On Parsimonious Care

Posted on February 4, 2010
Filed Under Medical ethics |

Regular readers will know that Dr. Virginia Hood, Chair of the American College of Physician’s Center for Ethics, Professionalism and Human Rights, has responded on behalf of the ACP to DrRich’s challenge to debate the New Ethics being promulgated by the ACP (and sister organizations) - and that the ACP’s response was the functional equivalent of an ethics Dear John letter.

The gist of this formal reply was: “There is no ethical issue here at all. It is quite surprising that anybody would take issue with the New Ethics. And indeed “nobody” has.”

DrRich, suitably brushed off, has already delivered his analysis of the ACP’s statement, a disappointing statement which left the fundamental ethical question (namely, why the New Ethics has rendered covert bedside rationing the ethical duty of physicians) not only unanswered, but unacknowledged. So much for the proposed “debate.”

So DrRich, who back in the day was the recipient of his rightful share of Dear John letters, knows his role here. The ACP is preening for the office of Virgin Queen of the Prom, and DrRich - the jilted boyfriend who knows she’s been sleeping with the lacrosse team - is supposed to keep out of the way and shut up. And so, while he reserves the right to elaborate on some of the more surprising implications of the New Ethics, he recognizes that the ACP (and likely the 120 other physician organizations that have signed on to this manifesto) are very satisfied with their new ethical standards, and are not interested in revisiting them.

But before finally leaving the ACP entirely to its own devices, dear readers, DrRich hopes you will forgive him if he cannot resist commenting on just one more, particularly curious aspect of Dr. Hood’s reply. He refers to her remarkable injunction that, in order to meet their new ethical obligation towards the fair distribution of society’s resources, physicians should engage in “parsimonious care.”

DrRich was pretty sure he knew what parsimonious meant, of course. But the fact that the Chair of the ACP’s Center for Ethics (&c.) was now specifically enjoining doctors to practice medicine parsimoniously made DrRich wonder if perhaps he’d gotten it wrong. So he decided he’d better look it up.

The common meaning for parsimonious, and the only meaning supplied by most dictionaries (such as Webster’s New World Dictionary) conveys the sense of stinginess, or extreme frugality. Other dictionaries and thesauruses suggest: excessively unwilling to spend, ungenerous, penurious, penny-pinching, miserly, sparing, grasping, tight, close, niggardly, illiberal, mean, avaricious, covetous, and tight-assed. Illustrated dictionaries are likely to show a picture of Jack Benny or pre-ghost-of-Christmas-Future Ebeneezer Scrooge, though children’s dictionaries will likely depict Scrooge McDuck, and if progressives had their own dictionary (and they certainly need one of their own), they would show a Republican elephant.

So it would certainly appear that the “parsimonious care” which Dr. Hood urges physicians to adopt hardly seems the kind of medical care patients would hope to receive, or that most doctors would aspire to give.

Perhaps, one might think, Dr. Hood simply misspoke in this instance. Indeed, if one can manage to work one’s way through the entire sentence (which reads, “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.”), it might be just possible to believe that perhaps she only meant “efficient.” And (one might speculate) in her hurry to toss off a quick reply to DrRich this past Sunday, no doubt so that she could get back to the Pro Bowl, she simply chose the wrong word inadvisedly.

But that’s not what happened. Dr. Hood did not misspeak. In fact, these words are not hers. She is quoting here directly from a key part of the ACP’s Ethics Manual.

Bear in mind that before it ever saw the light of day, the Ethics Manual received extremely close scrutiny. The Ethics Manual is a document whose every syllable has gone through numerous and careful edits and revisions, by many well-educated experts.  And experts on ethics, out of all the multitudes of wordsmiths residing in the academy, are the most careful and precise with their choice of words. The use of “parsimonious” was not an error, nor could it have been a subliminal choice. Like every other word in the Ethics Manual, “parsimonious” was very carefully considered, and was specifically chosen for its precise meaning. And therefore we can only conclude that what the ACP ethicists mean when they urge parsimonious care is: parsimonious care.

And most assuredly, parsimonious does not mean merely “efficient.” Indeed, the carefully-engineered sentence in which this word appears tells us that, while “parsimonious care” certainly encompasses efficiency, it’s something more than just efficient care. Efficient care is to parsimonious care as fondness is to lust; as a gentle  spring rain is to a deadly deluge. “Parsimonious” crosses that line which converts a virtue to a vice.

So yes, the ACP Ethics Manual exhorts physicians to efficient care; but also to something well beyond just efficient care - to parsimonious care. To miserly care; to penurious care; to grasping, tight, close, niggardly, illiberal, mean, avaricious, covetous and tight-assed care.

But, of course, only for the benefit of society as a whole.

Now, if we were actually engaging in a debate (which of course, he recognizes, we are not), DrRich would smugly turn to his opponent at this point and make the following summation: “Since the ‘parsimonious care’ you champion is quite consistent with the new Social Justice mandate as interpreted by me (i.e., a mandate to ration healthcare at the bedside), but not so much with the Social Justice mandate as interpreted by you (i.e., a mandate only to be efficient), I rest my case.” (Note: DrRich is courteous enough not to refer to himself in the third person when engaged in a one-on-one exchange, as that would seem impolite and arrogant.)

Then, DrRich would simply end this post, and wait for the ACP (presumably this time in consultation with the Chair of the ACP’s Center for  Lexicography) to attempt painfully to assemble some sort of rebuttal.

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Comments

15 Responses to “On Parsimonious Care”

  1. DayOwl on February 4th, 2010 4:52 pm

    I, too, was struck by the term “parsimonious”, but I clung to the hope that it was meant to be taken in the most positive light. But, really, it is barely a step away from, “insufficient” and no more than two minuscule steps from “no care at all”. The problem with this scheme is that an ever-increasing amount of time, money, and health care resources, including those of the insurance companies’, are being put work to deny care, rather than providing it. A patient can try many times to visit a PCP, paying a copay each time, and having similar resources from the insurance company paid out, and never receive all the care needed to resolve the health problem, or perhaps, after many such visits, finally receive what’s needed. This in itself is vastly inefficient. How many problems could be resolved using fewer resources than the gate-keeping scheme needs?

    The most troubling aspect of the New Ethics is that it seems to absolve physicians of responsibility for decisions that adversely effect the patient if they can be framed as “in the interests of the greater society”. They have seen the enemy, and it is the patients.

  2. Robyn on February 4th, 2010 8:33 pm

    I really liked this post. Big thumbs up (smile)! Robyn

  3. DrRich on February 4th, 2010 11:37 pm

    DayOwl,

    “They have seen the enemy, and it is the patients.”

    There may be more truth to this than both doctors and patients fear. I may post on this next week if I don’t find it too depressing to do so.

    Rich

  4. Red Baron on February 5th, 2010 2:09 pm

    Rich, you will never get a “new ethics” individual to see the reality of the conservation of energy for anyone other than someone else.

    Whatever budget proposal Dr Hood is suggesting, I would be interested to know if she also personally willing to place signs in every examination room suggesting she guarantee parsimonious care for all her patients?

    Or would she prefer the new age covert approach?

    … Indeed, since we are being parsimonious, why don’t we actually be parsimonious: for might parsimonious also mean we cut a few new age ethicist positions at the ACP so the less fortunate can afford care?

    Be well

  5. Red Baron on February 5th, 2010 5:12 pm

    Cures you Rich, you got me thinking on doctrine and it was the one thing the nihilist in me promised to not do… ;-)

    I realized your philosophical bias is coming through related to your particular career.

    So here is my question about your inner and out sphere argument.

    Are we really to treat all physicians the same in your model?

    Or do we split the atom so to speak even between different physicians?

    What about those who must make decisions in a matter of seconds?

    What about those who ALREADY have a responsibility to the many vs. the one? e.g. the Emergency Physician.

    I might remind you that the word “Triage” sits in every ED in the US (world) for a reason.

    The irreconcilable paradox may be a major identity problem causing untold anxious/neurosis for you internists. But for us working ER grunt docs, it is simply another day at work.

    Thoughts?

  6. Just_another_Joe on February 5th, 2010 5:39 pm

    Wonder if DrRich isn’t bordering on sophistry here (to make his point)….and I wonder if the reference is to “The principle of parsimony in medicine, and other essays”, by I. M. Tarlov (1969) Thomas, Springfield IL. Believe diagnostic parsimony is somewhere in between Occam’s razor (”entities must not be multiplied beyond necessity”) and Hickam’s dictum (”patients can have as many diseases as they damn well please”). Let’s just be clear that physicians should not limit what they try to do to help a given patients out of some concern for the ‘health of the system’….physicians need to be pure advocates for each patient…anything different is an abomination.

  7. Red Baron on February 5th, 2010 5:56 pm

    So how do you deal with the issue of “Triage”?

  8. Red Baron on February 5th, 2010 6:07 pm

    And I am impressed you have never sat in a peer review meeting where a root cause on a bad outcome reveals delay in arrival to the bedside of the patient by primary care.

    When asked why it took them so long to arrive to the patient’s bedside, the abomination physician responded “I was with another patient in my office and came as soon as I could”.

    Apparently Just_another_Joe has clearly figured out how to violate the boundary conditions of certain laws of physics every other physician I know (all nothing but abominations) seems trapped in.

    Rich, I take back what I said, it is not only the new agers who seemed to have figured out how to violate the conservation of energy, it is a few of your allies as well. ;-)

    … Now I know who to suggest to the powers that be as the next ACEP Keyone speaker.

  9. Robyn on February 5th, 2010 6:29 pm

    Just_Another_Joe - Not having a clue what you were talking about (smile) - I looked it up. Does this seem like a reasonable explanation to you?

    http://en.wikipedia.org/wiki/Occam’s_razor#Medicine

    If so - I don’t understand how this could relate to what Dr. Hood wrote - because she was talking about care - not diagnosis (and I think the best clinicians probably have diagnostic trees hard-wired into their brains).

    Anyway - I think if Dr. Hood was talking about thinking horses instead of zebras - or trying to figure out whether certain symptoms were the result of one - or more than one disease - or anything like that - she would have come right out and said it. Robyn

  10. Robyn on February 5th, 2010 6:32 pm

    The link I posted didn’t come through correctly. You’ll have to copy and paste.

  11. DrRich on February 5th, 2010 6:46 pm

    Just-another_Joe and Robyn,

    I wouldn’t exactly call it sophistry. Just in case the ACP would choose to respond to this post by invoking “parsimony in medicine” as what they were really talking about after all, I was (am) prepared with a very nice reply. So, sophistry? Perhaps. I was thinking more along the lines of “bait.”

    Rich

  12. DrRich on February 5th, 2010 7:02 pm

    Red,

    The kind of model I’m proposing, as I see it, would be applied mainly to those medical decisions that admit such philosophical niceties. Emergency care and triaging, in my opinion, is done very well in the U.S., and we ought to meddle with it as little as possible.

    To triage - as you and your peers do it - is indeed to “distribute limited medical resources,” in an effort to maximize the results for as many patients as possible. But these decisions are being made on site, with all “available resources,” and all the patients who at risk (that is, all the data), immediately at hand. Furthermore, the decisions are made by experienced healthcare professionals, who dynamically integrate all this “data” on the fly, and who themselves have to execute - and live with - the decisions they make. No externally-imposed process could ever hope to achieve the efficiency or outcomes you folks are providing already.

    But then, since I will actually not be invited to the table when your professional future is being decided by politicians, yeah, you’ll have to live with whatever rationing rules they come up with just like the rest of us schlubs.

    Rich

  13. Red Baron on February 5th, 2010 8:16 pm

    Rich, to be fair, EM physicians are currently being eaten alive on this irreconcilable paradox. The absolute #1 response we are never allowed to give to either patients, JCAHO, the BPQA, community physicians or opposing council is the fact that we were distracted from giving their patient our fullest attention as we were with another patient.

    Rationing is built into the very fabric of the universe only most people do not see it.

    Be well

  14. Red Baron on February 5th, 2010 8:17 pm

    And I hope you do understand that your very model means that when all is said and done, not all physicians are really equal.

    Think about it my friend ;-)

  15. Robyn on February 6th, 2010 6:44 pm

    Totally OT - but I am thrilled that one of my nieces just got accepted to medical school yesterday. I am thrilled for her because this is what she wanted - and it is far too early for me or her father (a nephrologist) to tell her about the sobering facts of life that are being discussed here. Robyn

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