Last year medical ethicist Howard Brody, M.D., published a book,
Hooked: Ethics, the Medical Profession, and the Pharmaceutical
Industry, about a subject that would quickly become a moving target.
"The scene was changing rapidly," Brody said of the mounting
public and professional concern about medicine's relationship with the
pharmaceutical industry. "It seemed to me that the minute the book was
in print, it would be out of date in two weeks. So I thought, What would be a
mechanism for keeping me abreast of new developments while also sharing new
information with the public?"
The answer was a Weblog, or "blog," a real-time, online,
running commentary on all matters related to the subject of
medical-pharmaceutical relationships. He named the blog "Hooked: Ethics,
Medicine and Pharma."
"I set up the blog with one intention—to serve as an update to
the book," said Brody, who is chair of family medicine and director of
the Institute for the Medical Humanities at the University of Texas Medical
Branch at Galveston.
Jim Sabin, M.D.: "In retrospect I can see there was a connection
between the very emotionally meaningful decision to wind up my clinical
practice and starting the blog."
At about the same time, his friend and colleague, psychiatrist Jim Sabin,
M.D., also began writing a blog called "Healthcare Organizational
"I had been thinking about writing a blog for a few years, but I put
it off thinking that I didn't have the technical expertise to do
it," Sabin said. "Then a year ago I made the decision to end my
clinical practice. When I really bit the bullet and started to come to terms
with the end of clinical practice, all of a sudden instead of dithering about
doing a blog, I decided that the only way I would learn about it is by doing
"In retrospect I can see there was a connection between the very
emotionally meaningful decision to wind up my clinical practice and starting
the blog," Sabin said. "It struck me that there is a deep
underlying connection in the area of reaching out to people and making
connections. Clinical practice, of course, is about making connections. And in
its own way, blogging has something of the same structure."
Sabin's and Brody's experience underscores two features of
blogging—the ability to stay with an evolving subject on a daily basis
over time and the capacity to connect in a new way with a universe of Internet
surfers looking for thoughtful discourse. These features may account for the
popularity of blogging and for turning the medical and health care"
blogosphere" into a new force for shaping public opinion.
Putting a figure on the number of blogs that are written by psychiatrists
and other doctors or are focused on medicine, science, and health is
impossible; but it is emblematic, perhaps, that Webster's
Dictionary—the old-fashioned one you hold in your hands—has
an entry for "blog" and defines it thus: "a Web site that
contains an online personal journal with reflections, comments, and often
hyperlinks provided by the writer."
It is telling as well that Health and Human Services Secretary Mike Leavitt
has his own blog on government policies related to health care.
"We live in an era when information has made a basic change,"
said Leavitt in an online symposium titled "The Health Blogosphere: What
It Means for Policy Debates and Journalism," sponsored by the Kaiser
Family Foundation. "It used to be we would go to libraries and
universities because... they stored and passed on and enhanced information. In
the information age, information goes where people are, and public
policymakers need to do the same."
"Do I expect that blogs are going to be a significant part of public
policy in government in the future?" he asked. "Absolutely. How? I
think we are all figuring that out."
One fact that has certainly contributed to the growth of the blogosphere is
that starting a Weblog now requires next to no technical expertise. Many Web
sites offer blog-starting tools that can be employed by the most naïve
"Basically, it's set up in such a way that Aunt Min can start
her own blog and put up pictures of her family," said Brody about
the Web site that hosts Hooked. "If it were technically difficult, I
wouldn't be doing it."
"If you can use e-mail, you should be able to start your own
blog," agreed "Roy," a clinician who is one of three
psychiatrists anonymously hosting a blog called Shrink Rap. "It is
devoted to everyday issues in psychiatry, ranging from private practice to
forensics to general-hospital psychiatry—what Roy, who asked to remain
anonymous for the purposes of this article, called the nuts and bolts of
The psychiatric threesome also produces a podcast called My Three
A sample of the topics posted on Shrink Rap includes "When Lawyers
Call," "CPT Billing Codes for Psychiatrists and
Psychotherapy," "Why Docs Don't Like Xanax," and"
Write on that Slate?"—a posting that addressed the concept
of the therapist as a "blank slate" and asked such questions as
"How exactly does it damage the patient's treatment if he knows
some information about a psychotherapist's personal life? Do we really
truly believe that there is a difference in treatment outcomes if a therapist
wears a wedding ring or doesn't? If he answers a question about where he
went on vacation or if he has children?"
"The goal was to make the blog a place where psychiatrists could talk
about issues that affect them on a daily basis," Roy told
Weblog writers agreed that blogging can be pleasurable, but"
it's demanding," Sabin said. "It's absolutely
clear that the more you post, the more readers you get. The blogs with the
highest readership have postings once or twice a day. My aspiration is to post
three times a week, and I don't accomplish that week in and week out. So
it's fun, but it's work."
Sabin, who has written books including Setting Limits Fairly and
No Margin, No Mission: Health Care Organizations and the Quest for Ethical
Excellence, has devoted a career to exploring how medical resources can
be ethically allocated across a population (Psychiatric News, June 3,
He is director of the ethics program at Harvard Pilgrim Health Care and a
clinical professor in the departments of ambulatory care/prevention and
psychiatry at Harvard Medical School.
"One of my missions on the blog is to contribute to detoxifying the
topic of including cost as a component when we think about the ethics of
health care," Sabin said. "So there are a lot of postings dealing
with cost that have in common the theme of encouraging or delineating
ethically robust ways of addressing the topic."
Postings on Sabin's blog include "Why We're so Ineffective
in Controlling Healthcare Costs," "Learning How to Ration,""
Technology Running Amok," and "Avastin 1/Cost Control
The last of them was a posting on July 8 about the anticancer drug Avastin:"
Only in the U.S. is it possible to ask 'When, if ever, should cost come
into the equation?' with regard to a drug that produces ambiguous benefits at
best for which billions of dollars are spent."
Psychiatrist Daniel Carlat, M.D., who writes "The Carlat Psychiatry
Blog: Supporting the Search for Honesty in Medical Education," agreed
that without an abiding interest in the subject matter, the Weblogger will
have a difficult time sustaining a successful site.
"Unless you feel passionately about your blog subject, chances are
you are not going to continue to be successful," said Carlat, an
assistant clinical professor of psychiatry at Tufts University School of
Medicine and cochair of the CME Committee of the Massachusetts Psychiatric
Bloggers who spoke with Psychiatric News said that there are
countless Weblogs given over entirely to spleen; the Internet is a safe haven
for all manner of rants and raves.
But thoughtful, articulate bloggers typically find each other in
cyberspace, trading posts and building up a community of readers and
"The thing that's interesting is that out in the blogosphere
there is a club, and I'm now a member of it," said Brody. "I
have these fellow bloggers, and we exchange things. If one of us posts
something that attracts interest, someone else may use it. These are careful,
thoughtful people doing their blogs. They are not just being incendiary, but
are trying to back up what they say."