Should PCPs Begin Packing Heat?

DrRich | September 29th, 2010 - 9:54 am

This is a delicate topic, and even DrRich (who has displayed on these pages a willingness to risk alienating Progressives, Conservatives, President Obama’s minions, fat people, editors of prestigious medical journals, global warming enthusiasts, babies, bunnies, and even his beloved fellow cardiologists) is hesitant to bring it up.

But events force DrRich to throw caution to the wind, and issue a warning, and a plea, to those among the broad community of physicians for whom he has the most respect – the PCPs. The event to which DrRich refers, of course, is the recent, tragic gunning-down of a physician at Johns Hopkins University Hospital by a disgruntled patient (or rather, by the clearly disgruntled son of a possibly disgruntled patient).

This is DrRich’s warning: the recent shooting at Johns Hopkins may indicate that the long-predicted (predicted by DrRich, at least) bloodbath of American PCPs may now be at hand. And this is his plea (and here is where even the usually audacious DrRich must admit to a slight bit of trepidation): PCPs, for your own good, for the survival of primary care medicine, and therefore for the success of Obamacare, you must now prepare to defend yourselves.

Yes, dear readers, it is time for American PCPs to begin packing heat.

DrRich well understands that many of his readers at this moment doubtless think he has, at long last, lost it; that his finely-honed (and amply-demonstrated) abilities in logical discourse have finally taken their leave, that he has, sadly, gone ’round the bend. DrRich forgives you for this reaction.

After all, the doctor who was shot (whose identity has not been disclosed, but who is apparently expected to recover fully), works at Johns Hopkins, one of the premier medical institutions in the world. And therefore, while its leaders undoubtedly give the requisite lip service to the importance of primary care medicine, Johns Hopkins likely does not have very many actual PCPs frequenting its premises. So (DrRich’s clever readers correctly surmise), it seems very unlikely that the shooting victim was a PCP; and for him to find a lesson for PCPs in this unfortunate incident is obviously too ridiculous for words.

DrRich does not take such criticism personally. He realizes that those of you who doubt him in this case are not being mean-spirited, but merely misinformed. DrRich accepts the fact that most of you do not scour the relevant scientific literature with as much care as he does. And so, he does not expect you to be aware of the recent work of one David Fishbain, Professor of Psychiatry and Behavioral Sciences at the University of Miami, who published a study in NewScientist Magazine which indicates that up to 1 in 20 patients would like to kill their primary care physicians.

Professor Fishbain learned this interesting tidbit in a survey he conducted among 800 patients undergoing physical rehabilitation or suffering significant pain.

Those PCPs who are reading this startling news, and who, by virtue of the fact that they are still working as PCPs, have have most likely honed their skills of denial to a high art form, are doubtless consoling themselves at this very moment with this observation: “Sure they want to kill me. But as they’re disabled, their chances of success seem low.”

So chew on this. In a control group of patients who were not suffering from pain or disability, Fishbain reported that “only” 1 in 50 admitted to having murderous tendencies toward their PCPs.

Any way you cut it, the math is not pretty: the typical PCP with a patient load of 3,000 souls can assume that at least 60 of these individuals (up to 150, if he/she treats a lot of patients with pain or disability) would not only like to see them dead, but would be pleased to be the instrument of their demise. Worse, even these statistics are surely unreasonably cheerful, as they rely on the likelihood that everyone who wants to see their doctor lying lifeless in a pool of blood are comfortable admitting this fact to medical researchers doing written surveys.

In any case, whatever the specialty might be of the physician who was shot at Johns Hopkins, it is the PCPs who are at the highest risk. And now that the shooting has actually begun, DrRich does not think PCPs should take much comfort in the possiblity that the first casualty may not have been one of them.

Why are patients murderously angry with their PCPs? Let us count the ways.

DrRich has expended much space and effort on this blog describing how PCPs have been maneuvered into covertly rationing healthcare at the bedside. Patients who go to their guideline-compliant, non-fraudulent PCPs these days will find themselves limited to 7.5 to 12.5 minutes of actual face time, most of which their doctor will spend sitting at a keyboard, staring at an LCD screen, desperately attempting to make the appropriate clicks on the most favorable little boxes next to a government-sanctioned Pay For Performance checklist. There will be little or no time for whatever pressing issues may be on the patient’s own (non-government-approved) agenda.

The patient, who has waited weeks for this opportunity, will be asked to wait weeks more for another appointment to discuss those other things – or will be directed to an emergency room.

But the greatest sin of all is that, to assuage their guilt and to make such behaviors seem less than reprehensible, physicians have allowed their professional organizations to formally adopt a new code of medical ethics, one which charges physicians with the task of achieving a just distribution of healthcare resources – namely, with covert healthcare rationing at the bedside. This new ethical obligation officially drives a stake into the heart of the classic doctor-patient relationship, and is an abject admission that the practice of medicine no longer constitutes a real profession.

Patients may not know the niceties of this New Age medical ethics – they may not be able to articulate the reasons they feel abandoned in their hour of need – but they certainly perceive its effects on their lives. Their anger is not unjustified.

The fallout for the medical profession from all these developments has landed disproportionately on the PCP. For most patients, their PCP is the face of the medical profession, and it is in the PCP’s office where they most often experience the changes.

PCP’s, of course, are no happier with this new reality than are their patients. The loss of their professional integrity and their ability to act as autonomous advocates for their patients has (far more than the steady ratcheting down of their pay) made primary care medicine an exquisitely unattractive proposition, both to current practitioners and to potential future PCPs.

Unfortunately, any notion that this damage to primary care medicine can be readily reversed is sadly mistaken. It would be a great mistake, for instance, to place the blame for all this on Obamacare. While Obamacare will indeed utterly rely on PCPs to do the dirty work of covert rationing, the basis for such reliance was established long ago by the medical profession itself, which voluntarily adopted their New Age ethics several years before anyone had ever heard of Barack Obama or his healthcare reforms.

So it should be no wonder that patients are pissed. And since that which is pissing them off is not going away anytime soon, and indeed is about to become greatly accelerated, PCPs must be alert to the likelihood that the lethal ideations entertained by a small but not insignificant proportion of American patients may soon find an outlet beyond mere daydreaming. The Johns Hopkins shooting ought to be a wake-up call to all doctors – but especially to the American PCP.

And so, as a public service, DrRich reluctantly suggests that perhaps it is time for PCPs to prepare to defend themselves in one of the few ways they have left to do so.

PCPs may have lost everything else, but to this point, at least, they still have the second amendment to rely on.

The Inevitability of Bias in Clinical Research

DrRich | September 23rd, 2010 - 6:47 pm

DrRich has said many times that clinical science is among the least exact of the sciences, and therefore, the results of clinical research are particularly susceptible to “spinning” by various interested parties, in order to yield the kind of results they would prefer to see.

Until recent times in American medicine, the parties who have been most interested in spinning clinical research have been the people who run drug companies and medical device companies (who need clinical research which supports the use of their products), and the medical specialists (who are more likely to be paid for performing medical procedures that are supported by clinical research). In writing about such data-spinning abuses, DrRich has particularly targeted his own Cardiology Guild, but only because he knows and loves cardiologists the best. He suspects that other specialists are doing exactly the same thing.

While DrRich has used reasonably gentle humor (laced, to be sure, with sarcasm and irony) to criticize doctors and their industry collaborators for twisting clinical data to their own ends, others have expressed the same concerns in much more indignant terms, and have threatened to employ professional sanctions, civil and criminal penalties, and everlasting perdition, to curtail such behaviors.

(Indeed, DrRich has always suspected that the real reason President Obama has not closed Guantanamo is so he has someplace to send recalcitrant American physicians who persist in accepting logo-ed plastic pens from drug reps, or who refuse to accept reduced Medicare/Medicaid reimbursement schedules, or who engage in the black market healthcare activities the President surely understands he is provoking. The one thing that can torpedo Obamacare completely is if American doctors refuse to go along, and any physician who shows signs of doing so will have to be dealt with harshly – if not by detention in exile, then by some other method.)

There is nothing wrong with a little old-fashioned American Puritanism, of course, and physicians and companies who behave badly ought to be punished. But DrRich begs his readers to understand that the inevitable bias in clinical research is not one-sided; it cuts both ways. And clearing the field, so that the only entities which are left to spin clinical research data will be the government-controlled expert panels, is a very bad idea.

DrRich must remind his readers that Obamacare provides for several distinguished expert panels, to be appointed by the executive branch of the federal government, to direct the studies, interpret the results, and apply the results to official reimbursement policies, of a species of clinical research which is called “comparative effectiveness research.”

Comparative effectiveness research comes in two flavors. First, there is the comparative effectiveness research whose unambiguous goal is to compare the clinical effectiveness among different treatment options, so as to offer physicians objective guidance in making the clinical decisions whose results are more likely to be clinically favorable to their patients. This kind of comparative effectiveness research is an unalloyed good, and it is as unassailable as babies and bunnies. Then there is Comparative Effectiveness Research (CER), which is to be operated by new government bureaucracies, whose agenda regarding what kind of effectiveness is actually to be compared is intentionally ambiguous, but which at the end of the day will be comparing cost effectiveness, as opposed to clinical effectiveness, so that doctors will make the clinical decisions whose results will be more favorable to healthcare cost containment.

Our policymakers have been studiously ambiguous about what they mean by  Comparative Effectiveness Research.

This ambiguity was made clear during the Obamacare debates when Peter Orszag testified on behalf of the administration before the Senate Finance Committee. When queried by skeptical Republicans on the ultimate goal of the proposed CER boards, Mr. Orszag was evasive. Specifically, when asked by Senator Kyle (R-Arizona) whether the CER board would be empowered to make decisions regarding which medical services will be reimbursed, Mr. Orszag finally replied, “Not at this point,” a reply which did not alleviate the suspicions of the minority party.

To state the ambiguity more plainly, it is clear that while the government’s CER panels will mainly be concerned about comparing cost effectiveness, the only kind of effectiveness they are willing to discuss publicly is clinical effectiveness. This studied ambiguity allows proponents of Obamacare to paint opponents of the CER panels as being against the “babies and bunnies” form of comparative effectiveness research, and thus reveal those nay-sayers as being beneath contempt, and unworthy of anyone’s attention. Meanwhile they will be free to advance their real “cost effectiveness” agenda.

Therein, of course, lies the government’s bias regarding clinical research. Since clinical research is the primary mechanism by which Obamacare proposes to cut the cost of healthcare, and since the new government panels provide the chief mechanism for controlling and applying the results of that clinical research, the government will be strongly biased toward research results that point toward the less expensive of the two treatments that are being compared.

The idea that government-controlled expert panels will be unbiased, of course, is so absurd that nobody can plausibly believe it. Where you go wrong, dear reader, is in believing that their bias can only take them so far; that clinical research, being science, will more or less yield the Truth; that while a biased party might shade things a bit in this direction or that, at the end of the day the answer which is reached will approximate the Answer.

In fact, clinical research is inherently biased, from the moment a research study is conceived. And those who conceive of, plan, conduct, and analyze the clinical study have every advantage. (This, indeed, is the very reason why everyone is so indignant about the studies conducted by medical industry and their minions in the medical academy.) That advantage is now, under law, defaulting to the government panels.

To be sure, many clinical researchers believe in their hearts and souls that bias can be eliminated through the use of randomized clinical trials (RCTs). In such trials, “like” groups of research subjects are divided randomly into two or more groups, and each group receives (for instance) a different therapy, whereupon differences in outcomes among the groups are attributed to the different therapies to which they were randomized. Indeed, the widespread belief that RCTs are the necessary and sufficient means to achieve “clinical truth” has become so deeply ingrained within the medical establishment that when anyone (such as DrRich) says otherwise, he immediately reveal himself as a scientific Neanderthal.

DrRich has previously observed that the widespread belief in RCTs has become like a Cult, whose creed can be reduced to three main tenets:

1) Data derived from randomized clinical trials represents Truth.
2) Data derived from non-randomized trials represents Falsity.
3) If you don’t believe this, you are a heathen.

Objective observers will find it at least a little ironic that an attempt to claim the scientific high ground has so obviously resulted in a new religion, replete with its own dogma.

The sad truth is that the results of RCTs are invariably dependent on the bias built into their design, and even if internally they are statistically legitimate, they can often send us down the wrong path.

Those who design RCTs (the smart ones, at least) know this. Like smart trial attorneys, they know the answer before they ever dare to ask the question. So they tailor their “question” in such a way as to yield the answer they want to get. Indeed, if a lawyer should end up asking a question in court that produces an unexpected answer, he or she is completely incompetent and ought to be sued for legal malpractice. In more cases than one might think, the same is true for those who design RCTs.

So, for instance, if you are a payer and want to limit the use of an expensive therapy, you design your RCT so that enrolled patients likely to respond to the therapy are diluted with a broad population of enrolled patients, many of whom are less likely to respond to the therapy, to assure that the average response of the whole population will be quite small. (In many instances the clinical characteristics of the likely responders and the likely non-responders will be reasonably apparent.)

On the other hand, if you are a company that wants to encourage the use of your expensive new product, you design an RCT that preferentially enrolls the relatively small subset of patients who are very likely to respond favorably, and then trust the marketplace (with a tweak from your DTC advertisements) to “extrapolate” the results to broader categories of individuals.

So RCTs do not eliminate statistical bias, as the dogma suggests. Rather, they simply offer an opportunity to control the statistical bias in your favor. Since most doctors (and most regulators, guideline writers, and reporters) don’t seem to get this, it becomes relatively easy to fool them.

What DrRich is saying, with regard to the government panels that will direct and interpret the CER (panels that will determine who gets what, when and how, and who gets paid for it and who doesn’t), is that even if those CER panels were not overtly biased against high-cost medical care, eliminating bias from their clinical research would be impossible. And given that the CER panels are being created expressly for the purpose of reducing high-cost medical care, the bias will likely become extravagant. But since that extravagant bias will be couched within the results of various RCTs, the Cult of Randomization will be invoked as “proof” that this expensive medical treatment is no better than that cheaper one.

DrRich has illustrated numerous times how the results of RCTs can be twisted and spun by interested parties, whether by private or government interests, to achieve the results one wants. The CER panels will (it seems obvious) become masterful at doing this.

The apparently widespread notion that industry-sponsored research is invariably biased, while government-sponsored research is entirely objective – and that therefore, the only thing we need to assure accurate clinical research is to have it all controlled by the government – is astoundingly naive.

DrRich believes that, since we cannot possibly eliminate bias from clinical research, we are more likely to approach the actual Truth if we: a) encourage clinical research by all parties – the government and private entities – so that, at least, we may be more likely to engender a “balance” of results; and b) insist that all clinical research be conducted with complete transparency, so that not only are the results made available to anyone who wants them, but also a complete accounting of all the other aspects of the research – including the study design, conduct of the study, and the analysis of the data.

Since bias cannot be eliminated from CER even if the federal CER panels wanted to (and they decidedly will not want to), then insisting on complete and total transparency (ideally, even to the point of making the raw data itself accessible), will be our chief defense. DrRich assumes, since covert rationing will undoubtedly be the CER board’s main, though unspoken, agenda, that such transparency will not be forthcoming without a fight.

Transparency will be worth fighting for, however. At least some bias in clinical research is unavoidable, so complete transparency is our best defense against the biased application of the results of clinical research, whether it is conducted by companies or CER panels.

The Proper SYNTAX For the GOD Panelists

DrRich | September 17th, 2010 - 8:27 am

Podcast:

In his last post, DrRich suggested that the Guideline Wars (i.e. the bloody battles over who gets to establish the patient-care guidelines that determine which patients will get which medical services, and which medical specialists will get to provide them) are about to enter the Obamacare phase, in which those who make the guidelines will no longer be medical professional organizations, but agents of the federal government. DrRich helpfully labeled the various guideline panels provided for by the Obamacare legislation as the “GOD panels” (for Government Operatives Deliberating), in order to avoid using the more inflammatory “death panels” terminology favored by certain less sophisticated commentators.

In addition, DrRich pointed out that his own tribe of medical specialists – the cardiologists – may perhaps be in a better position than most other physician tribes to manipulate the deliberations of these GOD panelists. The cardiologists would attempt such manipulations, DrRich suggested, by “pre-spinning” certain critical data from clinical trials, before that data is taken up by the government panels.

From their long experience in fighting the Guideline Wars, cardiologists understand that data from clinical science does not invariably lead to a fixed conclusion (as most proponents of evidence-based medicine seem to believe), but rather, can often be shaped into whatever sort of conclusion one might want to reach. Just as different primitive cultures discerned different constellations when they looked up into the same night sky, so will different groups of experts come to different conclusions when they look at the same clinical data.

Accordingly (DrRich submits), cardiologists have already embarked on the task of pre-spinning the data, such that when the GOD panelists look for the first time up into the vast and chaotic sky of clinical evidence, they will have in hand a map of the constellations as seen by the cardiologists.

To illustrate what he means, DrRich calls his readers’ attention to the SYNTAX trial, a clinical trial designed by cardiologists and their industry partners for the purpose of reaching a specific conclusion, but which (unfortunately for cardiologists) reached the opposite conclusion. If the data from the SYNTAX trial should ever fall into the hands of the GOD panelists (or any other guideline panels) in a pristine fashion, it could spell disaster. So the cardiologists have spent nearly two years attempting to make the data say what they want it to say, and today, after continuously massaging the data, issuing press release after press release, making presentation after presentation, and publishing academic paper after academic paper, it would be at least a little surprising if the God panelists, surveying this body of pre-spun data, would fail to produce clinical guidelines which provide the cardiologists at least some of what they’re after.

The SYNTAX trial randomized 1800 patients with complex coronary artery disease (i.e., CAD that produces either significant blockage in the left main coronary artery, or severe triple-vessel disease) to therapy with either bypass surgery or drug-eluting stents (DES), and assessed their long-term outcomes.

In general, patients with stable CAD (i.e., those who are not currently having a heart attack or unstable angina) do just as well with aggressive medical therapy as they do with invasive therapy. People like the ones enrolled in SYNTAX, however, are the exception to this rule. That is, patients with either of these two specific patterns of complex CAD have been shown to have improved survival if they receive bypass surgery. Indeed, these patients represent a virtual “last stand” for cardiac surgeons – they are nearly the only patients cardiologists (at least some cardiologists) still feel obligated to refer for bypass surgery. And, as one might expect, in their decades-long turf war with cardiac surgeons (a war from which they will not desist until they see the great majority of cardiac surgeons seeking jobs as beer vendors at sporting events), cardiologists have long chafed at this singular remaining obligation to refer.

Accordingly, SYNTAX, a study instigated by cardiologists and sponsored by Boston Scientific (a manufacturer of DES), was intended to show that with modern cardiac stents, stenting yields outcomes that are not significantly inferior to bypass surgery in these patients. Specifically, that is, SYNTAX was designed as a “non-inferiority trial.” This was certainly a modest goal – some might say too modest – but a positive result would enable cardiologists (the gatekeepers to all invasive CAD therapy) to simply keep these patients for themselves, just as they now do with all the other CAD patients. The SYNTAX trial asked the question, “Do I really have to refer these patients to the cardiac surgeon?” And the desired answer was, “No, it apparently is not statistically provable that you absolutely have to refer them, one supposes.” Judging from the study design, that answer would have been plenty rigorous enough for the study designers.

Alas, however, when the one-year follow-up data for the SYNTAX study was analyzed, the results turned out to be negative; stenting was significantly inferior to surgery. The endpoint of the study was a composite called MACCE (Major Adverse Cardiac and Cerebrovascular Events), and in this study included death, heart attack, stroke, and the need for more revascularization procedures. The bottom line is that in SYNTAX, the risk of MACCE was significantly higher for stenting than for bypass surgery. The study failed to meet even the modest non-inferiority goal the cardiologists had devised for it.

The one-year data for the SYNTAX trial was published in the spring of 2009 in the New England Journal of Medicine, just as the battle over healthcare reform was taking shape, and nearly six months after Sarah Palin had reported her mysterious vision of death panels. But whether one wanted to call them death panels, GOD panels, or panels of distinguished monkeys, it was clear by the time SYNTAX was published that the government, and no longer the physicians’ own specialist organizations, would be manufacturing all clinical guidelines in the near future. So disaster loomed.

But, the cardiology community quickly rallied, and launched into a concerted effort to spin the results of SYNTAX from a disaster into a victory, or at least, to something akin to victory. And the efforts of the cardiologists in this regard have been impressive over the last 18 months.

Within minutes of the publication of the original SYNTAX article, scores of press releases were launched, and scores of “experts” were dispatched to give interviews, implying that the SYNTAX study was a major, ground-breaking victory for stenting.

For instance, here’s the link to an article in the New York Times (subsequently reproduced in hundreds of newspapers around the country) entitled, “Heart Stents Found As Effective As Bypass For Many Patients.”

And here’s a triumphant press release from Boston Scientific, the study’s sponsor, in which the negative overall results of SYNTAX are buried deep within the 6th paragraph (following all kinds of positive-sounding fluff), and are difficult to locate even if you are specifically looking for them.

And here’s the more-than-triumphant press release from one of the leading clinical sites for the SYNTAX trial, which reads, in part:

“At NorthShore, we experienced stunning outcomes [emphasis DrRich's] in patients whose only option would have previously been bypass surgery,” said Ted Feldman, M.D, F.S.C.A.I., Director of Cardiac Catheterization Laboratory, NorthShore University HealthSystem, and a lead investigator of the trial. “The data in this study will provide cardiologists with additional information as they determine treatment therapy for patients with complex CAD.”

Most remarkable of all, we have the spectacle of the lead author of the SYNTAX paper, Dr Patrick W Serruys himself, telling Heartwire immediately after publication of the paper, that the paper’s concluding sentence (i.e., “CABG as compared with PCI is associated with a lower rate of MACCE at one year among patients with three-vessel or left main coronary artery disease (or both) and should therefore remain the standard of care for such patients.”), is just plain wrong. Serruys declared that this concluding sentence actually “is not the essence of the trial.” He only allowed that concluding sentence to appear in the paper, he said, “because the New England Journal of Medicine wanted something more conservative.” (Apparently, having the paper appear in a prestigious journal overrode the necessity of having the paper accurately reflect what the authors meant to say.)

In any case, Serruys insisted (despite the conclusion expressed in his ink-not-yet-dry paper) that many patients like the ones enrolled in the SYNTAX trial can safely be treated with stents, and indeed, he announced that he and his co-investigators were hard at work teasing apart the SYNTAX data in order to develop a so-called “SYNTAX score,” that would help cardiologists determine which patients they can treat themselves, without referring them for surgery. So indeed, despite the negative results, and despite the conclusion written in their own paper, the SYNTAX trial was immediately spun by key trial participants themselves into a win (while not a complete victory, still a win).

Before his readers come down too hard on the cardiologists for such behavior, DrRich feels obligated to point out a partially mitigating truth. Namely, cardiologists believe to the depths of their souls, notwithstanding the largely negative body of medical literature to the contrary, that stenting coronary artery blockages – in virtually any configuration and any clinical situation – saves lives. And if they haven’t been able to prove that yet, it’s just because of the vagaries of clinical research. One must not let spurious results from imperfect research block the Truth, lest one allow great harm to come to humanity.

The results of the SYNTAX trial must simply be wrong, cardiologists believe, and so they would be gravely harming patients if they did not take whatever steps were necessary to render the results of SYNTAX more favorable to stenting. To do otherwise would cause thousands of clinicians to make inappropriate decisions.

In this way, DrRich believes, cardiologists are no more guilty than are Progressives, another category of humans who believe with their hearts and souls in something that is simply not true (in the case of Progressives, that the great mass of humanity will willingly suppress their own individual interests in favor of the interests of the collective). Like the Progressives, cardiologists are often very nice, well-meaning, sensitive and compassionate individuals, and some of them would even be fun to go out with for a beer.

In other words, DrRich pleads, cardiologists are not being particularly evil in spinning the SYNTAX trial results; they are simply doing what comes naturally, and what they deeply believe to be the right thing.

This is why the SYNTAX investigators were convinced that, buried within the vast body of clinical data the SYNTAX trial has generated, there simply MUST be something useful to cardiologists. Accordingly, the SYNTAX investigators dived head-first into the proverbial room full of manure, enthusiastically digging for the pony which simply must be in there somewhere.

And indeed they quickly found their pony.

And here it is: While a straightforward analysis of the SYNTAX study shows that bypass surgery wins hands down over stenting, if one delves a bit deeper into the data, one finds that one of the components of the MACCE endpoint – the incidence of stroke – was statistically higher among the patients randomized to bypass surgery. One also finds that the incidence of needing revascularization during follow-up was higher in the stent patients. So, taking these two interesting observations together, the cardiologsts have concluded that patients receiving bypass surgery are trading a reduced need for subsequent revascularization for an increased risk of stroke – a bad trade indeed. Therefore, despite the overall results of the study, they have concluded that stents are better than bypass surgery for at least some patients. (And they promised to discover for us, during the data-mining exercise from which their “SYNTAX score” was subsequently invented, which patients those are.)

And this – the reduced incidence of stroke seen in the stent patients – is the basis for the celebratory statements which were issued by the SYNTAX investigators upon publication of their original paper.

DrRich agrees that, as a general proposition, he would probably rather have an extra invasive cardiac procedure than a stroke, and suspects that most people would say the same thing. But before we all buy what cardiologists are selling here, DrRich would like to make a few observations.

First, the results of the SYNTAX trial are the results. Stenting did not meet even its modest non-inferiority endpoint, and it failed to meet it by quite a lot. Once the pre-designated endpoint of a randomized clinical trial is determined, any remaining observations that can be gleaned from the large amounts of data invariably generated by such trials must be viewed as inconclusive, as merely hypothesis-generating. Such observations are not to be regarded as having sufficient statistical surety to vastly change medical practice, or to figure into evidence-based guidelines. So, another clinical study would need to be conducted to prove the hypothesis that strokes are less frequent with stenting than with bypass surgery in patients like these.

Similarly, the “SYNTAX score” – which indeed was generated and subsequently published as a “guide” for cardiologists treating patients with complex CAD, and which is therefore presumably being used today by cardiologists all over the world to select which of these complex patients they can just go ahead and stent rather than refer for bypass surgery – has no business being incorporated into clinical practice. An exercise like this – in which investigators comb retrospectively through the clinical data, selecting out patients who had good results with stenting, then devising a group of characteristics that appears to differentiate them from those who did not – cannot possibly yield a validated, widely-applicable clinical tool. If they want to claim that their SYNTAX score is clinically useful, they need to conduct another randomized clinical trial to test that hypothesis.

Next, and most remarkably, there’s the almost universally-ignored fact (reported by Dr Friedrich W Mohr, co-principle investigator of the trial), that among patients assigned to bypass surgery in the SYNTAX trial who experienced a stroke, nearly half of them had their strokes PRIOR TO SURGERY. What this means is that, in reality, the bypass surgery itself did not cause those strokes, a fact that ought to cause serious damage to the chief assertion of the stent-proponents. This fact alone turns their pony into a pig. The claim that stenting instead of surgery would have avoided these strokes is largely, if not entirely, spurious. Indeed, if anything, the fact that patients “randomized” to surgery apparently had a lot of strokes in the brief period of time between the act of randomization and the surgery itself ought to make one question whether the selection of therapy was really and truly random, or whether, somehow, patients who looked particularly sick got sent preferentially to the surgeons.

And finally, the clinical choice as it has been starkly painted by many proponents of stenting – that the real trade-off in choosing between stenting and bypass surgery in these patients is the choice between the higher risk of stroke with surgery versus the higher risk of revascularization with stenting – is incomplete and misleading. Presenting the choice in this way clearly favors stenting, and this presentation entirely explains the positive press releases and subsequent media coverage of the SYNTAX trial. But this is not a valid comparison of risks for several reasons:

1) As noted above, the actual risk of stroke posed by performing bypass surgery in the SYNTAX trial has been substantially overstated for public consumption (by implying that the surgery caused those strokes, when half occurred prior to surgery).

2) Surgeons in the SYNTAX trial most often did not employ newer techniques now in routine use, such as off-pump surgery and LIMA grafts, both of which can substantially reduce the risk of stroke and other embolic phenomena.

3) Re-occlusion of the involved arteries (which occurred about equally in both groups in this study, and which spokespersons for SYNTAX seem to brush off as not such a big deal), is an entirely different phenomenon in patients who have received DES than it is in patients who have had bypass surgery. After bypass surgery, re-occlusion tends to occur gradually, and the patient generally experiences recurrent symptoms of angina. But in DES, re-occlusion much more commonly occurs acutely, and catastrophically, leading rapidly to permanent cardiac damage and often, to sudden death.

4) Item # 3 might explain why the composite endpoint of “death, heart attack and stroke” was equal in both groups, even though stroke was significantly higher in the surgery group. That is, in order for the math to work out, the remaining dyad of “death and heart attack” necessarily must have been higher in the stent group. As far as DrRich can tell, this point has never been discussed in public.

5) In order to avoid the catastrophic re-occlusions seen with DES, cardiologists now insist that their DES patients take long-term, even life-long, Plavix, a powerful blood thinner. As the purveyor of a patient-oriented website on heart disease, DrRich cannot tell you how many distressed and stented-up patients have written to him with the following lament:

“My doctor put in one of those drug coated stents and has me on Plavix. He says if I stop the Plavix I could die, and won’t let me stop it for any reason. But I need my gallbladder out because I keep having gallbladder attacks, and the last one gave me blood poisoning. My surgeon says I need the surgery but he won’t do it unless I stop Plavix, and my cardiologist says no stopping the Plavix for any reason. What can I do? Can they just take these stents out so I can stop the Plavix?”

There is no easy answer to this question, at least not that DrRich can find. The DES patient commonly is left in the middle of a pissing match between surgeon and cardiologist. The fear of the cardiologist is that when one stops Plavix, there is a risk of sudden, catastrophic thrombosis of the coronary artery. But surgeons simply cannot operate safely on patients taking this drug. Few cardiologists seem to explain this to their patients before placing DES.

And more to the point at hand, none of the cardiologists spinning the SYNTAX trial are explaining to the public the implications of long-term Plavix. Even if their claims that stenting yields significantly fewer strokes turned out to be accurate, the choice here is clearly NOT a simple one between a higher risk of stroke on one hand, and a higher risk of needing “revascularization” (if they survive the re-occlusion, that is) on the other. There’s a lot more to think about than that, and cardiologists who imply otherwise are being either disingenuous, or delusional.

Just last week, SYNTAX investigators reported on the three-year outcomes in patients enrolled in the trial. The results, similar to the one-year outcomes, remain strongly in favor of bypass surgery at three years, and indeed, the incidence of stroke in stented patients has “caught up” with the incidence of stroke in the surgery patients.

This persistently bad news still does not really phase the cardiologists, who are now saying that the results of SYNTAX don’t really apply any more in any case, because drug-eluting stents have been improved since the trial was done.

It would appear that the cardiologists are going for some sort of official announcement to the effect that that the results of SYNTAX are, for practical purposes, indeterminate, and that what is needed is a new clinical trial, in which patients randomized to DES will receive the latest generation of stents. (Since there is a new generation of stents every year or so, this entire process can be repeated as needed until the cardiologists finally get the results they’re looking for, at which point they can declare final victory and stop.)

Summary:

All medical specialists should take a lesson from the cardiologists. In an era in which specialist organizations will no longer be writing the clinical guidelines for their own specialty, it is necessary to aggressively pre-spin any important clinical data upon which the GOD panels will be deliberating.

Considering the SYNTAX trial as a case study, one sees how it is possible to take the most straightforward results from a very straightforward clinical trial and, if not turn a negative outcome into a positive one, at least introduce enough complications, nuance, spin and uncertainty to cause any self-respecting GOD panelist to hesitate in making a definitive pronouncement on those results. Then, if you couple all the uncertainty you’ve created with a loud call for yet another clinical trial – one that will take into account new equipment, new techniques, new scoring systems &c., and that promises to clear up all the confusion you’ve dug up as a result of the last clinical trial – then you stand a decent chance of at least getting a postponement on any new guidelines harmful to your cause.

And this, you neurologists, gastroenterologists, pulmonologists and all you other, less savvy medical specialists, is how one can manage the GOD panels.

The Importance of Demonizing the Obese

DrRich | September 15th, 2010 - 6:02 am

The obese, like the poor and the uninsured, will always be with us. And like the poor and the uninsured, the obese have served as a useful foil to healthcare reformers. But while their fellow foils are portrayed as sympathetic victims of hard-hearted right-wingers, the obese serve a different purpose. It it their role to illustrate for the rest of us how too much individual latitude invariably leads to bad choices (in this case, sloth, gluttony, greed and self-indulgence) which do grave harm to the collective; and which, for the good of the collective, justify (indeed, require) firmly (but kindly) applied limits on that individual freedom. In these articles, DrRich elaborates on the critical importance of demonizing the obese.

Defending the Demonization of Obesity, Part 1

Defending the Demonization of Obesity, Part 2

Don’t Sweat the Obesity Dividend

How Fat People Reduce Global Warming

Defending the Anti-Obesity Movement, Again

How Cardiologists Will Manage the GOD Panelists

DrRich | September 14th, 2010 - 8:50 am

Podcast:

In quainter times, medical “guidelines” merely meant a set of general principles which doctors ought to keep in mind when deciding on the most appropriate medical care for their patients. But in recent years guidelines have come to represent reasonably firm expectations for medical practitioners. And doctors who fail to closely follow guidelines may not be looked upon favorably any more by insurance companies or Medicare.

Obviously, then, since the guidelines finally determine who gets what, when and how, controlling the guidelines (i.e., making sure the guidelines say what you want them to say) has become important to any interest group within the healthcare system. And nobody understands the critical importance of guidelines better than cardiologists, a group of which DrRich is a proud member.

In a valiant attempt to carve out as much turf for themselves as possible within a healthcare system driven by guidelines, cardiologists, through their powerful professional societies, have been vigorously fighting the Guideline Wars for two decades – well before most other medical specialties even recognized that a war was being fought. This long struggle has lent to the cardiology profession a certain level of experience and sophistication that may help them to preserve some of their hard-won turf, even as we move into a far more dangerous phase of the Guideline Wars, in which less robust specialties risk debilitation, and even extinction.

For, under Obamacare, guidelines are now to become far more than mere guideposts, or principles, or even strong expectations. They are to become handed-down and inviolable rules which will dictate the details of proper patient care, and which doctors must follow to the letter. Following this new species of guidelines as closely as scripture will be necessary for any doctor who wants to be officially tabulated as a “physician of quality,” who desires to be paid the going rates, and who would prefer to avoid fines or imprisonment for fraud (fraud being, of course, the failure to practice medicine according to the guidelines).

Whereas until now the Guideline Wars have been largely fought among various medical specialties competing for turf, from now on the major combatant in these wars will be the federal government. Under Obamacare, the official medical guidelines will no longer be determined by conflicted medical specialty organizations (which will always try to establish guidelines that cause the healthcare system to spend lots of money on their specialists), but instead by government panels, which will have their own obvious conflicts of interest.

Most observers of the healthcare system seem congenitally unable to recognize that a government bent on controlling the behavior of its citizens (in order to create the perfect healthcare system, which, in turn, is a necessary component of a perfect society) will be working under, if anything, more conflicts of interest than any other healthcare entity.  In particular, the government, and by extension its appointed panels, will be desperate to the point of apoplexy to avoid spending any money, at any time, for any medical services, any time they can get away with it. So ultimately, the widespread proposition that the government panels will be entirely free of any particular agendas, or conflicts, or prejudices, as they hand down the rules of medical engagement to physicians, is balderdash.

The abiding conceit of the government panelists, of course, is that they will behave in an entirely objective manner in rendering the guidelines of medical practice, and will simply follow the science wherever it may lead, without any prejudice whatsoever. That is, they will not actually create the guidelines, but will simply “discover” them, through the objective application of clinical science. In other words, under Obamacare, the “true” medical guidelines will be handed down not by flawed men saddled with conflicts of interest, but by the inherent properties of nature. The government panels will simply be interpreting nature, and will do so, unlike those conflicted physicians, without prejudice.

Indeed, DrRich will go so far at to point out that the Obamacare guidelines will come from GOD – Government Operatives Deliberating. Readers who think it is in poor taste to refer to these individuals – who will invent the guidelines which will determine life and death for so many of us – as GOD panelists should be reminded that other, less sensitive individuals have tried to label them “death panelists.” DrRich’s nomenclature is not only more descriptive, but is much kinder.

In any case, this is where cardiologists have a tactical advantage over most medical specialists as we enter the Obamacare phase of the Guideline Wars. For, in their decades-long struggle in those wars, cardiologists have discovered something that more naive and inexperienced medical specialists, as well as academics, and even most government advisers, are only dimly aware of. Namely, that there is no such thing as the objective application of clinical science. Inevitably, interpreting clinical science – which is among the most inexact of the sciences – incorporates inherent bias.

That bias can be applied either subconsciously or consciously, but one way or another it is applied. And the advantage the cardiologists have over other medical specialists is that they understand that, to have a better chance of getting what they want, they need to direct the application of bias in interpreting critical clinical trials, and they must do it aggressively.

At the highest levels, of course, the agents of the government understand the very same thing. This is why they are setting up their own panels to control the guidelines in the first place. And you can be sure they will choose their panelists carefully.

But DrRich (and his cardiologist friends) know that when the government panelists are being sworn in, they will not be told their true mission in stark terms. They will not be told, “Your job is to twist the eminently-twistable clinical data in any way you must in order to reduce spending on healthcare, no matter who is hurt by it.” This charge would be unacceptable to most of the individuals the government would prefer to choose as panelists, namely, proud and accomplished individuals with valued professional reputations to uphold (though, to be sure, with a proven track record of thinking about clinical science with the kind of bias the government appreciates).

Rather, the panelists will be told:

“Panelists! You have perhaps the most critically important job in all of healthcare, namely, reining in the counterproductive, harmful, wasteful activities of the self-serving medical profession, which is married to greed, and beholden to its evil partners in medical industry. Your job is to lead doctors (most of whom would do the right thing if they can be shown the way in a sufficiently forceful manner) out of the wilderness, and bring them to the path of righteousness. For we hold these truths to be self-evident: that good medical care is efficient medical care; indeed, it is parsimonious medical care; and this being the case, the proper interpretation of clinical science will virtually always show us that less is more. It is your job to interpret clinical science in that proper way, to show American physicians how to fulfill their primary moral obligation to the greater health of the collective.”

DrRich has already demonstrated that there are plenty of physician-ethicists in very high positions who completely buy this stuff. It will be no problem for the Feds to find as many of them as they want to populate the GOD panels, and indeed candidates are virtually tripping over each other to audition.

In any case, their government handlers will reassure all the panelists that they simply are to follow the science, while establishing very strong expectations as to where properly-applied science will inevitably lead. This procedure will be aimed at allowing panelists to maintain the soothing and necessary fiction that they are, in fact, functioning as unbiased agents of reason and logic, and are well-deserving of public adoration, and perhaps even of self-respect.

Cardiologists, battle-hardened Guideline Warriors that they are, understand the position in which the new GOD panelists will find themselves, and as a result they understand that the clinical science these panelists will use to fashion medical guidelines must not reach them in anything like a pristine condition. Rather, that clinical science must reach them “pre-spun,” with the “right” interpretations already spelled out for them by respected academic figures, and, to the fullest extent possible, already permeated into the public consciousness. Cardiologists hope that panelists will be relatively reluctant to make guidelines which are starkly opposed to such predisposed interpretations, for fear they will be found grating to professionals outside of government whose opinions they might value.

With such a strategy the cardiologists are perhaps clinging to a thin thread. It is, in fact, not much of a plan. But it beats whatever it is you gastroenterologists are doing.

In his next post DrRich will illustrate cardiologists’ new strategy of “pre-spinning” clinical trial data, in order to make it more difficult for GOD panelists to do them grave harm.

DrRich’s Theory Of Progressive Thought

DrRich | September 8th, 2010 - 10:52 am

Podcast:

DrRich has now read large portions of the “Patient Protection and Affordable Care Act,” i.e., Obamacare. He finds in it the very essence of Progressivism.  To understand Obamacare, then, we must understand the basics of Progressive thought.

DrRich has always found American Progressives to be a bit enigmatic. He has found much of their behavior to be persistently, almost defiantly, illogical and counterproductive to the rights Americans hold dear, rights which Progressives themselves also insist they revere – in particular, our inalienable rights to life, liberty and the pursuit of happiness.

As long as 20 years ago, DrRich had developed a sneaking suspicion that Progressives, their protests to the contrary notwithstanding, never really bought into the “inalienable” thing. On this point, he concluded, they were prevaricators. Since by then it was beginning to look like the Progressives were going to be running things for a while, it occurred to DrRich that it would be a good idea to understand what they really think, and what their agenda really was. And so, after much time and study and contemplation, DrRich developed his theory of Progressive thought, which he is now pleased to share with his readers so that they, in turn, might better understand Obamacare.

The Roots of Progressivism

When DrRich began his study of Progressives he did not quite know where to begin. So he decided to proceed, like Descartes before him, from the simplest and most irreducible of truths. Namely, that Progressives are really, really smart – or think they are. We know this because all the professors in all the best Ivy League schools are Progressives.

From this simple truth we can deduce that, whatever it is that Progressives are actually up to, it must have its roots in the writings of The Philosopher.

And sure enough, it was not at all difficult to discover the roots of Progressivism within the teachings of Aristotle.

Aristotle tells us that man is innately a political animal, an animal with an inherent propensity to gather into increasingly complex communities. The essence of man, according to Aristotle, is society.

The formation of complex societies is what defines mankind; it is what differentiates man from the rest of the animal kingdom. Hence, because man is defined by society, society is inherently on a higher plane of importance than the individual. Individuals are entirely beholden to and dependent upon and subservient to the society to which they belong. Indeed, they are defined as individuals by their place within that society. Without society, a man is just an ape (with a persistently infantile face).

In this sense, “socialism” is reduced quite simply to a philosophy in which society – the collective – takes precedence over the individual. Furthermore, the precedence of the collective over the individual is not something we can simply choose to accept or reject; it is the very essence of mankind. It is nature. It is just the way it is.

So, as you can see, Aristotle nailed Progressivism.

Clearly, while the name “progressivism” has only been around for a century or so (and we will shortly see from whence the name came), its roots are a very old idea. This idea, in fact, was the normal way of looking at the relationship between individuals and society until just a few hundred years ago, when humanists began to cautiously explore the radical notion that individuals (rather than the collective) constitute the fundamental unit of humanity. The new humanist heresy – which declared the primacy of the individual – was for a long time called “liberalism” (a term whose meaning has, recently, drastically changed, and is now a synonym for what had always been its opposite). Classical liberalism reached its zenith, DrRich thinks, a mere two and a half centuries after its painful birth, with the Declaration of Independence and the Constitution of the United States.

But to Progressives, classical liberalism has always been an aberration. Despite what America’s founding documents might say, society takes precedence over the individual. It takes this precedence by way of the very essence of mankind, as was taught by The Philosopher, and so it cannot be otherwise.

The Progressive Program

The Progressive Program – the thing that makes Progressives progressive – is to develop the perfect society. This program is not optional; it is dictated by the nature of mankind.

Since society is what defines mankind, it follows, as the night follows the day, that the program of mankind, the purpose, the work, the essence of mankind, is to create the perfect society.

The perfect society has two basic requirements. First, it must meet all the basic needs of the individuals within that society (such as food, clothing, shelter, sanitation, and health), without which individuals will always be tempted to engage in the counterproductive behavior of striving for things. Second, the social order must be of such a nature that it can persist, theoretically forever, without fundamental change. Indeed, the very notion of perfection implies that any change, of any type, is bad, since it will necessarily constitute a movement away from perfection.

The perfect society therefore requires complete stability. This would include (at a minimum) a stable population size, the preservation of natural resources and the earth’s environment (indeed, when one hears the word “sustainability,” one is listening to Progressive gospel), the careful management of the economy, and the careful control – if not suppression – of unplanned innovations. This latter refers both to material (or scientific) innovations, and innovations of thought, either of which will always threaten hard-won societal stability.

The perfection of society is the paramount work of mankind, so any method which may help in achieving this perfection is to be embraced; none discounted out of hand. The only considerations one must make in choosing methods of action are: Is this method practicable? And: Is this method more likely to be successful, or counterproductive? These two questions fully define Progressive ethics.

So that’s DrRich’s theory of Progressivism and the Progressive Program. While it is only a theory, DrRich hereby asserts that his formulation is correct.

He makes this assertion for the purpose of advancing the debate and inviting argument. If any of his readers have a better explanation of Progressivism, one that more successfully fits the facts and explains the otherwise difficult-to-explain behaviors we’ve seen from Progressives in recent years, why, DrRich will be delighted to hear it. If it is convincing, DrRich will cheerfully abandon his own theory and adopt yours.

But to accomplish this feat, your theory of Progressivism will have to offer a more successful explanation of the following Progressive behavioral phenomena than DrRich’s theory does:

Individuals and Groups Within Progressivism

While Progressivism by definition places individuals in a subservient position to society, this is not to say that individuals are merely interchangeable cogs in a great machine, or entirely analogous to worker bees in a hive. DrRich’s prior sarcasms aside, Progressive society is not the Borg.

Indeed, individuals within a Progressive society are differentiatable, and can be publicly celebrated or castigated as individuals. But to a great extent the potential worth of an individual is pre-determined by the group to which the individual belongs. Group identity in Progressive society is critically important, as it provides the only feasible means by which the leadership of Progressive societies can attempt to control and direct individual behaviors.

(Group identity is so critically important to Progressive thought that it has been given a special name – “Diversity” – and has been designated as the Cardinal Virtue, from which all the other, subsidiary, virtues – faith, hope, charity and the like – must necessarily spring.)

And so, to stand out as individuals, individuals must stand out as a member of their group, and the manner in which they stand out must fundamentally reflect the assigned essence of their group. So, for instance, Al Sharpton and Jesse Jackson are celebrated individuals, whose accomplishments nicely reflect their assigned group identities. In contrast, Clarence Thomas and Thomas Sowell are not celebrated by Progressives, and indeed are castigated as abominations, because their individual accomplishments do not reflect their assigned group identities.

Therefore, while individuals within Progressive societies can achieve a certain level of importance, individual importance is merely of tertiary concern, rather than primary or even secondary concern. Individuals can become officially “important” only if their importance reflects the essence of their assigned group; and the importance of the assigned group (the secondary concern), in turn, is proportional to its ability to advance the Progressive Program in general (which, of course, is the primary concern).

While individuals have the potential of rising to a state of importance within Progressivism, the vast majority of individuals will never actually do so. The great masses of individuals will be regarded by society as featureless members of their group, and will be treated accordingly. And the status of a particular group is always subject to change, given the extant needs of the leadership class. Certain groups (e.g. labor unions) may be exulted by the leadership, while others (e.g. the elderly, the white males, or the fat) will be devalued. Yet other groups (e.g. illegal aliens) may be celebrated by the leadership at one point in time (when, for instance, it behooves Progressive leaders to acquire voting rights for them before 2012), but then may be dismissed at some other point in time (in 2013, for instance, after the critical votes have been gathered, and now the group just represents large volumes of mouths to feed and healthcare to consume).

Good and Evil In Progressivism

Many Progressive intellectuals are fond of saying there are no absolutes, and so there is no such thing as inherent good and inherent evil. These intellectuals are wrong, even from within the Progressive paradigm. Because the Progressive Program – which, again, is to achieve a perfect society – is the innate agenda for mankind, there indeed exists a standard by which one can determine good and evil.

“Good” is anything which advances the Progressive Program; and “evil” is anything which threatens it.

Anyone who doubts the existence of good and evil within the Progressive Program need only observe the scores of behaviors and figures of speech which are condemned as unrelentingly evil by Progressives, with all the certainty and fervor of a Jonathan Edwards.

Accordingly, individuals who hinder the Progressive Program are a danger to mankind’s very essence. They are evil, and must be rehabilitated or eliminated.

Progressivism and the Leadership Class

Despite its lip service to the contrary, Progressivism is not egalitarian, even in theory.

The duty of mankind is to strive for the perfect society. The chief tool by which mankind is to achieve this program is man’s intellect and logic. It is axiomatic that only a minority of people will have the intellect and logic necessary to direct the program of mankind. Therefore, Progressivism fundamentally relies on an elite corps of individuals to guide our progress toward a perfect society. The perfect society will not just happen, it must be engineered by those who are gifted enough to lead.

The lack of egalitarianism in Progressive thought is illustrated by the special treatment accorded to the elite corps. The leadership class must be nurtured and valued by society. Furthermore, it must be given special privileges which others in society do not have. Because their work is so critical to the essential program, the elite must be removed from worry over the mundane necessities of life. That is, providing the leadership class with certain luxuries and privileges, and even freedom from having to follow all the rules that apply to the masses, is therefore not hypocrisy, but is an essential good. It redounds to the benefit of the Program.

Anyone who has not noticed recent glaring examples of this “different standard” for the Progressive elite should consider activating their “durable power of attorney” forthwith, so that a more alert individual can manage their affairs.

Progressivism and the Unwashed Masses

It goes without saying that, if left to their own devices, the populace would devolve into some primitive societal arrangement (such as capitalism) in which individuals would spend all their time striving to improve their own individual situations, even at the expense of others.

This means that the great unwashed masses must be “managed.”

Ideally, the best way to manage the population is through education, and so all efforts must be made – through formal education and by controlling the public media – to indoctrinate the population to the great benefits of the Progressive agenda, to the natural duty and obligation of all men and women to work within society to realize the Progressive Program, and to the inherent evil of all the alternatives. Since education will never be sufficient, the unwashed masses may need to be controlled through pacification (i.e., attempting to meet all their basic needs, so as to eliminate their impulse to strive). If this fails, they must be controlled through coercion, intimidation, peer-pressure, or (as a last resort or to serve as an object lesson) violence.

Fundamentally, the Progressive Program relies on all members of the great unwashed to subsume their own individual needs to the needs of the collective. That is, the Progressive Program requires a fundamental change in human nature. This change will never be forthcoming, and so Progressives are apparently doomed to be frustrated in their efforts. (However, as we will see shortly, Progressives ultimately have the answer to this problem, as well.)

So, despite their frequent hymns of praise to the worthiness of the common man, Progressives invariably develop an underlying contempt toward the unwashed masses. It is not difficult to spot this contempt if one is alert to it.

Progressivism and Politics

Under the Progressive Program, just like Aristotle says, mankind is essentially a political animal. In fact, the Progressive Program can only be achieved by political action. This means that politics – and to be clearer, political control – is the fundamental work of Progressives. Without politics, without political control, there is nothing. To lose political power is oblivion.

This attitude toward politics is in stark contrast to the attitude of conservatives, for whom government (and therefore politics) is merely a necessary evil, with which one must occasionally contend, when it cannot be avoided, as a part of life. For most conservatives politics is an afterthought.

For Progressives, politics is everything, the essence of human behavior. And it is worth any cost, any desperate measure, to maintain political control. Indeed, to fail to lie, cheat and steal in order to keep political control would be unethical.

Progressivism and Religion

Progressives have a natural adversity to organized religion. For one thing, religions tend to give a higher priority to some supernatural entity (and worse, to an afterlife), than to mankind’s “true” imperative, which is to achieve a perfect society right here on earth. However, since religious leaders can be readily coerced to serve the needs of the state (and always have been), this is not an insurmountable problem.

The real difficulty with organized religion is that the major ones stress the importance of the individual (since individual salvation, or individual enlightenment, is the major theme of the big religions). Under progressivism the inherent importance of individuals is necessarily subsumed by the importance of the collective, so by focusing the ultimate meaning of life on the individual, traditional religions become a major threat to Progressivism.

Apparently realizing that abolishing religion is far too difficult a task, Progressives have adopted the long-term strategy of infiltrating and co-opting religious establishments, and by means of introducing new ideas – such as group salvation, and the concept of social justice as a religious imperative – rendering religion, this “opiate of the masses,” less incompatible with the Progressive Program.

Progressivism and Eugenics

Since World War II, the enthusiasm with which Progressives publicly embrace the idea of eugenics has become muted. But eugenics is, in fact, inherently bound to Progressivism. One way or another, a perfect society will require far more perfect citizens than we have today. Indeed, the seething contempt with which Progressives regard the current genetic pool that comprises the unwashed masses is often difficult for them to suppress.

To a large extent, modern Progressivism was born as an offshoot of Darwinism. The idea that society could be perfected, and the idea that mankind could be perfected, were two sides of the same notion. And early Progressives unabashedly embraced both of these ideas, such that the idea of “culling the herd” became extraordinarily attractive to them – and they said so. Theodore Roosevelt, Woodrow Wilson, Bertrand Russell, H. G. Wells, and Margaret Sanger (the founder, as it happens, of Planned Parenthood) are only the most well-known Progressives who extolled the idea of eugenics.

But public support of eugenics among Progressives has become quite subdued, ever since the Nazis committed their atrocities explicitly in the name of achieving societal perfection.

One can argue, of course, whether the recent Progressive support of such activities as late-term abortions, or creating human embryos for experimentation, are partially aimed at desensitizing the public for future efforts to “guide” a more favorable genetic makeup for the population. Either way, DrRich reminds his readers of the history of Progressivism in this regard, and of the inherent attractiveness of eugenics to the Progressive Program, and urges them to remain alert.

Progressivism and Environmentalism

Radical environmentalism and the Progressive Program are not perfectly compatible. But they are close.

Radical environmentalists believe that humanity is a plague upon Planet Earth. Everything man has done since the day he first learned to cultivate crops (and thus for the first time became a different kind of animal) has been bad. And anything which delays, halts or reverses the sins mankind has perpetrated upon sacred Gaia, since that day he first departed from Nature, is a good thing. So the radical environmentalists are in favor of strong central governments which will control the behaviors of individuals (and which might ultimately drastically reduce or eliminate the human population).

Progressives are certainly on board with controlling man’s effect on the environment, but (in most cases) they are not in favor of returning mankind to a hunter/gatherer condition (since most Progressives do not view this condition as the embodiment of a perfect society). Rather, they view the environmental movement – in particular, the Global Warming Theory – as a good way to get the populace to give them the power they need to carry out their Progressive Program. So Progressives have completely embraced the Global Warming Theory as a means to their own political end. Accordingly they have declared man-made global warming to be settled science, and they suppress any efforts to study it further.

DrRich is very sorry about this. He suspects that global warming is happening, and concedes that human behavior may be playing a role, and is saddened that this scientific question has been absorbed into the Progressive agenda in such a way that we are not allowed to find out what’s really going on.

Progressivism and the Great American Experiment

Unlike any other nation in the history of mankind, the United States was not founded because of geography, race, religion or ethnicity. It was founded on an idea. It was founded on the still-radical idea that individual autonomy – the individual’s God-given right to life, liberty, and the pursuit of happiness – is the chief Fact of humankind, and that the only legitimate role of government is to create an environment in which individuals can enjoy those rights to the fullest extent possible.

One can see immediately that the Great American Experiment – which awards primacy to individual autonomy – is fundamentally incompatible with Progressivism. But because a majority of Americans still like the ideas expressed in the Declaration of Independence, the Progressives need to play their cards close to their chests. They need to proceed carefully – but relentlessly.

By slowly re-interpreting the Constitution, and slowly addicting a critical mass of Americans to an array of government programs, Progressives are certain they will ultimately prevail. They have been at it for over 100 years, and have come a long way. DrRich cannot tell whether or not we have already passed the Event Horizon, the point beyond which restoring the Great American Experiment will become impossible. But we are at least very close.

In fact, one plausible theory for President Obama’s headlong pursuit of programs and policies which anger the majority of Americans, and which gravely and immanently threaten the political control which is the center of the Progressive universe, is that he sees America as being at the very cusp of that Event Horizon, and believes that one last, small push will gain it, and make the Progressive Program irreversible, whatever might happen in the next election or two.

Progressivism and Healthcare

DrRich does not need to say much about Progressivism and healthcare right now. Many of the posts in this blog have pertained to this very question, as, undoubtedly, will many more.

But to really understand the current American healthcare system, and to understand Obamacare (the future American healthcare system), it is necessary to understand Progressivism. DrRich sincerely hopes that this current post will help a few of his readers understand, if not Progressive thought itself, at least DrRich’s conceptualization of it.

Shout-Outs to Dr. John and the Dinosaur

DrRich | September 7th, 2010 - 3:17 pm

DrRich would like to congratulate Dr. John M. for his one-year anniversary in the blogosphere.  While DrRich is not precisely at the same place on the political scale as Dr. John, he finds himself agreeing with his EP colleague the vast majority of the time.  Dr. John has established a truly excellent blog, which should be of interest to anyone who cares about healthcare, heart rhythm disturbances, or bicycle racing. Highly recommended.

And DrRich would be remiss not to point his readers to Grand Rounds this week, which is posted at Musings of a Dinosaur.  It is a baseball-themed Grand Rounds, which, DrRich thinks, is OK – though as a Pittsburgh Pirates fan he is no longer familiar with such concepts as “double play” or “grand slam home run.”   But as a blogger whose posts are (presumably) controversial enough that he is used to his submissions for Grand Rounds being summarily rejected, DrRich wants to thank Dr. Dino for penning him into the lineup this game.

PCPs: We Are The Borg. Prepare To Be Assimilated.

DrRich | September 3rd, 2010 - 10:33 am

Podcast:

In a remarkable article that somehow* was accepted for publication in the Annals of Internal Medicine, the White House offered some friendly advice to American PCPs who may be wondering how Obamacare will affect them. That advice, to summarize, is: “We are the Borg. Prepare to be assimilated.”
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* DrRich is forced to wonder whether yet another group of medical editors is auditioning for the death panels.
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The article was written by Ezekiel Emanuel from the White House’s Office of Management and Budget, and Nancy-Ann M. De Parle, who is Mr. Obama’s Czar of Healthcare Reform. (A third author was from the McKinsey Group.) After reminding physicians of their moral obligation to the collective, the White House authors rhapsodized about all of the wonderful changes inherent in Obamacare that will help physicians to realize this obligation.

There’s actually no need to read the entire article, assuming you heard any of the 400 speeches President Obama delivered in his unsuccessful attempt to convince the public that his healthcare reforms ought to displace the holy writ as The Good News. The meat of the article, if you’re a physician, appears at the end:

These reforms will unleash forces that favor integration across the continuum of care. Some organizing function will need to be developed to track quality measures, account for and manage shared financial incentives, and oversee care coordination….These coordinating functions, to the extent that they currently exist, traditionally have been managed by hospitals or health plans….As physicians organize themselves into increasing larger groups — patient-centered medical home practices and accountable care organizations — they are, out of necessity, investing in information technology tools that are becoming both cheaper and more capable and investing in the acquisition or development of management skills that could provide these organizing functions efficiently for physicians groups….For physicians, this means a profession that is more rewarding, more productive, and better able to realize its moral ideal.

DrRich translates this message thusly: “Physicians! You have been neglecting your moral obligation to the collective, in favor of your archaic devotion to the individual patient. Under Obamacare you will need to join organizations which are devoted to the collective goals of Obamacare, and which therefore will guarantee the proper moral ideals. You must function not as individual decisionmakers, but as integrated cogs in a vast healthcare continuum, which will stretch from the centralized bastion of gleaming moral authority (from which we pen this message) all the way down to the humble tip of your stethoscope. You will be rewarded for your cooperation, or suffer for your resistance (resistance, of course, being futile).  So rejoice for the health of the collective, and for your own well-being, and prepare to be assimilated.”

Ostensibly this message is for all American physicians, but it was submitted to the Annals of Internal Medicine for a reason. The Annals is the journal of record for doctors who practice internal medicine, and who comprise the largest group of PCPs. The White House in this article is speaking directly to American PCPs.

This is because PCPs pose the greatest short-term threat to Obamacare.

Most medical specialists have already been “assimilated.” Because they require lots of expensive stuff to practice their specialties – things like gamma cameras, operating suites, catheterization laboratories, hordes of highly trained medical technicians, &c. – it is very difficult for most specialists to function as independent operators. If you want medical specialists to follow the rules, all you have to do is make following the rules a requirement for keeping their access to all the technology and the complex infrastructure they need to practice their specialties.

Only PCPs can fairly readily make themselves independent from the collective.  And more and more PCPs are choosing to do so.

The White House does not like this.  The Annals article, DrRich thinks, is the administration’s first official attempt to curtail the PCPs’ fledgling independence movement. The threat is veiled – the article instead appeals to the PCPs purported moral obligation to the collective, and emphasizes the rewards that will follow when PCPs allow themselves to be assimilated into the Borg.

So this first attempt, for the most part, is merely creepy. The next step will not be as benign.

DrRich urges his PCP friends to take heed. If you have any thought of striking out on your own, and starting a direct pay practice – thus reasserting your profession’s real moral obligation, which is to your patients – you had better act now, before it becomes a federal crime to do so.