Getting Square With the Nurses

July 9th, 2008 by DrRich

Last month, DrRich wrote about how “doctor-nurses” are fixing to displace primary care doctors, and how the noble American Medical Association – champion, as always, of the American PCP – is mobilizing with decisive action to prevent this tragedy from taking place.*

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.

Posted in Primary Care in America | 5 Comments »

Another Reason To Let the Doctor-Nurses Take the Whole Thing

June 18th, 2008 by DrRich

According to NewScientist Magazine, David Fishbain, Professor of Psychiatry and Behavioral Sciences at the University of Miami, says that up to 1 in 20 patients would like to kill their primary care physicians.*

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.

Posted in Primary Care in America | 7 Comments »

Hey PCPs - Here They Come!

June 17th, 2008 by DrRich

The June 16 issue of AMANews reports that the National Board of Medical Examiners will begin offering a certification examination this fall for graduates of “doctor of nursing practice” programs. Revealingly, the test will be based on Step 3 of the U.S. Medical Licensing Exam.

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.

Posted in Primary Care in America | 14 Comments »

The Right Way to Think About Medical Ethics

June 11th, 2008 by DrRich

Wherein long-time readers of this blog (or anyone who has merely read the title of this post) will be reminded that DrRich, not unlike some more well-known figures, does not mind audacity.

Both Dr. Gault and Sandy Szwarc have recently revisited the current state of medical ethics, and once again, both have found modern medical ethics wanting. Dr. Gaulte recounts the recent, sad history in which ethicists steeped in utilitarianism have seen fit to add the ethical precept of Social Justice to the individual physician’s ethical obligations. While this change brings medical ethics more in line with the actual behavior of American doctors in the wild, Ms. Szwarc nicely elaborates for us why this change in ethical precepts poses a grave threat. (She even bravely uses the “other” N-word, that word which today is invariably banned in polite conversations on ethics, but which, for better or worse, is unfortunately quite illustrative of the ultimate fruits of utilitarianism. Utilitarianism has again become fashionable after an all-too-brief time-out, and so we must not insult or embarrass respectable modern ethicists by dwelling too deeply on the lessons of history.)

DrRich himself has pointed out that by making Social Justice a chief ethical mandate of physicians at the bedside, doctors have not only committed professional suicide, but have formally embraced the covert rationing of their patients’ healthcare, and all of the social ills that flow therefrom (social ills whose enumeration is the main subject of this blog).

So several of us in the medical blogosphere have made, and continue to make, the point that the “new” medical ethics is counterproductive to the medical profession, to society, and to patients. But still, it must be acknowledged that the “old” ethics, under which the doctor’s only obligation was to the rights and welfare of the individual patient, no longer seems feasible. Any doctor who doggedly sticks to classic medical ethics today is likely to find him/herself out on the street in short order. And besides, the argument of the utilitarians that Social Justice must be honored within the healthcare system is, in fact, legitimate and essential.

Acknowledging that it does little good to criticize the status quo without offering something better, DrRich feels obligated to propose a different way of looking at medical ethics that a) honors the classic ethical obligations of physicians, and b) honors the needs of society. If he has seen fit to label this proposed solution for medical ethics “the right way,” it is more in the way of challenging his critics to engage in debate than to declare a final victory. Though, if critics fail to engage, DrRich will naturally assume he must indeed have nailed it.

“Classic” medical ethics.

Classically, doctors have been obligated to recognize two ethical precepts: Patient Welfare and Patient Autonomy.

The precept of Patient Welfare (also called the precept of beneficence, or “first, do no harm,”) obligates the doctor to always behave in a way that accrues to the benefit of the individual patient. The doctor’s patient comes first, and must be the doctor’s primary concern, above, for instance, personal and financial considerations.

Under the precept of Patient Autonomy, patients are acknowledged to have the right to self-determination regarding their own healthcare. Fundamentally, this means that patients have the right to know, and the doctor is obligated to inform them, of any and all information that might help them make their decisions regarding their own healthcare.

So classically, doctors were obligated to do whatever they must to assure that their individual patients were fully informed about all their medical options, and to act to assure that their patients got the care they needed (as long as, fully informed, they agreed to it).

Since under classical medical ethics the doctor’s one and only ethical obligation was to the patient, classical ethics did not allow the doctor to recognize any limits. Whatever bit of medical care promised even a small hope of benefitting the patient, doctors were obligated to offer it, no matter how expensive it might be to do so. This ethical system worked well enough until 40-50 years ago, since medical technology up to that time was relatively primitive, limited, and cheap.

The “New” medical ethics.

DrRich will not review here how skyrocketing costs, produced by rapidly advancing technology and an aging population, eventually led to the unavoidable need to ration healthcare, or how, because we’re Americans and Americans don’t ration, the unavoidable rationing was necessarily covert. (See virtually any post ever written on this blog for details.)

But, by the 1990s, medical ethicists became troubled that doctors who were forced to conduct covert rationing at the bedside could not do so under the classic ethical precepts that obligated the doctor to the welfare of their individual patients. But rather than pointing out that their behavior had become unethical, and calling for doctors to insist on being allowed to practice medicine without violating their fundamental ethical and professional obligations, ethicists instead began calling for a “new ethics” that would encompass doctors’ actual behavior.

This feat was accomplished in 2002, when the ABIM Foundation, the ACP-ASIM Foundation, and the European Federation of Internal Medicine published their manifesto, Medical Professionalism in the New Millennium: A Physician Charter. In it, these respected organizations proclaimed a third ethical precept: The principle of Social Justice. Social Justice charges physicians to work for “the fair distribution of healthcare resources.” That is, it specifically and directly justifies bedside rationing. (For a fuller discussion of this point, go here.)

That this third medical precept so directly contradicts the first two is either ignored by ethicists or celebrated as “balance.” DrRich’s only surprise is that ethicists have not (yet) found within this utter contradiction the virtue of diversity (the uber-virtue, from which the seven classic - though subsidiary - virtues must necessarily spring).

The negative implications of this official “new” medical ethic on doctors, patients, and society are truly staggering. For a masterful discussion of those implications, DrRich refers you to again to Ms. Szwarc. Here, DrRich will take only enough space to reiterate for his physician colleagues that once we physicians adopted this new ethic, we surrendered any claim we might have had to the title “professional,” and accordingly, we made ourselves fair game to any treatment, tactic, or travesty that any more powerful interest group (such as trial lawyers, Congress, or doctor-nurses) can get away with foisting on us. Physicians no longer have any ethical standing for turning such attacks aside. Rather, as non-professionals, our ability to withstand attacks can only be proportionate to whatever socioeconomical or political pressure we can muster.

So if “classical” medical ethics has been rendered obsolete by rising costs that mandate limits on spending, and if “new” medical ethics is irredeemably bad, then what are we to do? The answer of course, is “right” medical ethics.

The “Right” medical ethics

Medical ethics would be “right” if it could be made to comport with the classic notion of the doctor’s primary obligation to his/her individual patients, and yet respect society’s need for cost control. That is, the “right” ethics will recognize that society’s needs and the needs of individual patients are often in conflict, and will provide an ethical framework for resolving these conflicts.

We can profitably address this problem if we think of the ethics of healthcare as being organized into two concentric spheres. The outer sphere holds the ethical precepts adopted by society in order to guide the behavior of the healthcare system for the entire population. These outer-sphere precepts help ensure that the needs of society as a whole are served in an ethical manner by the healthcare system.

Contained within (and therefore subject to) that outer sphere of societal precepts is an inner sphere which holds the ethical precepts that govern the behavior of the healthcare system (including the behavior of physicians) toward individual patients. Inner-sphere precepts help ensure that individual needs within the healthcare system are addressed in an ethical manner - yet, in a manner consistent with outer-sphere (societal) precepts.

So, while the physician’s primary ethical obligation must be for the benefit of the individual patient, and thus while the physician must operate according to ethical precepts that honor this duty to individual patients (the inner-sphere precepts), their behavior must also conform with the ethical constraints imposed by society on the entire population (the outer-sphere precepts).

Because doctors and patients operating within the inner sphere must honor outer-sphere ethical precepts, it would be easy to surmise that the needs of society must always take precedence over the needs of the individual. To some degree this is the case. But it is more useful to think of the inner-sphere precepts as an immutable core of ethical beliefs that serve the fundamental American commitment to the autonomy of the individual, and of the outer sphere as a coating, fashioned by society and therefore changeable, that places a limit on individual autonomy, while protecting its essential immutability.

The inner sphere - ethical precepts for individuals

The inner sphere of ethical precepts - the core - obligates physicians to place the interests of their individual patient above all else, within the bounds imposed by society. This inner sphere holds the two ethical precepts of classical medical ethics, described above - patient welfare and patient autonomy.

While individual autonomy is critical, it has its limits. When a patient demands that everything possible be done for them, they are exceeding the bounds of autonomy if doing “everything” means that some other individual would thereby be deprived of what otherwise would be rightfully theirs. These bounds of autonomy are defined by the outer sphere.

The outer sphere - ethical precepts for society.

Under any equitable healthcare system we are going to have to carefully define our outer sphere ethical norms, because those are the standards that bound and govern the inner-sphere behaviors of doctors and patients. The outer sphere also consists of two ethical precepts, societal beneficence and distributive justice.

Societal beneficence (or social welfare) requires the healthcare system to maximize the overall public good realized from whatever resources society expends on healthcare. Social welfare is not the same as patient welfare, because what is optimal for an individual patient may often reduce overall benefit to society, and vice versa.

Distributive justice requires the benefits of the healthcare system to be distributed fairly, that is, in a way that does not discriminate against individuals or groups based on who they are.

The outer-sphere precepts honor society’s right to accrue optimal benefits from whatever resources society provides collectively toward healthcare. That is, the outer-sphere precepts recognize society’s legitimate interest in limiting and equitably distributing society’s collective resources.

Medical ethics and the spheres.

Now it is easy to see why the American healthcare system is presently inequitable and unethical. A hallmark of our system is the lack (thanks to our culture of no limits) of effective outer-sphere societal norms that would bound the appropriate behavior of individual physicians and patients. This lack makes it entirely feasible and very common for some patients to soak up a disproportionate share of publicly funded healthcare resources while others (though they are also paying into the system) are left with next to nothing.

Establishing equity should have nothing to do with adjusting the inner-sphere precepts. Individuals in the United States (to paraphrase the Declaration of Independence) have a self-evident right to their individual autonomy. The inner-sphere precepts are granted to us by the Creator, by natural law, or at the very least, by the Magna Carta and its derivative documents. As Americans we should avoid modifying the inner-sphere precepts at all costs, since, once we do, we are abandoning our foundational principles.

It is the outer-sphere precepts - those that can be negotiated legitimately by society, and which can legitimately limit the scope of inner-sphere behaviors - that we need to get into proper order.

A properly functioning system of medical ethics, therefore, would have society negotiate a set of outer-sphere precepts that would transparently define the rules for how society has chosen to set limits on healthcare spending. Then, within that system of societal rules, doctors and patients would work together, under a fully restored doctor-patient relationship, to assure that every patient receives all the information he needs on all the legitimately available medical options, and that the doctor leaves no stone unturned in obtaining those legitimate medical services for her patient.

In stark contrast is the process which gave birth to the “new” medical ethics now being promulgated by medical ethicists and the medical establishment now under their thrall. The current ethical model was the result of ethicists responding to the lack of functional outer-sphere precepts by simply moving the principles of societal beneficence and distributive justice (lumped together as Social Justice) down into the inner sphere, where individual doctors are expected to deal with them. You can’t actually do that, of course, because these are intrinsically outer-sphere norms. But our present-day ethicists have deemed it so, thus formally placing doctors into the position of having to serve the best interest of their patients (individual beneficence and autonomy) while at the same time, rationing healthcare covertly, at the bedside (societal beneficence and distributive justice). These interests, being often in stark conflict, simply are not possible for a physician to manage at the bedside. Charging doctors with the obligation to act in such an illogical, nonsensical and indeed impossible manner produces no good, and much harm.

Ethicists behaving badly

DrRich has thought long and hard about why medical ethicists have created such a non-solution for us. Are they stupid? DrRich thinks not, having tried unsuccessfully to read some of the arcane literature they produce, which is chock full of logical legerdemain, and by which (it appears to DrRich) they can justify almost any behavior you care to imagine. The stupid could simply not do that.

Rather, DrRich sadly concludes, it is cowardice. For, once ethicists determine that it is the obligation of society to establish the rules for limiting the rising cost of healthcare, the ethicists will be placed squarely in the line of fire; that is, the ethicists themselves will be asked to lead the process. Finding that to be a very scary prospect (many ethicists having chosen their field of endeavor, it seems to DrRich, precisely because it allows them to substitute critical commentary for difficult action), they instead have placed doctors in the position of having to ration healthcare for society at the same time they are supposed to be advocating for their individual patients. If there ever was an example of ethicists behaving badly, this is surely it.

If it’s any consolation to them, DrRich would like to assure modern ethicists that, having observed their recent behavior, he personally would never choose to burden them with the task of determining society’s rules for rationing healthcare. Indeed, if DrRich were in charge ethicists would have nothing to worry about, and might just as well tell us the truth.

Posted in Medical ethics | 4 Comments »

Debating Malpractice Reform

May 19th, 2008 by DrRich

And now, for the main event.

DB has challenged DrRich to defend the “unusual” position on medical malpractice reform he staked out in this space a little over a week ago.

In issuing this challenge, DB made two major points. First, DB notes that the present malpractice environment is universally counteproductive. To elaborate: There can be no doubt that today’s malpractice environment causes “financial and psychic” harm to doctors. It causes doctors to waste money on needless tests and so fiscally harms the healthcare system. It exposes patients to unnecessary tests and so harms their time, energy and potentially their safety. It renders every doctor-patient encounter a potentially adversarial one, and so harms the doctor-patient relationship.

On this first point, DrRich cheerfully concedes. The present malpractice environment does all this harm and more.

Secondly, DB points us to the malpractice reforms that have been enacted in Texas, and asks DrRich how he supposes these reforms will harm the doctor-patient relationship.

DrRich doesn’t know the details of the Texas reforms, but from what he knows, only lawyers (who, DrRich would like to remind one and all, he despises) would argue that such reforms would materially harm a patient’s ability to seek just redress from true medical malpractice. So, DrRich cheerfully concedes on this second point, too. Malpractice reforms of the sort enacted in Texas are good for doctors and the healthcare system. Such reforms may likely have a salutary effect on the doctor-patient relationship (by possibly reducing the notion of “patient as adversary,” that causes doctors to practice defensive medicine aimed at protecting themselves more than at helping their patients).

And furthermore, DrRich celebrates the fact that society, through its duly elected representatives (in this case the Texas legislature), will at least occasionally consider the respective interests of all parties involved (the doctors, patients, the state populace, and yes, even the trial lawyers), and enact malpractice reforms like these which will best meet its overall needs. That’s how the system is supposed to work.

So, has DB just won this debate hands down?

Yes and no. Yes, in that, regarding the specific propositions DB has laid down (that the malpractice environment is univerally harmful, and that the Texas reforms are reasonable), DrRich cheerfully concedes both points. No, in that, regarding the basic message of his original post, DrRich gives no ground. (The reason DrRich can “cheerfully” concede to DB’s propositions is that he can do so without giving up any of the ground he originally claimed.)

Before explaining how he can agree with DB’s propositions without giving ground (which, everyone will have to admit, will be a real trick), DrRich needs to make two additional concessions. First, in the attempt to make his posts interesting and memorable while at the same time making serious points, DrRich is not above affecting a bombastic personality, using semi-archaic verbiage, liberally employing irony and sarcasm, and engaging in a certain amount of exaggeration and hyperbole. Simply consider some of the titles DrRich has chosen for his postings: A Truly Admirable Degree of Inefficiency, Why Canadians and Other More Advanced Civilizations Should Root Against US Healthcare Reform, How to Invest in the New Medicare Audits, and, of course, Proof that Warren Buffet Reads This Blog. (Important note to readers: Whenever DrRich purports to dispense investment advice of any variety whatsoever, you can safely assume he’s engaging in hyperbole. NEVER take DrRich’s investment advice.) DrRich humbly submits that the title of the post now in question, Covert Rationing Makes Malpractice Reform A Bad Idea also employs at least a bit of hyperbole.

Second, it is noted with dismay that DB says he had difficulty following the logic in DrRich’s original post on malpractice reform. DrRich has been reading DB’s blog for a long, long time, and has come to admire him as a paragon of logical thought and expression. So the fault here can only be DrRich’s. And if as a consequence DB attacked a hill that DrRich was actually not defending, the responsibility for this misdirection also lies with DrRich (who, it may fairly be claimed, must have lined the summit with Quaker guns to draw and waste DB’s fire).*

So DrRich will now try to: 1) restate more clearly the proposition he inadequately conveyed in his original posting, 2) elaborate on why he believes this proposition to be true, and finally 3) suggest what doctors ought to be doing to place the issue of medical malpractice on a more equitable footing.

DrRich’s Proposition: For doctors to push hard for malpractice reform at this juncture is, in principle, counterproductive in the long-term both for them and for their patients.

Why DrRich believes this proposition to be true:

A) The medical profession is being systematically and purposefully destroyed. In the attempt to control healthcare costs (as they have been deputized by society to do), the feds and the insurance carriers have, in uncountable ways, coerced physicians to place the needs of the payers ahead of the needs of their individual patients. That is, they are intentionally destroying the doctor-patient relationship, killing medical professionalism, and causing doctors to abandon their patients to their own devices in an increasingly hostile healthcare system. This process has been firmly established. It has been legislated by Congress, embodied in volumes and volumes of rules, regulations and “guidelines” (strictly and ruthlessly enforced), upheld by the U.S. Supreme Court, and finally (and most tellingly) sanctioned as being entirely “ethical” by revered medical organizations. And when insurers insisted that doctors sign Gag Clauses, and when doctors did so with nary a whimper of protest, doctors were in effect signing the death certificate of their profession.

B) Losing their professionalism is a crushing defeat. While the term “professional” is claimed by many occupations today, traditionally there are only three - divinity, law, and medicine. Traditionally, what distinguishes a professional from other individuals is not merely their level of knowledge or proficiency at a particular occupation, but rather their commitment to a formal ethical code of conduct by which they pledge their primary allegience to their individual client (or parishoner or patient). This code has been considered vital because the professional is in possession of special expertise and special knowledge (at least some of which is provided to them in full confidence by their client) that, if misused, can bring irreversible harm to their client.

This code is indispensible.

The medical profession has formally dispensed with it.

Whether doctors realize it or not, abandoning this code of conduct has left them without the ethical grounding that earns them the recognition and respect and consideration always due to professionals. It has stripped them of the special status which they feel they deserve, and that in past times served them and society well. For instance, the loss of their ethical grounding has made doctors fair game for encroachment by lesser-trained individuals who can follow guidelines and complete checklists every bit as well as they can (and much more compliantly than they can), and who have the government-issued certificates to prove it.

C) Doctors are engaged in an existential battle, a battle for professional survival. The only thing that can save them - if it’s not already too late - is to find a way to forge a new relationship with their patients, a new partnership. This is probably not possible under the traditional healthcare system, since doctors have been so deeply and fundamentally compromised there. It may be possible under new practice arrangements, such as retainer practices. But whatever it takes, unless doctors can come to a new arrangement with their patients - “I’ll be your true and dedicated advocate in matters related to your healthcare; you guard and support my professional standing” - they are professionally lost, no better than pieceworkers, and are fair game for whatever the authorities choose to throw their way.

D) It is in this context that fighting hard for malpractice reform at this time is counterproductive. Doctors owe it to their patients and to their professional survival to do - and to be seen as doing - everything humanly possible to re-earn the confidence of their patients, and to forge that new alliance. To instead make the issue of malpractice reform their primary concern, or even one of many primary concerns, is (again, at this juncture) a further capitulation to the profession-ending process. For, no matter how you cut it, to fight for malpractice reform at this point in time - even the more reasonable and defensible kinds of reform like the ones in Texas - is to protect themselves by further limiting the prerogatives of the patients they have just officially abandoned. Such an action at this critical time sends the wrong message to the patients whose confidence they ought to be doing everything in their power to regain. Lobbying loud and hard for legal protection against the patients they have just abandoned will not help the profession’s long-term prognosis.

And, to be blunt, if doctors have resigned themselves to becoming former professionals, to becoming primarily accountable to the government and the insurers instead of remaining vigorous and true advocates for their individual patients as their profession requires, then they should not expect to arouse widespread public indignation or sympathy over the fact that their work environment is more stressful, risky and unfair than it ought to be. Of course, when society notices that the malpractice issue is becoming so severe that doctors are becoming scarce, then society may choose fix it just enough to entice doctors to continue taking the risk. This, DrRich submits, is what happened in Texas. But once doctors abandon their professionalism, they lose their standing for any special considerations beyond the strictly utilitarian.

The right way to get malpractice reform:

The moment physicians take charge of their situation, refuse to let their profession die an ignominious death at the hands of the insurers and the feds (and of the compromised ethicists who tell them it is quite appropriate for individual doctors to place societal beneficence ahead of the good of their individual patients), and establish modes of practice that again allow them to become partners with their patients in a new doctor-patient relationship, THAT’S THE MOMENT doctors can insist on fair and equitable malpractice reform. At that moment, malpractice reform becomes part of a package that restores medical professionalism, and offers patients protections they can never get in a court of law (where they can go only after the damage has already been done).

In summary, DB is right on both of the points he sets out. The current state of the medical malpractice system harms everybody, and reasonable reforms like the one instituted in Texas remove at least some of that harm. And for more states to institute such reforms would be a favorable development.

But once doctors finally abandon their professionalism, then whatever happens to them - whether it’s malpractice abuse or displacement by doctor-nurses - is fair game. Their fate will be determined by arbitrary political and economic forces, rather than by what’s right or fair or equitable or professionally appropriate. Even if Texas-style reforms were to become the law of the land, the medical profession would still be dismantled and patients would still be abandoned within a hostile healthcare system. Malpractice reform without professional survival is fundamentally worthless.

DrRich’s point, as poorly stated as it might have been, is that if doctors are unwilling to go to the mat defending their profession, then fighting for medical malpractice reform is really immaterial and irrelevant, if not counterproductive, in the big scheme of things. Such reforms will certainly make the diminished lives of doctors more comfortable, and will save society some money to boot. But doctors should not ask non-doctors to fight along with them, or to care more than passingly about their comfort or security, or even to not deeply resent that they are choosing to waste what little leverage and what little time they have left on advancing malpractice reform, instead of reasserting their rightful role as their patients’ advocates.

DrRich apologizes for the length of this post, but it is a debating strategy he has found useful in the past. Drone on and on, and the opponent may lose his place, go to sleep, or just become so bored that he is struck dumb. DrRich waits to see which of these effects he might have had on DB.

*DrRich naturally assumes that a denizen of the South like DB will be acquainted with the deceptive techniques of General Lee and other creative commanders of the former CSA.

Posted in Medical malpractice | 5 Comments »

Primary Care: Time to Reboot

April 8th, 2008 by DrRich

American primary care medicine has entered into a period of change. “Change” is perhaps too mild a term; many - especially the primary care practitioners (PCPs) themselves - might call it a period of crisis. In any case it is change so profound that one might be forgiven for thinking Senator Obama is already president.

Consider. PCPs have been hogtied to a dysfunctional reimbursement system that (thanks to the government, the insurers, the AMA, and their own specialist colleagues) has drastically and systematically devalued their training, expertise, and time. The very concept of what a PCP is and does (and indeed, what they should be called - whether PCP, family doctor, general practitioner, gatekeeper, or medical homemaker) seems in constant flux.

Whatever it is PCPs do, the government, the insurance industry, and experts on medical policy have spent years making the primary care job seem, well, easy. Their practices have been reduced to a series of discrete, easily cookbookified tasks. Each of these tasks can be directed by “guidelines” (devised, of course, by non-PCP “experts”), compliance to which can be easily tabulated and monitored, thereby to determine the adequacy of the individual PCP’s performance. And, because their job is now so codified, they are expected to perform it accurately and reproducibly in a matter of minutes (some say 7.5 minutes per patient encounter, though others will allow up to 12.5), just like any other rote industrial process.

To make matters worse, PCPs are slowly awakening to the realization that they are being squeezed out from the bottom. Some of what they do (the really easy stuff) is being corporatized into mini-clinics by the large drug store chains, and the rest is being threatened by newly assertive nurse practitioners and doctor-nurses, who are at least tacitly supported by the insurance industry. (Thanks to Dr. Poses for pointing out the relationship between doctor-nurses and big insurance.)

No wonder PCPs have become so terminally frustrated.

It is natural for PCPs to want to fight the changes that are destroying their profession, and causing their numbers to dwindle. Many have offered ideas. Gain the public’s support by alerting them to the impending and dangerous shortage of PCPs. Improve PCP payment schedules. Forgive the student loans of young doctors who choose primary care. Lobby congress for pro-PCP legislation. Offer novenas.

Some of this (DrRich is thinking the novenas) might hold off the inevitable for a time. But PCPs are fighting more here than just the government, the insurers, their specialist colleagues, and nurses filled with thoughts of vengeance (for 150 years of having to give unquestioning obedience to arrogant, clueless and unfeeling doctors, if you care to ask them). The PCPs are fighting history.

What is happening to PCPs is what happens to many experts whose jobs are fundamentally based on knowledge and/or technology. That is, as knowledge and technology advance, some (and perhaps a lot) of what the experts do can be sufficiently simplified and “democratized” that less well-trained individuals become enabled (or believe they are enabled, which amounts to the same thing) to do it themselves.

This is what the market is telling PCPs has happened to them. A substantial part of what they do indeed has been reduced to guidelines and cookbooks (thanks to remarkable advances in clinical studies and medical technology). The typical patient (note: DrRich said “typical”) with hypertension, diabetes, cholesterol abnormalities, and common infections can be relied upon to respond reasonably well to reasonably standardized therapy. And the market is saying to the PCP: “We can find ways of doing this without you.”

The same thing has happened countless times in history. The 1500-year monopoly enjoyed by the clergy in interpreting the Word of God was completely disrupted by the printing press and by the upstarts who translated scripture into the vernacular. The music industry has been fundamentally disrupted by digital recording software, which enables anyone with a PC to do things that had always required multi-million dollar studios. Ditto for book publishing. Ditto for real estate agents, accountants, car dealers, teachers, newspapers. All are wrestling to one degree or another with the “creative destruction” that is produced by advancing knowledge and/or technology.

For the most part, of course, nobody (except, perhaps, the doctor-nurses) will come right out and tell the PCPs to go away altogether. Instead, they’re telling them to dumb down, to just follow the rules, to stick to the guidelines and be paid to perform (one thinks of trained seals), to become like the lesser-trained practitioners who inevitably will be replacing them over the next decade or so. That’s where the profession is going, they’re being told. Get with the program, adapt to reality - or don’t let the door hit you where you keep your wallet.

Looking at the situation from this more historical perspective, one can see why it seems futile for PCPs to respond by railing and complaining, by lobbying for the public and the legislatures to understand that they’re actually quite important, by appealing to their specialist colleagues for more than lip-service support, or by trying to convince more medical students to choose a disintegrating profession such as this.

PCPs are in the path of a tidal wave of disruption, triggered by economic realities and enabled by technology. They are unlikely to prevail by a’wishing, and a’hoping, and a’singing, and a’praying.

From the perspective of history, it becomes apparent that what PCPs need to do is reboot. They need to reinvent themselves in a way that is compatible with the new reality. So far, they seem to be seeing only the disruption part of the creative disruption now tearing their profession apart. They need to find the creative part.

From a simple examination of history, two possibilities will immediately come to mind.

1) Just as advancing medical knowledge and technology has made it possible for lesser-trained individuals to encroach on their turf, so have the same advances made it feasible for PCPs to encroach on the turf of their snugger (and smugger) colleagues - the specialists. Observing how some of the bread-and-butter skills of the PCP have been sufficiently reduced to the point that nurses can do it, one finds it inconceivable that similar basic skills now monopolized by specialists haven’t been similarly reduced. It is undeniably true that for a lot of what specialists do, one doesn’t actually need a specialist anymore to do it. (As a cardiologist, DrRich knows for a fact that this is the case, but unfortunately he is bound by blood-oaths extracted by the high priests of his guild - oaths which mortgaged the immortal souls of his progeny down through 10 generations - not to mention the specifics. Sorry.) But look around. You’ll find examples easily enough.

Fundamentally, advancing technology allows individuals to migrate upwards into areas formerly occupied only by more specialized individuals. This is a law of technologically progressive societies. That nurses are aggressively migrating upwards onto the turf of PCPs is merely a case in point. So, rather than fighting a doomed-by-history rear guard action against the advancing army of nurses, why should PCPs not instead launch a blessed-by-history invasion of their own, against the smugocracy (the people whose jobs end in -ologist)? Heck, they’ll even have the insurers and the feds on their side for once (for the same reason the doctor-nurses now do). Wouldn’t that be novel?

2)Another law of technologically progressive societies is that, whenever specialists are displaced by upwardly mobile, technology-enabled non-specialists, there will always be a portion of the customer base that is likewise displaced. That is, the new, less-sophisticated service providers will be able to provide useful services to a majority of customers - but not to all customers. The customers with high-end needs, who are left out under the new regime, present a new business opportunity.

PCPs operate in a world where the majority of their patients probably have relatively common, relatively easily cookbooked medical problems, and most of these patients will do just fine with their new doctor-nurses. But a substantial minority will have high-end needs, either in terms of complex medical problems that cannot be reduced to simple treatment pathways, or in terms of atypical medical problems that are not easily diagnosed.

DB has discussed at some length this “long tail” in the patient population, as defined by some aspect of material complexity in their medical conditions. The long tail simply cannot be served by guideline-directed care, whether administered by doctor-nurses, or by those more malleable (or complexity-averse) PCPs who will simply allow themselves to be absorbed by the new, dumbed-down primary care regime. Long-tail patients, the outliers, will not be small in number. They will comprise an important new business opportunity, “new” because it is a niche that is not recognized today, as it will be when these patients are being systematically (instead of randomly) culled out.

That business opportunity can be filled by many of today’s PCPs. These will be doctors who enjoy puzzling through complex diagnostic problems, and dealing with complex management issues, and have been trained to do so. To DrRich, this spells “internist.” Doctor-nurses can’t do this job. Specialists can’t do it either. This will be a specific niche for internists.

The best part is that the feds and the insurers, in selling us on the dumbed-down PCP model, are busily assuring us that there is no substantial need for sophisticated PCPs (hence, the appropriateness of doctor-nurses). And in proving the point they’ll be able to rely on carefully constructed, population-based outcome measures (which, since they speak to the average patient, will look very favorable) to marginalize the complaints of the outlying patients. Having refused to acknowledge the existence of complex patients, they’ll hardly be able to make special provisions for their care.

This leaves the door wide open for internists to establish practices to provide healthcare services to patients with difficult diagnostic or management problems, who are being neglected and mishandled by the “official” healthcare system. (These patients know who they are, and are desperately looking even today for somebody to help them.) And since to insurance companies and the feds these patients don’t exist, these practices will have the opportunity to operate outside the system, as private-pay practices, which will eliminate the demeaning checklists, the one-size-fits all guidelines, and the stifling time limits under which PCPs now must operate. And, like plumbers and electricians, they can get paid for what their time and expertise is worth.

(To those of you who immediately object to such a thing because asking patients to pay themselves for medical care is unethical, DrRich asserts it is indeed possible to do this entirely fairly and ethically, while allowing almost anyone who wants this kind of service to have it, and some day he will describe how. But for now, just celebrate the right of people to spend their own money on their own healthcare even when it’s provided by actual physicians, just as [DrRich suspects] you celebrate their right to spend money on chelationists, homeopaths, or reiki practitioners.)

The bottom line, as DrRich sees it, is that the identity crisis now being experienced by American PCPs, while certainly catalyzed by healthcare economics and politics, is a manifestation of the natural and inevitable disruption produced by advancing knowledge and technology. PCPs may be the first, but all physicians will soon face similar challenges as long as medicine continues to advance.

If the PCPs respond logically to this crisis - that is, instead of fighting it, recognizing the opportunities it presents - their specialist colleagues will soon experience their own “encroachment from below,” which is the hallmark of a mobile, technologically progressive society.

Posted in New business models for healthcare, Primary Care in America | 19 Comments »

More Guidelines: What Are They Smoking?

April 4th, 2008 by DrRich

This is a heads-up for all you primary care doctors out there, who struggle during each and every patient visit to get through your Pay for Performance Checklist of Vital Healthcare Services (different checklists for different patients, of course, depending on their insurer), during the 7.5 minutes that the feds and the insurance companies have graciously allotted to you, in order to document for the appropriate accountants your fine performance as a modern American physician.

No doubt one item that appears on your checklist has to do with counseling your patient on smoking cessation. It’s likely you may have thought this to be one of the less objectionable mandates. You can get through your well-rehearsed pitch on smoking cessation in 20 seconds or less (unless this is one of those rare patients who is actually serious about trying to quit), and thereby make up some of the precious time, from your 7.5 minutes, that you have already spent earning some more challenging check mark (trying, perhaps, to talk the patient into taking the extraordinary steps necessary to get his hemoglobin A1c down that last 0.5% to target).

So: 20 seconds spent on smoking cessation. Check.

But whoa. Not so fast there, Dr. Welby.

Did you know there are guidelines for physicians on smoking cessation? Did you know that these guidelines were devised under the auspices of the federal government, by a committee of anti-smoking zealots (not that there’s anything wrong with that)?

From this latter fact, of course, there are certain things we already know about these guidelines before we ever have a look at them. We know that they will be very long and detailed and tedious, because a) they are federal guidelines, and b) they are devised by people whose one and only mission in life - a mission that they clearly believe is far more important than healthcare reform, terrorism, or global warming (or global cooling, as it turns out the case may be*) - is to relieve the world from the scourge of smoking, and who have been given the authority (i.e., the guideline-generating authority) to make it your primary mission in life, too.

Now have a peek at the actual guidelines; here they are. Notice, first, that the federal guidelines for physicians on smoking cessation are 196 pages long. Notice how they step you through the process of counseling, and then step you through each of the measures you must take in order to assure that your patient achieves success. And notice that an early branch point in the process of counseling is where the patient informs you of whether he/she is willing to go any further with efforts at smoking cessation; and notice further that when the patient informs you that he/she is indeed NOT willing to go any further, the guidelines do not relieve you of your obligations, no, but instead provide for interventions you must now conduct on this unwilling patient “designed to increase their motivation to quit.”

This, of course, is all to say: Your 20-second spiel on the evils of smoking just doesn’t cut the mustard, doctor. To really earn that smoking-cessation credit on your P4P checklist, you need to do a lot more than that. The 196 pages of deadly serious federal guidelines detail what that is.

Lest you are tempted to dismiss as an absurdity the expectation that you’re supposed to cram 2 hours of anti-smoking counseling into a 7.5 minute patient visit, there’s one more thing you ought to know.

One John Banzhaf, Executive Director and Chief Counsel for Action on Smoking and Health (ASH), who bills himself as the “law professor who masterminded litigation against the tobacco industry,” is not taking lightly, doctor, your obvious laxity on following federal guidelines on smoking cessation. Accordingly he has sent a letter to each of the 50 state health commissioners warning them that he will soon begin instigating medical malpractice suits, on behalf of smokers who continue to smoke as the result of their doctor’s refusal to follow federal guidelines.

Mr. Banzhaf informs the commissioners that “physicians are killing more than 40,000 American smokers each year by failing to follow federal guidelines.” That’s right, doctor, you’re killing them.(Cigarettes don’t kill people; people kill people.) Specifically he invokes the doctor’s obligation to “warn the smoking patient about the many dangers of smoking and provide effective medical treatment for the majority who wish to quit.” (Emphasis DrRich’s.) That is, it’s your job not just to counsel them and treat them, but also to see that they actually quit smoking. If you don’t follow this mandate, you’re killing them. And you must pay.

When the federal government takes the pains necessary to draft detailed management guidelines for physicians, guidelines that, if followed as written, will save tens of thousands of lives each year, society has every right to expect you to follow those guidelines to the letter - and save those lives. (This is such a brilliant scheme for ending smoking-related death and disability, one must wonder why it hasn’t yet been applied to other intractable medical problems. Just think of the good that could be accomplished, for instance, by federal guidelines that require physicians to cure cancer.)

In any case, consider these guidelines next time you’re putting that little check mark next to “Smoking cessation counseling” on your P4P checklist, and ask yourself: “Have I really done all that I am obligated to?”

Just one last thing, doctor. DrRich may be overstepping his bounds here, and if so just ignore him. But come on. If this is what “traditional” primary care medicine has come to at last, why would you continue to do it? Let WalMart and the doctor-nurses take it if they want it so badly. Extricate yourself from this muddle and practice real medicine, and let the devil take the hindmost.

*If it’s really global cooling after all, shouldn’t we be lobbying our congresspersons to change the CAFE standards to require American cars to get no more than 5 miles per gallon? Let’s get that temp back up!

Posted in General Rationing Issues, Primary Care in America | 8 Comments »