What is Transparency?

Since posting this on Friday, I've been talking to friends about the risks of blogging with my particular brand of candor. Some are worried I am exposing myself too much on my blog, especially when it comes to my professional life. I worry about this too, but for a different reason.

I thought long and hard before starting this blog. Not only did I want to sustain the momentum of writing it, I wanted it to be purposeful and, above all, useful to other people in similar situations. In reading the other medical blogs, I didn't find much about the challenges of being a small-town doctor, so I decided to devote my blog to rural medicine. Not only did I want to write about medical developments and healthcare policy, I also wanted to write about the day-to-day life of a rural doctor. I believed I could provide a personal voice from the front line of medicine, not only responding to elements of the healthcare crisis, but also showing what I do and how I feel about doing it.

To this end, I write case reports and birth stories, disguising patient details in the finished post. I do the same thing when I write about career difficulties and job woes. Yet for some reason, the latter topic inspires more concern. Friends are worried that I'll get myself into trouble by describing--in composite or fictionalized form--the types of organizational challenges facing rural doctors as we try to assemble a regional health care system that makes sense. Why is this less discreet than discussing composite case studies? Perhaps because it exposes the the most basic relationships between the people and organizations that deliver health care in this country.

This raises another question: What is transparency? There's a lot of talk out there about the need for greater transparency in the way healthcare is delivered, from CMS policy statements to disclosure of medical errors. And yet the more transparency everybody demands, the more baroque and inaccessible the language to discuss these matters becomes. It's as if the need to disclose problems within the healthcare system is creating a culture of evasion, in which you can avoid disclosure by avoiding any examination of the roots of these problems.

It reminds me of verbal manipulations that entered the mainstream consciousness during the Iran-Contra Affair. Joan Didion, one of my favorite writers, wrote a novel entitled The Last Thing He Wanted demonstrating the layers of misrepresentation and absurdity possible by using such language. I believe we are developing a similar vocabulary when try to talk about medicine and healthcare.

By avoiding frank representation of our real working lives--including the relationships between doctors and hospitals, primary care doctors and specialists, insurance companies and everyone--we're creating an environment in which complex language and socially-acceptable evasions can thrive. Why not take a stand against this trend by writing in detail about the work we do and where we do it? Even though these relationships are formalized in written agreements, most details between doctors and healthcare organizations are not subject to gag rules, nor should they be. I don't believe that spelling out my financial profile or job dilemmas, especially in fictionalized form, will harm the clinics and hospitals I work for, whereas doing so might actually help create real discussion about these issues.

The goal of transparency is a greater common understanding of how processes work, so that special interests and self-promotion cannot corrupt the system. Don't let this ideal to deteriorate into a mere buzzword which can be used to perpetuate the decline of the healthcare system.

Comments

[doc mike]

I respect doctors who blog, but just can't do it myself. Don't keep a diary any more, nothing that would be discoverable in a lawsuit.
I hate practicing in a rural setting and am moving to a larger community after 14 years in a small town.

[Kim]

I discovered that it took too much energy to NOT be transparent. About the only thing that isn't widely known is where I work, but it is definitely in the San Francisco Bay Area.

While all my patients are composites, I have quite a few to draw from after 30 years, I just talk about how I feel about things.

Everyone at work knows I blog. Some of them actually read it. I don't think anyone cares!
: )

[Bruce]

Thanks for your commitment to transparency, even if it requires some fictionalization. The writing brings insight both to you and to your readers. Insight is always a good thing and we all learn from your musings, whether in rural practice or not.