I’ve never been sued for malpractice in thirty years of practicing medicine, most of it in one of the highest risk specialties for getting sued — pediatric critical care. I’d like to think this is because I’ve practiced good medicine, but I know that’s not the reason. Mainly, I’ve just been lucky, and my luck could change in a moment. I have highly competent, even stellar colleagues who’ve been sued multiple times, mainly because they’ve been unlucky.

As a tort, a personal injury matter, malpractice is intended to do two things. First, it is a way to compensate patients who have been injured by physicians’ avoidable mistakes. And we do need to have some way to accomplish that. Unfortunately, what data we have about malpractice litigation suggests it’s a poor way to do it; most of the truly injured go uncompensated and some who are not reap huge windfall settlements in the lottery that is malpractice litigation.

Our malpractice system has a second purpose. Malpractice litigation, or the threat of it, is also supposed to police the medical profession by keeping us on our toes. Unfortunately, it does a poor job at that, too. It turns out that medical skill has nothing to do with a doctor’s chances of getting sued; truly bad doctors get away with truly bad things and our best doctors get sued.

What do I think about this? I think we must have a way for patients who have been harmed to seek compensation for their injury, and we must have a way to protect the public from incompetent doctors. Our current system does neither of these. It also injects a large but unknown expense into the healthcare system when doctors order tests and consultations their patients don’t need.

If you would like to read more about this very volatile issue it’s best to look at several viewpoints. To get you started, here is the position of the American Medical Association, here is a typical media polemic that questions the AMA motives, and here is the point of view from a left-leaning think tank. Finally, here is one suggested solution, one which aims to make the entire process more even-handed to both doctors and patients; I recommend it to you.

It seems to me there are two sorts of arguments about the advisability of having a universal healthcare program, one which would cover all Americans. One of these is a moral and philosophical one — that we should have it because it is the right of all Americans to have access to healthcare. If you subscribe to that view, as I do, then the issue is not if, but how. Working through how best to structure it — public, private, or some combination of those — would necessarily involve trying to make the program as cost-effective as possible. But saving money is not the reason to do it.

Proponents of universal healthcare, however, often make the argument it will save money in the long run. The notion is that with better primary and preventative care, people will be able to avoid costly medical needs later by heading off complications of chronic conditions. I have no doubt many individuals would be helped in this way. But I think any savings of that sort would be swamped by the huge influx of people, bringing with them previously unmet demands for medical services. This demand will inevitably increase costs.

Can we do anything about this? Since any budget would be limited in some way, would we need to ration care? Honestly, perhaps we would. But the first thing to do to reduce demand is to weed out the many, many treatments research has shown to have marginal benefits over cheaper alternatives; some are even worthless.

There are many good places you can read about this giant gorilla in the room — the need to control demand for healthcare services in some way — and suggestions about how to do it. One key observation for the most expensive new drugs and services is that their development tends to drive the demand for them, rather than the other way around. You can read more about how this works (with some good illustrations) on Maggie Mahar’s excellent Health Beat blog.

Most children with significant brain injury spend time in a PICU. Like most experienced pediatric intensivists, I have seen hundreds of these children over the years, with dozens at least in the severe category. In one sense the term “traumatic brain injury” has limited usefulness because it covers such a wide range of injuries, from mild concussions to more extensive injury, to lethal damage. In another sense, however, it is a very useful diagnostic category because the brain responds to a wide variety of injuries in a very similar, stereotypic way.

Our understanding of the manifestations of TBI has grown over the years considerably. When head CT scans became available we could for the first time assess such things as bleeding inside the skull or swelling of the brain easily and safely. I remember how exciting it was in 1974 to see the first simple CT images taken on grainy Poloroid snapshots. Now we have sophisticated computer reconstructions of the brain. The technology represented such a breakthrough that its inventors received the Nobel Prize for it.

We soon realized, however, that some injuries to the brain, particularly what we call shear injury, are not well seen on CT — it takes an MRI scan to do that. We also came to realize that the most important thing we could do in the PICU for a child with severe TBI was to make sure the injury did not get worse: simple supportive measures like relieving pain and keeping the heart and lungs working well were key supportive measures to use while we waited for the child’s brain to heal.

Increasing understanding of milder forms of TBI have made us realize it is much more common than we once thought. For children, although the long-term outcome for mild to moderate TBI is good, persistent problems with such things as headache, mood changes, and difficulties in school are not uncommon, and these can last for months. There is a great deal of information available about TBI. There are many misconceptions about it, too. You can find authoritative, respected advice from the National Institutes of Health here and from the Brain Trauma Foundation here, and many more useful links here.

There has been much recent news coverage of a case in which the parents of a child with autism believed vaccinations the child received contributed to the child’s problem. The parents, one of whom is a physician, even appeared on Larry King. There is also much discussion in the medical blogosphere, for example here and here. Amid all the controversy, it is important to understand that the circumstances of this case cannot be generalized to other children. The child had a previously undiagnosed genetic problem that may well have predisposed the child to develop reactions to many stresses, one of which could have been the battery of vaccines she received.

What can we learn from this? The particular case was settled without anybody proving or disproving the truth of any link between vaccines and autism. There is an enormously contentious debate about the validity of this link — books, websites, and thousands of pending cases claim there is one. For its part, the medical scientific community has produced a long list of studies showing no association.

What do I think about it? Parents today forget how many children commonly died in the past from things like whooping cough and diphtheria. In the PICU I still care for the occasional child who becomes deathly ill from whooping cough. My own family tradition in medicine goes back over a century, and both my father and grandfather would attest to how many children once died from these diseases. Parents today who choose not to vaccinate their children are, in effect, taking advantage of the vaccine-induced rarity of these infections in the population; if vaccine rates fall, the diseases come back quickly.

What should a parent who is concerned about vaccinations do? First, of course, discuss your concerns with your child’s physician. But also read about the controversy yourself, and don’t confine your reading to one viewpoint or the other. Recognize that some claims are just silly. For example, I have heard the argument that physicians have a financial interest in promoting vaccines; of course a few dollars for a shot of whooping cough vaccine can prevent a PICU bill of many thousands of dollars. Also recognize that some physicians are going to be plain unwilling to discuss the issue at all. That is also silly — those of us who believe that, on balance, vaccines are a positive good should be able to explain why we think so.

An interesting footnote to this case is that the child’s parents are not anti-vaccine; they advise other parents to vaccinate their children.

The overwhelming costs of PICU care can financially cripple a family. I see this from time to time, and to me it is the most frustrating part of a medical career I otherwise love. I’ve just seen yet another example.

Parents who are between jobs often have a gap in their health insurance coverage. The federal COBRA legislation provides a way for some families to continue the coverage they had with a previous employer for up to eighteen months after leaving that job, but the cost of that coverage is so high many families cross their fingers and go without any health insurance, especially if a parent expects to start a new job with health care benefits soon. Even though such families cannot afford COBRA coverage, they have incomes too high to qualify for Medicaid. They have no choice but to hope everyone stays healthy.

I have just seen yet another result of that gamble; a child experienced a serious illness a mere week before the new insurance for his family would start, and there is no retroactive coverage allowed. The family’s bill will be in the many tens of thousands of dollars.

I’m not a scholar of medical economics. However, I do have nearly three decades in the trenches of the PICU. As I’ve written before, our current way of paying the costs for critically ill children is dysfunctional; it bankrupts families and discourages the kind of ongoing medical care that can head off the need for PICU care. And this is more than financially expensive — it can cause children to suffer things that might well have been avoided.