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?
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’.
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.
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.
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.
Proof That Warren Buffet Reads This Blog
May 17th, 2008 by DrRich
Yesterday, Jacob Goldstein of the Wall Street Journal Health Blog reported that Warren Buffet greatly increased his stake in big health insurers during the first quarter of 2008. Specifically, he added 300,000 shares of WellPoint and 400,000 shares of UnitedHealth to the holdings of Berkshire Hathaway. Notably, the stock prices of both of these insurers have been tanking for months. So why would Mr. Buffet be buying them?
Mr. Buffet has a simple answer: “If we’re going to be buying things, we want to buy them on sale.”
To which the WSJ replies: “Of course, if it was simply a matter of increasing holdings that are falling, we’d all be billionaires. There must be more to it than that.”
Indeed, there is more to it than that, and careful readers of this blog (as Mr. Buffet must surely be) realize what that is.
The case against buying health insurance stock, it goes without saying, is plain for anyone to see. As DrRich has pointed out more than once, the mega-insurance companies have traditionally had three major pathways for increasing shareholder value:
1) Acquiring and privatizing community assets - generally non-profit hospitals and non-profit insurers - for a tiny fraction of their true value (through the collusion and/or ignorance of boards of trustees, state attorneys general, and state insurance commissioners), then letting the market assign the actual value of those formerly public assets to the company’s stock price.
2) Mergers and acquisitions of smaller insurers, i.e., through the consolidation of the industry.
3) Taking advantage of certain opportunities for “efficiency” that big insurance companies’ quasi-monopolies have bought them, such as cherrypicking patients, handcuffing doctors, retrospectively denying coverage to insured individuals, and the manifold other activities we can safely bundle under the rubric, “covert rationing.”
Obviously, all three of these pathways are closing off. There are few community-owned assets left to acquire, and consolidation has already left the U.S. with just a handful of important health insurance carriers. As for the “efficiencies,” opportunities here are drying up as well. For instance, this past December, shareholders of UnitedHealth Group (concerned because subscribers to the company’s insurance products had decreased by 315,000 in 2007) demanded a promise from company executives that the insurer would become “nicer” to its subscribers. Their own shareholders are wrecking their business model!
Insurance companies are left with the impossible task of trying to make a profit (and worse, to demonstrate continued growth) by actually managing the healthcare of sick people. This has never been accomplished in the modern era, and in all likelihood is not within the realm of possibility.
This explains why the stock prices of the big health insurers have been heading south for some time now. But what explains Warren Buffet’s enthusiasm for these failing businesses?
Two things. First, he recognizes the growing prospect of a Democratic victory this fall, in both houses of Congress and the Presidency. Second, he has clearly read and digested DrRich’s posting of six months ago that describes what will happen to the insurance industry with a Democratic victory.
Republican-style healthcare reform, even with a Republican such as John McCain, would bring the rapid and painful death of the health insurance industry. This, simply, is because the Republican strategy for healthcare reform relies on “competition and efficiency” in the private insurance market to save the healthcare system. Republicans, apparently, have not noticed that the insurance companies have been desperately trying their brand of “efficiency” for more than a decade now, and it’s been a disaster. The insurers have shot their efficiency wad; they’re entirely bereft of ideas; they haven’t a clue. Indeed, one can only imagine how the notion of a Republican victory, and the unbearable expectations such a victory will place upon them, must shake insurance executives to their core.
On the surface, Democrats will also put the insurance industry in an untenable position, as it is clearly their aim to drive insurers out of business (though they won’t actually tell us so). But Democrats actually have no performance expectations whatsoever for the insurance industry. Their only expectation is that the insurance companies should fail in due time. This prospect - as long as it’s preceded by one last, massive windfall - is quite acceptable to an insurance industry itself, which, realistically, can only be looking for a graceful exit strategy at this point.
As it happens, that one last windfall for the insurance industry is an integral part of the Democrat’s promise. For, before they drive private insurers into oblivion, the Democrats will present them with the gift of government-paid insurance premiums for many (Obama) or all (Clinton) of the 47 million uninsured Americans. These new premiums will amount to as much as $150 billion per annum. So, for at least a while, the Democrats will guarantee that health insurance profits will rise, executives bonuses will increase, and - more to the point - their stock prices will soar.
Which brings us back to what Warren Buffet is up to. DrRich is a great admirer of Mr. Buffet, and is sincerely happy to have been of assistance in furthering his understanding of the complex interplay between politics and the fiscal status of the big health insurers. So far, Mr. Buffet is playing the game perfectly.
DrRich does respectfully remind him, however, to carefully monitor this blog for the “sell” signal.
__________
Addendum. DrRich has just noticed that his deeply admired fellow blogger, DB, has challenged him this morning to a discussion of honor over the topic of malpractice reform, where DrRich has taken a very contrarian and highly unpopular position. Indeed, even DrRich hates himself for making such an argument. Nonetheless, DrRich is compelled, reluctantly, to answer in the affirmative (this being a matter of honor), and will post a reply within a day or two.
Happy Anniversary, If I Do Say So Myself
May 15th, 2008 by DrRich
They said it couldn’t be done.
They said, “An entire blog devoted to covert healthcare rationing? Ha!” They said, “Perhaps you’ll come up with a posting or two, but an entire blog? Why, you’ll run out of things to say inside of a week.” They said, “Covert rationing indeed!”
So today, on the First Anniversary of the Covert Rationing Blog, DrRich asks Them, “Who’s laughing now?”
Of course, because covert rationing is the lifeblood of the American healthcare system, the glue that holds the whole thing together, it is actually child’s play to come up with topics to write about. So DrRich does not feel as if he has accomplished any great feat here (despite having shown Them to be wrong! wrong! wrong!), any more than anyone should feel superior who has merely taken up the task to write down the obvious. If any accolades are to come his way, it ought to be for no more than his plodding persistence.
The real accolades ought to go to his fellow medical bloggers (many of the best of whom are listed in the column to the right), who have inspired and supported DrRich over this past year (and indeed, who are often quoted here), and who are doing a real service to American society. Few journalists in the mainstream media “get” what’s really going on nearly as well as these people do.
During the past year DrRich has attempted to interpret many aspects of American healthcare through the prism of covert rationing. Accordingly, both for readers who have been with him through the whole journey, and for those who have only recently found this blog, DrRich would like to take this opportunity to point to the posts which have generated the most interest, surprise or commentary. All of them illustrate the pervasive, destructive, wasteful, and enervating influence of covert rationing on the healthcare system and on American society - which (aside from keeping DrRich off the streets) is the real purpose of this blog.
Why patients should review their health records
Gag Clauses are obsolete for a reason
Pay for Performance and covert rationing (Part 2 here)
Why healthcare inflation is not explained by waste and inefficiency
A modest proposal for controlling drug prices
E&M guidelines and patient care
Physician Report cards and the designated driver
The transcendant importance of retainer medicine
Capitation and ratting on patients
How to invest in the new Medicare audits
Is guideline tyranny causing guideline anarchy? (Part 2 here)
Covert Rationing Makes Malpractice Reform A Bad Idea
May 9th, 2008 by DrRich
Our friend Kevin Pho was undoubtedly correct when he pointed out in his recent op-ed in USA Today that arbitrary and unrestrained medical malpractice lawsuits are a blight on our healthcare system. The always-looming threat of malpractice suits elicits expensive and wasteful defensive behaviors from doctors and hospitals, and is a major source of physician frustration. Almost everyone except the trial lawyers (and their minions in the various federal and state legislatures) understand that medical malpractice is in dire need of reform.
So it deeply pains DrRich to say that significant malpractice reform at this juncture is a bad idea, certainly for patients, and in truth even for the medical profession.
Realizing that he has just alienated at least the estimated 60% of his readership who are of the medical persuasion, DrRich hastens to assure one and all that he is second to none when it comes to despising lawyers. Consider:
1) DrRich’s initial baptism by trial lawyer occurred right after he entered practice as a general internist 30 years ago. During his very first month of practice, he wrote a refill prescription for a patient whose own doctor was unavailable. Two years later he was named in a malpractice suit, alleging that he had written this prescription incorrectly. It turned out that the patient was not harmed by the medication (her suit was for another issue entirely, involving another doctor), and it also turned out that DrRich had written the prescription correctly in the first place. But it took a full 18 (nerve wracking) months of legal maneuvering to acquire a copy of the prescription from the plaintiff’s attorney, during which time DrRich was pressured to “settle” (he did not settle), and after which the suit against him was summarily dropped. Fortunately this has been DrRich’s only direct encounter with a malpractice suit, but unfortunately it was not his only encounter with lawyerly ethics.
2) Eighteen years later, by this time a professor of medicine and a cardiac electrophysiologist (hey - if you’re going to specialize, specialize!), DrRich was ensnared in one of the federal government’s very first major dragnets aimed at healthcare “fraud.” DrRich was, of course, completely and demonstrably innocent of all allegations. But proving his innocence required him to endure a severely prolonged, difficult and frightening ordeal, highlighted by an actual show trial before Congress (replete with masked, voice-altered witnesses). You can read the whole incredible tale here. (Memo to the Office of the Inspector General: Just kidding, you guys are great. Thanks for the memories.) It was this experience that prodded DrRich to finally ask himself what the heck was going on, and that ultimately led him to discover the Grand Unification Theory of Healthcare. (As a catalyst for discovering universal truths, DrRich has concluded, it would be far easier just to have an apple fall on your head.)
3) Then, another 10 years later, after DrRich had left the practice of medicine altogether to become a consultant and writer (which he had hoped would be a less hazardous venue), an attorney who was suing a big biotech company leaked to the New York Times a memo DrRich had written as a consultant to that company. The NY Times immediately made DrRich’s memo the subject of a major article that proved quite embarrassing (though inappropriately so) to the company. You can read the Times article here. Subpoenas immediately began raining down on DrRich from all directions, and his life once again needlessly became a circus of depositions and other legal maneuverings. DrRich will be happy to tell you all the details of this episode once he’s sure it’s all over, which at this moment he’s not.
All of this is simply to demonstrate that DrRich has earned his lawyer-despising chops the hard way. His numerous and oft-painful encounters with attorneys, during his long and varied career, have left DrRich more than a little sympathetic with the likes of Dick the Butcher, the cutthroat in Shakespeare’s Henry VI, who said, “The first thing we do, let’s kill all the lawyers.”*
So: If you’ve waded through this confession of faith, you can plainly see that DrRich is no friend to lawyers, and would like nothing better than to climb onto the malpractice-reform bandwagon, there to join his colleagues in demanding an end to the waste, intimidation, heartache and expense brought on by the systematic abuse of medical malpractice suits.
But alas, to his unending regret he cannot.
The reason he cannot, of course, is covert rationing.
A central goal of covert rationing is to make physicians answerable, above all, to one or more central authorities (whether the government or mega-insurance companies) rather than to their patients. The litany, to refresh everyone’s memory, goes like this:
- Healthcare rationing is unavoidable.
- But we’re Americans and Americans don’t ration.
- So we’ve deputized the government and the insurers to do the rationing covertly.
- Covert rationing requires controlling the behavior of physicians; specifically, it requires coercing them to place the needs of the payers ahead of the needs of their patients.
- Patients are thus fundamentally and purposefully marginalized within the healthcare system.
In a thousand ways, covert rationing leads directly to the destruction of the classic doctor-patient relationship, a relationship formerly revered and sanctified by law, tradition and ethics, in which the primary responsibility of the doctor was for the welfare of his/her individual patient.
Turning the physician’s efforts away from individual patients and towards the good of the whole (”good of the whole” as defined by guideline-creating groups and other policy-making bodies whose output can be easily influenced by central authorities) has become a major emphasis of today’s healthcare system. Accordingly, the death of the classic doctor-patient relationship has been decreed by Congress, supported by medical ethicists, upheld by the U.S. Supreme Court, and incorporated into guideline-directed routine medical practice. It is being taught to young doctors today from the outset, many of whom seem to regard the old notion that every patient should be evaluated and treated as a unique individual as anachronistic and inefficient.
When physicians abandon the classic doctor-patient relationship, even though it’s through coercion, they abandon what defines them as professionals. It diminishes doctors to a stature no higher than that of pieceworkers, who get paid by the procedure or by the completed checklist. It is the loss of this innate professional purpose, DrRich believes, which accounts for the greatest part of the frustration being expressed by physicians today.
For patients, the loss of the classic doctor-patient relationship - losing their one and only true advocate, whose job it is to take their part within an adversarial healthcare system - is a threat to more than mere professional pride or purpose. It is a threat to life and limb. Patients are left to their own devices, alone, abandoned, and marginalized in hostile territory, their ostensible Guides distracted by their own needs (and indeed, perhaps no more reliable than so many Gollums).
Consider the implications of the malpractice system to patients in such an environment. In a healthcare system where physicians are being urged, cajoled, threatened, incented and coerced to practice medicine to some statistical mean and not to the individual, and where the “mean” to which they are supposed to aspire is determined by central authorities mad with the need to covertly ration care, the only real leverage patients retain is the implied threat to sue doctors who fail to address their individual needs. The threat of malpractice litigation, as wasteful and counterproductive as it is, provides at least some degree of balance in the doctor-patient encounter, and gives doctors (even those whose professional pride has been successfully eroded by all the many efforts aimed at doing just that) a good reason to always ask themselves, “Is this action I’m about to take the action that THIS patient really needs me to take?”
And in a distressingly sad way, because the threat of litigation may cause some doctors to ask this question more often than the central authorities would like them to, the specter of malpractice suits may even, to some small degree, help to uphold medical professionalism. And at least to this tiny extent the threat of lawsuit, in the long run, may be beneficial to doctors.
There’s more. The malpractice travesty, as bad as it is, is at best a distraction. It distracts physicians from focusing on the main event, from that which is really destroying their profession. For once you destroy the doctor-patient relationship you leave the medical profession adrift and rudderless, buffeted by the four winds and capricious currents. You leave it subject to a gathering host of oppressors, with their decrees and directives that in earlier days would have been dismissed as beneath consideration. You leave it defenseless against encroachment from groups with far less training and expertise, but who can also do the piecework, fill out the checklists, follow the guidelines, and who have the government-sanctioned certificates to prove it.
In the face of all this, for doctors to focus exclusively or even primarily on malpractice reform - which, all niceties aside, will in some fundamental way further limit the prerogatives of their abandoned patients - is perhaps worse than merely a distraction. It is a complete capitulation. It is a plea not for the restoration of their profession, but instead for mere consistency, to force the plaintiffs’ attorneys to recognize, as the doctors themselves have done, that the standards of care have been formally diminished, that it is not fair to hold doctors to a standard in a court of law that they are enjoined from achieving in the clinic. It is an acknowledgment that the classic doctor-patient relationship, that which defines medicine as a true profession and not just a trade, is dead and gone and is not coming back.
If doctors will extricate themselves from a system in which they are working primarily for the government and insurers instead of for their patients; if they will reinvent styles of medical practice in which they can give primacy to their individual patients instead of to the payers; then at last we all will be morally obligated to insist on fundamental malpractice reform. But as long as doctors allow themselves to practice in an environment that systematically disenfranchises and marginalizes their patients, no reform should be supported or even permitted that will push patients farther into the margins.
DrRich has tried mightily during this past year to illustrate how covert rationing always leads to inefficiency, waste, inequity, destruction - and absurdity. That it can turn an utter travesty like our current state of malpractice litigation into something we ought to refrain from vigorously reforming is, perhaps, the most absurd result of covert rationing we have seen yet.
* Attorneys themselves famously insist that Shakespeare was actually paying them a compliment by putting these words in Dick’s mouth. What the Bard actually meant, they theorize, is that before any violent overthrow of a civil government can be effected, one first must eliminate the protectors of society, namely, the lawyers. But prithee! (Olde English for “Give me a break!”) Leave it to the self-serving lawyers to so completely twist a context as crystal clear as the one in which this line appears. Dick the Butcher, quite undeniably, was simply enumerating just one more delight - the premier one at that - to add to the veritable garden of delights that would become theirs once he and his gang took over. And anyone who says otherwise is either a member of the legal profession, or someone disgustingly sympathetic to it. Which (he is taking very great pains to point out), DrRich is not.
Smile When You Call Me Optimist
April 14th, 2008 by DrRich
In a previous post, DrRich gave his thoughts on the distressing condition of the American primary care physician (PCP), and described how the feds, the insurance companies, and the currents of history are conspiring to fundamentally devalue and disrupt their once-honored profession. Further, he attempted to describe some options that disaffected PCPs might explore which might possibly open the door to new, more sustainable business models.
This posting has generated a robust commentary, for which DrRich is grateful, as he thoroughly enjoys engaging in give-and-take with his readers, whose thoughtfulness and intelligence invariably challenges him to bring his analyses into sharper focus.
And based on this most recent commentary, DrRich finds that there is indeed an issue that clearly needs more focus - that of his purported optimism. It seems that some readers, in perusing the previous post, came away with the idea that DrRich is saying something like this: While history is demanding that PCPs must suffer a great disruption, history also points the way to their salvation; that, indeed, PCPs merely need to jump in the boat, and the currents of history will sweep them into the promised land.
To the extent that he created any impression that the transformation he’s proposing for PCPs is likely to be automatic, or straightforward, or easy, or without significant hazard, or (least of all) universal, DrRich most humbly apologizes.
He would like to set the record straight.
Here’s what history dictates: As long as there are free markets, the “final solution” being embraced by the insurers and the feds - that of a dumbed-down, malleable population of front line medical practitioners (whether made up of indoctrinated younger physicians, “broken” older physicians, ascendant nurses, or some combination of these) who will provide all basic medical services and control access to more specialized services - will ultimately not prevail. The large number of patients who have needs that will not be met by this solution will create an irreducible demand that the market will somehow conspire to meet. That, if anything, is the “optimistic” part of DrRich’s synthesis.
PCPs are in an unique position to fulfill much of this demand, and DrRich tried to describe two general pathways that might be explored for doing so (there are almost certainly others). But he certainly did not mean to imply that this would be easy to do, or that more than a minority of PCPs would embark on such a path, or would be able do it successfully. Indeed it seems likely that most PCPs will take the course of least resistance, as they seem to be doing now, gradually allowing themselves to be absorbed by the diminished model now being offered by the insurers and the feds, complaining about but not really fighting their fates, and all the while hoping for early retirement.
History reveals this to be the general rule. Most persecuted Puritans did not migrate to the New World (where they faced hurdles arguably even more off-putting than the threat of malpractice suits and specialist-dominated credential committees). Most Goths, upon being overrun by the invading Huns and facing the choice of absorption or migrating to territory occupied by somebody else, did not move south to sack Rome. Most PCPs will likewise accept their fate, and simply try to make the best of it.
Any pioneering PCPs who attempt instead to blaze these new trails will face huge hurdles, and they’re hurdles anyone (including DrRich) can see very clearly. They include the strong opposition (to put it mildly) PCPs will get from specialists as they explore ways to encroach on their turf; the attacks they’ll suffer from malpractice lawyers as they undertake to perform services traditionally done by specialist physicians (lawyers being the specialists’ great allies in this instance); the steady resistance of the insurers; the notion dearly held by most of the public that people shouldn’t have to pay for ANY of their own healthcare; and the parallel notion dearly held by many government officials that people shouldn’t be ALLOWED to pay for any of their own healthcare, and that any attempts to arrange for people to do so should be met with the most extreme prosecutorial wrath.
So, while DrRich believes history helps to explain what’s going on in the world of the American PCP, and helps (at least vaguely) to point the way for some of them, history rarely unfolds easily, or quickly, or without pain, bloodshed, tragedy and travesty. Generations (or centuries) can pass before a resolution is reached.
But if some insist on characterizing this as optimism, who is DrRich to object?
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!
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