Fun With Randomized Trials, and Breasts
July 18th, 2008 by DrRich
The Cochrane Collaboration has created something of a stir with its latest review on the advisability of doing breast self-examinations, which concluded, in essence, that they’re not advisable. Specifically, they found that women who perform breast self-examinations end up producing more harm than good, so women should be discouraged from the practice.
The Cochrane Collaboration is a highly regarded resource for those who value evidence-based medicine, medical guidelines, and the randomized clinical trials that support such tools. The experts at Cochrane conduct reviews of all randomized clinical trials (RCTs) that meet their strict criteria for scientific and statistical robustness, and periodically publish summaries of the scientific evidence thereby derived, on particular clinical topics. Cochrane reviews are thorough and straightforward, and virtually always present an accurate reflection of the up-to-date evidence as supported by RCTs.
Despite the respect in which the Cochrane Collaboration is held, DrRich finds it at least mildly interesting that their conclusions regarding breast self-examination have not been generally construed as being politically incorrect. After all, several aspects of political incorrectness, ones at least as incorrect as your more standard species of political incorrectness, can be readily identified within the Cochrane review. For example, one could easily allege that anti-women, anti-self-empowerment, or anti-early-detection thinking riddles this report. And if the review had emanated from say, the White House, one almost certainly would. But in fact most media reports, while expressing a certain amount of surprise, have seemed very reluctant to criticize the Cochrane Collaboration’s conclusions. And physician experts who have been excavated by the media for their comments have also given at least tepid support.
(Not all commentators have blindly accepted Cochrane’s recommendations. DrRich refers you to his colleague Trisha Torrey, for example, who expresses an appropriate amount of skepticism. But the traditional media, and their Rolodex physicians, have on the whole swallowed it. See here and here.)
The general support for Cochrane’s report on breast self-examination, DrRich submits, is a direct reflection of the exulted position that RCTs have achieved today all across the modern medical (and media) landscape. If a statistically legitimate RCT reaches some conclusion, no matter how strange, counterintuitive, or wrong that conclusion might seem, it is a conclusion that must be accepted. That this belief in RCTs trumps even the powerful social force of political correctness speaks to its ultimate strength.
DrRich has previously observed that our widespread belief in RCTs can be reduced to three main tenets:
1) Data derived from randomized clinical trials represents Truth.
2) Data derived from non-randomized trials represents Falsity.
3) If you don’t believe this, you are a heathen.
Objective observers will find it at least a little ironic that an attempt to claim the scientific high ground has so obviously resulted in a new religion, replete with its own dogma. True Believers will not see the irony, thus providing even more evidence that what we’re dealing with here is indeed a religion and not objective scientific thought. (Religions deal in mystery, and not irony.)
The sad truth is that the results of RCTs are invariably dependent on the bias built into their design, and even if internally they are statistically legitimate, they can often send us down the wrong path.
Those who design RCTs (the smart ones, at least) know this. They are like smart trial attorneys, in that they know the answer before they ever dare to ask the question. So they tailor their “question” in such a way as to yield the answer they want to get. Indeed, if a lawyer should end up asking a question that produces an unexpected answer, he or she is completely incompetent and ought to be sued for legal malpractice. In more cases than one might think, the same is true for those who design RCTs.
So, for instance, if you are a payer and want to limit the use of an expensive therapy, you design your RCT so that enrolled patients likely to respond to the therapy are diluted with lots of enrolled patients much less likely to respond, to assure that the average response of the whole population will be quite small. (In many instances the clinical characteristics of the likely responders and the likely non-responders will be reasonably apparent.)
On the other hand, if you are a company that wants to encourage the use of your product, you design an RCT that preferentially enrolls patients who are very likely to respond favorably, and then trust the marketplace (with a tweak from your DTC advertisements) to “extrapolate” the results to broader categories of individuals.
So RCTs do not in any way eliminate statistical bias, as most seem to think. Rather, they simply offer an opportunity to control the statistical bias in your favor. Since most doctors (and most regulators, guideline writers, and reporters) don’t seem to get this, it becomes relatively easy to fool them.
DrRich does not know if the people who designed the RCTs looking at breast self-examination tried intentionally to bias the results against self-examination, or if it was an accident. But that is what they did.
The RCTs which the Cochrane Collaboration reviewed looking at breast self-examination indicate that, in large populations of women in Russia and China, who go on to receive Russian and Chinese healthcare, breast self examination did not improve overall survival. And since those who did self-examination underwent twice as many breast biopsies, many of which revealed benign lumps, they experienced net harm. DrRich does not quibble with any of this. It is almost certainly true.
On the other hand, while most RCTs do not reveal it (since they look at aggregate results and not individuals), it is most often the case that some individual participants in even a negative study will experience benefit from the intervention being tested. In the breast-self examination studies, for instance, it is a certainty that individual women benefited at least to the extent that their breast cancers were detected earlier than they otherwise would have been. (In the Russian study this was proven to be the case.) These women had at least a shot at better survival by virtue of their earlier detection.
But whatever the overall results of these RCTs conducted in such exotic locales, they can have nothing whatsoever to do with women in America in 2008, who receive far more aggressive, tailored, and sophisticated therapy for breast cancer than women in virtually any other country in the world. (The optimal treatment of breast cancer depends on correct staging, on correct genetic testing of the tumor, and on optimizing the individual’s surgical and medical therapies, often employing very new drugs.) In any case, earlier detection of breast cancer is far more likely to be a significant factor in determining outcome in the U.S than it is in recently (or presently) Communist countries with 3rd world healthcare systems.
To be sure, DrRich does not pretend to know anything about the various specific institutions in Russia and China where these studies were conducted. Perhaps they were conducted in those rare showcase institutions that appear here and there under authoritarian regimes, of the sort Michael Moore frequents when he goes to Cuba, and where the level of medical care is said to more nearly approximate medical care in the United States. (Occasional institutions like this will survive even in the U. S. after Healthcare Reform, so that our Congresspersons will have someplace to go.) While this seems very unlikely - could a few showcase hospitals really accommodate the nearly 400,000 women enrolled in these studies? - one must suppose it is possible.
But even if all 400,000 study participants received showcase healthcare, advances in the therapy of breast cancer since the 1990s, when these women were studied, would likely yield different (and better) results today. Does any American oncologist believe that the early detection of breast cancer in 2008 does not improve a woman’s prognosis?
In light of such considerations, why are American doctors apparently so ready to accept the results of the Cochrane review, and to stop recommending breast self-examination? The answer is clear: It is because the data came from RCTs, and since RCTs always yield the truth (you heathen), all other considerations must fall away. Such is the depth of our faith.
DrRich will leave it for another day to discuss the favorable implications to the healthcare system of discouraging breast self-examination (such as having to pay for fewer biopsies), or the lessons that ought to be learned from this example about the advisability of blindly accepting formal guidelines just because they are derived from RCTs, and instead will simply give some friendly advice to the women who might be reading this blog:
First, it is probably a good idea to continue with your breast self-examinations. The downside of doing so is that you may be subjected to a breast biopsy for a benign lump. So take that into consideration. But the upside is that self-examination offers the (proven, according to the RCT data) potential for earlier detection, and therefore offers better odds of long-term survival if cancer is present.
And second, if breast cancer is diagnosed, try to get your therapy in the U.S. rather than in Russia or China. For the average patient in those countries, it would appear that cancer therapy sucks.
Finally, DrRich will close with this plea: Can our guideline writers, at least in the U.S., please refrain from creating new guidelines that are suitable for 3rd world healthcare systems, at least for the year or so it might take for the American healthcare system to actually be reduced to those levels?
How Covert Rationing Precludes Efficiency
July 3rd, 2008 by DrRich
(Don’t forget to check out the Independence Day version of Medical Grand Rounds.)
Depending on which news source you read, physicians either are or are not about to get hit with a 10.6% pay cut from Medicare. (The actual outcome of the pay cut kerfuffle, some say, will depend on how many Republican Senators are buttonholed by how many American doctors at July 4 picnics.)
Many people have formed rather firm opinions on this matter. Physicians, for instance, mostly disapprove of the pay cuts. Others (most often non-Medicare-aged non-physicians with what is termed today a “progressive” outlook) feel strongly that doctors are among the most coddled and advantaged groups in the land, and that a modest sacrifice like this pay cut is the least they ought to be willing to offer for the public good. And of course, DrRich himself has an opinion on the matter, which will be well-known to most readers of this blog.
But on the other hand, most Americans haven’t really given it much thought. After all, most Americans are not doctors, they’re not on Medicare, they’re not politicians, and they’re not sick. Besides, some have suggested, the Bible-thumping, gun-toting masses are too disaffected with such concerns as the cost of gasoline, food prices, job security, health insurance, and the 15 (or 16 - one loses count) consecutive losing records of the Pittsburgh Pirates, to be able to concentrate on the truly lofty questions. Furthermore, it is commonly believed by well-educated (and especially progressive) persons that the great unwashed are just a bit too dim to understand the really important issues, and so must be reassured (and led along) with easy-to-digest, 10-second “executive summaries,” which can be repeated over and over and over, as needed. So, for instance, we can’t let a few greedy doctors and fat cat Republican Senators destabilize Medicare.
DrRich, on the other hand, who was himself held in captivity by two of these Bible-thumping, gun-toting hoi polloi for the first 18 years of his life before escaping to more enlightened environs, grudgingly came to realize they weren’t so dumb after all. Indeed, in comparison to many of the Harvard-educated Top Scientists and Top Doctors with whom DrRich (who did not go to Harvard) has had the honor of working, Mom, Dad and the guys in the steel mill (with whom DrRich also had the honor of working, back when America still had steel mills) displayed a very comparable degree of innate intelligence, and a far superior degree of general wisdom and common sense.
But not even Dad (the smartest man DrRich ever knew, uncommonly smart even for a steel worker) could have figured out how doctors are getting paid today, or what’s up with the projected physician pay cuts. (He would have easily brushed aside the assertion that doctors themselves ought to embrace the cuts out of a sense of altruism, or alternatively, guilt.)
The sad fact is that anyone who actually tries to look behind the headlines to figure out why physicians are (or are not) about to get hit with a 10.6% pay cut by Medicare will quickly be swept away by a maelstrom of tangled laws, policies, regulations, interpretations, guidelines, secret committee proceedings, quid pro quos, tit for tats, and “unintended consequences” of both varieties (i.e., the actually unintended ones and the secretly intended ones), that surpasseth all understanding.
Go ahead, try it yourself.
First, DrRich recommends you study the Happy Hospitalist’s latest exposition on how doctors actually get paid. It is the clearest explanation DrRich has ever seen. But even though Happy has taken very great pains to simplify the processes involved, in order to make them remotely understandable (and to such effect that he deserves a Pulitzer, or whatever the blogging equivalent may be), their complexity is breathtaking. Trying to explain how physicians get paid is akin to explaining how one achieves the mystic vision of the Great All; one can come close to the truth with the use of language, symbols, graphics, analogy, starvation, exposure to the elements and controlled breathing, but one must actually experience it to appreciate the essential wonder and transcendent awe.
Then, for a clear explanation of how changes to physicians pay are accomplished, DrRich insists you deconstruct Robert Laszewski’s article in Health Affairs. This is merely a description of Congressional procedure, not really that much more complicated than most things Congress does, and is necessarily much simpler to follow than the Byzantine convolutions tackled by the Happy Hospitalist. But still, it is fairly frightening that any aspect of America’s healthcare is decided in such a manner.
However, to really begin to get a general idea of the complexity of the whole system, one must synthesize these two articles - the process for regulating the system of physician reimbursement (Laszewski) and the system of reimbursement itself (Happy.) By “one,” DrRich is referring to you, the reader, as it is far beyond the poor abilities of DrRich to do so himself.
Don’t feel badly if you can’t synthesize this mess, either. For in truth, the physician reimbursement system is not meant to be understood by mortal man.
And that’s the point.
It turns out that this incomprehensible physician reimbursement system was set on its current path by one simple desire: to force doctors to covertly ration healthcare. As Laszewski explains in another article,
The idea was to set an “affordable” physician cost trend and when real costs exceeded that level Medicare would compensate for it by cutting future fees. The. . .message to doctors was simple: If you spend too much the Medicare program will compensate by cutting your fees in the future to balance things out. The objective was to give physicians a reason to control their costs.
Yes, that’s right. The original purpose behind this whole mess was to induce physicians to stop spending so much of Medicare’s money on patients’ medical care.
But when you set out to do such a thing, you can’t just come right out and say so, because that would be admitting to rationing. Instead, you’ve got to hide your real purpose in soothing language (generally it’s best to employ irony, and talk about improving efficiency and quality), and in bureaucratic processes that are so convoluted that the casual observer (or even the serious investigator) will not be able to discern their real intention.
Things get bad enough, as DrRich has described numerous times, when the bureaucratic entity running the covert rationing effort is a private insurance company.
But to really appreciate the potential for the opacity, complexity, and inefficiency demanded by covert rationing, one must study the government’s efforts in this arena. To the mere goal of profit which is the lifeblood of any company (too often fueled by excessive greed, one must admit), add the much stronger and additional aims of power and influence that fundamentally motivate our politicians, regulators, administrators, and others too numerous to mention who work for the government. Then stir in the absolute need to make convoluted deals, compromises and concessions with sundry interest groups and diverse colleagues and acquaintances, influences that may or may not have anything whatsoever to do with healthcare. Pretty soon you have the kind of “system” that is partially explained by a synthesis of the exertions of the Happy Hospitalist and Robert Laszewski.
The current physician reimbursement system is emblematic of what we might expect if we turned the entire healthcare system over to the government, and those who rail against such a single-payer system ought to use this example as an object lesson. For those who favor a single-payer system, however, such examples are simple to counter with illustrations of the egregious and heart-rending abuses perpetrated by private health insurers.
This is all to say that the real issue is not so much with the government or with the private insurers. Whatever travesties these entities perpetrate simply follows from the job we’ve all given them, which is, to ration our healthcare covertly. Covert rationing is rationing by whatever means you can get away with, and so utterly requires head fakes, misdirection, systematized inefficiencies, complexity, delusion (of self and others) and flat out lies. These things simply cannot be accomplished in a system characterized by transparency and smooth efficiency.
So if we’re going to continue rationing healthcare covertly, it really doesn’t matter all that much whether the rationing bureaucracy is controlled by the feds or private insurers. As the (other) Poet says, Fire or ice; either will suffice.
Medical Grand Rounds, Vol 4, No. 41
July 1st, 2008 by DrRich
Welcome to Medical Grand Rounds, Volume 4, Number 41, July 1, 2008. This week, bloggers from across the Internet have submitted articles that will help us celebrate the 232nd birthday of the United States of America. Their patriotic postings, organized according to their relationship to the Founding, follow:
Lists of Grievances
Annie at Home of the Brave sets the tone for this week’s Grand Rounds. She does a brilliant job showing what the Founders might have said about the current state of the American healthcare system, in What They Were Saying: A Riff on the Declaration and Resolves of the First Continental Congress. The First Continental Congress, of course, met in 1774 to petition King George for a redress of grievances stemming from the Intolerable Acts. The King rebuffed their petition and a shooting war broke out the following year, which led to, well, quite a bit. (Faced with their own intolerable Acts, many doctors, in stark contrast to the Founders, simply keep their heads down and continue making those little marks on their Pay For Performance checklists.)
Ian Furst of Wait Time & Delayed Care is Canadian and knows something about healthcare and the bureaucracy (not that doctors in the U.S. have any excuse not to know the same thing). Ian analyzes the results of England’s 4-hour ER wait-time guarantee, and shows once again how bureaucrats tweaking one variable in a complex system always manage to create interesting unintended consequences. But, since these unintended consequences will always require further bureaucratic activities in order to produce corrections, they guarantee perpetual growth of the bureaucracy, and thus are seen, by the people who really matter, as exceedingly good things.
Speaking of the proper limits of government, Doc Gurley considers, in her post, Hope and Death, the implications of the California Assembly’s latest bill, essentially requiring doctors to tell patients when they are terminally ill. This information, no doubt, would substantially lower patients’ expectations, and patients with low expectations can be managed very cheaply. (Which explains the legislative impetus to become involved in such matters.) But as Doc Gurley points out, the definition of “terminally ill” is often in the eye of the beholder, and the definition favored by those running the healthcare budget may be quite different from the definition patients (and doctors, if left to their proper medical functions) would favor. Doctors not wanting to break the law (or expose themselves to yet another, particularly promising, form of healthcare fraud) will predictably begin shading the definition of “terminally ill” toward the cost-saving side, i.e., making the determination somewhat earlier than traditional (or proper). DrRich predicts that our faithful public servants will soon take note of the prolonged anguish that will ensue as a result of the newly prolonged (by legislation) duration of terminal illnesses, and their bureaucratic compassion will move them to legislate a mitigation; namely, a law requiring the easy availability of physician-assisted suicide.
The Happy Hospitalist this week offers one of his patented, in-depth analyses of the utter mess that Medicare has become, in This is What You Voted For. For a system that produces the exact opposite of what it says it wants to produce, you can hardly beat Medicare. Happy says, “Look out America, get ready for even lower access to cheap effective [primary] care and a highly expensive and wasteful proceduralization [by specialists] of your friends and family. . .Well America, this is what you voted for. I hope you’re ready to live with the consequences.” Taking into account the bizarre incentives, Byzantine inefficiencies, and systematized grievances that are provided in such luxurious abundance by Medicare, Happy (and DrRich) can only marvel in dazed wonderment that anyone thinks that turning the whole healthcare system over to these people is a good idea. Imagine our honored forebears clamoring to turn over the entire colonial economic system to the perpetrators of the Stamp Act!
And anyone who still thinks any government knows how (or can know how) to run a healthcare system should become a regular reader of Dr. John Crippen’s NHS Blog Doctor, to get a taste of what healthcare across the pond is really like. His recent posting, The Rise of the Healthcare Professionals, describes just a few examples of the systematized dumbing-down of healthcare that has accompanied England’s NHS, and will accompany any system in which codified policies, procedures, and guidelines, handed down from on-high and strictly enforced, replace genuine medical thought.
Inalienable Rights
DrRich has always been amused by those boutique diseases that doctors occasionally invent in order to justify new avenues for payment. Psychiatrists (in DrRich’s humble opinion) have been particularly adept at this game. Dr. Shock MD PhD gives us his opinion on the latest such neo-diagnosis - Internet Addiction. Dr. Shock, we are happy to note, is not enamored with this new disease, and to his very great credit finds in America’s founding documents an inalienable right to the Internet. All self respecting bloggers must unite against declaring as a disease the robust appreciation of the Internet!
The anonymous blogger who writes How to Cope With Pain wonders in Can I Still Blog? whether blogging is an inalienable right - and concludes that while it may be a right, the fact that something is a right does not necessarily relieve you of the attendant risks or consequences. So that’s why all those other physician-bloggers choose to remain anonymous! Is it too late to inform you that DrRich is actually a 58-year-old housewife from the upper Midwest who learned everything she knows about medicine from Dr. Kildare reruns?
Alvaro at Sharp Brains talks about the inalienable right of men and women to own functioning brains - and what they can do to keep them - in Why We Need Walking Book Clubs.
Theresa Chan at Rural Doctoring tells a painful story, in Another Reason Why Healthcare is Going Down the Toilet, documenting how some patients (and patients’ families) feel they have an inalienable right to all the time and toil they desire of physicians, and for free.
The Spirit of the Individual, That Which Made America Great
Rob, at Musings of a Distractable Mind, shows us that the independent, creative spirit that made America what it is remains alive and well - even in PCPs! DrRich has long maintained that PCPs need to think outside the box in order to salvage their profession, and in What are You Going to Do? Rob demonstrates thinking that is, uh, way outside the box.
Over at Insure Blog they’re talking about another aspect of the right to fend for yourself - this time, using a patient’s own cloned immune cells to treat cancer. This research, which comes from the UK, is not funded by the National Health Service, nor has the NHS expressed the least interest in it. So, one might say, the British government is keen to remain “independent” of potentially expensive cancer cures. Read about it in Interesting Cancer News.
David E. Williams at the Health Business Blog tells us about an idea whose time has surely come - enticing patients to take their medication by rewarding them with chances in a lottery. Now, what can be more American than that? Go read You gotta play to win.
Kim of Emergiblog reminds us in Give Me Empathy, or Give Me . . . Another Nurse, how, when we are sick and frightened, nothing can soothe us like the presence of a confident, knowledgeable and empathetic nurse. The continued empathy of nurses is quite remarkable to DrRich, who notes that nurses are under as much stress from the bureaucracy as are doctors. Add to that the stress from being expected to follow orders from those harried, frustrated, angry, not-always-clear-thinking doctors, while still doing the right thing for the patient - dual responsibilities that are not always 100% in alignment. Continued empathy under such challenging conditions can only be attributed to individual character and dedication.
Kerri of Six Until Me reminds us in My Own Shoes that knowledgeable, intelligent and rational patients will always take doctors’ recommendations under advisement, but may ultimately decide that their own personal situation is best served by some deviation from those recommendations. Such patients are not being “non-compliant;” they are considering the doctor’s advice within the context of the totality of their lives (which will always include data their doctors can never fully understand), and exercising their own individual judgment.
Christian Sinclair at Pallimed reports on the practice of hospice medicine during the ongoing Midwestern floods. His report reminds us of America’s greatest asset - the dedication, ingenuity and spirit of individual Americans - which is always most impressive under the toughest of circumstances.
Christine of You Don’t Look Sick tells us how patients can take a major step toward declaring their own independence from a hostile healthcare system - by taking charge of their own medical records. Great advice for any patient.
Standing Up To Powerful Authorities
Dr. Mintz takes on the all-powerful popular media in telling us the truth about the 8 drugs that doctors wouldn’t take. It is very popular to bash the drug companies these days, and accordingly, any negative news about (expensive) new drugs is invariably hyped far beyond any objectivity. DrRich would likely say that this behavior is just another example of covert rationing. But Dr. Mintz more usefully provides the objective truth about these “never drugs.” Perhaps, as a follow-up, he should write about the 8 sources of medical news that doctors (at least the smart ones) wouldn’t read.
JunkMD over at Progress Notes sounds like he’s just about ready to tell the feds what they can do with their latest pay cut. In They Just Don’t Get It, he is fed up both with his Medicare-age Senators and with fellow citizens who expect him to just sit there and take it. Maybe, he allows, it’s time to consider retainer medicine. “Opponents of this model wonder who will see the patients who can’t afford a retainer physician. Well, if none of us are in business, it won’t matter.” That sounds about right to DrRich.
DrRich his own self offers an alternative (and most uplifting) explanation for the fact that doctors apparently owe the IRS multi-millions of dollars in unpaid taxes. Rather than merely being tax cheats, perhaps these physicians are emulating their forebears who nobly defied oppressive Acts of Parliament by throwing tea into Boston harbor. But then again, perhaps not.
The Freedom From Misinformation Act
Dean Moyer of The Back Pain Blog helps one reader declare her independence from misinformation by answering the question Can Herniated Discs Really Heal?
Dr. Paul Auerbach at Medicine for the Outdoors tells those who are exposed to the smoke from wildfires (now raging in California) how to stay healthy. Being aware of oncoming threats in this case is a bit more complicated than “one if by land, two if by sea,” but is no less important.
When DrRich was a medical student, the only decent doctor show on TV was Marcus Welby, MD - a series that was heavy on personal interaction but weak on medical information. So cracking the books was the only good option for learning a little medicine. Today, medical students have many more options. Monash medical student, for instance, is fighting misinformation (his and ours) by reviewing episodes of House.
David Harlow of HealthBlawg reports on the launch of the Massachusetts eHealth Collaborative’s latest Health Information Exchange (HIE). An HIE is more about interdependence than independence, but then, our Founders also banded together (vowing to hang together so as not to hang separately), in their struggle for autonomy.
And Dr Penna reports on new information on Genetic Risk Factors for Alzheimer’s Disease. If you decide to get the test, don’t tell the government or United HealthGroup.
The Obligations of the Individual in a Free Society
Marshall, the Episcopal Chaplain at the Bedside, reminds us in Returning to those Hard Conversations that doctors caring for the terminally ill should more often just say the plain truth, even when it’s painful (for the doctors) to do so.
Dr. Val and the Voice of Reason informs us that it’s plain to both the Surgeon General and to any beat cop that “most people just don’t know what it means to be a good citizen anymore.” Read her plain-spoken interview with Sgt. Zlotkus here, then go do the right thing.
Tories
Some, when a growing conflict reaches the point of no return, will always side with the more powerful disputant. In the Colorado Health Insurance Insider, Louise writes about why doctors are unhappy, and postulates that as a result many physicians now say they are in favor of universal, single-payer (i.e., government) healthcare. DrRich simply notes that after the American Revolution, thousands of Americans who had favored continued rule by the King moved to Canada and got what they desired; and finds it interesting that today’s Americans who want the sovereign power to take over healthcare could do exactly the same thing (if they were to lose the “healthcare wars,” as unlikely as it now may seem), and with precisely the same result.
Am Ang Zhang of The Cockroach Catcher blog tells us about the systematic abuse of the diagnosis of Post Traumatic Stress Disorder by “an alliance of antiwar psychiatrists, VA hospital administrators, and patients who never saw combat or even Vietnam service but found that reciting the PTSD symptoms would result in the awarding of disability payments.” Read about it in PTSD: Diagnosis du Jour. Even John Adams has an opinion about this one.
Picnic Advice, or Don’t Be Stupid
RLBates of Suture For a Living wants to make sure we have a happy 4th. She posts again this year on fireworks safety - a matter whose importance she, a plastic surgeon, unfortunately knows all about.
The Samurai Radiologist at Not Totally Rad offers advice on keeping kids from ingesting foreign objects in Coming Soon to a Child’s Stomach Near You. SR helpfully reports on a missive he received from a concerned parent who is dismayed by the existence of such a thing as Kellogg’s Lego Fruit-Flavoured Snacks: “I just spent the first three years of my son’s life trying to get him not to eat blocks, and now you’re telling him they taste like [fornicating] strawberries. Thanks a lot assholes.” Picnic advice like this you can’t get just anywhere.
What Doesn’t Kill You Will Make You Stronger
Americans have learned repeatedly that adversity produces strength. So, if the rising prices of food have you down, Walter, at Highlight Health, urges you to be of good cheer! In The Upside of High Food Prices he describes how more people are eating local produce - and eating healthier. He neglects to point out (though DrRich will kindly take up the slack) the other problem caused by cheap food that is now being mitigated. We refer, obviously, to the fact that cheap food is the chief source of what has become the latest scourge-of-society: obesity.
Service and Sacrifice
Fighting for what you believe in is always costly, and the cost is never more apparent than in Healthline’s posting on Suicides in US Troops. If you know a serviceman or servicewoman this holiday, let them know how much we all love them and value their service and sacrifice.
The Most Important Aspect of Any Holiday
Bongi at other things amanzi offers us the sad and most affecting story of little k. On this holiday - or any holiday - the best lessen we can take away from k’s story is to gather around us those we love, give them a hug, then count our blessings and thank God for every one of them.
Next Week’s Grand Rounds
Next week Grand Rounds will be hosted by The Blog that Ate Manhattan.
Are Doctors Garnishing Tax Payments to Recover Funds From Medicare?
June 25th, 2008 by DrRich
The Wall Street Journal recently reported that Congress is urging Medicare administrators to assist the IRS in garnishing payments to doctors (and other “contractors”) who owe federal taxes. The Government Accountability Office estimates that providers owe more than $2 billion in back taxes, and withholding Medicare payments to providers is seen as an expeditious method of collecting those owed monies.
DrRich is shocked (shocked) not only that a body of Solons such as Our Congress could so egregiously misinterpret the actions of forthright American physicians, but also that the WSJ itself (a bastion of American capitalistic thought) could fail to recognize the true nature of those actions.
For DrRich suspects there is an alternative explanation that places the alleged tax deficiencies of American doctors in a somewhat different, and far more heroic, light. Namely, when (if) doctors are withholding tax payments, they are not doing so as common tax cheats. Heavens, no. Rather, they are doing so for entirely justifiable and noble (if illegal) reasons.
First, they are trying to break even. In contrast to what is seen with most of the revered professions (wherein the payment due to the professional is transparently negotiated, or is simply “set” by the professionals themselves according to what the market will bear), the pay of physicians is determined by Acts of Congress. Even now, before the next set of impending, Congressionally-determined physician pay cuts, Medicare does not reimburse doctors enough to cover the overhead of most office visits.* Some say this makes the business of office practice economically dicey. In fact, it is already impossible for a stand-alone, independent primary care doctor to make a living caring for Medicare patients.
Second, Medicare has successfully inculcated the Fear of God into physicians regarding the now-federal crime of healthcare fraud. The penalties for committing healthcare fraud are so onerous that merely being accused of it is enough to induce most physicians to beg for a settlement deal, regardless of the strength of their defense, and regardless of the fact that most such settlements are personally and professionally ruinous. And the opportunities to be accused of fraud are unlimited for even the most fastidiously honest among physicians. (The arcane E&M coding rules, which have been formally proven impossible to follow, afford the opportunity for the feds to point the fickle finger of fraud, quite arbitrarily, toward any American doctor who treats Medicare patients, at any time.) Not wanting to appear fraudulent to Medicare is foremost in the minds of American doctors (which pushes “wanting to help their patients” down to Number Three on physicians’ priority list, right after “wanting to avoid spurious malpractice suits”).
As a result of these two considerations, it is conceivable** that some physicians, wanting to continue the noble practice of caring for Medicare patients, but at the same time wanting to be fairly reimbursed for same (at least to the extent of breaking even), have made a simple calculus. Inasmuch as the government owes them fair reimbursement for services they render to government entitlees, and inasmuch as the government has not been forthcoming with said fair reimbursement (and promises to be even less forthcoming in the very near future), therefore (some physicians may have concluded), they will simply exercise whatever opportunities they may find to recover some of these owed funds on their own initiative. For much the same reason that Congress is proposing to garnish Medicare payments to doctors, perhaps some doctors are garnishing tax payments to the IRS.***
It would indeed be telling if physicians who reach such conclusions (if indeed there are such physicians) have decided to recover funds they feel the government rightfully owes them, not from Medicare, but instead from the IRS. These doctors would obviously have concluded, quite logically, that dealing with the wrath of the IRS is far, far less intimidating than dealing with the wrath of the federal healthcare fraud establishment, whose tactics would make the average American physician beg for the rights and considerations afforded to your average Guantanamo detainee (especially since last week.)
Small wonder that the relatively meek and unassuming IRS has asked for the help of their nastier federal brethren in cracking down on recalcitrant doctors.
Whatever the correct explanation for it, however, the prospect of the IRS and Medicare teaming up in enforcement efforts ought to send chills through every American physician, and should stimulate among them significant second thoughts about their career paths.
Speaking of which, here’s a second thought they should consider, and soon.
*These comments, as usual, pertain almost exclusively to PCPs. Specialists (such as DrRich when he still practiced), are doing just fine, what with the procedure-based reimbursement system their brethren on the RUC have arranged for them. Unlike PCPs, who lose money every time a Medicare patient darkens their door, specialists can make up for lowered per-unit reimbursements by cutting corners and increasing the volume of procedures they perform. It’s not particularly pleasant (or safe), but it is what it is, and the specialists have learned to get by.
**Note to IRS and CMS agents: Hi, fellas. DrRich has no personal knowledge, direct or indirect, of any of this sort of illegal behavior; he is simply taking known facts and extrapolating them to their logical conclusions.
***It is a law of history that bad law and bad regulations eventually create contempt for authority, and progressively render various illegal actions rationalizable, reasonable, justifiable, and finally, ethical. Even those who sympathize with physicians on this matter (and DrRich suspects these are few indeed), would say that that the rationale for not paying owed taxes has progressed certainly no further than the “rationalizable” stage, if that. But the natural tendency of governmental authority to progress toward arbitrariness is the very thing that led Jefferson to muse that continued societal vitality might require revolutions every few generations. I’m just sayin’.
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.
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.
Why Backdating Stock Options Is Completely Understandable
June 4th, 2008 by DrRich
The Wall Street Journal Health Blog reported yesterday that Bill McGuire, the former CEO of UnitedHealth, did not know that backdating stock options was wrong. McGuire was eventually fired for his unfortunate backdating activities.
According to the WSJ, in the way of explaining how McGuire might be unaware that backdating stock options is frowned upon his attorneys state (in a brief filed on his behalf in a shareholder lawsuit), “Dr. McGuire has no formal training or degrees in finance, accounting or law. His only professional training is as a medical doctor with a specialty in pulmonology.”
The WSJ Health Blog, affecting its usual snarky tone, scoffs at this: “The Health Blog has no formal training in pulmonology, but the sums involved in this case do make us gasp for breath.” The value of McGuire’s backdated stock options, they go on to say, has been estimated at $1 billion.
It will undoubtedly be a great comfort to Dr. McGuire that DrRich now wishes to come to his defense.
Yes, it is clearly absurd for McGuire to argue that, because he’s just a dumb pulmonologist, he didn’t know that backdating was wrong. Every doctor, even radiologists*, understand that backdating important documents is wrong and probably illegal.
What the WSJ, and more importantly the litigious and thankless shareholders of UnitedHealth, fail to realize is that the skewing of McGuire’s moral compass has nothing whatever to do with his original profession or training. Rather, it is an essential skill required by anybody running a health insurance company.
These outfits, which exist to covertly ration healthcare, have got to do everything they can possibly get away with to avoid subscribers who are ill or might become ill, who are economically disadvantaged, or who are particularly demanding. They are obligated to do whatever it takes to deny coverage retrospectively to legitimate subscribers who have developed expensive illnesses. In a thousand ways they have got to play fast and loose with the rules and - more to the point - with documents. In fact, if the purpose of documents is not to manipulate the facts to the company’s best advantage, then what earthly good are they?
Once McGuire became the CEO of such an organization, manipulating the truth, largely through the creative use of documents, must have become second nature. And he must have become very good at it. (Otherwise why would the shareholders award him all those stock options?) Getting documents to say what you need them to say would become more than second nature to such a one; it would become why God put him on the earth in the first place.
So when a CEO of a big health insurer is given yet another document on which changing something as simple as a date will significantly improve the bottom line, it must have been unthinkable - nay, unethical! - for him to not simply go ahead and change the date.
The WSJ can laugh all it wants at McGuire’s plea that he didn’t know backdating was wrong. And the shareholders can profess as much outrage as they please. One might as well rail at a rigorously trained pit bull which, in the frenzy of a death match, clamps its jaws on the calf of a spectator who has inadvertently strayed too close to the action. If you’re going to employ such single-minded beasts, be careful of the objects you place before them.
DrRich hopes that it provides Dr. McGuire with a touch of consolation to know that at least one compassionate observer buys his protest of innocence without any reservation whatsoever. Indeed, DrRich would be far more disturbed by the notion that a CEO of a successful health insurance company might actually understand right from wrong, yet still do his job anyway.
* Cardiologists (like DrRich) and radiologists are traditional enemies, engaging as they often do in turf battles over medical procedures, promulgating dueling guidelines, and the like. Consequently, for a member of one group to impugn the native intelligence of the other, as DrRich has done here, is a revered and honored pastime for both of these specialties. So no one need take offense at DrRich’s gratuitous slur of radiological aptitude. Anyone who does is as thin-skinned as a pathologist.
Hope for the Medical Home?
June 3rd, 2008 by DrRich
Last summer DrRich wrote a post that was pretty hard on the Medical Home, and since that time he has seen no good reason to reconsider his opinion. Rather (as usual after officially pontificating on some topic), DrRich has remained smugly satisfied that he nailed it.
But now something has happened to make DrRich wonder whether some good might come out of the Medical Home after all, namely, that Dr. Centor (the much admired DB) has become formally involved in developing demonstration projects of the Medical Home for the American College of Physicians (ACP) and American Society of Internal Medicine (ASIM).
DrRich is completely serious about this: if DB is involved, the Medical Home is worth another look. DB fully appreciates the importance of the doctor-patient relationship, the limitations of professional guidelines, and the potential for abuse with Pay for Performance. If a model for the Medical Home can be developed that adquately honors these considerations, it could be a very good thing for doctors, patients, and the healthcare system in general.
So DrRich pledges to keep an open mind as he follows DB’s reports on his work. Here are some things DrRich will be watching for, and some questions he will be asking himself as he observes.
1) The concept of Medical Home itself seems quite useful. Under the Medical Home paradigm, patients would have a dedicated personal physician who partners with them, over time, coordinating all their medical care and guiding them, whenever necessary, through the hostile halls of American healthcare. That’s the nugget of it, at least as DrRich understands it.
But really, what’s new here? Hasn’t this been the fundamental idea behind primary care medicine for the past 50 years? Why does the ACP find it necessary, at this juncture, to recapture and rechristen its own central idea?
2) The ACP, to its credit, asserts that the Medical Home will help to repair the doctor-patient relationship. But what does it mean by that? Is the ACP simply referring to the fact that, with a long-term relationship, doctors and patients will become closer, and doctors will get to really know their patients (i.e., will acquire a deep understanding of their medical conditions, likes, dislikes and propensities), which will enable better medical care? These are all good things, to be sure.
But it doesn’t actually address the fundamental problem with the doctor-patient relationship today, which is: doctors have been maneuvered into placing the needs of the payers (whether insurers or the feds) ahead of the needs of their patients. Instead of honoring their defining professional obligation to always make the needs of their individual patients their chief consideration, doctors have been told they need to make the needs of “society” primary.
Indeed, the inability of doctors to honor their fundamental ethical obligation has caused the ACP-ASIM to “revise” its formal declaration of medical ethics (under the theory that if it becomes too difficult to honor a code of ethics, then change it), so as to obligate doctors to honor society’s needs rather than their individual patient’s needs. A patient facing a doctor today cannot know whether the doctor’s recommendations are based on what would be best for that patient, or on what would be best for society (i.e., cost reduction), and for the doctor to place the patient into such a position has become perfectly ethical.
DrRich has gone on and on about how this “new ethic” formally destroys medical professionalism. The question for now is: In repairing the doctor-patient relationship, which ethic will the Medical Home honor, the traditional one or the “new” one?
3) Will the new Medical Home efforts of the ACP look any more promising than its first effort? That first effort was done in conjunction with UnitedHealth Group, and DrRich has written about it here. There was much not to like about it, but chief among them was the new physician reimbursement scheme that it incorporated:
“UnitedHealth Group will pay participating physician practices a monthly care-management fee based on projected savings for all patients that select a medical home. In addition, the company will share any excess savings that accrue from the pilot program with the physician practices and — by way of premium reductions — with employers.”
That is, doctors were to be paid according to their ability to not spend UnitedHealth Group’s money on patient care. The less they spend on patient care, the more doctors make.
Such an arrangement is all perfectly ethical, according to the new ACP-ASIM standards, but it doesn’t do much for the doctor-patient relationship, at least as DrRich conceives of it. Will the next ACP-endorsed Medical Home really be aimed at benefiting the doctor, the patient, and the doctor-patient relationship - or will it again be aimed at benefiting the bottom line?
In summary, given the deep and abiding need of the payers to covertly ration healthcare, given the steps that have already been taken to wreck medical professionalism and the doctor-patient relationship, and given the unpromising initial efforts of the ACP in the Medical Home arena, the sole cause for DrRich to have any degree of optimism is - DB.
To be sure, DrRich does not expect DB to single-handedly get the ACP-ASIM onto the right-thinking path and make the Medical Home what it really ought to be. But DrRich does trust that DB’s heart and intellect are in the right place and that he will make every effort to steer the Medical Home in as favorable a direction as possible. With at least a bit of hope in the outcome, DrRich wishes DB the strength and fortitude this new effort will require, and is very glad that somebody who understands the underlying issues, and who is capable of expressing them, is participating in it.
In the meantime, in order to get all the benefits of the Medical Home, including a fully restored traditional doctor-patient relationship, and without all the insurer’s schemes and incentives aimed at covertly rationing his medical care, DrRich will continue under the care of his excellent retainer internist.
More Fun With Guidelines
May 27th, 2008 by DrRich
Lately DrRich has advanced the proposition that the “Guideline Movement” (the push to reduce all of medical practice to a set of fixed rules by which physician behavior can be controlled) is leading to guideline anarchy (whereby numerous interest groups, from the government to industry to professional societies, have begun a mad dash to create their own sets of guidelines in an attempt to get doctors to behave in ways that will further their own special agendas).
In the effort to give substance - and by extension, some level of legitimacy - to his theory, DrRich gave several examples of anarchical guidelines, and even proposed three different categories of them (i.e., Dueling Guidelines, Predatory Guidelines, and Industry-driven Guidelines).
DrRich is already beginning to see that, once you start looking for them, examples of guideline anarchy begin showing up all over the place. Consider a few of the more interesting ones DrRich has come across just over the couple of weeks:
Dueling Guidelines: Mammograms for women under 50.
DrRich was reminded of this obvious example by a reader. Whether women between 40 - 50 years of age should get routine mammograms has been a point of controversy for some years. Screening these younger women undoubtedly reveals cases of curable breast cancer that otherwise might have been missed. However, such screening also leads to many false positive mammograms, causing unnecessary invasive procedures (and unnecessary anxiety). Because the incidence of breast cancer is lower in younger women, it has been difficult to show objectively that the overall benefits outweigh the negatives of routine mammograms in this age group.
Still, the American Cancer Society, American College of Radiology, and the National Cancer Institute (groups that might benefit by more screening and by finding more cases of potential cancer that need to be evaluated) have long been persuaded that women over 40 should have routine screening. On the other hand, the American College of Physicians and the Canadian Task Force on the Periodic Health Examination (groups that traditionally have relied on overall population-based outcomes, and which are interested in cost savings) say that based on objective evidence, most women should wait until they are 50.
This example is interesting because it shows what happens to dueling guidelines over time. Due largely to vocal and effective lobbying from many groups in favor of screening, professional groups have tended to migrate from the “no” to the “yes” camp. The most recent converts have been the United States Preventive Services Task Force and the American Academy of Family Physicians, groups that traditionally have been in the “cost savings” camp. While the actual data has not changed appreciably, some guidelines have (apparently for non-data-based reasons).
Dueling Guidelines: Fancy anticoagulation for acute coronary syndrome.
A recent editorial appearing in The Lancet points with dismay to two sets of dueling guidelines, one from the American College of Cardiology (ACC) and American Heart Association (AHA), and the other from the European Society of Cardiology (ESC), on the use of two space-age anticoagulation medications in patients with acute coronary syndromes. While the details are fairly mind-numbing and can safely be left alone, the important point is that, after reviewing the same scientific evidence and using the same criteria for rating the evidence, the ACC/AHA essentially said, “yes, use the drugs;” while the ESC said, “no, not so much.” (We may be seeing a trend here, where professional organizations based in the U.S. seem to favor paying for fancy new drugs whose benefit may be considered by more cost-conscious organizations, like those in Europe, as marginal and not worth paying for.)
In any case, it is instructive to hear the lament of the Lancet’s editorialists, who complain,
“The committees reviewed the same research and used nearly identical criteria to rate the strength of the recommendations and to grade the quality of the evidence, but they interpreted the evidence for acute anticoagulant use differently and so reached different conclusions. Therefore, physicians who read recommendations from both the US and European societies might be confused.” (Eikelboom J, Guyatt G and Hirsh J. Guidelines for anticoagulant use in acute coronary syndromes. Lancet 2008; 371: 1559-1561.)
Yes, that’s dueling guidelines for you. If the editorialists would just become regular readers of this blog, they would not find their case so inexplicable.
Premature Guidelines: Beta blockers in noncardiac surgery.
This example requires defining a fourth category of guideline anarchy: Premature Guidelines are guidelines that are promulgated not so much before all the data is in (because all the data will never be in), but rather, before a reasonable amount of data is in. The reason organizations will find it advisable to jump the gun on guidelines is obvious - if you want to get doctors to act in a certain way, and if making guidelines is the best way to do that, the first ones to establish guidelines have a head start on controlling physician behavior.
Our example: Previous (but small) studies have shown that for patients at increased risk for heart disease who are having noncardiac surgery, treatment with beta blockers at the time of surgery reduces the incidence of heart attacks. So, the AHA and ACC (our recurrent friends and aggressive wielders of guidelines) have written formal guidelines that recommend the use of beta blockers in these patients. These particular guidelines, being attractively easy for bureaucrats to track by a simple review of medical records, have been very popular and quite widely adopted as quality measures, performance measures, items on P4P checklists, etc. Accordingly, lots and lots (and lots) of patients have received beta blockers during their noncardiac surgery because of these guidelines over the past several years.
But a very large and well-conducted study (the POISE study) now appearing in The Lancet shows that, while the incidence of heart attack is indeed reduced with the use of beta blockers, the incidence of stroke and of death are significantly increased. The net effect of using beta blockers turns out to be strongly negative. How embarrassing this will be for the AHA, ACC, and thousands of doctors and hospitals who have been dutifully following the guidelines so as to be good medical citizens!
The authors of the study have not played down the inflammatory implications of their new findings. According to theHeart.org, the lead author of the POISE study opines:
“If even only 10% of physicians followed these guidelines — which incidentally in the US are used in quality assessments, where you have people going around ranking hospitals in terms of whether or not they are giving perioperative beta blockers — and if the POISE data are true, then in the past decade 800,000 people would have died prematurely and 500,000 would have had a major stroke perioperatively because we gave beta blockers.”
Oops.
To be fair, an accompanying editorial, written by two physicians partially responsible for the existing guidelines, urges doctors not to panic, and suggests that there’s still a prominent place for beta blockers in these patients, and even suggests (vaguely) what that place might be. They are very reassuring. Unfortunately the data, at the moment, is not. All this will be straightened out over time, of course. But in the meantime we’ve got premature guidelines that remain in force, directing doctors to do something that - by all appearances - is harmful to patients.
(On his About.com heart disease site, DrRich discusses the POISE study, without the sarcasm, for patients who might need to interpret this new information. DB also addresses the implications of the POISE study, here.)
Way-premature Industry-driven Guidelines: Use of IVUS in stent placement.
In a presentation made earlier this month in Barcelona at the EuroPCR meetings, investigators urged that cardiologists use intravascular ultrasound (IVUS) whenever they place stents in coronary arteries. They urge this based on observational data suggesting that using IVUS (an invasive ultrasound technique for visualizing the interior of the artery) can lead to (marginally) improved clinical outcomes. This “suggestion” clearly does not amount to actual “guidelines,” but DrRich includes it here as an interesting view of the type of stuff that can quickly lead to guidelines.
The evidence currently supporting IVUS is not definitive, to say the least. It is based on relatively small observational studies and not on randomized clinical trials. But still, because IVUS is a highly specialized and expensive technique, it is bound to bring a very favorable level of reimbursement to cardiologists, if indeed it were a reimbursable technique. And a very important step to making it reimbursable would be to generate guidelines supporting (or preferably, demanding) its use. And to generate such guidelines, first one must create a groundswell of support among the cardiology thought leaders.
And that’s what was going on at EuroPCR. Indeed, the cardiologist/investigator who is the chief proponent of using IVUS (himself a major shareholder, consultant and speaker for the company that makes IVUS technology), urges that IVUS not be held to “unreasonable” standards such as those requiring randomized clinical trials, but instead that its advantages to patients are so patently obvious that it ought to be made a routine part of stent placement NOW.
Whether this particular example of way-premature industry-based guidelines will ever get anywhere, DrRich obviously cannot say. He offers this example simply as an illustration of the kind of “thinking” that, in the old days, used to lead to fancy dinners, $100 ink pens, trips to Honolulu, and even to compliant female companionship for influential (if geeky) medical thought leaders, all in an effort to increase sales; but that in the modern era leads to guidelines.
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.
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