A Peculiar Predicament
"The hospital is a peculiar business. It is multipronged and loses business on a lot of procedures but it has to keep doing them. It loses money on Medicaid patients and makes money on private patients."

So observes James C. Robinson, PhD, MPH, a professor of health economics at the University of California, Berkeley, and author of a study on variation in costs and reimbursement in cardiac valve replacement surgery. His analysis of 37 hospitals provides the foundation for our cover story (page 6), which addresses the challenges of containing heart valve-related costs at a time when reimbursement is shrinking and payors are demanding more proof of value.

Physicians also might be described as multipronged. They function in a complex world of (usually) nonprofit hospitals, for-profit suppliers, private and public payors, patients and a web of societal constructs that are rooted in one, but rarely all, of these groups. The articles in this issue touch on many of these aspects in the physician's work life.

One reality is litigation. Given that a practicing specialist has a lifetime chance of nearly 100 percent that he or she will face a malpractice lawsuit, it might be worth reading our piece on malpractice, its impact on practice and possible areas of reform.

Nothing replaces good clinical judgment, but adding evidence-based procedures and products to the process helps ensure that patients receive the best care available at a given time. With that in mind, we provide an update on how CABG grafting decisions can reduce complications and the emerging use of PET imaging for quantifying myocardial blood flow, which may become a powerful tool with the new tracers on the market, and seeking to reach the U.S. market.

Sadly, practicing state-of-the-art and informed medicine won't guarantee a career free of litigation, though, for either physicians or hospitals. Peculiar indeed.