Monday, July 21, 2014

A physician does not need to be society's steward to "Choose wisely"regarding medical advice

Eliminating dangerous and unnecessary medical tests and treatments is the ostensible aim of the "Choosing Wisely" ( CW) initiative that is being promoted by the American Board of Internal Medicine Foundation (ABIMF).

I submit that is is not only unnecessary to evoke the principle of physicians as stewards of society's medical resources to accomplish that goal but it is a dangerous concept and promotes the idea that the individual exists to further the welfare of the collective or " society" Even the most cursory study of world history in the 20th century should disabuse one of the notion that such an approach works out well.

If a physician strives to do what is right for the patients,not to harm the patient and respects the patient's autonomy no other ethical principle is necessary to achieve what the choosing wisely campaign purports to accomplish. Following century's  old  medical ethics it all that is required. A physician so directed would not knowingly order tests or treatments that are harmful to the patient or useless and thereby waste the patient's money, whether or not all or most  of the reimbursement is from an insurance company or the government.The physician by choosing wisely is not saving some mythical society's resources but is spending less of a particular entity's money.

It is not necessary to compare  spending patterns per capital in various countries to cajole physicians to reduce or eliminate  tests or treatments that are useless and or harmful. It is not necessary to change the culture of medicine which has been the announced aim of some spokesmen for ABIMS and ACP to get doctors to do what is right in their best judgment  for their patients.

When my family or I go to a physician I want her to recommended a test or treatment based on her judgement as to whether that would be in the bests interest of her patient and not based on some imaginary role as a steward of some mythical collectively owned resource.

 The folks at ABIMF have been very explicit about linking their version of social justice with the Choosing Wisely initiative.See here.  I submit that physicians have attempted to do what in their judgment is right for their patients without evoking the notion of social justice and that includes not harming the patient by ordering harmful procedures and treatment.Social justice as the term is generally used involves redistribution from the better off to the most disadvantaged. ABIMF's version of social justice is based on utilitarianism keyed to QALY ( quality adjusted life years) per dollar spent and seems to be obsessed with spending less money generally on health care.Think about that for a moment. In what other profession is there a well funded campaign to spend less on what members of the profession have much of their lives learning how to do? Cui Bono.

Being a physician is not the easiest job in the world.It continues  to be true that life is short,the art long, opportunity fleeting, experience treacherous and judgment difficult. My physician has enough to do without assuming the pretense of being a steward of anything-her fiduciary duty to her patient is more than adequate.

Friday, July 18, 2014

The population medicine approach does not respect the separateness of the individual,traditional or Rawlsian social justice nor evidence based medicine

 The population medicine approach disrespects the separateness and sanctity of the individual and individual liberty. It is antithetical to not only traditional medical ethics but also to the ethics of classic liberalism. Further it violates a major element in the concept of evidence based medicine, patient autonomy. It is not compatible with the social justice concepts as formulated by John Rawls and does not conform with the generally accepted meaning of social justice as redistribution from the less to the more needy.

The population medicine approach is basically utilitarianism which champions policies and actions that are supposed to bring about the greatest good for the greatest number. I say "supposed" because even the founder of utilitarianism recognized that logically and practically determining the aggregate utility or happiness did not make sense.Jermey Betham realized that adding John's happiness and Mary's happiness and subtracting Fred sadness was nonsense.

Quoting Bentham  "Tis vain to talk of adding quantities which after the addition will continue distinct as they were before, one man's happiness will never be another man's happiness;a gain to one man is no gain to another;you might as well pretend to add twenty apples to twenty pears, which after you had done that could not be forty of any one thing  but twenty of each just as there was before. ( ref. pg 136, A system of Liberty, by George H. Smith.) . Bentham admitted his "hedonic calculus" was based on a fiction  but he felt it was a necessary framework to get things done or legislation passed or policies accepted.

His approach echoes the thinking of the man who approached a psychiatrist and told him that he was very worried about his brother. Why are  you worried? Doctor, he thinks he is a chicken. Well, that is very serious you need to get him hospitalized.No, the man replied, we can't do that, we need the eggs.

 Bentham also needed the eggs.

 Everyone make decisions in everyday lives.It may not involve a formal or explicit cost-benefit analysis but it often involves a trade off. Utilitarianism goes beyond  making a trade-off within a person's life to the making of trade- offs between persons' lives and without their consent throwing the discreteness of individual under the bus. The population medicine approach does just that.

Consider the following quote from Dr. Harold Sox writing in the November 13,2013 issue of the Journal of the American Medical Association:Here he is  writing about allocation of funds occurring in the population medicine approach across patients and programs in which funds would be shifted to program in which the value was higher, as judged by QALY per dollar spent.

"It will take several generations to realize the full benefit of investments in disease prevention.In the short run,these investments draw resources away from tests and treatments from some sick people.In the long run, disease prevention and better low cost technology could reduce the outlay for treatment. In the interim, skillful clinical decision making can made the most of limited resources"
"Using the same metric of value and the same decision making principles for patients and for populations would be an important step toward a system that fairly allocates resources between the healthy many and the sick few."

The proponents of population medicine cavalierly admit there will be winners and losers. Dr. David Eddy in a series of articles In JAMA in 1995  said exactly that when he discussed the system that he proposed  as achieving better quality at lower cost. It was simply utilitarianism with cost effectiveness being a key metric in the allocations that would be made.Population Medicine is simply utilitarianism using quality adjusted life years (QALY) per dollar spent as the new metric of happiness or utility.

Sir J.A. Muir Gray writing in the Lancet (Vol 382,July 20,2013 ) in a commentary entitled "The Art of Medicine.The shift to personalized and population medicine" said in part:

'In the 21th century clinicians have a responsibility to the population they serves,to the patients they never see, as well as to the patients who have consulted or have been referred.,individual clinicians, while still focused on the needs of the individual in front of them when in the consultation, also make decisions about the allocation and  use  of resources to maximize value for all the people  the population they serve.This could be a decision that will reduce the amount of care that some would receive and increase the amount of resources for another group of patients,or perhaps put resources into education so that generalists can better manage the patient that specialists do not need to see."

Winners and losers but  more than that- Dr. Muir Grey would have the physicians also use their "charismatic and sapiential authority to promote health and prevent disease and encourages sustainable care , getting the best balance of benefit to harm, while minimizing the amount of carbon generated."

This is  a tall order- to balance care for your patient and everyone else and strive to save the environment.Medical school will have to get even longer and harder to churn out docs with that skill set.Actually the rank and file docs will not have the allocation problem,the Platonic Guardians of Population Medicine will make the big decisions and the regular physicians will just adhere to guidelines.

The proponents of population medicine seem to think they have solved what Bentham thought impossible summing individual utilities by  using the QALY tool, quality adjusted life years which seem more scientific and objective that the "utils" of the early Benthamites.

 The ACP and ABIM Foundation are popularizing the new medical ethics. It appears that this new medical ethical system is an important prerequisite for population medicine  Here is how a former President of ACP, Dr. Harold Sox, ( ref. JAMA Nov.13.2013,vol310,no 8) explains it.

"Throughout history,codes of professional conduct have called on clinicians to make each patient's interests their highest priority.If resources becomes limited,clinicians will find themselves unable to adhere to that standard of practice for all patients.In 2002,a new code of conduct ,the Charter for Professionalism ,addressed this conflict by calling of physicians to consider the needs of all when treating the individual. While meeting the needs of individual patients,physicians are required to provided health care that is based on wise and cost-effective management of limited clinical resources.The provision of unnecessary  services not only exposes patient to avoidable harm and expense but also diminishes the  the resources available to others.
This remarkable passage indicates that the physician has an ethical imperative to balance the needs of the individual patient with the needs of society.With this foundational  principle of the population health approach, the Charter, in effect calls on clinicians to allocate resources. However, it does not provide specific advice. Recent programs such as the American Board of Internal Medicine  Foundation's Choosing Wisely campaign, are beginning to fill this knowledge gap, as do some practice guidelines." 

Dr. Sox speaks about "if resources become limited". By definition resources are limited. there has never been a limitless amount of medical care available.Apparently fiduciary duty to the  patient was acceptable as long as resources were not limited but by definition resources are limited.There has never been an unlimited amount of medical resources.

In this passage Dr. Sox ties together the Charter, the Choosing Wisely Campaign and the population medicine approach. Although Dr. Sox omitted mention, the Charter inserted a third ethical principle to the physician's ethical responsibility.It added to beneficence and non malfeasance, the furtherance of social justice which they stipulated was the fair and equitable allocation of medical resources which they later clarified  to mean that physicians should follow medical  guidelines based on cost effectiveness. But social justice as expounded by Rawls and as generally understood by most people means redistribution to the advantage of the most disadvantaged and that is not what population medicine offers. Shifting of resources to one group from another based on comparative QALY calculations may or may not necessary benefit the most disadvantaged in society. The choosing wisely campaign began with a suggestion to which few physicians would object: eliminate tests and treatments that are harmful or wasteful. But it was not necessary to invent a new ethical principle for physician to accomplish that goal. The ethical precepts of beneficence and non malfeasance covered that.One need not resort to claiming  that such act were required because physicists were the stewards of society's limited medical resource. It was sufficient to require that under the rubric acting a fiduciary agent of the patient.Further, the Choosing Wisely movement is morphing into something that some (see here) would want to be much more transformative.

Population Medicine approach is not compatible with the basic elements of evidence based medicine.Dr. David Sackett said:"Evidence based medicine is not “cookbook” medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook approaches to individual patient care."

In the scenario described above by Dr. Sox in which funds might be diverted from someone's treatment to benefit some anonymous future person we hear no mention of consent of the patient.  Is it assumed that everyone will selflessly agree to sacrifice for the good of the collective.?Social and political schemes based on that principle worked out rather poorly in the 20th century.
The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at:

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at: is Dr. David Sacket's definition of Evidence Based Medicine (EBM) :"EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal preferences and unique concerns, expectations, and values. The best research evidence is usually found in clinically relevant research that has been conducted using sound methodology". (Sackett D, 2002)What seems lacking in Dr. Sox commentary about population medicine is mention of the patient personal preferences and concerns and values. There is nothing said about how the patient might feel in the scenario Sox describes in which funds that could have been used to treat  some one's illness are diverted to some preventive program in which the result may take generations to be achieved. In a system in which its proponents admit there will be winners and looses we are not told to what extent if any will the values and wishes of the loser be considered .Drs Eddy and Muir Grey seem to assume that patients  will be just fine when funds are directed away from their or their children's or spouses  care to some other use judged to be more valuable or cost effective. Programs which depend on changing human nature have not worked out well.Look at the dismal history of collective planning in the 20th century.
The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at:
I submit that population medicine approach and the usual notion of social justice and in particular John Rawls's definition of social justice are not compatible. In fact much of Rawl's magum opus ,A Theory of Justice,was  written at least in part to refute utilitarianism  which is  a principle on which population medicine depends. Rawls said the utilitarianism did not respect the separateness of the individual and argues strongly against treating people as means some social end,In the case of population medicine , this would be optimizing the QALY or QALY per dollar spent.

To mix the concept of social justice and population medicine as done by spokesmen for the ACP and ABIMF is  a masterful muddle of mixing incompatible concepts and stirring it up with platitudes,gratuitous assertions and non sequiturs.

So, other than  that the population medicine approach contradicts traditional medical ethics,does not further social justice as it is commonly understood, flouts a key element of evidence based medicine,and requires individuals to sacrifice  themselves to some alleged greaert good, it seems like a  pretty good idea.

Friday, June 13, 2014

Does the concept of "value based payments" make any sense at all?

Greg Scandlen at the Health Policy Blog comments on the term "value based" quoting from a worth- reading article by David Carr writing on the site Information Week. Here is link to Scandlen 's thoughts.

Scandlen deftly takes apart a widely quoted article by Michael Porter that appeared in the NEJM in 2010 .

The concepts  of professor Porter are widely quoted and for him value is defined as "health outcome per dollar spent" but he spends considerable effort in explicating how elusive and difficult that is to put into meaningful operational use.

A number of the concepts that Porter has made popular ,after a little thought, seem more to be catchy platitudes than useful,reality based insights.For example the notion of improving performance and accountability by "having a shared goal that unites the interests and activities of all stakeholder.s"Is there any real sense in which the patient has a shared goal with the third party payer?

quoting Scandlen:

" ..I would argue that the whole idea that “value to the patient” can be defined objectively is misguided. Even with precisely the same cost and the same medical outcome, the “value” of a service will be different for every patient. Dick Cheney seems to be very happy with his heart transplant and thrilled to extend his life by several more years. Someone else might think that the ordeal of the surgery and medical attention isn’t worth it. Or they might think that their life is pretty crappy and not worth extending."

In other words, value is subjective and in the eyes of the beholder which should be the patient and  not the cost effectiveness practitioners who can "determine" the value with numbers and regressions, even though at the end of the analysis someone has to make a value judgment call.

I have ranted about this near naked emperor before.  See here.

 The " value based payments" meme seems more and more to be  just another phony-baloney justification for third party payers to limit expenditures for medical care and dress it up with platitudes.

Friday, June 06, 2014

Is the underlying problem with the VA hospitals scandals greed?

Perhaps self-interest in a better word to describe what is going here.

There is a wide spread and naive notion that for-profit institutions,  aka business, are driven by greed and that dishonesty and bad motives dominate their existence and that non-profit organizations are the opposite in every regard; But folks who populate non-profit organizations are cut from the same cloth as the rest of humanity and for them as for everyone incentives matter.

This commentary by Glen Reynolds gets it right.

I quote from  his  comments from USA Today:

"In other words, they cooked the books. And what's more, they did it to ensure bigger "performance bonuses." The performance may have been fake, but the bonuses were real. (One whistle-blower compared the operation to a "crime syndicate.")
And that captures an important point. People sometimes think that government or "nonprofit" operations will be run more honestly than for-profit businesses because the businesses operate on the basis of "greed." But, in fact, greed is a human characteristic that is present in any organization made up of humans. It's all about incentives." ....And, ironically, a for-profit medical system might actually offer employees less room for greed than a government system. That's because VA patients were stuck with the VA. If wait times were long, they just had to wait, or do without care. In a free-market system, a provider whose wait times were too long would lose business, and even if the employees faked up the wait-time numbers, that loss of business would show up on the bottom line. That would lead top managers to act, or lose their jobs."

If you look at the history of the VA system you will see greed and corruption boiling over the top at the very beginning..The historian  Burt Folsom gives a brief review of the origin of the VA system and the corruption and mismanagement that characterized its early days under the administration of President  Warren Harding.

The point is that people act in their self interest ( when their actions rub up against our moral priors we call it greed) and that markets impose the discipline of profit and loss that are lacking in  monopolies such as the socialized medicine of the VA system and often -but not always- direct that greed to the benefit of others.

As Milton Friedman said the question is: under what system will
greed lead to the  least harm,his answer was capitalism.Here is his priceless reply to Phil Donahue .

Saturday, May 31, 2014

Wanted: Men of System to manage the Population Medicine Approach and maximize society's helath

 Let's begin with explaining Men of System and Population Medicine Approach (PMA)

 Adam Smith , in his first book, The Theory of Moral Sentiments spoke of the "man of system"

"The man of system, on the contrary, is apt to be very wise in his own conceit; and is often so enamoured with the supposed beauty of his own ideal plan of government, that he cannot suffer the smallest deviation from any part of it. He goes on to establish it completely and in all its parts, without any regard either to the great interests, or to the strong prejudices which may oppose it. He seems to imagine that he can arrange the different members of a great society with as much ease as the hand arranges the different pieces upon a chess-board. He does not consider that the pieces upon the chess-board have no other principle of motion besides that which the hand impresses upon them; but that, in the great chess-board of human society, every single piece has a principle of motion of its own, altogether different from that which the legislature might chuse [sic] to impress upon it. "

  Dr. Harold C. Sox, , former President of the American College of Physicians (ACP) and former editor of the Journal of that organization, The Annals of Internal Medicine  explains and seemingly recommends the PMA in a commentary in JAMA (November 33,2013) entitled 'Resolving the Tension Between Population Health and Individual  Health Care ".

In this formulation  it is claimed that  one treats the population much as a physician would treat an individual patient.One uses the same "value metric" and the same few decision making principles. For example one would screen a given patient only if that would maximize that person's welfare and similarly in considering applying  a screening procedure to a group would involve screening only those who would gain QALYs. Cox admits we don't really have all that information yet but "the challenge would be to develop models of the principal high stakes decisions of clinical medicine, perhaps starting by identifying these decisions and developing the evidence to inform them"We would need to determine the frequency,causes and consequences of the common medical conditions in a population and devise strategies for dealing with them over the life span.  The public health system and the health care system  and community leaders need to plan together.

Then resources could be allocated between disease-specific programs so that they would be moved from groups of patients less likely to benefit to groups more likely to benefit.

Sox  then seems to admit there may be some growing pains with this approach but in the long run there will be benefit,. That is my paraphrasing now a quote :

"It will take several generations to realize the full benefit of investments in disease prevention. In the short run, these investments may draw resources away from tests and treatment for some sick people. In the long run,disease prevention and better low cost technology could reduce the outlay for treatment. In the interim, skillful clinical decision making can make the most of limited resources. 

To make the population medicine approach operational it would be necessary for physicians to consider themselves practitioners of population medicine and support a system that "fairly allocates resources between the healthy many and sick few:" The Charter for Professionalism paves the way for that by admonishing physicians that they are the stewards of medical resources and that cost effectiveness is the new polar star.As long as physicians considered themselves to be fiduciary agents of their individual patients the scheme would not work. The publication of "Medical Professionalism in the New Millennium:A Physician charter" in 2202 was an important step in the movement to further the dogma of medical collectivism..

To achieve this medical  utopia the Men of System of whom Adam Smith wrote will be required ; some one will be needed to move the different  members of society around the chess board of utilitarian health care with its fair and cost effective allocation of health care resources. And while only a few physicians can be the Platonic Guardians ,some of whom will likely expend their energies on IPAB, the rank and file docs can work for the common good by adhering to guidelines. 

Thursday, May 29, 2014

Swedish study provides More data but not much definitive useful information regarding levels of exercise and atrial fibrillation risk

A recent article in BMJ has stirred  more comments regards the possibility that there is a "j shaped" curve in regard to the relationship between level of exercise and development of atrial fibrillation (AF).

There have been number of publications addressing this issue and to my eye there is good evidence that there is an increased incidence of AF in long time endurance athletes. The magnitude of this increased risk and what this correlates with is less clear-duration of exercise,intensity, height?, genetic profile, confounding factors, etc etc.

The BMJ article is from Sweden by Nikola Drca and is a long term followup of over 44000 men who completed exercise questionnaires and provided  in part retrospective estimates  of hours per week exercised at ages 15,30, and 50.These questionnaires were then linked with data indicating whether they had developed AF.The AF numbers are relatively hard data the historical data much less so.

Of those men who said they exercised more than 5 hours per week at age 30 there was a relative risk (RR) of 1.19 (CI 1.05-1.36) this increased risk in the greater  than 5 hour per week exercise category was only found for age 30, not at age 15 nor age 50 and the RR was higher for the  high exercise at age 30 group  who then stopped exercising  (RR 1.49).

Several points come to mind

When the number in the study group is very large, very small differences in the measured outcomes become statistically significant.  Relative risks less than 2-3 are generally not considered very convincing evidence that there may be causation.My favorite quote in this regard is from Michale Thur , epidemiologist at the American Cancer Society:,

 With epidemiology you can tell a little thing from a big thing.What's very hard to do is to tell a little thing from nothing at all.

and a RR of 1.19 is pretty little 

In trying to assess significance of RRs  from observational epidemiology studies. it is sometimes useful to consider what is the prior evidence and look at biological plausibility (which old time internists like to think of sometimes as pathophysiology or disease mechanism.)

There are a number of studies that suggest long term endurance athletes have a increased risk of AF but  that is not what the data here suggest at all.The 30 year old heavy exercisers had  increased risk while the 50 year old exercisers did not and there was even  greater risk  in those 30 year old heavy exercisers  who quit. That does not seem like a dose response relationship, i.e more exercise more AF.

What would be the pathophysiology evoked to explain heavy exercise at 30 but not at 50 being related to increased risk of AF.

So what would be the take home advice? Don't begin heavy exercise until age 50 ? But if you are 30 and exercising a lot , don't quite. None of that makes sense if we believe the is a j shaped curve regarding duration of exercise  and risk of AF or if there is a positive relationship between  duration of exercise and AF.I n spite of headlines emphasizing the 30 year old heavy exercisers risk I think overall the study is more reassuring to long time endurance athletes than it is concerning.The RR for the 30 year old group could easily be just statistical noise and the lack of increased risk for the others a more reliable finding.

 For a more detailed and less biased discussion of this general topic I suggest the excellent blog written by Dr. Larry Creswell.

Disclosure of conflict of interest: I have been doing long distance running for almost 40 years .(Fortunately I did not begin distance running until after age 30,so there should be no problem). So, my mind set  is to be critical of studies that purport to show a problem with too much running.

Thursday, May 15, 2014

Former president of American College of Physicians explains the population medicine approach and we should be afraid,very afraid

Dr. Harold C. Sox has played a leadership role in the American College of Physicians  for many years, serving as President of the ACP and long time editor of the Annals of Internal Medicine.

 In the opening paragraph of a commentary in JAMA entitled "Resolving the Tension between Population health can individual health care" (JAMA November 13, 2013,Volume 310, number 18) he states:

"Perhaps the de facto organizing principle of US health care approaching each patient strictly as in individual is obsolete.The population heath approach is an alternative. It aims to improve and maintain health across a defined population."

Later repeating a major theme of the publication,"Medical Professionalism in the new millennium,a physician charter" , Dr Sox says:

"..the physician has an ethical imperative to balance the needs of the individual patient with the needs of  society."

 Dr. Sox  then explains in broad terms how to practice population medicine.

"Planning to optimize population health will mean determining the frequency,causes and consequences of he common medical conditions in a population and devising strategies for dealing with them over a lifetime. "...
resources must be allocated across program to prevent,detect and treat disease and its risk factors. "...One reasonable principle to move resources from groups of patients less likely to benefit to groups more likely to benefit."

With the application of this utilitarian calculus there will be winners and losers which Sox seems to admit implicitly the following paragraph.

"It will take several generations to realize the benefit of investments in disease prevention.In the short run, these investments may draw resources away from the tests and treatment of some sick people.In the long run, diseased prevention and better low-cost technology could reduce the outlay for treatment."

So, in the short run the population medicine approach might deprive some sick patients of treatments but in the long run "the outlay for treatment " could be reduced. Withholding treatment  for those who are sick now for some  purported,future , hypothetical benefit to anonymous  people is completely antithetical to basic medical ethics and has no place in a nation with any remnant of individual freedom remaining.

Dr. Sox after already seemingly condoning  sacrifice of the individual's welfare to some nebulous greater social good then closes the commentary with the following platitude which seems to contradict his earlier statements;
"Much of medical practice has changed but not the basis of patient -centered care."

The term "patient centered care" is a trendy, feel-good cliche with out well defined operational meaning but I cannot believe that any generally accepted understanding of that phrase could possibly include not treating the sick to gain some allegedly future benefit to some some subset  of well people.

As someone who did his medical training in the same time frame as Dr. Sox in which the notion of the  physician as the fiduciary of the patient  was sacrosanct   I find his comments wrong on so many levels that I cannot find the words to express it but to the extent that views such as those expressed in his commentary are more widely accepted there is reason to be afraid,very afraid.

Dr Michel Accad critiqued the  this creed of medical collectivism in his blog writing in part:

"...beyond ignoring the obvious tension between the individual and the group, hoodwinking physicians into practicing "population medicine" is of course the essential means to confuse practitioners into thoughtlessly carrying  out sweeping interventions whose primary benefit is the profit of third parties."