First Installment of DrRich’s Book Is Published

DrRich | February 29th, 2012 - 8:35 am

Open Wide And Say Moo! – The Good Citizen’s Guide To Right Thoughts and Right Actions Under Obamacare

OK. The first, irreversible step has been taken. (Nothing after you hit the “send” button is reversible on the Internet.)

I have posted the first installment of my latest (but, I hope, not my last) project, which is to say, composing a new book (of the above title) in real-time, on-line, chapter-by-chapter, until I finish or am hauled off by the fates (or something).

For a full explanation of what this is all about, read this.

So without further ado, here is the first installment: the Introduction.

Please Leave Your Comments Here Regarding DrRich’s Book-In-Progress

DrRich | February 29th, 2012 - 8:20 am

I am attempting to collect all the comments anyone cares to make (good or bad, constructive or de-constructive) regarding my on-going, real-time on-line book, right here.  I am hoping that compiling all the comments in one place will help me with the CQI process.  Thank you very much for your cooperation.

Embarking On Something A Little Different

DrRich | February 28th, 2012 - 8:26 am

As I was sending in the (finally!) completed manuscript of the 5th edition of my textbook of electrophysiology last week, I was interrupted by two thoughts.

The first was that, while I enjoyed writing this book, I did not have as much fun as I had with the first four editions. Oh sure, I still entertained myself by trying to embed as many jokes, innuendos, double entendres and other amusements as I could into the text (95% of which, as always, will be caught and removed prior to publication by the editors – who are up to my tricks). But still, writing about cardiac electrophysiology is necessarily a desiccating endeavor. I guess I’ve gotten used to the free-reign style of writing I employ here at the CRB, and perhaps it’s ruined me for writing textbooks, at least as far as my own enjoyment is concerned. Sure would be fun to write a book in the style of this blog.

The second thought came to me as I pressed the “send” button, thus instantaneously zapping all the text, tables, and illustrations that comprise a medical textbook to the publisher. Even as recently as seven years ago, when I did the 4th edition, the process involved bundling up three copies of a thick manuscript, and three glossy prints each of all the illustrations, tables, etc., into a bulky package, and hauling it to the US Postal Service for (eventual) delivery.  How the world has changed in so short a time! (I sez to myself.) No need to do things the old way anymore.

Ruminating on these two thoughts for a matter of mere hours, I called an audible on my plans (such as they were) for my immediate future.

I’ve been thinking for more than a year that I need to write another book on American healthcare. It would be a book about what Obamacare expects (and will demand) from all of us citizens. I believe that if we Americans understood what really is to be expected of us from now on (instead of believing the soothing prevarications and wishful thinking commonly thrown our way), then we would do something about it. But Life got in the way, and I have not done much more than think about such a book.

My failure to act creates a seemingly insurmountable problem. The message I hope to convey, if it has any legitimacy at all, is most pertinent right now, before the November election. Given that I have not begun my book, the time frame appears difficult.

Indeed, as anyone who has published a book knows, unless you are writing about last week’s celebrity kidnapping or, perhaps, a Whitney Houston bio (in other words, unless you are writing about recent events so momentous that the usual chains of publishing protocol must be rent asunder to accommodate you), the time that elapses between the conception and the publication of a book is usually measured in years.

But, as I have noted, things have changed. So I have decided to try taking advantage of some of these changes, to try something a little different.

I am going to attempt to write my book right here, on this blog.

This is what I propose to do. Working as quickly as I can (while still fulfilling all my commitments to the various enterprises which are actually paying me to do things), I will compose my new book in real time, on line, here on the CRB. Quite simply, as I finish each chapter I will post it here.

The chapters I put up here will be a work in progress, essentially a draft. I reserve the right to change what I have written at any time, as much as I think I need to. I make no representations regarding how often I will post chapters, or even whether I will be able to carry this project to completion in a reasonable time, or at all. (I’ve never written a book like this before – I doubt many have – and I don’t really know that it’s feasible.)   I risk making a great fool of myself, but acquaintances would tell you that such a result should not create too great an additional burden for me.

I am sure regular readers will recognize large parts of this book as I post it, because I intend to incorporate themes – and even text – from some of my blog postings from the last five years. But I hope that presenting those words and themes in the more coherent and more logical form of a book will give them new life, and possibly extend their meaning.

Because this will be a work in progress, I invite (beg) comments and criticisms from all (or, as the case may be, both) of you.  I promise to consider every comment seriously (as indeed I always do), and I will undoubtedly incorporate many of them into the revisions I’ll be making all the time.

Once I decide that the book is finished, I will plan to publish it in electronic book form (Kindle for sure, maybe Nook) under my own label. Unless this occurs by Labor Day at the latest I will consider the entire effort an abject failure. If by some miracle the book does well in electronic format, I will plan to seek a real publisher in the future.

I realize how backward this all is. But (sez I) see how the world has changed in such a short time!

I will end this strange post with a personal note.

I will embark on writing this book despite my better judgment. On two occasions in my career – once as a practicing physician and once as a consultant to a biomedical company – I had very scary and very personal run-ins with officials of the federal government who had the authority (and the desire) to extract large fines and/or lengthy incarcerations from lots of people.  While I myself was not a direct target in either of these matters, and indeed suffered no real damage from either, these episodes were extremely distressing to me, and even life-changing.

I have written about one of these encounters in my temporarily obsolete book, “Fixing American Healthcare” (I’m hoping it will eventually come back in style, thus rendering its current obsolescence obsolete), and here on the CRB. I have not written about the second encounter, which was much more recent. In that second encounter, while I was being interrogated under oath by a prosecutor from the Department of Justice, the opening line of questioning, which lasted far longer than I ever could have imagined, concerned my writings here on the CRB, writings which were not remotely related in any way to the matter at hand. While the line of questioning itself was not particularly intimidating, and even occasionally bordered on expressing amusement (it might have been irony, though I do not expect irony from the DOJ), the message seemed clear: We in the DOJ know who you are, and we know in some detail what you’ve been saying about the government’s role in the healthcare system. And we find it very interesting.

I must have looked as calm and collected as Richard Nixon during the Kennedy debates.

In short, I doubt that such episodes with the Feds are things I could ever get used to, and I would prefer to avoid them in the future if possible.

And so I am ambivalent about the ultimate success of this book. I would be delighted, of course, if the book is successful, as that would indicate that a lot of people will have found it helpful to them, and perhaps some of them will be motivated to affect certain changes that might help all of us. The remote prospect of such an outcome is what compels me to write it.

But I must admit that if this book simply drops into oblivion – which is certainly the more likely outcome – that would be just fine with me. I will be able to tell myself (when what I think I see coming actually arrives), that I did what I could to sound the alarm. I will have done what I thought I must do. And having tried my best, I hope to enjoy my failure (and thus my success in staying under the radar as much as possible) with equanimity. And with an abiding sense of peace I will take my Obamacare medicine along with everyone else.

Here is the up-to-date archive for all the chapters that have been posted so far.

Limiting Individual Prerogatives in Healthcare

DrRich | February 25th, 2012 - 9:24 am

Now that President Obama’s healthcare reform has become the law of the land, it is time for us to prepare ourselves for the real fight. Namely, will individual Americans ultimately be restrained, by law or by subterfuge, from using their own resources to pay for their own medical care?  This notion is not as far-fetched as you might think. In this series of posts, DrRich explores this question, and demonstrates just how far we’ve already come in limiting the healthcare prerogatives of individuals.

Limiting Individual Prerogatives:

Part 1: The Real Fight Is Just Beginning

Part 2: Hillary Started It

Part 3: Breaking the Doctor-Patient Relationship

Part 4: Medicare Already Does It

Update: Why Angering Catholics Makes Sense For Obama

DrRich Is A Top Online Influencer On Heart Disease

DrRich | February 25th, 2012 - 8:32 am

Readers who believe that DrRich is primarily a clown, an obfuscator, a confabulator, an out-of-touch Old Fart, or just your run-of-the-mill, close-minded, middle-American, gun-toting Bible-thumper (see? DrRich DOES read all his email), might be surprised (if not dismayed) to learn that, this week, he has received an Incredible Honor.

According to ShareCareNow, a relatively new enterprise created by former WebMD Founder Jeff Arnold and Dr. Mehmet Oz, DrRich is one of the Top 10 Most Influential Online Voices In Heart Disease.

See for yourself, right here. And here’s a blurb about it from MarketWatch.

Of course, this designation has nothing to do with DrRich’s stellar work here at the Covert Rationing Blog. It is based entirely on his efforts at the Heart Health Center at, which DrRich has run now for going on 12 years. His site is dedicated to helping people who have heart disease, or who have loved ones with heart disease, or who are at risk of developing cardiovascular disease. He attempts to explain the basics – and even the complexities, whenever they are pertinent – of all types of heart and vascular conditions, and to clarify for his readers the continuous stream of hype and misinformation perpetrated by a largely ignorant press and the medical experts who (sometimes unconsciously) manipulate it. (In fact, he has tried more than once to change the name of his heart disease site to “Secret Cardiology,” but the people who run – i.e., the nice folks at the New York Times – are against it.)

As DrRich understands it, his designation as the fourth most influential online voice on heart disease is based on a proprietary ShareCareNow algorithm incorporating some 40 objective measures. The only thing he knows for sure is that the opinions of those readers mentioned in the first paragraph of this post were obviously not incorporated into the algorithm. Which proves that not all the big on-line organizations have ready access to all our email, after all.

How comforting is that?

Some Advice About Salt

DrRich | February 21st, 2012 - 4:31 pm


In a previous post, DrRich explained to his loyal readers why the Central Authority’s recent assault on salt is, at best, premature.

Our leaders, of course, insist that the benefits of a universal sodium restriction, applied to each and every American citizen, is more than merely an extraordinarily healthful idea – it is settled science. And anyone who says otherwise is the moral equivalent of a Holocaust Denier (or worse, a Global Warming Denier).

DrRich’s earlier post argued that the available data falls far short of supporting a universal sodium restriction, and suggested that the government is embarking on yet another experiment to be perpetrated upon the population at large, much like Our Leaders’ earlier unfortunate experiments with low-fat diets, and adding trans-fats to most of our processed foods. Since that earlier post, several new scientific studies have been published which lend support to DrRich’s qualms about a universal salt restriction, and which suggest that, indeed, low salt intakes are likely to be quite dangerous to a substantial minority of people.

However, we are now in a new era of herd medicine. And a universal sodium restriction illustrates the very nature of herd medicine. Our Central Authority calculates that a universal sodium restriction is likely to add up to a better overall collective outcome. And if 10-20% of the people suffer because of this policy, that’s not really relevant. It’s the overall outcome that is dispositive.

And people who complain about this are just being troublemakers.

Because a sodium restriction is settled science, new data (unless it is supportive data), by definition, is not allowed into the discussion. Indeed, by definition, the discussion is over. And those people and organizations who have petitioned the government to reconsider its universal sodium restriction policy, citing lots of scientific evidence to show why this policy is at best unproven and quite likely dangerous to the public, are just identifying themselves as some of the people with whom DrRich will be doing morning jumping jacks when he is finally assigned to his reeducation camp.

And so, realizing that it is pointless, DrRich will not rail any further against the government’s policy on salt restriction. Instead, he will undertake the task of providing useful advice to his readers, aimed at helping them to cope with the inevitable changes that are coming to the foods they eat – and perhaps, helping them to get enough sodium in their diets to avoid early death.

First, DrRich urges his readers to notice that purchasing bags of salt, even in large quantities, is not yet illegal – and indeed there is, as yet, no special “salt surcharge” or “salt tax” added to the purchase price. Further, DrRich reminds his readers that salt is famous for being storable for very long periods of time. So stock up while you can. Ten to 15 years of salt in your cupboard will likely take you up to the point where total societal collapse, Greek-style, will make the amount of salt in your diet the least of your worries.

As a simple precaution, however, when you buy your bags of salt you should not use your credit card or your debit card, and by no means should you allow your friendly neighborhood grocer to tabulate your purchase in the grocery’s rewards program. Use cash. (Indeed, since your future healthcare may very well depend on your long-term compliance with various dietary directives, you should probably begin purchasing only fruits and vegetables with any of these non-cash alternatives.)

If you keep your salt purchases to under $20 cash at a time, odds are you will not trigger official scrutiny.

Second, a week or two ago the CDC released an extremely helpful report which lists the 10 food categories which contribute most of the sodium consumption to the American diet.

These include:

- bread and rolls,
- cold cuts/cured meats,
- pizza,
- poultry,
- soups,
- sandwiches,
- cheese,
- pasta mixed dishes,
- meat mixed dishes,
- savory snacks.

These delightful culinary treats, the CDC warns us, are deadly due to their salt content. The Agency further indicates that strong government action is necessary, and is coming, to remove these dangerous products from the grocer’s shelves. (And the CDC, DrRich reminds his readers, is a government agency, and therefore is one of the manifold voices of the Central Authority. We must take its pronouncements seriously.)

So once again, stock up while you can. Some of these foodstuffs can be purchased in jars and cans, and will keep for years. Dried pasta and savory snacks also store quite well. Other items on this list can be bought and frozen. And of course, you can buy a bread maker, which, utilizing the bags of salt you have on hand, can furnish you with all the sodium-laden bread you are likely to need.  And once again, use cash.

DrRich sincerely thanks the government for providing this helpful list of essential foodstuffs which it is targeting for obliteration.

Third, when we are stocking up for the shortages which the government has now pledged to create, it is inevitable that we will misjudge on the necessary quantities. We may find, for instance, that we have way too many Cheetos on hand, and not enough linguini. This means we had better be prepared to barter with our neighbors.

Since it is relatively unlikely that American greenbacks, by that time, will be valued enough to induce your neighbor to part with irreplaceable cans of chicken noodle soup, DrRich humbly suggests that you begin laying up a few dozen cartons of cigarettes. If you travel to any socialist country, you will find that cigarettes are the universal currency, and can get you just about whatever you need.

Finally, even if you do not believe that owning salt or salty foods is about to become at least a misdemeanor, or that we are about to become a barter economy, you should still find the government’s Salt Target List helpful. The companies that make this stuff are about to come upon very hard times. So scour your investment portfolio before it is too late, and make the necessary adjustments.

DrRich, as always, is pleased to be of assistance.

Addendum To Prior Post – I Rest My Case

DrRich | February 10th, 2012 - 12:42 pm

During the time DrRich was composing and recording his prior post – published moments ago – President Obama announced his “compromise” to the dust-up with Catholics over mandated contraception/abortion/sterilization services.

DrRich asks his readers to note that the President’s solution to this problem preserves the one and only thing that he truly needs his original directive to accomplish – namely, to assure that women will receive these newly mandated medical services without paying for them.  This is the one point he cannot abandon.

Case Closed.

Why Angering Catholics Makes Sense For Obama

DrRich | February 10th, 2012 - 12:05 pm


President Obama unleashed a firestorm when he ordered HHS to issue a directive requiring all organizations providing health insurance to their employees to cover contraception, “morning after” pills, and sterilization procedures.  This directive has stunned the American Catholic leadership, whose support for the Obamacare legislation (they tell us) was predicated on assurances that healthcare reform would never require Catholic institutions to violate their fundamental principles. The bishops, and many American Catholics, feel betrayed.

Some bishops feel personally betrayed. New York Archbishop Timothy Dolan met in the Oval Office with the President in November to discuss this very issue, and was assured by Obama’s own lips that the administration was committed to protecting the church’s principles. This new directive, Archbishop Dolan now says plaintively, “seems to be at odds with the very assurances that he gave me.” (This is as close as an Archbishop may come, when speaking of the President, to saying, “He lied to me.”)

Progressives (who innately dislike organized religion because a) religions find a higher authority than the enlightened leadership the Progressives propose to create for us, and b) religion stresses individual conscience and individual salvation over collective priorities), tend to be delighted with the new rule, which puts the principles of religious belief into their proper place. Their only reservation about this directive is that the backlash might be politically disadvantageous at this particular moment.

And indeed, that backlash promises to be formidable. Catholics are outraged. Despite the fact that Catholics (Progressives assure us) use birth control with as much enthusiasm as anyone else, they find it quite disturbing that the government is willing to direct their Church to pay for something which the Church (whatever the behavior of its members may be) considers a sin. Whatever else this directive may be, it is clearly an attack on religious freedom. Leaders of other religions – evangelicals, Mormons, Jews – have also expressed outrage at the President’s directive, and organized American religions of all types are mounting a campaign to have this rule reversed.

Senator Rubio and other members of Congress find in this directive a constitutional crisis in the making, and are introducing legislation to prevent the government from mandating that religious organizations violate their religious principles.

It is said that Vice President Biden, a Catholic, urged the President not to issue this directive. And several Democrat members of Congress, sensing growing political repercussions, have pleaded with the President to reverse himself on this issue. There is no telling what the President – who has proven remarkably willing to reverse himself on even his most heartfelt promises – will end up doing. But for now he is holding firm. Catholics will have up to a year to “phase in” their capitulation on their religious beliefs, but they still must capitulate.

The most interesting question, to DrRich at least, is: Why did President Obama choose, in an election year, to issue this directive, which he knew without any doubt, from Archbishop Dolan himself if not from other sources, would create huge problems with American Catholics? Catholics make up 27% of the electorate, and almost 50% of American Catholics are of the Hispanic variety, a group which, it is said, tends to take its Catholicism far more seriously than your average non-Hispanic Catholic. The president can ill afford to lose a substantial degree of support from Catholics, or especially, Hispanics. It also should have been plain to him that this directive would raise the specter of the government trampling on religious freedoms for people of all faiths – and with everything else going on, why would he want to add this issue to the mix in an election year? Finally, he had to know that his new rule would (yet again) call into question the degree of respect he has for the American Constitution as it is written.

Despite the fact that he is being cheered on by true Progressives (even causing Ms. Maddow to gleefully invoke, once again, her Amish Bus Driver Rule), the President’s directive, in net, is shaping up to become a major political liability for him, and in a critical election year to boot. And it would have been easy for President Obama – a very smart man – to see this ahead of time. Issuing this directive at this juncture makes no sense politically.

So why did he do it?

The reason DrRich is compelled, once again, to tear himself away from the fascinating re-write of his textbook of electrophysiology, to the point that he finds himself posting more often during his blogging sabbatical than during normal times, is that nobody in the media seems to have figured out the correct answer to this question. And it is important to know the correct answer, because it tells us a lot about the battle that is really shaping up.

The President did not issue this politically counterproductive directive because it was necessary for the health of American women. (One set of healthcare services American women have plenty of access to, regardless of their income levels, is birth control and abortion services. That, after all, is why we taxpayers fund Planned Parenthood.) So to imply, as some have done, that without this directive American women would be falling dead on the streets is just absurd.

Nor did he issue it in order to further weaken religious freedom, or to further undermine the Constitution as our founders gave it to us. These features of his directive, DrRich submits, are merely useful side benefits, and would not have been compelling enough to jeopardize his re-election.

The reason President Obama issued this directive was not to undermine religious or constitutional principles, but rather, to establish new principles of his own that are critical both to Obamacare and to the overarching Progressive agenda.

DrRich has pointed out many times that the real battle we will face as Obamacare is being rolled out is the battle over whether American citizens will retain individual freedom sufficient to be permitted to spend their own money on their own healthcare. Indeed, DrRich has written a series of posts that spells all this out in painful detail. If you need to know why limiting individual prerogatives is so critically important to Progressives, and why Obamacare must be the vehicle for establishing these limitations, simply read the first post in that series.

DrRich understands how paranoid this all sounds at first glance. To see the truth of it, one must take several glances, and observe, over time, the actual behavior of Progressives in the wild.

DrRich hereby asserts that this new directive – which various commentators insist protects the health of women, or undermines religious freedom, or tears down Constitutional guarantees – actually was issued in order to establish, once and for all, the essential set of foundational principles for Obamacare, to wit:

1) The government will determine what constitutes healthcare and what does not.
2) If the government says it’s healthcare, every insurance product must cover it.
3) If it’s not covered by insurance, thou shalt not have access to it.

The first two of these principles are pretty obvious, and constitute, in fact, the overt meaning of the President’s directive. The government has determined that contraception, abortifacients, and sterilization constitute essential healthcare services, and therefore all employers must cover them, whatever their religious beliefs or other sensibilities may be.

But if you listen carefully to the arguments being made by supporters of the new directive, you will hear them saying that it’s critical that women have access to these services, as Jay Carney, the President’s Press Secretary avers, without paying for them themselves.

And that’s what the whole fight comes down to. Women must be provided these services without paying for them.

Progressives pretend they mean by this that many, many women are going without these services today because they cannot afford them, and so we must make sure the services are provided for them free of charge. But of all medical services that exist today, access to birth control and abortion are likely the ones which are most accessible to women of all socioeconomic backgrounds. And if there are women whose financial status still precludes receiving these services (among whom are most likely not the women gainfully employed by Catholic institutions), surely the President can imagine remedies for this situation that do not require taking the kind of extraordinary political risk he has just taken.

No. Women must be provided these services without paying for them NOT because there are so many women going without them today due to the cost to them. Rather, women must be provided these services without paying for them because we cannot allow women (or any patient) to pay for these services (or any service the Central Authority classifies as “healthcare”) out of their own pockets.

All healthcare services must be covered by all insurance products – regardless of which institutions provide those insurance products – precisely because nobody can be permitted to pay for healthcare outside the sanctioned insurance product.

This is the principle which is being established by the President’s new directive. This principle, so critical to Obamacare and to the Progressive agenda, is a principle worth fighting for. None of the other explanations offered by proponents or opponents of the President’s action make any sense. Establishing this critical principle is the only thing that justifies the huge political risk the President is now taking.

And now, retreating back to the far simpler task of explaining the intricacies of cardiac electrophysiology to novices, DrRich helpfully and humbly reminds his readers: I told you so.

We Interrupt This Hiatus For A Special Message

DrRich | February 7th, 2012 - 2:57 pm

As readers can imagine, few things could interrupt my temporary break from blogging – a break in which I have lost myself in the pleasures of figuring out how best to explain to novice readers the differences between the effective, relative and functional refractory periods of cardiac Purkinje fibers, and a host of other fascinating electrophysiologic arcana. With one’s brain wrapped around delights such as that, blogging fades to a barely remembered romp through some distant dreamscape.

One of the few things that could bring me back from these nether regions to the Covert Rationing Blog, if only for a moment, has happened. The esteemed Dr. Robert Centor, affectionately known as DB in the medical blogosphere, has made a comment on one of my posts, and it is a comment that deserves serious consideration. Further, I find I cannot give his comment appropriate justice by simply answering it with another comment. It requires more.

So, we interrupt this hiatus from blogging in order to give the kind of thoughtful response DB’s comment deserves.

I have been a reader of DB’s blog for several years – substantially longer than the nearly five years I have been writing the CRB. I consider DB to be the voice of internal medicine as it should be practiced. DB is a master of cutting through the fluff to get at the root of what is ailing the practice of medicine today. He has substantially influenced my thinking over the years, and many of DB’s writings have validated (in my mind, at least) certain of my syntheses of some key problems regarding the present state of medical practice. Indeed, out of sheer respect for DB I have dropped in this post the rather haughty 3rd person approach I traditionally use herein.

At one time I was a relatively frequent commenter on DB’s blog, and the exchanges that ensued between us have been some of the highlights of my blogging career (such as it is). But two years ago I stopped posting comments on DB’s Medical Rants, and I stopped making any reference here to DB or his blog. I did so for one simple reason.

It was two years ago that I had my public dust-up with the ACP over the issue of medical ethics. It was a dust-up that drew the notice and disapprobation of some individuals quite well placed within the ACP leadership. Knowing that DB is a member of the ACP’s Board of Regents, I feared that if I continued acting as if I were one of his “blogging buddies” it might reflect poorly on him. The ACP (an organization of which I was a proud member for over 25 years, quitting only when they published their New Medical Ethics in 2002) badly needs voices like DB’s. Indeed, the fact that they value his voice gives me hope. So, out of respect for him, and in consideration of what I guessed were his best interests, I stopped interacting with DB and his blog altogether, though I have remained a regular reader. I realize that, realistically, what I may do or not do almost certainly has no effect whatsoever on DB’s relationship with the ACP, but it was something I felt I needed to do.

In any case, that self-imposed avoidance has now been made moot by DB himself.

In his comment DB takes exception to one (or more likely, several) of my recent posts. I will reproduce his entire comment here:

“First, I admit to bias as a member of the ACP Board of Regents.

DrRich (whom I like and admire) has used a technique that we all use. He has established a straw man and beat that straw man into submission.

ACP advocates strongly for high-value, cost-conscious care (HVCCC). In fact a recent Annals article – Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care – – very explicitly attacks low value high cost care.

Advocating for HVCCC does not mean advocating for rationing based on cost alone.

As DrRich always states, we have covert rationing and we believe that rationing has no relation to value.

ACP has challenged all physicians to avoid medications and tests that do not have high value. How is that “herd medicine”?

Please review the recommendations in the recent Annals article and tell us where we have developed recommendations for cost reasons only.

I admire your debating skills, but in my opinion you are not addressing the same question that we are addressing. I speak from clinical experience. I see too many tests ordered that cannot help the patient. I see too many treatments that cost too much without a clear advantage over less expensive treatments.

We should strive for high value care for all our patients. We should eschew low value expensive care for most patients (of course one can construct exceptions to this generalization). Let’s not let hyperbole confuse the issue. We cannot afford unnecessary expenses. We challenge you to define unnecessary. I think you can.”

I believe DB has misunderstood my main argument. This is not his fault. I have been accused more than once of being somewhat obtuse. So let me state it very explicitly:

1) It has been determined that individualized decision making by doctors and patients is the problem, and to resolve this problem clinical decisions need to be centralized.*
2) Obamacare renders much individualized decision making illegal, and establishes formal mechanisms for centralized decision making.
3) The ACP’s New Medical Ethics, whether by intention or not, has allowed agents of the Central Authority to argue that individualized decision making is unethical.
4) Centralized decision making will likely yield better results for the collective, better results for the “average” patients, but suboptimal results for people on the wrong side of the distribution curve – and terrible results for people on the tail of the curve. DB himself has written about this tail.


* From the book “New Rules,” by Berwick and Brennan:

“Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care. . .is to constrain decentralized individualized decision making.”


There is nothing in my argument that says physicians should avoid attempting to practice high-value medicine. Obviously, they should. There is nothing in this argument that says it is wrong or counterproductive for the ACP (or other professional organizations) to devise publications, guidelines, opinions, or any other kind of aid to assist doctors in making appropriate clinical decisions that will minimize waste for society and harm to their patients. Doing these things is good for the healthcare system and for mankind.

What is wrong is a system that says that centrally-generated clinical “guidelines” must be followed to the letter by all doctors for all patients under all circumstances, and that failing to do so is both illegal and unethical.

The document to which DB refers me – an attempt by the ACP to assign values to certain clinical services – is a good one, and I am sure clinicians should find it helpful. I can’t help but believe that he sent me to this particular document because it explicitly calls out implantable defibrillators (the development of which played a significant role in my professional career) as a high-value medical service. That’s very nice.

But this fact leads me to use, as an example of what I’m talking about, the abuse of ICD guidelines by the Central Authority. A year ago an article appeared in JAMA complaining that 22% of ICD implants did not meet the guidelines. That number (which seems about right to me, if guidelines were being treated as just that) was widely castigated as evidence that doctors were engaging in widespread abuse of this expensive medical device. This was followed, 2 weeks later, by an announcement that the Department of Justice was conducting an investigation of guideline violations by ICD implanters. As a first step in this investigation, the DOJ elicited the cooperation of the Heart Rhythm Society – the professional organization of electrophysiologists – and the HRS let out that it was effectively gagged from further comment or action on behalf of its members for the duration of the investigation.

The specific part of the ICD guidelines that produced the majority of the “violations” was not that ICDs were being used in people who did not really need them. Rather, it was that ICDs were being implanted earlier than the Feds preferred for people who, everyone agreed, should have an ICD. That is, implanters were not waiting the full mandated 4 – 6 weeks after a heart attack, or after heart failure was diagnosed, before implanting ICDs in some of their patients. Two points about this: First, there are clearly individuals who should receive their ICDs within the first month of a heart attack or heart failure diagnosis, despite what the guidelines say. (For instance, if the patient also has an indication for a pacemaker – not an uncommon thing – following the guidelines would require first implanting a pacemaker, then, a few weeks later, doing a second invasive procedure to replace it with an ICD). Second, the clinical evidence supporting this 4 – 6 week waiting period is based on two fundamentally flawed studies, and constituted the weakest part of the clinical evidence regarding ICDs, and while it is now apparently considered settled science if not gospel, it was originally considered highly controversial when the guidelines first appeared.

We don’t know what the results of the DOJ’s investigation will be. Perhaps nothing will come of it and no electrophysiologists will go to jail this time.

Here’s what we do know:

- Doctors are expected to follow clinical guidelines to the letter, with every patient, whether it makes sense for an individual or not.
- Doctors who are not following centralized guidelines to the letter are behaving illegally, and the DOJ – that’s the DEPARTMENT OF JUSTICE people, and not HHS or Medicare – will investigate, and at least threaten criminal prosecution.
- Doctors who are not following centralized guidelines to the letter are behaving unethically. (Go back and re-read the commentary from the press and from other physicians, especially physicians who strongly support Obamacare’s centralized decision making, about the ethics of these ICD-guideline-violators.)
- Such legal and ethical intimidation will prevent doctors from “violating” guidelines for their individual patients who are a standard deviation or two away from the mean, and who clearly need an exception.

That’s my argument. The activities of the ACP, vis a vis establishing helpful studies of the relative clinical value of various clinical actions, or even guidelines for clinical practice (if treated as actual guidelines), are to be lauded and not criticized, and I so laud them.

The ACP has not instituted herd medicine, nor advocated it explicitly, to my knowledge. My only criticism of the ACP has to do with their altering the precepts of medical ethics to make it ethically compatible for doctors to go along with herd medicine. The Central Authority on its own volition has taken it the rest of the way – to where it’s unethical NOT to go along with heard medicine. This “adjustment” of medical ethics is just what the Central Authority needed in order to validate its policy of centralized decision making, and the ACP provided it. The glee on the part of the government’s agents in response to the ACP’s New Ethics is palpable.

I still find this a sad, sad thing for the profession, and especially for patients. I also find it very sad for the ACP itself which, by producing the kind of helpful resources to which DB has referred us, would continue to be a great force for good – were it not for this one very basic, very fundamental, very critical, and therefore utterly tragic flaw.

DrRich Is Still Here

DrRich | February 2nd, 2012 - 11:42 am

It’s just that I am occupied at the moment finishing up the 5th edition of my introductory textbook of electrophysiology. It is a book which aims to simplify and demystify a particularly arcane branch of the cardiologic arts, and it has proven to be quite popular (among a certain type of readership) for nearly 25 years.

The publisher insists that I update this book every few years, to keep it “fresh.” Because it is a very basic textbook, and because the basics of electrophysiology remain nearly unchanged, my chief aim in doing these revisions is not to screw it up too much.

A secondary aim is to slip past the eagle-eyed editors (who have the reputation of the publishing house to uphold, and who believe textbooks of medicine should be serious tracts) as much humor as possible – which means I have to disguise it. (Regular readers of this blog will know what I mean.) By this means I keep myself engaged and entertained in what otherwise – after all this time – might have become mere tedium.

It is in the interest of my contractual obligation to finish this project in a timely fashion that I have had to leave off – for what I intend will be a very brief interval – composing posts for the Covert Rationing Blog.

I hope that my few readers will indulge me in this hiatus, and in the meantime that you will keep in mind (without my constant reminders) that they really are out to get you.