Medical Ethics Smack Down 3: Much Ado?

Posted on February 1, 2010
Filed Under Medical ethics |

Last week, DrRich noted that the Covert Rationing Blog and the ACP Advocate Blog were named as co-finalists in 2009 Medical Weblog Award Competition, in the category of Best Health Policy/Ethics Blog. (Voting continues through Feb. 14.) DrRich, ever the opportunist, latched on to this fortuitous occasion to issue a challenge to Bob Doherty, author of the ACP Advocate blog, to engage in a debate over that very topic - medical ethics. He made this audacious challenge because the ACP is a chief signatory of a new code of “medical ethics for a new millennium,” formally promulgated in 2002 by an international group of medical professional organizations (a grouping DrRich has called - for convenience sake only - the Millennialists). And DrRich has taken great exception to this New Ethics, which, he asserts, does great damage to the doctor-patient relationship and to the medical profession. (DrRich details his objection to the New Ethics here, and describes the right way to do medical ethics here.)

A few days ago Mr. Doherty (who is also the ACP’s Senior Vice President of Governmental Affairs and Public Policy), graciously agreed to engage in this discussion, and promised to do so after consulting with the ACP’s Committee on Ethics, Professionalism, and Human Rights.

DrRich had hoped that Mr. Doherty would reply with a post on his ACP blog, which (since it likely has a vastly greater readership than the CRB), would more effectively give this topic some much-needed airing - and in particular, might engage some of the ACP’s membership (specialists in internal medicine) in this important discussion. DrRich was disappointed, then, when the reply came today in the form of a comment, which was tacked on to a long queue of reader’s comments at the end of DrRich’s posting.

DrRich was also very disappointed by the content of the reply which, fundamentally, was: This is a non-issue, and even if it was an issue, it’s now a settled issue. (So go away.)

Because he fears that his readers may not find the ACP’s response (buried as it is), DrRich will post it here in its entirety. But first he will very briefly summarize his complaint against the New Ethics promulgated by the ACP and other Millennialists.  The New Ethics takes classical medical ethics (which obligates doctors to always place the welfare of their individual patients first) and adds on to it a new ethical obligation, called Social Justice, which obligates doctors to work toward “the fair distribution of healthcare resources.” This new obligation (which is to society) will inherently conflict, at least some of the time, with the physician’s traditional obligation to the individual patient. So, under the New Ethics, the doctor’s loyalty is now officially divided. DrRich asserts that this divided loyalty (which is now declared to be entirely ethical) leaves the patient in a dangerous position, and breaks the profession of medicine.

In the ACP’s response Mr. Doherty begins: “I asked Dr. Virginia Hood, chair of ACP’s Committee on Ethics, Professionalism, and Human Rights, to respond to Dr. Rich’s post. Her reply is below:”

Much ado?

We are surprised to see the comments about ACP and medical ethics. We urge readers to read the actual text of the ACP Ethics Manual (the College’s Code of Ethics) and the Professionalism Charter, which the College’s Foundation helped develop. Both say that social justice is a consideration in medical ethics, but the physician’s primary responsibility is to his or her patient. Resource allocation decisions are policy decisions and are most appropriately made at the system level, not at the bedside. The Ethics Manual discusses at length the clinician’s primary role as an advocate for individual patients. But it also notes the duty to practice effective health care and use resources responsibly, which are not incompatible with being a patient advocate. As the Manual notes, physicians should not overtest or otherwise overuse services:

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available [i].

This is nothing new. Indeed using “effective and efficient health care and health care resources responsibly” for all patients is one way to minimize rationing as the result of an over costly system. The Manual also says that physicians and their professional societies should work toward ensuring access to health care for all and the elimination of discrimination, and deficiencies in availability and quality, in health care services. Likewise, the Charter on Medical Professionalism endorsed by ACP and 120 other medical organizations in the USA and internationally, states that professionalism involves commitments to improving quality of care, improving access to care, eliminating discrimination in health care, and yes, to a just distribution of finite resources. But the Charter explains the commitment to a fair distribution of finite resources as follows:

While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others [ii].

The patient-physician relationship and our medical ethics are the soul of medicine. The blog commentators are correct– it is important that we get it right.

Thank you.

Virginia Hood, MD, FACP
Chair, American College of Physicians Ethics, Professionalism and Human Rights Committee

As much as DrRich may feel he has been condescended to here (as if the ACP has found a fly buzzing around its head and has attempted to swat it away), and recognizing that the ACP has decided not to engage in a give-and-take (which, of course is their prerogative), but rather, has responded with a brush-off statement which they have chosen to bury in the comments section of DrRich’s obscure blog (which is also their prerogative), DrRich will attempt to reply as politely and as analytically as possible. (He does, however, sincerely hope that Mr. Doherty - who really seems like a good person and is an excellent writer - will not be called to the woodshed for obligating an august Ethics Committee Chairperson from this prestigious organization to issue a formal response to an annoying blogger such as himself.)

Dr. Hood’s artful (and dismissive, it seems to DrRich) statement can be fairly summarized thusly: After beginning with the implication that DrRich is making much ado (about nothing), and that she is surprised that anyone would dissent from ACP’s New Ethics, she says that the New Ethics does not entail the problem that DrRich alleges; indeed, there really is nothing new about it. Of course patients come first. (Just study the various documents the ACP has published on this point.) Cost-effective and efficient care is a part of good medicine, and always has been. What we mean by a fair distribution of finite resources is to practice medicine wisely, so as not to waste resources and not to expose patients to the risk of medical services they do not need.  The legitimacy of the New Ethics is supported by the fact that it has been formally adopted by 120 medical organizations internationally (which to DrRich means that when you go to a doctor anywhere, this is the code of ethics under which they are now officially practicing).

There is a lot in her statement DrRich could comment on, but he does not want to bore his readers with a lengthy parsing of this finely crafted response. Rather, he will just talk about its main point.

Fundamentally, Dr. Hood is denying that there’s any problem. There’s no conflict between “the fair distribution of healthcare resources” and doing what’s best for individual patients - and furthermore, she’s surprised anyone would think so.

DrRich does not accuse her of sophistry. Perhaps she is just deceived.

The fact that there are huge conflicts between providing individuals with all the healthcare that would likely be useful to them, and the inability of society to pay for such a thing, is the fundamental problem with the public funding of healthcare. We simply can’t afford to buy everybody all the healthcare that would likely benefit them. There’s not enough money in the world to do that.

Consider just a few of the examples DrRich has discussed here over the years. Implantable defibrillators have been shown to significantly improve the survival of a substantial minority of patients who have heart disease, and indeed guidelines issued by cardiologists’ professional organizations indicate that defibrillators ought to be implanted at a rate of about five times their current actual implant rate. But if doctors actually did that, it would cost Medicare an extra $7 - $8 billion each year. Then there’s the fact that if doctors used the statin drug Crestor in the way the very well-designed and compelling JUPITER trial says doctors should use it, we would be spending an extra $10 billion per year on Crestor. In a thousand ways, the “best” healthcare for the individual is very often not cheaper (or better for society) than less-good healthcare, and DrRich is impressed that Dr. Hood is willing to say that it is.

Dr. Hood would likely deal with this problem, and implies so, by devising “guidelines” that doctors would be ethically obligated to follow. Obviously, it is entirely possible to convert “guidelines” from just that (i.e., a set of guidelines which doctors ought to take into strong account when deciding what’s best for their individual patients) into a set of formal rules that must be followed, and which will then be enforced by federal regulators (and their posse of ethicists). Indeed, such “guidelines” might be one of the ways in which society imposes its own goals over those of individual patients. But that is not the same thing as insisting that individual patients (who often do not fit the “average” profile) will necessarily profit if doctors always follow the guidelines as a matter of policy, or of enforced expectations, or of “quality”.

(Further, as DrRich has pointed out, the rapidly developing paradigm in which “guidelines” are becoming inviolate rules has led competing organizations to rush to issue their own sets of competing guidelines, that best comport with their individual agendas. While this phenomenon of “guideline wars” is endlessly amusing, it may not always serve the best interests of doctors or their patients.)

And then there’s the problem that, no matter how you define “waste” or “inefficiency” or “unnecessary care,” there simply cannot be enough of it to account for the runaway healthcare inflation we’re seeing (as DrRich has shown here). A substantial proportion of this fiscally disastrous healthcare inflation must necessarily derive from the delivery of healthcare that is actually useful.

So the crux of Dr. Hood’s reply - that all the ACP is talking about when it mandates that doctors fairly distribute limited resources is that they ought to practice good medicine, and if they did that simple thing no useful therapy would need to be withheld from any individual patient - is absurd on its face.

DrRich would be less disturbed by Dr. Hood’s assertion if he really thought it was simply a misapprehension of the truth. And perhaps it is. After all, her statement reads as if she is truly surprised that anyone would think otherwise.

Perhaps Dr. Hood came to her high station within the ACP’s Ethics Committee very recently, and is unaware of the history of the new Professionalism Charter which advanced this New Ethics, or of the controversy that was raised by many critics at the time of its adoption, or indeed, of some of the language that was in its penultimate version (and that was likely removed to silence some of those critics). Indeed, she cannot be aware if it, since she is “surprised to see” that anyone is bothered by the Charter, and since she believes that questioning it is but “much ado.”  But to anyone who knows a little of that history, Dr. Hood’s assertion that controversy over this Charter is a novel experience, or most especially, her assertion that this New Ethics is really “nothing new,” would come as a very great surprise indeed.

First, we should note, if the new Professionalism Charter was really “nothing new,” and was just a restatement of the physician’s traditional obligation to place the patient first, and if fairly distributing society’s resources really was just a matter of practicing good medicine, then there would have been no need for a new Charter of medical ethics in the first place. And certainly the need would not have been pressing. It would have served quite nicely instead to produce some sort of document reminding doctors that unneeded healthcare services expose their patients to unneeded risk, so (based on the traditional ethical precept of patient welfare), to remain ethical they must stop being wasteful. Certainly, this kind of wasteful medicine would not produce a need to redefine medical ethics.

But the new Charter’s very first sentence describes something more dire, more pressing, than can be explained by Dr. Hood’s benign assertions. It says, “Physicians today are experiencing frustration as changes in the health care delivery systems in virtually all industrialized countries threaten the very nature and values of medical professionalism.” So: the whole purpose of this new Charter, its entire impetus, was the frustration of physicians.

Frustration? What frustration is that? Interestingly, the document does not come right out and say it. The closest it comes to spelling it out is to say, “We share the view that medicine’s commitment to the patient is being challenged by external forces of change within our societies.”

But even though the document seems strangely reticent about spelling out which frustration produced the very impetus for its creation, we can rely on the fact that the document must be designed to cure this mysterious frustration (whatever it is), and that the only revolutionary change in the document is an addition to the code of medical ethics requiring physicians to work for “the fair distribution of healthcare resources.” We can only conclude that this new ethical obligation is meant as a cure for that foundational frustration, and that therefore this frustration must be that doctors are finding it impossible to meet their traditional ethical obligation to to place their patients’ needs first.

But, as it happens, we do not really have to resort to this sort of documentary detective work to parse out the purpose of the new Professionalism Charter. That purpose was quite open at the time this document was being developed - and it produced robust controversy that was certainly no secret. One can read about this controversy in many places, but for our purposes now (i.e., in replying to Dr. Hood’s assertion that there’s nothing new here, and that it is a matter of some astonishment that anyone would find the Physicians Charter controversial) it might be best to refer to one of the ACP’s own publications from that time.

An article in the July, 2001 ACP-ASIM Observer, which was entitled, “Charter on medical professionalism addresses issues of finite resources,” goes into some length about the controversy. And it is very plain that the objection many raised to the new Charter was precisely that which DrRich is raising now in his challenge to the ACP: that the New Ethics being espoused in the Professionalism Charter fundamentally and explicitly divides the loyalty of the physician between the patient’s needs and society’s needs. When one listens to the defenders of the new Charter (quoted extensively in the ACP-ASIM Observer article), one finds the unmistakable tones of utilitarianism: We have to change our ethical precepts, the argument goes, because that’s just the way the world works now.

This article also indicates that the draft of the Physicians Charter presented to ACP general membership at their annual meeting in 2001, a few months before the final version was finally published, was perhaps more forthcoming than the final version, regarding what it was really all about. For instance, this nearly-final version of the Charter specifically admonished physicians that they must “be aware that the decisions they make about individual patients have an impact on the resources available to others.” One can only assume that this sort of explicit language was taken out of that final version in response to the critics (who were many, and vocal) to soften the blow.

Indeed, the “softer” language of this strange final version (which has all the hallmarks of a heavily edited document, beginning as it does with a heartfelt cry against the frustrations being experienced by physicians, then neglecting to spell out what those frustrations are, and never explicitly saying which aspect of the document addresses those frustrations), is now possibly soft enough, if not read carefully, to allow defenders of the Professionalism Charter to get away with asserting (as Dr. Hood has done) that the New Ethics is really pretty much the same as the old ethics, and does not change anything. (So move along, move along.)

But the New Ethics changes everything.

DrRich is very sorry about this, and is especially sorry that the ACP’s Ethics Committee, and the other 120 physicians organizations that have adopted this New Ethics, insist they do not see a problem here. DrRich assumes by this response that the ACP has little interest in revisiting its new ethical stance, and further, is undoubtedly busily training today’s medical students that doing what’s best for society is the same as doing what’s best for the individual.

This is a theme, DrRich thinks, he’s heard a lot lately.

Patients who want a true advocate in their life-and-death encounters with the healthcare system, an advocate whose loyalty is not divided between them and a society that, with increasing desperation, wants not to spend its money on them, had better go out and hire their own. Your doctor will now find it officially unethical to serve that office him-or-herself.

And meanwhile, we can now be sure that the physicians organizations which are responsible for protecting the ethical foundation of the profession of medicine are quite satisfied with the job they are doing.

******

(DrRich now thinks you should not vote either for him - since he’s particularly out of sorts about this whole ethics thing - or the ACP Blog.  Go vote for the pharma guy.)

Comments

12 Responses to “Medical Ethics Smack Down 3: Much Ado?”

  1. Red Baron on February 2nd, 2010 7:51 am

    Ah Rich, you are a national treasure, even if this is debate has an element of The butter battle book to those without your passion for doctrine. ;-)

    Please remember that for some of us, this is whole doctrinal debate on rationing is simply another version of “a rose by any other name DOES NOT smell as sweet”.

    … But I do understand we all have our own theologies we are willing to go to (blog) war over.

    Be well my friend

  2. DrRich on February 2nd, 2010 9:18 am

    Red,

    Yes, sadly ’tis so.

    I would much rather have received a nomination for “Best Healthcare Satire,” as it would have been lots more fun (and likely more entertaining) to run with that. But as the nomination was for Policy/Ethics, I was left with having to engage in deep wonkification.

    Rich

  3. CD Sudduth on February 2nd, 2010 2:15 pm

    “Indeed using “effective and efficient health care and health care resources responsibly” for all patients is one way to minimize rationing as the result of an over costly system. ”

    Alas, it seems Dr. Hood has been savoring the utilization review “Kool Aid” at her local hospital’s MD appreciation day. Including double speak such as this in the clinical calculus of patient care is also the best way to maximize the physician as the most efficient rationing tool in the policy makers toolbox.

  4. Just_another_Joe on February 2nd, 2010 6:06 pm

    Dr. Rich…I’d have to side with Thoreau here…”Any man more right than his neighbors constitutes a majority of one” Keep at it!!! It doesn’t matter that the ACP won’t engage…after all, they represent the incumbents who have a vested interest in the current system…the conflict you describe is raging in every office visit, every nursing home, every patient suffering from a chronic disease…and it will only get worse as our population ages…doctors should shun the efforts to make them social engineers, and must not leave healthcare policy to politicians.

  5. Robyn on February 2nd, 2010 7:33 pm

    Just_another_Joe - there has been a fair amount of political commentary as of late questioning why physicians have - in general - been missing in action in terms of the debate about the various “health care reform bills”. So why are they MIA? I can understand them not being a part of the AMA efforts (the AMA is pretty much like the ABA (American Bar Association) these days - a mostly liberal group with a liberal agenda - which is why most lawyers don’t belong to the ABA. But there are other more grass roots down to earth lobbying organizations for doctors - like the Florida Medical Association. It gets down in the dirt and lobbies/argues on behalf of doctors all the time. I’m sure there are similar state medical associations. As well as associations that operate on behalf of doctors in particular specialties. Etc. You doctors have to get together and get your local groups to fight for you. Give them money to lobby for you - and stand up and be heard.

    I also agree that health care policy should not be left to politicians - or their wonks. I have a distant cousin who was such a “wonk” in the Clinton administration. He is now a professor. I asked him recently whether he knew the dollar amount of government subsidy to Part A/B Medicare patients with less than $170k MAGI (you need more than that to pay more than minimum Part B premium). To my surprise - he didn’t have a clue. Note that the answer (looked it up) is almost $9k a year. No wonder Medicare is going broke (and the “boomer generation” hasn’t even hit Medicare yet - my husband - who will be going on Medicare - was born in 1945 - he is not a “boomer”).

    BTW - the nursing home problem is more complicated than the Social Security problem (which is very actuarial) - and less complicated than the Medicare problem (which is almost totally non-actuarial). We became good friends with the CEO of my FIL’s nursing home (non-profit religious). He had been CEO for a long time. Average stay costs X (always going up - but more or less in line with inflation) - but average length of stay (from admission to death) has remained pretty much constant at about 2.5 years (perhaps his number is off - but if you get data from 1000 SNFs over a period of years - I’ll bet it’s not off by much). And about 50% of all Americans wind up in nursing homes. That percentage hasn’t varied a lot over the years. His idea - and I thought it was reasonable - was to add a long term SNF component to FICA (not the stupid one that’s been proposed in the health care bills - but a real one). How much money do I need to contribute now to cover 2.5 years of care X years from now assuming inflation is Y and assuming I have a 50% chance of needing a SNF. Numbers can be re-jiggered every 5 years or so to account for changes in inflation. It’s a great idea - except that (IMO) any such fund would probably be borrowed and frittered away by the government. OTOH - it’s a reasonable way for younger people to plan for their possible need for SNFs in the future.

  6. Red Baron on February 2nd, 2010 9:09 pm

    Robyn

    Remove the liberal/conservative label and you will not be so easily “fooled by randomness”.

    If people put more money into the health care system, then the health care system has more money.

    That little fact is all you need to know.

    Now you know which side physicians are on.

    As to wondering whether there are those in some professions who might give up some freedoms for a little more money?

    Interesting theoretical question… I guess that your guess is probably as good as ours. ;-)

    Be well

  7. Just_another_Joe on February 3rd, 2010 8:29 am

    At the risk of trying to give a simple answer to a complex question, practicing physicians have been overwhelmed with the ‘administrivia’ created to assure to payors, regulators, administrators, and the plaintiff’s bar that they are indeed doing a good job (and I would hasten to point out, that what all of this does in encourage/incentivize them to be good at the paperwork, not at clinical care). The onslaught has been so relentless that they have found themselves on a downward spiral from disappointed, to distracted, to disaffected, and most recently, to disheartened and disgusted. I hold out hope that some will resonate with the passion and persuasive arguments of the good DrRich, though many appear to be walking slowly and quietly, head-down, into that gray twilight of a career that once offered the potential of using sharp mind and judgment to help the infirmed, and now offers the threat of regulatory retribution, the nightmare of malpractice litigation, and the constant questioning of one’s ‘true’ motivation.

    The overwhelming majority of physicians I have trained with and worked with early in my career would do anything for their patients, at any time….and yet even these ‘old-schoolers’ have grown weary of the whitering questions and re-examination of their motives and actions. It appears to me that the relentless installation of ‘process’ has methodically separated the doctor from the patient, to the dramatic detriment of each.

  8. Robyn on February 3rd, 2010 7:00 pm

    Hi Red Baron - Couldn’t agree with you more. When I discuss health care policy with people - I always bring up the simple fact that since health care costs are 16% of GDP - it means that every average person/family has to pay 16% of gross income to “pay as we go” (perhaps older wealthier should pay more - and younger poorer should pay less - but it has to be 16% on average - and average in this country is younger middle aged people who don’t earn a ton of money). If we want more (and we will definitely need more as our population ages) - then the percentage has to go up.

    As with FICA (people think in terms of their “take home pay” - not their gross income - and consider their tax refunds when they get them as a gift as opposed to a suggestion that their paychecks are being overwithheld) - people who have employer based health care have for years been shielded from the costs of that care. Because no one tells them what it costs. If I had employees these days - I’d give them an unofficial document showing exactly what I’m paying for them.

    The problem has become acute in recent years because “gold plated” health insurance has become unaffordable except perhaps for high income earners (who don’t need it) - and certain union and government employees. If you talk to any small business person today - they’re hurting - and hurting bad. I spoke with my accountant the other day (small business - maybe 20 employees) - and he was just informed that his group health plan cost would increase 30% in a couple of months. Now he and the other senior partners could afford bigger deductibles - but what about the 30 something receptionist with a kid or two earning $30k a year?

    And yet - I think many people will have to get used to the idea that they may have to give up their iPhones and their HBO and their manicures and their botox (I live in an area where everyone who’s 37 wants to look 27 - at my age - I know I wouldn’t be fooling anyone!) to pay for their health care. Unless they want to enter a new era of health care - the kind that Just_Another_Joe alludes to when describing the current psychological state of doctors who are my age (62) - and perhaps up to 20 years younger. The kind where you see a nurse most of the time for most stuff - and seeing a doctor is a rare privilege - even if the doctor wasn’t trained in the US and doesn’t speak English very well. I can tell you that my GYN (a nationally respected gynecological oncologist - and no - I don’t have cancer - just met him during an emergency hysterectomy) left Jackson Memorial Hospital about 15 years ago because he was sick of spending 90% of his time delivering Haitian babies. He came to Mayo JAX - much better at the time. But he didn’t think for more than 2 seconds when he reached Mayo’s retirement age. He’s history.

    My brother is a nephrologist - and I can always sense the weariness and irritation in his voice when I try to discuss any of these issues with him. I don’t recall the whole history - but a long ways back - the government decided that doctors like him couldn’t have financial interests in dialysis centers - so he had to sell his interest to a bunch of non-doctors. They made all the money and still do (or perhaps things have changed since then - my brother isn’t very open with us about this stuff).

    I can tell you that I as a patient feel caught in the middle. I *like/respect* most of my doctors - and still respect the few with “rough edges” (mostly surgical types with no social skills) because they’re very competent. But when my insurance company tells me to pay $100 to my internist for my annual checkup (very thorough - maybe 45 minutes) - and almost $4k for the MRI I had last month (you read it right - $4k for one MRI) - I have to wonder what the heck is going on. I pay my plumbing firm more for services rendered on an hourly basis than my internist. Love my plumbing firm - it’s worth every penny - and it even makes emergency house calls on Sunday. But I think my internist should be paid a whole lot more - like maybe 3 times as much as current reimbursement rates under my insurance policy (6-10 times as much under Medicare?). I did a lot of hourly work when I practiced law - I hire a lawyer every now and then - and you can’t buy a good lawyer these days for less than about $300/hour (and that’s in Jacksonville - try $500+/hour in a more major metro area). Robyn

    P.S. In all of this - I wonder what people do about dental care - where very few people have any insurance - or insurance that covers more than the basics. My Dad had a complicated tooth extraction yesterday (tooth gave up the ghost and broke into a bunch of parts) - and it cost $700.

  9. Red Baron on February 3rd, 2010 9:45 pm

    So many questions and issues, so little time and I do not want to hijack Rich’s blog.

    Rich and I see eye to eye on a great many issues but we also differ on a great many as well. So please remember that anything I say is mine and mine alone- Rich is a far better physician/humanitarian than the rest of us working docs combined.

    My response?

    I could go into a long tirade on the conservation of energy/fractals and complex systems etc… but I think I will let it go and simply share the following thoughts to help you in your quest to understand “the truth” (whatever that is).

    Think of our current debate in health care as a four dimensional battlefield where the axes are:

    1. Universality (X)
    2. Costs (Y)
    3. Complexity (Z)
    4. Volume (W)

    This is like the standard X, Y, Z axis of a 3 dimensional graph only there is a fourth dimension (w) for volume

    Most people understand 1 and 2 (e.g. Is everyone covered when they get sick? How do we lower health care costs? etc… but many people have trouble comprehending 3 and 4 which I might restate as: 3. “the more complex the care, the more costly the care” (e.g. liver transplants are more expensive than sore throats) and 4. “The greater the volume of care we provide, the more it will cost us” (e.g if you go to the doctor’s office twice a year you will spend twice as much as going once a year).

    So if I understand you correctly, some of the patterns you see do not make sense. Specifically, you do not understand why primary care physicians make so little money.

    My response: competition lowers prices. e.g. issue #3 or complexity

    I suspect primary care physicians are having much greater competition from mid-level providers such as physician assistants and nurse practitioners than the physician sub-specialist are.

    … Rich may have other thoughts on this issue.

    Further it is easier for foreign medical graduates to enter primary care residencies in the US than it is for them to enter sub-specialty residencies..

    The combination of these two factors is keeping primary care physician salaries low.

    … But don’t worry about them too much, the market is adjusting.

    It is the specialists I would be worrying about tomorrow. Hitching one’s horse to a very complex system has its risk as well. ;-)

    Be well

  10. Drthom on February 4th, 2010 1:06 am

    “which to DrRich means that when you go to a doctor anywhere, this is the code of ethics under which they are now officially practicing).”

    an excellent discussion but this statement is presumtive to the point of insult. I am a son of Hippocrates and Osler, of Nightengale and Barton. I stand on their shoulders and I have sworn to practice as they have taught. Being human and imperfect, I fall far short in many ways, not the least of which by sbmitting to membership in societies which allow political expediency to divert them from their true purpose. Now they only distract me, but if it reaches a point that I have to submit to their flawed, collectivist ethical constructs in order to legally practice, I will go underground or overseas.

    I don’t know what the ACP is doing under these guidlines, but it ain’t practicing medicine in any form that the founders of our great and noble calling would recognize………Them calling it medicine don’t make it so. Their moral authority only comes from these foundations those great men and women bequeathed to us. I suggest Dr Hood reread “Equimenitas” before suggesting the ACP’s Guidlines are ” nothing new”

  11. DrRich on February 4th, 2010 7:37 am

    Drthom,

    Great point. I am sure tens of thousands of doctors in the US and worldwide agree with you (I know quite a few of them myself), and are actually doing what they are supposed to be doing for their patients, despite what their ethically bankrupt professional leaders have signed them up for.

    The operative word in the quote you object to, though, is “officially.” Thanks to official medical ethics, patients have little way of knowing, when they see a new doctor, whether they’re getting a party-line doctor who subscribes to the Social Justice At The Bedside directive, or a rebel like yourself. Perhaps the rebels should post a plaque in their office, next to their diplomas, indicating they remain sons (or daughters) of Hippocrates and Osler.

    I have little doubt that medical students everywhere are being taught the stuff Dr. Hood is dishing out. After the stuff they just got finished learning about the founding of our country, at the hands of our public schools and our colleges, I’m very afraid they’re buying it whole.

    Rich

  12. Robyn on February 4th, 2010 8:29 pm

    Red Baron - I understand your 4 axes - but I’m not sure I agree with your conclusion that more competition leads to lower reimbursement for PCPs. I live in a more or less upper middle class zipcode which has experienced great growth since we moved here 15 years ago. If I had to guess - I’d say we have 10-15 times as many doctors now as we had then. And perhaps 90% are in elective/cosmetic specialties (everything from teeth whitening to botox - which it seems every doctor does - to getting bigger or smaller boobs). But it is very hard to a find a PCP. My husband had I had the same internist for over a decade - and when she had to retire at a relatively young age due to illness - we had to find a new one. Took us over a year - and the only reason we found one is an internist from Mayo opened up a new primary care practice - another doctor at Mayo told us about her - we liked her - and were 2 of her first patients.

    Now we do have the PAs in a box at our local Walgreen’s and the like - but I don’t think your average 50+ person with a six figure income (and there are an awful lot of people like that where I live) feel comfortable getting their primary care in a Walgreen’s (my husband and I once dropped into one of those places to say “hi” when we were buying some holiday decorations - and I have to tell you - the provider there knew less about medicine than we do - didn’t exactly inspire a whole lot of confidence). So I think there is something more going on than competition.

    Frankly - one of the areas that confuses me a lot is the discounts we get through our PPO (we are members of an old obsolete state high risk health plan - but it is managed through a national PPO - First Health Network. The PPO discounts range from 5% (at Mayo) to 40-50% at other providers. I can almost understand the 5% discount at Mayo (but not really - since Mayo accepts 60-80% discounts from list prices for Medicare patients) - but not the large negotiated discounts with other providers. Perhaps someone could explain this to me.

    BTW - what do you mean when you say “the market is adjusting”? Robyn

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