The Cochrane Collaboration is a highly regarded resource for those who value evidence-based medicine, medical guidelines, and the randomized clinical trials that support such tools. The experts at Cochrane conduct reviews of all randomized clinical trials (RCTs) that meet their strict criteria for scientific and statistical robustness, and periodically publish summaries of the scientific evidence thereby derived, on particular clinical topics. Cochrane reviews are thorough and straightforward, and virtually always present an accurate reflection of the up-to-date evidence as supported by RCTs.

Despite the respect in which the Cochrane Collaboration is held, DrRich finds it at least mildly interesting that their conclusions regarding breast self-examination have not been generally construed as being politically incorrect. After all, several aspects of political incorrectness, ones at least as incorrect as your more standard species of political incorrectness, can be readily identified within the Cochrane review. For example, one could easily allege that anti-women, anti-self-empowerment, or anti-early-detection thinking riddles this report. And if the review had emanated from say, the White House, one almost certainly would. But in fact most media reports, while expressing a certain amount of surprise, have seemed very reluctant to criticize the Cochrane Collaboration’s conclusions. And physician experts who have been excavated by the media for their comments have also given at least tepid support.

(Not all commentators have blindly accepted Cochrane’s recommendations. DrRich refers you to his colleague Trisha Torrey, for example, who expresses an appropriate amount of skepticism. But the traditional media, and their Rolodex physicians, have on the whole swallowed it. See here and here.)

The general support for Cochrane’s report on breast self-examination, DrRich submits, is a direct reflection of the exulted position that RCTs have achieved today all across the modern medical (and media) landscape. If a statistically legitimate RCT reaches some conclusion, no matter how strange, counterintuitive, or wrong that conclusion might seem, it is a conclusion that must be accepted. That this belief in RCTs trumps even the powerful social force of political correctness speaks to its ultimate strength.

DrRich has previously observed that our widespread belief in RCTs 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. True Believers will not see the irony, thus providing even more evidence that what we’re dealing with here is indeed a religion and not objective scientific thought. (Religions deal in mystery, and not irony.)

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. They are like smart trial attorneys, in that 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 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 lots of enrolled patients much less likely to respond, 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 product, you design an RCT that preferentially enrolls 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 in any way eliminate statistical bias, as most seem to think. 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.

DrRich does not know if the people who designed the RCTs looking at breast self-examination tried intentionally to bias the results against self-examination, or if it was an accident. But that is what they did.

The RCTs which the Cochrane Collaboration reviewed looking at breast self-examination indicate that, in large populations of women in Russia and China, who go on to receive Russian and Chinese healthcare, breast self examination did not improve overall survival. And since those who did self-examination underwent twice as many breast biopsies, many of which revealed benign lumps, they experienced net harm. DrRich does not quibble with any of this. It is almost certainly true.

On the other hand, while most RCTs do not reveal it (since they look at aggregate results and not individuals), it is most often the case that some individual participants in even a negative study will experience benefit from the intervention being tested. In the breast-self examination studies, for instance, it is a certainty that individual women benefited at least to the extent that their breast cancers were detected earlier than they otherwise would have been. (In the Russian study this was proven to be the case.) These women had at least a shot at better survival by virtue of their earlier detection.

But whatever the overall results of these RCTs conducted in such exotic locales, they can have nothing whatsoever to do with women in America in 2008, who receive far more aggressive, tailored, and sophisticated therapy for breast cancer than women in virtually any other country in the world. (The optimal treatment of breast cancer depends on correct staging, on correct genetic testing of the tumor, and on optimizing the individual’s surgical and medical therapies, often employing very new drugs.) In any case, earlier detection of breast cancer is far more likely to be a significant factor in determining outcome in the U.S than it is in recently (or presently) Communist countries with 3rd world healthcare systems.

To be sure, DrRich does not pretend to know anything about the various specific institutions in Russia and China where these studies were conducted. Perhaps they were conducted in those rare showcase institutions that appear here and there under authoritarian regimes, of the sort Michael Moore frequents when he goes to Cuba, and where the level of medical care is said to more nearly approximate medical care in the United States. (Occasional institutions like this will survive even in the U. S. after Healthcare Reform, so that our Congresspersons will have someplace to go.) While this seems very unlikely - could a few showcase hospitals really accommodate the nearly 400,000 women enrolled in these studies? - one must suppose it is possible.

But even if all 400,000 study participants received showcase healthcare, advances in the therapy of breast cancer since the 1990s, when these women were studied, would likely yield different (and better) results today. Does any American oncologist believe that the early detection of breast cancer in 2008 does not improve a woman’s prognosis?

In light of such considerations, why are American doctors apparently so ready to accept the results of the Cochrane review, and to stop recommending breast self-examination? The answer is clear: It is because the data came from RCTs, and since RCTs always yield the truth (you heathen), all other considerations must fall away. Such is the depth of our faith.

DrRich will leave it for another day to discuss the favorable implications to the healthcare system of discouraging breast self-examination (such as having to pay for fewer biopsies), or the lessons that ought to be learned from this example about the advisability of blindly accepting formal guidelines just because they are derived from RCTs, and instead will simply give some friendly advice to the women who might be reading this blog:

First, it is probably a good idea to continue with your breast self-examinations. The downside of doing so is that you may be subjected to a breast biopsy for a benign lump. So take that into consideration. But the upside is that self-examination offers the (proven, according to the RCT data) potential for earlier detection, and therefore offers better odds of long-term survival if cancer is present.

And second, if breast cancer is diagnosed, try to get your therapy in the U.S. rather than in Russia or China. For the average patient in those countries, it would appear that cancer therapy sucks.

Finally, DrRich will close with this plea: Can our guideline writers, at least in the U.S., please refrain from creating new guidelines that are suitable for 3rd world healthcare systems, at least for the year or so it might take for the American healthcare system to actually be reduced to those levels?

Doctors now have an 18-month reprieve before the next round of pay cuts are scheduled to kick in. And members of Congress, who were unable to stomach the blowback that would have occurred if they had allowed the relatively “small” pay cut this year, fully realize that they’re not going to get away with the next one either, which is scheduled to come in at 20%. This gives them 18 months to find a solution to the physician reimbursement mechanism which, DrRich reminds you, they all agree is broken.

That reimbursement mechanism, of course, is so fundamentally ridiculous that it can only be understood by recognizing that it is a fairly typical bureaucratic attempt to covertly ration healthcare. Covert rationing requires systems that maximize complexity and inefficiency. So, while regulators might have achieved the desired cost cutting by the simple expediency of declaring an arbitrary series of pay cuts for doctors, they instead saw fit to conjure up a truly Byzantine system of rules, formulas, regulations and calculations, whose machinations are somehow linked to projected changes in GDP, which themselves are the product of arcane and mystical divinations made by such prevaricators as econometricians. This sort of “system” serves covert rationing well. It allows Congress to represent the physician pay cuts as being the result of a scientifically derived and economically justified process, which is so finely calibrated as to make it nearly a crime for Congress (or anyone else) to “adjust” it .

We aren’t supposed to notice that the physician reimbursement mechanism fails to recognize even the most basic principles of economics. And if doctors point out that neither the number of sick people nor the overhead of medical practices track in any way with the projected GDP, they reveal themselves as being either unsophisticated or greedy. Either way, they can be safely ignored.

At least, that’s how the process is supposed to work. With this latest round of scheduled pay cuts, however, while Congress did its best to take the issue to the wall, in the end our elected representatives were forced to admit that the physician reimbursement system simply doesn’t work. By this admission we can only conclude that the reimbursement system at last has become politically infeasible. .

Infeasible though it might be, Congress is far from prepared to come up with a substitute. As Mr. Pear reports, “Democrats and Republicans agree that. . . fixing it would be phenomenally expensive.” For instance, if Congress were to do what at first blush seems to be the most logical thing, that is, to simply repeal the current mechanism and allow payments to doctors to grow at the rate of medical inflation, the Congressional Budget Office estimates it would cost Medicare $65 billion in the first five years and nearly $200 billion in the next five years. You go tell the voters that doctors are worth that kind of money.

The bottom line: Paying doctors in some reasonable manner is simply not an option.

The solution Congress is turning to, according to Mr. Pear, is to assign the job of figuring out physician reimbursement to the doctors themselves: “Lawmakers are pleading with physicians’ groups to come forward with a comprehensive proposal.”

We have seen, of course, the sort of thing that happens when you turn over to “physician’s groups” the honor of figuring out how the limited physician reimbursement pie is going to be divvied up. The RUC is the result of such an effort, and there, as one would expect, the powerful specialists have completely overwhelmed the voice of the relatively weak primary care physicians, much to the detriment of not only the PCPs, but also of patients, the healthcare system, and the healthcare budget itself. (While some may consider it ironic that a process initiated in an effort to covertly ration healthcare ends up increasing costs, this is actually the most common outcome of the programmed inefficiencies that invariably accompany covert rationing efforts.) In any case, Congress now proposes more of the same - that is, let the doctors figure it out.

DrRich has pointed out many times that doctors really do want to do what’s best for their patients, and that indeed, wanting to do what’s best for their patients is as high as number three on doctors’ priority list. Priority number one is maintaining their individual viability as practitioners (a priority that requires them to keep the payers happy above all else). And priority number two is protecting the integrity their professional turf, that is, maintaining the prerogatives of their specific medical specialty. (Cynics should recognize that no doctor who ignores priorities one and two will very long be in a position to exercise priority three.)

Congress is now proposing to remake the physician reimbursement system by turning it into a turf battle among physician groups. The battle will be bloody.

Congress is faced with a kennel full of starving dogs, of many various breeds, and has decided it will feed them with a single lamb shank. Rather than figuring out how to distribute the lamb shank so that smaller (yet valuable) dogs will not be torn apart in the struggle, they have elected instead to just go ahead and toss the shank over the fence, and let the dogs figure out how to divide it up. The result will not be pretty, nor will it be hard to predict.

DrRich would rather not watch. He merely (as a courtesy, no more), shouts this new warning to PCPs (the smallest dogs in the kennel). He will then hide his eyes from the carnage.

One of the more remarkable responses to this article came in the form of a blog entry by DrRich’s colleague Annie, an entry which was, let’s say, critical.

DrRich is very sorry to have raised Annie’s ire, especially since Annie represents a combination of two of DrRich’s favorite kinds of people – nurses, and students of the Constitution. It is in this latter capacity that she writes for the blog Home of the Brave, a site that, if a bit leftward-leaning for DrRich’s tastes, is nonetheless dedicated to the very worthwhile goal of discussing “U.S. history, the state of the union, the state of the U.S. Constitution.” DrRich even gave top billing to one of Annie’s posts last week in Medical Grand Rounds – her nicely tuned article showing what the Founders might have said about the current sad state of the American healthcare system, an article which he now recommends again to everyone.

This public recognition of Annie’s obvious merits, despite the article she had written in response to DrRich’s posting on doctor-nurses, ought to attest to DrRich’s essential fair-mindedness and objectivity. For in that article Annie was less than kind to DrRich’s sensibilities. For instance, referencing DrRich, Annie said,

A few physicians are skeered of a new demon. They’ve got their Salem witch hunter judicial robes on, and they’re ready to order the press, the pyre or just a good old pompous piosity to their screed. What has their panties all in a bunch?

Doctorally educated nurses. I. am. not. making. this. up. They’re afraid of nurses.

What nurse bashing this is and based on what? Fear of competition?

Annie goes on some more about DrRich’s manhood and such (for the record, DrRich does NOT wear panties), but you get the idea.

More relevantly (more relevantly, at least, to everyone else if not to DrRich), Annie’s post points out that: a) nurses with doctorate degrees are not a new phenomenon; b) the vast majority of nurses are not out to displace physicians, or to usurp the title “doctor;” c) since there is an acknowledged shortage of PCPs, surely something has to be done to fill the void, and nurses – working in full partnership with doctors, as always – can help; d) the formidable Mary Mundiger (formidable, at least, to the lily-livered DrRich) does NOT speak for the large majority of nurses; and e) the organization that actually does speak for most nurses is the very reasonable American Association of Colleges of Nursing (AACN).

And the AACN is greatly disturbed by ideas, put forth by misguided paranoids like DrRich, that doctor-nurses may be getting ready to take over for actual physicians, and is distressed by the blowback that has already been experienced by the nursing profession as a result of such ideas. Indeed, Annie points out, the AACN is so alarmed by the resolutions being considered by the AMA (described here) - resolutions that, if passed, would potentially result in sending nurses a strongly worded letter - that it has issued a white paper itself urging the AMA not to take such drastic action.* This white paper passionately expresses

concerns regarding Resolutions 303 and 214, which are coming forward to the American Medical Association (AMA) House of Delegates. . .AACN is distressed by the tone of these resolutions, which may weaken the good working relationships established between many physicians and nurses….AACN requests that the AMA withdraw Resolutions 303 and 214, and if that is not possible, we urge members of the AMA’s House of Delegates to vote against these measures.

That is (Annie assures us, and the AACN certainly confirms), nurses, even most of the doctorally trained ones, want to play nice with physicians. And DrRich’s screed on the impending take-over of American medicine by hordes of aggressive nurses is both overdone, and very counterproductive.

In response, DrRich can only offer that he fervently desires that Annie, and any others who may have been offended by his earlier post, go back and read it again, but this time read it keeping in mind the following prompt: Irony. For DrRich’s comments were mainly aimed at satirizing the response of the emasculated and morally bankrupt medical establishment to the inevitable encroachment by nurses on what has traditionally been medical turf. DrRich was attempting to be ironic. (A colleague of DrRich’s, reading Annie’s posting, commented that those who miss the poorly-hidden subtleties of irony also may be likely to miss the well-hidden subtleties of difficult medical diagnoses. But this is unkind and likely incorrect, and DrRich chooses not to subscribe to it. Besides, this snide comment presupposes that DrRich does irony well, which may not be a good bet.)

Furthermore, DrRich would like to go on record to say that virtually everything Annie says (except for the personal stuff about his cowardice, Puritanical judgmentalism, exaggerated piety, panties, etc., much of which is simply not true) is pretty much correct. DrRich agrees that the large majority of nurses have no intention or desire to fundamentally displace American PCPs. And DrRich further agrees that doctors who resent nurses because they think they’re after their jobs are badly misguided.

But it’s not because ascendant nurses aren’t about to displace them that they’re misguided. They are indeed about to be so displaced. Rather, they’re misguided because most nurses don’t want any part of it either, just like Annie says.

Anyone who had read DrRich’s earlier articles on the plight of the PCP would understand that he does not consider the prospect of nurses encroaching on the turf of PCPs to be evil or bad, but simply the normal pattern in a modern society wherever advancing technology enables lesser-trained individuals to do things that in the past required highly-trained specialists. DrRich would never bash nurses for simply playing their natural part in the evolution of a technological society. He would sooner criticize a grizzly bear for dining on the entrails of an elk which had died of the mange.

The quotation Annie provides from the AACN white paper, protesting because the AMA is accusing nurses of doing what nurses are, in fact, doing (however involuntarily it may be) is quite telling. The train is leaving the station. The writing is on the wall. While it is clearly not Annie’s intent, or the AACN’s intent, or the AMA’s intent for nurses to replace PCPs, it’s happening just the same, as the night follows the day. Neither the PCPs, nor the nurses who may be startled and intimidated by the prospect, can ultimately stop it.

Those doctors who do view the encroachment by nurses as an unadulterated evil deed will see the protestations of innocence by the AACN - while events on the ground so clearly contradict them - as something similar to the soothing murmurings of the Japanese Ambassador while preparations for Pearl Harbor were in their final stages. They will see it as disingenuous at best, treachery at worst. But viewing it this way is simply wrong.

The posting by Annie and the white paper of the AACN are actually indications that most nurses are as apprehensive as are the PCPs they are displacing. And why shouldn’t they be? Look at the new responsibilities and risks the nurses will be acquiring - medical, moral, legal, financial and otherwise. Historical upheavals like this are often unkind to all parties involved, even the supposed “winners.”

If further evidence is needed that DrRich is correct (beyond simply studying the history of technological societies), simply read the July 2008 Update of the Hospital Outpatient Prospective Payment System issued by CMS. This document (if you can get through it) among other things removes language from the Medicare Benefit Policy Manual that had required that “services furnished in provider-based departments of hospitals must be rendered under the direct supervision of a physician who is treating the patient.” That is, non-physician care providers are now allowed to provide care for Medicare patients in a hospital outpatient department without any supervision by any physician who is caring for the patient.

CMS is already there, and is very obviously clearing the path for the inevitable. Everybody needs to get ready for this - the PCPs, and the patients, and even the reluctant nurses.

* This is an example of irony.

Depending on which news source you read, physicians either are or are not about to get hit with a 10.6% pay cut from Medicare. (The actual outcome of the pay cut kerfuffle, some say, will depend on how many Republican Senators are buttonholed by how many American doctors at July 4 picnics.)

Many people have formed rather firm opinions on this matter. Physicians, for instance, mostly disapprove of the pay cuts. Others (most often non-Medicare-aged non-physicians with what is termed today a “progressive” outlook) feel strongly that doctors are among the most coddled and advantaged groups in the land, and that a modest sacrifice like this pay cut is the least they ought to be willing to offer for the public good. And of course, DrRich himself has an opinion on the matter, which will be well-known to most readers of this blog.

But on the other hand, most Americans haven’t really given it much thought. After all, most Americans are not doctors, they’re not on Medicare, they’re not politicians, and they’re not sick. Besides, some have suggested, the Bible-thumping, gun-toting masses are too disaffected with such concerns as the cost of gasoline, food prices, job security, health insurance, and the 15 (or 16 - one loses count) consecutive losing records of the Pittsburgh Pirates, to be able to concentrate on the truly lofty questions. Furthermore, it is commonly believed by well-educated (and especially progressive) persons that the great unwashed are just a bit too dim to understand the really important issues, and so must be reassured (and led along) with easy-to-digest, 10-second “executive summaries,” which can be repeated over and over and over, as needed. So, for instance, we can’t let a few greedy doctors and fat cat Republican Senators destabilize Medicare.

DrRich, on the other hand, who was himself held in captivity by two of these Bible-thumping, gun-toting hoi polloi for the first 18 years of his life before escaping to more enlightened environs, grudgingly came to realize they weren’t so dumb after all. Indeed, in comparison to many of the Harvard-educated Top Scientists and Top Doctors with whom DrRich (who did not go to Harvard) has had the honor of working, Mom, Dad and the guys in the steel mill (with whom DrRich also had the honor of working, back when America still had steel mills) displayed a very comparable degree of innate intelligence, and a far superior degree of general wisdom and common sense.

But not even Dad (the smartest man DrRich ever knew, uncommonly smart even for a steel worker) could have figured out how doctors are getting paid today, or what’s up with the projected physician pay cuts. (He would have easily brushed aside the assertion that doctors themselves ought to embrace the cuts out of a sense of altruism, or alternatively, guilt.)

The sad fact is that anyone who actually tries to look behind the headlines to figure out why physicians are (or are not) about to get hit with a 10.6% pay cut by Medicare will quickly be swept away by a maelstrom of tangled laws, policies, regulations, interpretations, guidelines, secret committee proceedings, quid pro quos, tit for tats, and “unintended consequences” of both varieties (i.e., the actually unintended ones and the secretly intended ones), that surpasseth all understanding.

Go ahead, try it yourself.

First, DrRich recommends you study the Happy Hospitalist’s latest exposition on how doctors actually get paid. It is the clearest explanation DrRich has ever seen. But even though Happy has taken very great pains to simplify the processes involved, in order to make them remotely understandable (and to such effect that he deserves a Pulitzer, or whatever the blogging equivalent may be), their complexity is breathtaking. Trying to explain how physicians get paid is akin to explaining how one achieves the mystic vision of the Great All; one can come close to the truth with the use of language, symbols, graphics, analogy, starvation, exposure to the elements and controlled breathing, but one must actually experience it to appreciate the essential wonder and transcendent awe.

Then, for a clear explanation of how changes to physicians pay are accomplished, DrRich insists you deconstruct Robert Laszewski’s article in Health Affairs. This is merely a description of Congressional procedure, not really that much more complicated than most things Congress does, and is necessarily much simpler to follow than the Byzantine convolutions tackled by the Happy Hospitalist. But still, it is fairly frightening that any aspect of America’s healthcare is decided in such a manner.

However, to really begin to get a general idea of the complexity of the whole system, one must synthesize these two articles - the process for regulating the system of physician reimbursement (Laszewski) and the system of reimbursement itself (Happy.) By “one,” DrRich is referring to you, the reader, as it is far beyond the poor abilities of DrRich to do so himself.

Don’t feel badly if you can’t synthesize this mess, either. For in truth, the physician reimbursement system is not meant to be understood by mortal man.

And that’s the point.

It turns out that this incomprehensible physician reimbursement system was set on its current path by one simple desire: to force doctors to covertly ration healthcare. As Laszewski explains in another article,

The idea was to set an “affordable” physician cost trend and when real costs exceeded that level Medicare would compensate for it by cutting future fees. The. . .message to doctors was simple: If you spend too much the Medicare program will compensate by cutting your fees in the future to balance things out. The objective was to give physicians a reason to control their costs.

Yes, that’s right. The original purpose behind this whole mess was to induce physicians to stop spending so much of Medicare’s money on patients’ medical care.

But when you set out to do such a thing, you can’t just come right out and say so, because that would be admitting to rationing. Instead, you’ve got to hide your real purpose in soothing language (generally it’s best to employ irony, and talk about improving efficiency and quality), and in bureaucratic processes that are so convoluted that the casual observer (or even the serious investigator) will not be able to discern their real intention.

Things get bad enough, as DrRich has described numerous times, when the bureaucratic entity running the covert rationing effort is a private insurance company.

But to really appreciate the potential for the opacity, complexity, and inefficiency demanded by covert rationing, one must study the government’s efforts in this arena. To the mere goal of profit which is the lifeblood of any company (too often fueled by excessive greed, one must admit), add the much stronger and additional aims of power and influence that fundamentally motivate our politicians, regulators, administrators, and others too numerous to mention who work for the government. Then stir in the absolute need to make convoluted deals, compromises and concessions with sundry interest groups and diverse colleagues and acquaintances, influences that may or may not have anything whatsoever to do with healthcare. Pretty soon you have the kind of “system” that is partially explained by a synthesis of the exertions of the Happy Hospitalist and Robert Laszewski.

The current physician reimbursement system is emblematic of what we might expect if we turned the entire healthcare system over to the government, and those who rail against such a single-payer system ought to use this example as an object lesson. For those who favor a single-payer system, however, such examples are simple to counter with illustrations of the egregious and heart-rending abuses perpetrated by private health insurers.

This is all to say that the real issue is not so much with the government or with the private insurers. Whatever travesties these entities perpetrate simply follows from the job we’ve all given them, which is, to ration our healthcare covertly. Covert rationing is rationing by whatever means you can get away with, and so utterly requires head fakes, misdirection, systematized inefficiencies, complexity, delusion (of self and others) and flat out lies. These things simply cannot be accomplished in a system characterized by transparency and smooth efficiency.

So if we’re going to continue rationing healthcare covertly, it really doesn’t matter all that much whether the rationing bureaucracy is controlled by the feds or private insurers. As the (other) Poet says, Fire or ice; either will suffice.

Welcome to Medical Grand Rounds, Volume 4, Number 41, July 1, 2008. This week, bloggers from across the Internet have submitted articles that will help us celebrate the 232nd birthday of the United States of America. Their patriotic postings, organized according to their relationship to the Founding, follow:

Lists of Grievances

Annie at Home of the Brave sets the tone for this week’s Grand Rounds. She does a brilliant job showing what the Founders might have said about the current state of the American healthcare system, in What They Were Saying: A Riff on the Declaration and Resolves of the First Continental Congress. The First Continental Congress, of course, met in 1774 to petition King George for a redress of grievances stemming from the Intolerable Acts. The King rebuffed their petition and a shooting war broke out the following year, which led to, well, quite a bit. (Faced with their own intolerable Acts, many doctors, in stark contrast to the Founders, simply keep their heads down and continue making those little marks on their Pay For Performance checklists.)

Ian Furst of Wait Time & Delayed Care is Canadian and knows something about healthcare and the bureaucracy (not that doctors in the U.S. have any excuse not to know the same thing). Ian analyzes the results of England’s 4-hour ER wait-time guarantee, and shows once again how bureaucrats tweaking one variable in a complex system always manage to create interesting unintended consequences. But, since these unintended consequences will always require further bureaucratic activities in order to produce corrections, they guarantee perpetual growth of the bureaucracy, and thus are seen, by the people who really matter, as exceedingly good things.

Speaking of the proper limits of government, Doc Gurley considers, in her post, Hope and Death, the implications of the California Assembly’s latest bill, essentially requiring doctors to tell patients when they are terminally ill. This information, no doubt, would substantially lower patients’ expectations, and patients with low expectations can be managed very cheaply. (Which explains the legislative impetus to become involved in such matters.) But as Doc Gurley points out, the definition of “terminally ill” is often in the eye of the beholder, and the definition favored by those running the healthcare budget may be quite different from the definition patients (and doctors, if left to their proper medical functions) would favor. Doctors not wanting to break the law (or expose themselves to yet another, particularly promising, form of healthcare fraud) will predictably begin shading the definition of “terminally ill” toward the cost-saving side, i.e., making the determination somewhat earlier than traditional (or proper). DrRich predicts that our faithful public servants will soon take note of the prolonged anguish that will ensue as a result of the newly prolonged (by legislation) duration of terminal illnesses, and their bureaucratic compassion will move them to legislate a mitigation; namely, a law requiring the easy availability of physician-assisted suicide.

The Happy Hospitalist this week offers one of his patented, in-depth analyses of the utter mess that Medicare has become, in This is What You Voted For. For a system that produces the exact opposite of what it says it wants to produce, you can hardly beat Medicare. Happy says, “Look out America, get ready for even lower access to cheap effective [primary] care and a highly expensive and wasteful proceduralization [by specialists] of your friends and family. . .Well America, this is what you voted for. I hope you’re ready to live with the consequences.” Taking into account the bizarre incentives, Byzantine inefficiencies, and systematized grievances that are provided in such luxurious abundance by Medicare, Happy (and DrRich) can only marvel in dazed wonderment that anyone thinks that turning the whole healthcare system over to these people is a good idea. Imagine our honored forebears clamoring to turn over the entire colonial economic system to the perpetrators of the Stamp Act!

And anyone who still thinks any government knows how (or can know how) to run a healthcare system should become a regular reader of Dr. John Crippen’s NHS Blog Doctor, to get a taste of what healthcare across the pond is really like. His recent posting, The Rise of the Healthcare Professionals, describes just a few examples of the systematized dumbing-down of healthcare that has accompanied England’s NHS, and will accompany any system in which codified policies, procedures, and guidelines, handed down from on-high and strictly enforced, replace genuine medical thought.

Inalienable Rights

DrRich has always been amused by those boutique diseases that doctors occasionally invent in order to justify new avenues for payment. Psychiatrists (in DrRich’s humble opinion) have been particularly adept at this game. Dr. Shock MD PhD gives us his opinion on the latest such neo-diagnosis - Internet Addiction. Dr. Shock, we are happy to note, is not enamored with this new disease, and to his very great credit finds in America’s founding documents an inalienable right to the Internet. All self respecting bloggers must unite against declaring as a disease the robust appreciation of the Internet!

The anonymous blogger who writes How to Cope With Pain wonders in Can I Still Blog? whether blogging is an inalienable right - and concludes that while it may be a right, the fact that something is a right does not necessarily relieve you of the attendant risks or consequences. So that’s why all those other physician-bloggers choose to remain anonymous! Is it too late to inform you that DrRich is actually a 58-year-old housewife from the upper Midwest who learned everything she knows about medicine from Dr. Kildare reruns?

Alvaro at Sharp Brains talks about the inalienable right of men and women to own functioning brains - and what they can do to keep them - in Why We Need Walking Book Clubs.

Theresa Chan at Rural Doctoring tells a painful story, in Another Reason Why Healthcare is Going Down the Toilet, documenting how some patients (and patients’ families) feel they have an inalienable right to all the time and toil they desire of physicians, and for free.

The Spirit of the Individual, That Which Made America Great

Rob, at Musings of a Distractable Mind, shows us that the independent, creative spirit that made America what it is remains alive and well - even in PCPs! DrRich has long maintained that PCPs need to think outside the box in order to salvage their profession, and in What are You Going to Do? Rob demonstrates thinking that is, uh, way outside the box.

Over at Insure Blog they’re talking about another aspect of the right to fend for yourself - this time, using a patient’s own cloned immune cells to treat cancer. This research, which comes from the UK, is not funded by the National Health Service, nor has the NHS expressed the least interest in it. So, one might say, the British government is keen to remain “independent” of potentially expensive cancer cures. Read about it in Interesting Cancer News.

David E. Williams at the Health Business Blog tells us about an idea whose time has surely come - enticing patients to take their medication by rewarding them with chances in a lottery. Now, what can be more American than that? Go read You gotta play to win.

Kim of Emergiblog reminds us in Give Me Empathy, or Give Me . . . Another Nurse, how, when we are sick and frightened, nothing can soothe us like the presence of a confident, knowledgeable and empathetic nurse. The continued empathy of nurses is quite remarkable to DrRich, who notes that nurses are under as much stress from the bureaucracy as are doctors. Add to that the stress from being expected to follow orders from those harried, frustrated, angry, not-always-clear-thinking doctors, while still doing the right thing for the patient - dual responsibilities that are not always 100% in alignment. Continued empathy under such challenging conditions can only be attributed to individual character and dedication.

Kerri of Six Until Me reminds us in My Own Shoes that knowledgeable, intelligent and rational patients will always take doctors’ recommendations under advisement, but may ultimately decide that their own personal situation is best served by some deviation from those recommendations. Such patients are not being “non-compliant;” they are considering the doctor’s advice within the context of the totality of their lives (which will always include data their doctors can never fully understand), and exercising their own individual judgment.

Christian Sinclair at Pallimed reports on the practice of hospice medicine during the ongoing Midwestern floods. His report reminds us of America’s greatest asset - the dedication, ingenuity and spirit of individual Americans - which is always most impressive under the toughest of circumstances.

Christine of You Don’t Look Sick tells us how patients can take a major step toward declaring their own independence from a hostile healthcare system - by taking charge of their own medical records. Great advice for any patient.

Standing Up To Powerful Authorities

Dr. Mintz takes on the all-powerful popular media in telling us the truth about the 8 drugs that doctors wouldn’t take. It is very popular to bash the drug companies these days, and accordingly, any negative news about (expensive) new drugs is invariably hyped far beyond any objectivity. DrRich would likely say that this behavior is just another example of covert rationing. But Dr. Mintz more usefully provides the objective truth about these “never drugs.” Perhaps, as a follow-up, he should write about the 8 sources of medical news that doctors (at least the smart ones) wouldn’t read.

JunkMD over at Progress Notes sounds like he’s just about ready to tell the feds what they can do with their latest pay cut. In They Just Don’t Get It, he is fed up both with his Medicare-age Senators and with fellow citizens who expect him to just sit there and take it. Maybe, he allows, it’s time to consider retainer medicine. “Opponents of this model wonder who will see the patients who can’t afford a retainer physician. Well, if none of us are in business, it won’t matter.” That sounds about right to DrRich.

DrRich his own self offers an alternative (and most uplifting) explanation for the fact that doctors apparently owe the IRS multi-millions of dollars in unpaid taxes. Rather than merely being tax cheats, perhaps these physicians are emulating their forebears who nobly defied oppressive Acts of Parliament by throwing tea into Boston harbor. But then again, perhaps not.

The Freedom From Misinformation Act

Dean Moyer of The Back Pain Blog helps one reader declare her independence from misinformation by answering the question Can Herniated Discs Really Heal?

Dr. Paul Auerbach at Medicine for the Outdoors tells those who are exposed to the smoke from wildfires (now raging in California) how to stay healthy. Being aware of oncoming threats in this case is a bit more complicated than “one if by land, two if by sea,” but is no less important.

When DrRich was a medical student, the only decent doctor show on TV was Marcus Welby, MD - a series that was heavy on personal interaction but weak on medical information. So cracking the books was the only good option for learning a little medicine. Today, medical students have many more options. Monash medical student, for instance, is fighting misinformation (his and ours) by reviewing episodes of House.

David Harlow of HealthBlawg reports on the launch of the Massachusetts eHealth Collaborative’s latest Health Information Exchange (HIE). An HIE is more about interdependence than independence, but then, our Founders also banded together (vowing to hang together so as not to hang separately), in their struggle for autonomy.

And Dr Penna reports on new information on Genetic Risk Factors for Alzheimer’s Disease. If you decide to get the test, don’t tell the government or United HealthGroup.

The Obligations of the Individual in a Free Society

Marshall, the Episcopal Chaplain at the Bedside, reminds us in Returning to those Hard Conversations that doctors caring for the terminally ill should more often just say the plain truth, even when it’s painful (for the doctors) to do so.

Dr. Val and the Voice of Reason informs us that it’s plain to both the Surgeon General and to any beat cop that “most people just don’t know what it means to be a good citizen anymore.” Read her plain-spoken interview with Sgt. Zlotkus here, then go do the right thing.

Tories

Some, when a growing conflict reaches the point of no return, will always side with the more powerful disputant. In the Colorado Health Insurance Insider, Louise writes about why doctors are unhappy, and postulates that as a result many physicians now say they are in favor of universal, single-payer (i.e., government) healthcare. DrRich simply notes that after the American Revolution, thousands of Americans who had favored continued rule by the King moved to Canada and got what they desired; and finds it interesting that today’s Americans who want the sovereign power to take over healthcare could do exactly the same thing (if they were to lose the “healthcare wars,” as unlikely as it now may seem), and with precisely the same result.

Am Ang Zhang of The Cockroach Catcher blog tells us about the systematic abuse of the diagnosis of Post Traumatic Stress Disorder by “an alliance of antiwar psychiatrists, VA hospital administrators, and patients who never saw combat or even Vietnam service but found that reciting the PTSD symptoms would result in the awarding of disability payments.” Read about it in PTSD: Diagnosis du Jour. Even John Adams has an opinion about this one.

Picnic Advice, or Don’t Be Stupid

RLBates of Suture For a Living wants to make sure we have a happy 4th. She posts again this year on fireworks safety - a matter whose importance she, a plastic surgeon, unfortunately knows all about.

The Samurai Radiologist at Not Totally Rad offers advice on keeping kids from ingesting foreign objects in Coming Soon to a Child’s Stomach Near You. SR helpfully reports on a missive he received from a concerned parent who is dismayed by the existence of such a thing as Kellogg’s Lego Fruit-Flavoured Snacks: “I just spent the first three years of my son’s life trying to get him not to eat blocks, and now you’re telling him they taste like [fornicating] strawberries. Thanks a lot assholes.” Picnic advice like this you can’t get just anywhere.

What Doesn’t Kill You Will Make You Stronger

Americans have learned repeatedly that adversity produces strength. So, if the rising prices of food have you down, Walter, at Highlight Health, urges you to be of good cheer! In The Upside of High Food Prices he describes how more people are eating local produce - and eating healthier. He neglects to point out (though DrRich will kindly take up the slack) the other problem caused by cheap food that is now being mitigated. We refer, obviously, to the fact that cheap food is the chief source of what has become the latest scourge-of-society: obesity.

Service and Sacrifice

Fighting for what you believe in is always costly, and the cost is never more apparent than in Healthline’s posting on Suicides in US Troops. If you know a serviceman or servicewoman this holiday, let them know how much we all love them and value their service and sacrifice.

The Most Important Aspect of Any Holiday

Bongi at other things amanzi offers us the sad and most affecting story of little k. On this holiday - or any holiday - the best lessen we can take away from k’s story is to gather around us those we love, give them a hug, then count our blessings and thank God for every one of them.

Next Week’s Grand Rounds

Next week Grand Rounds will be hosted by The Blog that Ate Manhattan.

In honor of the 232nd birthday of the United States of America, please try to relate your submission to some aspect of Independence Day (note to Gen X: the historical event, not the movie). In ginning up such a relationship, don’t be afraid to stretch things a bit. For instance, a submission might relate to July 4 by touching upon topics such as:

• the inalienable rights of man
• lists of grievances
• battling against all-powerful enemies
• admirable handwriting
• noble hypocrisy (such as, creating soaring rhetoric on the inalienable human rights while holding slaves)
• fireworks
• men who wear wigs
• men who are whigs
• picnic shirts and other attire suitable for dining out of doors
• winning by not losing
• the advisability of eating potato salad on such a hot day
• points of no return
• The World Turned Upside Down
• things that can be accomplished without any help whatsoever from Washington, D.C.

You get the idea.

You may send your submissions to: DrRich@covertrationingblog.com.

DrRich is shocked (shocked) not only that a body of Solons such as Our Congress could so egregiously misinterpret the actions of forthright American physicians, but also that the WSJ itself (a bastion of American capitalistic thought) could fail to recognize the true nature of those actions.

For DrRich suspects there is an alternative explanation that places the alleged tax deficiencies of American doctors in a somewhat different, and far more heroic, light. Namely, when (if) doctors are withholding tax payments, they are not doing so as common tax cheats. Heavens, no. Rather, they are doing so for entirely justifiable and noble (if illegal) reasons.

First, they are trying to break even. In contrast to what is seen with most of the revered professions (wherein the payment due to the professional is transparently negotiated, or is simply “set” by the professionals themselves according to what the market will bear), the pay of physicians is determined by Acts of Congress. Even now, before the next set of impending, Congressionally-determined physician pay cuts, Medicare does not reimburse doctors enough to cover the overhead of most office visits.* Some say this makes the business of office practice economically dicey. In fact, it is already impossible for a stand-alone, independent primary care doctor to make a living caring for Medicare patients.

Second, Medicare has successfully inculcated the Fear of God into physicians regarding the now-federal crime of healthcare fraud. The penalties for committing healthcare fraud are so onerous that merely being accused of it is enough to induce most physicians to beg for a settlement deal, regardless of the strength of their defense, and regardless of the fact that most such settlements are personally and professionally ruinous. And the opportunities to be accused of fraud are unlimited for even the most fastidiously honest among physicians. (The arcane E&M coding rules, which have been formally proven impossible to follow, afford the opportunity for the feds to point the fickle finger of fraud, quite arbitrarily, toward any American doctor who treats Medicare patients, at any time.) Not wanting to appear fraudulent to Medicare is foremost in the minds of American doctors (which pushes “wanting to help their patients” down to Number Three on physicians’ priority list, right after “wanting to avoid spurious malpractice suits”).

As a result of these two considerations, it is conceivable** that some physicians, wanting to continue the noble practice of caring for Medicare patients, but at the same time wanting to be fairly reimbursed for same (at least to the extent of breaking even), have made a simple calculus. Inasmuch as the government owes them fair reimbursement for services they render to government entitlees, and inasmuch as the government has not been forthcoming with said fair reimbursement (and promises to be even less forthcoming in the very near future), therefore (some physicians may have concluded), they will simply exercise whatever opportunities they may find to recover some of these owed funds on their own initiative. For much the same reason that Congress is proposing to garnish Medicare payments to doctors, perhaps some doctors are garnishing tax payments to the IRS.***

It would indeed be telling if physicians who reach such conclusions (if indeed there are such physicians) have decided to recover funds they feel the government rightfully owes them, not from Medicare, but instead from the IRS. These doctors would obviously have concluded, quite logically, that dealing with the wrath of the IRS is far, far less intimidating than dealing with the wrath of the federal healthcare fraud establishment, whose tactics would make the average American physician beg for the rights and considerations afforded to your average Guantanamo detainee (especially since last week.)

Small wonder that the relatively meek and unassuming IRS has asked for the help of their nastier federal brethren in cracking down on recalcitrant doctors.

Whatever the correct explanation for it, however, the prospect of the IRS and Medicare teaming up in enforcement efforts ought to send chills through every American physician, and should stimulate among them significant second thoughts about their career paths.

Speaking of which, here’s a second thought they should consider, and soon.

*These comments, as usual, pertain almost exclusively to PCPs. Specialists (such as DrRich when he still practiced), are doing just fine, what with the procedure-based reimbursement system their brethren on the RUC have arranged for them. Unlike PCPs, who lose money every time a Medicare patient darkens their door, specialists can make up for lowered per-unit reimbursements by cutting corners and increasing the volume of procedures they perform. It’s not particularly pleasant (or safe), but it is what it is, and the specialists have learned to get by.

**Note to IRS and CMS agents: Hi, fellas. DrRich has no personal knowledge, direct or indirect, of any of this sort of illegal behavior; he is simply taking known facts and extrapolating them to their logical conclusions.

***It is a law of history that bad law and bad regulations eventually create contempt for authority, and progressively render various illegal actions rationalizable, reasonable, justifiable, and finally, ethical. Even those who sympathize with physicians on this matter (and DrRich suspects these are few indeed), would say that that the rationale for not paying owed taxes has progressed certainly no further than the “rationalizable” stage, if that. But the natural tendency of governmental authority to progress toward arbitrariness is the very thing that  led Jefferson to muse that continued societal vitality might require revolutions every few generations. I’m just sayin’.

Whether you are concerned about the care about the quality of your own health care, or the status of health care in America — or both — a wonderful first step in your education is reading Dr. Rich Fogoros’ Fixing American Healthcare.”

Read the entire review here.

He learned this interesting tidbit in a survey he conducted among 800 patients undergoing physical rehabilitation or suffering significant pain. He presented his findings at the American Pain Society meetings in Tampa in May.

DrRich, who knows his readers, suspects that several who are physicians and who are unreasonably upbeat or excessively cynical (either personality trait will do) are at this moment thinking, “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 not suffering from pain or disability, Fishbain reported that “only” 1 in 50 admitted to having murderous tendencies toward their doctors.

The math is not pretty: the typical primary care physician 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. (These statistics assume, of course, 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.)

We have expended much space on this blog describing how physicians have been maneuvered into covertly rationing healthcare at the bedside, how they have allowed themselves to be limited to 7.5 minutes per patient encounter, and how they have acceded to spending those 7.5 minutes making little marks on a handed-down-from-on-high Pay For Performance checklist (thus leaving little or no time for whatever pressing issues may be on the patient’s own agenda). We have described how, to assuage guilt and to make such behaviors seem less than reprehensible, revered medical organizations have formally amended the code of medical ethics, thus officially wrecking the classic doctor-patient relationship - and committing professional suicide.

The fallout from these developments has landed disproportionately on the PCP, the gatekeeper for the bulk of expensive medical services, whose actions the healthcare system must control at any cost. The loss of PCPs’ professional integrity and their ability to act as autonomous advocates for their patients has done far more than the steady ratcheting down of their pay to make primary care medicine exquisitely unattractive, both to current practitioners and to potential future PCPs. (As per design, says DrRich.) Consequently, this carefully manufactured “PCP shortage” will soon become the medical crisis du jour.

When this crisis is finally ripe for unveiling, the healthcare system will be ready with a solution. Doctor-nurses (the healthcare system fervently hopes) will be more malleable than today’s PCPs, less encumbered by tradition, attitude, and delusions of autonomy, and more likely to follow whatever guidelines the “experts” choose to hand them.

But what about the risk to doctor-nurses from murderous patients?

If the healthcare system is wise enough to create enough of these doctor-nurses, they will be able to relax the 7.5 minute-limit-per-patient-encounter, thus decompressing some of the frustration patients now feel when they leave the doctor’s office, and preventing doctor-nurses from becoming as much a target for patients’ wrath as PCPs apparently are today. To receive that extra time however, doctor-nurses will need to use it wisely, unlike their physician forebears. They will need to spend it engaging in relationship-building and other feel-good activities, instead of (as physicians all too often are wont to do) uncovering new, potentially expensive medical issues that need to be explored.

Doctor-nurses are in the catbird seat, and as long as they follow the script and stick to the guidelines, they’ll be given enough time to keep their patients from hating them.

As for the soon-to-be-obsolete PCPs, DrRich has previously made them some friendly suggestions for salvaging their professional integrity, and he cannot understand why they are not adopting them. Are they waiting for the bullets to fly?

*Thanks to Laura Dolson, Guide to Lowcarb Diets at About.com, for pointing DrRich to this important study.

Doctor-nurses will soon be Board Certified, just like, uh, doctor-doctors.

The AMA leadership sees this development as potentially alarming. Doctor-nurses, they suspect, may soon use their new NBME certification status as “as leverage to seek scope-of-practice expansions that cross into medical practice.”

Mary Mundinger, the leading spokesperson for doctor-nurses and not one to mince words, has chosen not to soothe such suspicions. Says Doctor Mundinger, “While a primary care physician went to medical school and did residency, a nurse practitioner with a DNP has achieved many of the same competencies but through nursing education. They have the same skills in identifying a disease state and treating it, but it’s a different hybrid of care.” In other words doctor-nurses have simply taken a different pathway to the same end. Indeed, once doctor-nurses demonstrate their clinical competence, Mundinger maintains, the legal pathways will open to the expansion of their scope of practice.

But the mighty AMA is having none of that. At press time, the AMA House of Delegates was considering several new resolutions that would challenge this clear encroachment on the turf of American PCPs. For instance, the AMA will consider endorsing a policy that recommends that the title “doctor” be reserved for physicians (and dentists, podiatrists, PhDs, and certain sports figures such as Dr. J. - but not for nurses). Another resolution the AMA may (or may not) consider would recommend that the title “resident” be reserved for those in a medical (or dental or podiatry) training program and, presumably, for denizens of nursing homes - but not for those in the “residency” portion of the doctor-nurse training program. The House of Delegates may even consider resolutions protesting the NBME’s decision to offer a certification exam to doctor-nurses in the first place. (The NBME has already responded to such complaints: “We’re a testing organization, and this fit our mission,” said a NBME vice president who, incidentally, is an MD himself.) Finally, the AMA may resolve to “insist” that doctor-nurses practice medicine only under the supervision of doctor-doctors. The American Academy of Family Physicians has threatened to join the AMA in considering these strong actions.

So, it appears, the professional bodies representing the interests of American PCPs may very well adopt the same Ultimate Weapon often employed by the United Nations when it confronts aggressive, threatening dictators around the world (such as Iranian President Ahmadinejad who, while ignoring calls from the UN to abandon his nuclear weapons program, simultaneously threatens Israel with annihilation). In other words, the AMA and AAFP are very close to pulling the trigger to counter a clear and present, self-declared, existential threat with the dreaded Strongly Worded Letter.

Dr. Muldinger is, no doubt, really, really scared.

This is all, of course, a kabuki dance. If the government, the insurers, the AMA, and their own specialist colleagues really cared about primary care physicians, they would not have systematically devalued their training, expertise and time. They would not have allowed the practice of primary care medicine to be reduced to a series of handed-down “guidelines.” If their own professional organizations cared about them, they would not have adopted a new code of medical ethics that make doctors primarily responsible to society’s needs instead of the needs of their patients, thus removing any true professional distinction doctors might have from “lesser” practitioners like doctor-nurses.

The remarkably anemic response of the AMA and AAFP to the aggressively ascendant doctor-nurses, of course, merely reflects how truly weakened the position of PCPs has become. PCPs are, and have allowed themselves to become, well and truly screwed.

Having taken such careful pains to make primary care medicine so exquisitely unattractive to present and future physicians as to assure that the growing “PCP shortage” will become the next real medical crisis, the healthcare system is now grooming its solution to this manufactured crisis, namely, the doctor-nurses. These doctor-nurses will fulfill all the criteria the healthcare system desires for its practitioners of primary care medicine (no matter what healthcare reforms we may end up with). They will be “doctors” who are duly “certified” in primary care medicine by respected testing organizations, who have just enough training to diagnose and treat the average patient (i.e., the ones with high blood, low blood, fat blood and sugar), and who will cheerfully, unquestioningly (and with far better compliance than MDs - what with their traditions, attitudes, etc. - can ever hope to offer), follow whatever guidelines are handed down to them by the experts. And they will do it all for less pay and with less lip than the now-obsolete physician PCPs. These new practitioners of primary care medicine will be a perfect fit.

DrRich sees no future in PCPs wasting what little emotional and professional capital they may have left in fighting an ultimately doomed rear-guard action against the doctor-nurses. Given the present state of our healthcare system, the rise of doctor-nurses is as inevitable as the rise of the middle class at the end of the feudal era. There’s little to be gained here in fighting history.

Instead, PCPs need to recognize the realities, and completely reinvent themselves. DrRich has previously suggested how they might approach this difficult but enlivening task. Now that the doctor-nurses have taken another major step to becoming the primary care deliverers of the future (an eventuality which the healthcare system has done everything to arrange), perhaps more PCPs will begin to think more usefully about how they can reinstate their professionalism, and remake themselves in a more sustainable form.

But whatever they do, hitching their hopes to the verbal ejaculations of the AMA, the AAFP, or any other of the professional organizations that have led them to this impasse, seems a particularly useless strategy, every bit as useless as sending the blue-helmeted peacekeepers off to fight your battles for you.