instead of better with the current economic system.

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Uniform Documents: During the Clinton health-care reform initiative more than 20 years ago, he made a comment that I thought was interesting. He indicated that by simply having everyone using the same forms to submit for insurance claims, the system would save an extraordinarily high amount of money (tens of billions of dollars) through increased efficiency (decrease errors, etc.). Is the bureaucracy of sending in for insurance reimbursement a cumbersome process that would allow for significant savings if we were to adopt a uniform claims system?

Arthur Feldman: Your are absolutely correct. The other time consuming process is getting pre-approval for procedures. That requires an army of staff.

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Olney, Md.: I am a well-compensated health-care provider with gold-plated medical insurance and the wait time for an appointment with my private sector dermatologist is 3 months. This is not unusual. I wait about 2 months to see my GYN and about a month to get in for a non-emergent appt with primary care. I'm tired of listening to how "awful" it would be if we had a public option (emphasis on the word 'option'). With all due respect Dr. Feldman, you work in academic medicine (as do I). You, of all people, should understand the needs of the disadvantaged who present themselves in the Jefferson ED. And yes, I am willing to pay more taxes than I already pay in my upper income bracket to support health care that does not discriminate and ration based on income.

Arthur Feldman: I don't disagree with you at all. My concern is that our emergency department will be overwhelmed even with the type of reform you espouse. First, the current bill will allow physicians and hospitals to opt out of a government option. That means that community hospitals will send us those patients that are either not insured or underinsured. Second, many of our ER frequent flyers are either drug or alcohol abusers, homeless, or have chronic psychiatric problems. These individuals will not have the government option or private insurance and without the funds we now receive for these types of patients (which is excluded in the bill before congress) we will have trouble making ends meet.

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Silver Spring, Md.: Dr. Feldman, Thanks for your article and your chat. Just wanted to point out that you may do well to heed your own recommendation that we need more data and less anecdotes. Instead of suggesting that we gather some anecdotes from hospital administrators in Detroit, it would be good to cite data on the frequency with which Canadians seek care in the U.S. Thanks again!

Arthur Feldman: I agree completely. Data has been sorely lacking in all discussions about health care reform.

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Richmond, Va.: There is one historical aspect to the delivery of medical services that I've yet to understand. And that is how did the community hospitals transition (over the past twenty years or so) to for-profit institutions?

Arthur Feldman: It happened in part when states let their certificate of needs laws sundown.

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Canadian/British-style rationing? : Since nobody has infinite money, isn't it true that all health care is rationed? But in Canada and England, it is done by physicians and scientists while here it is done by insurance company employees and how much money the patient has.

Arthur Feldman: I agree. That is why many of us are so concerned that physicians have played very little role in the current health care reform debates. No one wants rationing or end-of-life care issues to be determined by anyone but their physician.

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Tort reform: You make an interesting point about the inclusion of tort reform in a health-care reform effort. However, as much as I'm certain doctors would also like sensible tort reform, it seems separate, and larger, than the issue of making sure that there's someone to pick up the reasonable medical bills of the sick. After all, I bet that uninsured patients file lawsuits regarding their medical care -or lack thereof- as well.

After all, doctors aren't the only targets of indiscriminate lawsuits -- in the U.S., anyone can sue anyone else over anything. I'd hate to see universal coverage be derailed because we haven't figured out how to efficiently deter plaintiffs from making frivolous, groundless and/or delusional claims, or efficiently dispatch such claims, when filed.

In the meantime, wouldn't developing, adhering to, and possibly publicizing standard treatment protocols help reduce wasteful "defensive medicine?"

Arthur Feldman: To effectively move towards the type of health care system we want in the future - we must ask doctors to make concessions and to change some of their practice culture. It is hard for doctors not to be cynical when they see that our government is unwilling to control the legal profession and to move them into the future as well.

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Herndon, Va.: What do you think the drug industry contributes to the high cost of medical care in this country and what should be done about it?

Arthur Feldman: This is an excellent question. Although we hear about the abuses of the pharmaceutical industry, experts have shown that the cost of drugs is a small fraction of the global health care costs. None the less - the cost of drugs is of great importance to patients who don't have an insurance plan that covers drug costs. This is a problem that has to be approached in a number of ways: 1) we have to reign in pharmaceutical company spending on advertisements to the public and payments to physicians; 2) we have to streamline the FDA process so that drugs get to the market quicker; 3) we need to improve the regulatory environment so that drugs can be evaluated in the US and not outside the US keeping research dollars in our own country; 4) we need to review and optimize the patent laws; and 5) we need to insure (through the FDA) that pharma is using pharmacogenomics or personalized medicine to define what patients will actually respond to a drug based on their genotype rather than getting approval for a broad base of patients.

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Rice Lake, Wisc.: I am a psychiatrist in a multi-specialty group with access to state of the art technology and all that. Mental health services need even more attention. I can't tell you how heartbreaking it is not to be able to help people out who have lost their jobs, then their insurance and now are going through bankruptcy b/u health care. If fix means more taxes, well I am prepared to pay that to help others out.

Do you really believe that an incremental approach is even possible? Last time health care was attempted was many years ago. If because of well intentioned opposition from advocates like you this attempt fails, would we all be better off or worse off than how things are now?

Arthur Feldman: I think a good historical analogy is the space program. We had a young aggressive president who believed that we needed to win the race to space and made it a national priority. However, he didn't design the program nor did congress - they simply supported it with money. Then, he brought the experts together to make the thousand moving parts work. It took almost 8 years to get a man to the moon - but it was done safely and effectively. Now we have another aggressive young president who has a very well intentioned and important and imperative goal - fixing our broken health care system. What I am asking for is the same type of program- focused, driven by the experts, and free of the influences of lobbyists and private interest groups - with the primary goal of improving health care for every American

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"Managed care": I have relatives who deal with health insurance companies professionally, and they cannot utter that phrase without the bile rising in their throats. They explain the insanity of the current system this way -- just because a health insurance carrier has authorized a treatment does NOT mean that the provider has agreed to pay for the treatment. Have you had similar experiences?

Arthur Feldman: My biggest challenge is trying to figure out how to treat a patient when their insurance company has denied my ability to do a test or administer a therapy.

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Anonymous: Actually, I don't want my end-of-life care to be determined by my physician; I want it determined by me with the support of my physician. Hence the idea of a covered appointment with my physician to discuss those plans and ensure that he or she is comfortable seeing them through should that contingency arise.

Arthur Feldman: I don't think any physician should make end of life decisions for a patient. The important goal - and something that congress has actually gotten right - is to insure that all patients have these types of conversations with their physicians and with their families.

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Washington, D.C.: Sir, I hardly think a few "hospital administrators from Detroit" seeing wealthy Canadians from north of the border constitutes a wholesale exodus of Canadians seeking care in the U.S. Yes, if you have the financial means in Canada you can see a "private physician" or even leave the country -- just like here (Concierge Health Insurance comes to mind) or like foreign dignitaries seeking care in the U.S. But unlike in the U.S., everyone else is still covered in Canada.

Arthur Feldman: you are correct - but not everyone loves the system

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Rehoboth Beach, Del.: Would you support a "Peace Corps" or "Americorps"-type program aimed at newly graduated medical students whereby the government could help pay a graduate's college loan debt in exchange for pursuing needed disciplines, setting up practices in required areas, or performing services for lower for lower costs?

Arthur Feldman: I don't think it needs to be a "corp." I believe that any graduating physician who commits to practicing in an underserved area - be it rural or urban - for a period of ten years should have their tuition paid for over that period of time. Hopefully, these individuals will become members of their communities and remain there for the duration of their practice. My concern with the "peace corp" analogy is that students join the peace corp for only a short period of time.

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Anonymous: Would it be better if a expert commission was formed to devise the answers and form a new plan?

Arthur Feldman: That's what I believe would be best for the American people.

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Rockville, Md.: "...experts have shown that the cost of drugs is a small fraction of the global health care costs."

Yes, it's AMERICANS who pay high drug costs to subsidize the rest of the world and the pharma companies prohibit us from buying them from foreign sources.

How do we lower drug costs IN THE USA?

Arthur Feldman: better effectiveness research. we must understand whether a new drug is better than an old drug - not if it is better than a placebo. Second, most patients probably take too many drugs. We need to learn what drugs work in a particular patient - not in the population as a whole. Finally, we must lower the costs of drug development - and then we can hold pharma accountable for costs. Every part of health care must be "regulated" not just physicians and hospitals.

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Olney, Md.: Sir, the question is not whether or not we ration health care in the U.S. -- we do -- based on income and insurance company profit margins. Of course this begs the question that if you are going to reimburse based on performance we have to fund the research that collects the evidence and continuously evaluates the outcomes which underlie clinical practice.

Arthur Feldman: You are absolutely right. Only recently have we begun to develop the appropriate metrics that will allow us to measure performance. I am proud to say that the American College of Cardiology and the American Heart Association have been leaders in those efforts. We need other medical groups to follow suit.

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Salt Lake City, Utah: Number 1 and 10 seem to deal with bad outcomes from bad insurance company behavior. Do you think rigorous regulation of health insurance companies would prevent these same companies from constantly lobbying the government to allow them to make more money as with Medicare Advantage (private companies administering Medicare)? On malpractice reform, Texas has it, but the costs have not been reduced and the benefits have not been seen. It seems the victimized patients have suffered more is all.

Arthur Feldman: I believe that competition is important. I actually favor a government-sponsored health plan. However, I think that we need more than just competition - we also need tight regulations. For example, there is no reason that a patient can't cross state lines to purchase their insurance - or to get their care!

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Washington, D.C.: The problem with the "panel of experts" is that you then have to decide what counts as an expert. Physicians? Insurers? Government wonks? Patient advocates? And then once the panel decides, you have no guarantee that anyone will adopt the experts plan. Your panel doesn't avoid the political problems of health-care reform - it just makes them less obvious.

Arthur Feldman: There is actually a new and rapidly growing discipline of outcomes researchers that come from many academic institutions and have made outcomes research a true science. In addition, our business schools are filled with economists who focus on health care. We need a panel that is not in any way influenced by lobbyists and thus have no conflicts of interest.

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Huntington, W.Va.: "What I am asking for is the same type of program -- focused, driven by the experts, and free of the influences of lobbyists and private interest groups"

One man's expert is another man's lobbyist.

Arthur Feldman: if we make some beginning steps (eg. tort reform, regulation of insurance companies, etc.) people will become less cynical and we can make serious progress

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Alerxandria, Va.: I don't know how to say this politely, but you don't seem terribly well-informed about all the research on health services that has gone on at think tanks (e.g., RAND, CAP)and universities, sponsored by the government and private foundations (RWJ, KFF, Commonwealth). When you say "so many parts of the system are broken, and no one is focused on fixing them", I get the impression that you are not aware of the reams of data that have been collected regarding the operation and costs of our health care system. Also, the very well-known Institute for Healthcare Improvement, is dedicated to system reform and has achieved substantial gains.

Also, why bring up NIH? Nobody is saying it's not important, but funding of research is logically and, as far as I know, legislatively independent of funding for health services and policies governing insurance.

Arthur Feldman: Why bring up the NIH - +because the greatest changes in health care over the past three decades have come from NIH sponsored research: vaccines to protect from child-hood diseases; treatments that have made AIDS into a disease you can live with; life-saving medications for patients with an acute MI; new targeted pharmacology that markedly extends the lives of patients with some cancer, and treatments that have extended the life expectancy of a heart failure patient from 6 months to many years. Only continued research - including outcomes and comparative research - will allow us to improve the life expectancy of Americans.

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Washington, D.C.: Re: "Medical Corps" option. In Vietnam physicians may apply for and if selected, they may attend a residency in France supported by the French government. In exchange they agree to work for 10 years (I think -- it may be longer) in the Vietnamese public health hospital system. They may moonlight in the private sector but in exchange for a western residency they "pay back" in the public sector. And U.K. physicians do not have their entire educations paid for.

Arthur Feldman: One of our Pennsylvania state senators brought a bill before the senate to create tuition reimbursements for any student who remained in PA and served in an underserved area after completing their training. The state legislature failed to pass the bill

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Kensington, Md.: Sir:

I am glad you brought up the issue of the supply of doctors and other health-care workers. For many years, labor economists had been tracking the shortage of nurses and other assistants, and I presume that problem has grown rather than solved itself. Presumably, whatever health-care reform we have would lead to increased utilization of health care, but without a commensurate increase in medical staff, costs will necessarily rise and the entire plan will be self-defeating.

I have long advocated the government fully subsidizing the cost of medical training. But your article makes me realize that the schools themselves might be unprepared to train more MDs, nurses, and medical assistants. That in itself seems like an even bigger looming crisis than the status quo of the uninsured we face now.

Arthur Feldman: It isn't just the schools. There is a governmental cap on the number of post-graduate training spots in the U.S. This was set by the Balanced Budget Act of 1996.

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D.C.: Doctors are pathetically inept and unwilling to police themselves when they are made aware of others in the medical community who commit gross malpractice. The state medical licensing boards do not adequately protect the public from these doctors and, until they do, malpractice lawsuits should not be capped. What say you to the inadequate policing doctors do amongst themselves?

Arthur Feldman: I am in total agreement. One problem is that when we try to police unruly or incompetent physicians the very lawyers that sue us for malpractice - sue us for restraint of trade or breach of contract! In addition, in some states, peer-review records are publicly accessible making it very difficult to adequately review issues of care. This is another need for tort reform. In addition, we now train our students both here and at other institutions in professionalism. This will be important in changing the culture of our future medical work force.

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Arthur Feldman: I am afraid our time is up. I want to thank everyone for joining me this afternoon and discussing this critically important topic. I have found it very educational - and I hope that each of you feels the same.

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Editor's Note: washingtonpost.com moderators retain editorial control over Discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions. washingtonpost.com is not responsible for any content posted by third parties.


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