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Risk

Risk. It precedes, accompanies and follows our every step. Variably referred to as chance, a majority of people view it as a negative-if not consciously, then subconsciously. How we view it and how we manage it is a subject with compelling ramifications.

Chinese culture has long linked risk net with opportunity. By treating risk as a double-sided coin, one suddenly embraces a duality of options. By applying calculations to these options, one controls the degree to which one puts something at risk.

Physicians are royalty in the world of risk. Pity the investment banker who holds the fate of a large corporation in his or her hands. The cardiac surgeon holds a living, beating heart. By what other measure might we value an action than how it impacts the living world? To what degree can monetary risk compare to the risking of lives? There is risk and there is RISK.

But with the onset of modem statistics came the actuary, whose job it was to determine the probabilities of risk's occurrence. The actuarial table became a slide rule of life's trials. Merely looking at one could bring on a depression. Short of being struck by lightening, the risks we face, once quantified, seemed to suggest a world whose imagination for doing us in is never ending. Life insurance premiums, based in part on actuarial tables, seemed a paltry sum in the face of such bitter odds at survival.

Which brings one to the irony of medical malpractice insurance. Physicians, whose responsibility includes the detection of risk, the prevention of risk and the ultimate management of risk's malicious effects on our bodies, are burdened by financial and professional risk that undermines their effectiveness at achieving these very tasks. For the sole practitioner, the risks of risk management are so great that the management often suffers. Not surprisingly, many practitioners retire early, leave the field or get MBAs after medical school.

The larger picture tells a parallel tale. Unable to keep pace with the onerous costs of insurance, small hospitals consolidate or are accumulated (bought out). Insurance companies and HMOs grow larger and, guided by a culture whose priorities are financial, employ the actuarial tables as if they were Rosetta stones.

The beating heart in the surgeon's hand is now viewed as a statistical model. Parameters are set. Factors are weighed. And, after a little number crunching, the fate of that heart emerges from a computer printer, along with the fates of millions of others. This is the business of modern medicine. Insensitive, impersonal and fundamentally indecent.

But most physicians march on, despite the irony, despite the ludicrous manner by which healthcare is measured and doled out, despite the heavy costs of managing the risk of malpractice. They carry on because they deeply understand that risk is a value laden term, whose highest meaning is ultimately manifest under their watch.

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