Friday, November 27, 2015

The Medical Progressives are an influental subset of the Ruling Class

The core belief of the Medical Progressives (MPs) is that medicine and health care are  too important and complex to be left to decisions made by individual patients and their physicians. What is needed , in slightly paraphrased words of one of the MP's upper echelon, Dr Don Berwick: We need wise leaders with ideas.

He and another leader of the MPs, Dr. Troyen Brennan expressed their credo explicit in their book entitled "New Rules". Here is a key quote.

"Today, this isolated relationship[  speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The
primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.

Decentralized decision making means individual people making their own individual medical decisions with the counsel of their physicians. There must be a word stronger than hubris to describe the attitude of the medical progressive elite.

The MPs advocate and promote abolition of the traditional fiduciary of the physician to his patient. Phrases like " Rules with authority" and the "constraint of individualized decision making" made it clear what they propose. Some one will be making the rules for everyone rather than the individual physician patient "dyad" and those rules need to be enforced.Advocates of individual liberty should probably thank Dr. Brennan and Berwick for their making  it crystal clear what they want for medical care in this country.

Others in the MP  community have approached that aim with a more opaque and convoluted game plan.

One approach in that regard has been the advocacy of the concept of social justice as a primary precept in the physician's ethics code., particularly as advocated in the new medical professionalism.Advocacy for social justice would appear on the surface to have nothing to do with destruction the medical ethical principle of the fiduciary duty to the patient. But here is how I believe it has worked out.

First the term social justice was promoted as  an obligation of physicians.The Overton window of discourse has been significantly shifted. Social justice was not specifically defined but served  as a general feel good, ambiguous idea that would be be unlikely to generate much opposition.It could mean many things; aid to dependent children,initiative to eliminate racial biases and generally hep the poor. social justice as a egalitarian concept-equal respect for all.   As time went on social justice as a physician obligation took roots and became acceptable part of the rhetoric of health care  and the various problems associated with it although it was never clear exactly how individual docs would fulfill that obligation. It was not long until the MPs made it clear how that should be done.

 Certain factions of the MPs proceeded to phase two of the bate and switch strategy  and quietly and without debate sneaked  in the idea that the social justice obligation of the physicians was actually to be stewards of the nations finite medical resources. Implicit in this concept is the idea that individually owned assets and knowledge and skills composed an entity that was collectively owned to which everyone by virtue of their existence were entitled to their share of this medical commons.

With collective ownership everyone cannot just wade in and consume whatever and everything they want.The common will be overgrazed .We will need leaders with ideas about how the contents of this collective owned aggregate will be distributed.

Now we can see  the key role of the MPs. Someone has to oversee this collective. Someone has to have the knowledge, and skills to make the decisions as to how this collective  pie will be sliced.Next we are told that the pie is best sliced with the sophisticated tools of cost effectiveness analysis so that everyone can enjoy high value care and we will eliminate low value care.

Thursday, November 26, 2015

Thanksgiving thoughts for 2015-be thankful US is still in the top 20 in the freedom index (barely)

According to the latest ( 2015) rating and ranking of economic freedom  from the Libertarian leaning Fraser  Institute in Canada The US is ranking 20 of the 157 countries in their analysis in the year 2000 the US was second only  to Hong  Kong. So what is going on. Was  not the US the country that was the prototype for individual freedom, private property rights, contact law and general rule of law ? Was that not what Jefferson and Madison had in mind?What has happened in the last 15 years?

What does Fraser mean when they speak of economic freedom?

I quote from their website:

" Individuals have economic freedom when property they acquire without the use of force, fraud, or theft is protected from physical invasions by others and they are free to use, exchange, or give their property as long as their actions do not violate the identical rights of others. An index of economic freedom should measure the extent to which rightly acquired property is protected and individuals are engaged in voluntary transactions".

Here is the link to their report entitled "The Human Freedom Index, a global measure of personal,civil and economic freedom"

Here is the listing of countries as reported and commented on the the blog zerohedge:See

Some of the factors that are the usual suspects in our declining freedom are: increasing use of land use controls including eminent domain ,hypertrophied requirements for licensing  many occupations ( think flower arrangement  and dread lock hair styling),the effect of the various "wars", i.e. war on drugs,war on terror,the Patriotic Act with its warrant less wire taps and secret court proceedings and widespread surveillance of American citizens,etc.

The is little to be optimistic, freedom wise, about on the medical care front.With ACA citizens are forced by law to purchase a product,if physicians chooses not to use computers in a very specific way dictated by the government they will be penalized. And for a list of just some of the liberty limiting things going on now or being proposed see this link from the Weinmann Report. 

Tuesday, November 24, 2015

Does the " gold standard test" for pulmonary emboli have a false postive rate of 5% or 25%?

You can find articles in the medical literature that claim both?

For the most part and for most of the time that CTA  (computed axial tomographic angiography) ( AKA pulmonary CT Angiography) has been used the consensus number for the false positive rate is about 5%.

Two more recent articles provide data that strongly suggest that the real false positive rate may be considerably higher than that.

Hutchinson et al published an article in the American Journal of Radiology in August 2015 entitled Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography" (august 2015,vol.205, number 2, 271-277)

 In the study all pulmonary CTAs  read-as- positive for pulmonary emboli (PE) done in a referral university hospital over a 12 month period were reviewed . There were 174 cases originally reported as positive for PE. The images were reviewed by a panel of three chest radiologists with over ten yeas of experience. I assume by each.

Those cases in which all three of the radiologists agree that the studies were negative for PE were considered false positive. 45/174 were false positive or 25.9 %,

Cases which were considered false positive tended to be in the segmental or subsegmental vessels .
According to the three judge panel the reasons for false positivity were breath holding artifact and beam hardening artifact.

A previous article published in CHEST in 2009 ( Miller wt et al , Frequency and Causes of false-positive CTPA exams in community Hospitals, Chest 2009,,136 4,Meeting Abstract 145) reported a value of 11% for false positive tests.This study , although it involved large numbers of cases, was much less methodologically sound and , perhaps for that reason attracted not much attention. 608 cases originally read as positive for PE were reviewed  by a single radiologist who found that 11% were "either false positive or probably false positive". Most ( 82%) were judged by the reviewing radiologist to be due to technical factors, which included" pulsation artifact,streak artifact,volume averaging, and quantum mottle". 66% of the false positive cases were at the subsegmental level.This article  seemed mainly to be a he said she said type exercise with one radiologist compared with a number of other radiologist's film readings.So how do you know who is right?

It seems well known that technical factors are the major reason for false positive readings and analyzing findings at the subsegmental  level. is particularly difficult.

A widely read and quoted article from the NEJM by Stein in 2006 quote the value of 5% false positive rate and I suspect the 5% value, more or less, is what most physicians accept as correct.

These  data are derived from the famous PIOPED 11 study. The CTAs were read by two radiologists and the  process to determine  positive and negative was rigorous and detailed and can be found in the method section of the article. However it is not the case that the CTA was directly  compared to the then gold standard of pulmonary angiogram,which ,of course, was also not done in the Huthcinson paper.From the Stein paper a specificity of 95% was reported.

It is easy to discount the Miller paper but the Hutchinson paper is disconcerting particularly in light of my recent health events.I was diagnosed by CTA as having several PEs.I had the study re-read by a long time friend who is a radiologist radiologist who said he could detect no emboli.To break the tie I had my treating physician to review the study with a radiologist of his choice who concluded that there were several artifacts present that could be mistaken for emboli but that there were  one or two  he said likely were clots. My doctor and I agreed to continue the apixaban for the agreed upon 3 months ( this was a provoked embolic situation).More on that "teaching moment " later.

Monday, November 23, 2015

Bundled medical payments and the Nirvana fallacy

Browsing the subset of medical literature that deals with policy reveals  a campaign against fee for service in medical care and typically recommends using a bundled payment model in its place as one of several purported ways to improve health care financing and quality.

What are the arguments against the fee for service (FFS) method of medical care payment?

The issue of asymmetrical information is often raised in the argument that physicians know so much more than their patients that they can make recommendations for tests or treatment based more on the economic gain to the docs that the benefit to the patient and the information challenged patients don't know enough to protect themselves from the rapacious docs.

Harold Dementz introduced the term Nirvana fallacy. quoting Demsetz:

"The view that now pervades much public policy economics implicitly presents the relevant choice as between an ideal norm and an existing 'imperfect' institutional arrangement. This nirvana approach differs considerably from a comparative institution approach in which the relevant choice is between alternative real institutional arrangements."

At times the less vigorous versions anti FFS argument blend (morph) into a version of the Underware Gnome economics.

Step 1.eliminate fee for service in medical care
Step 3.Achieve less expensive,higher quality care.

 Attempts to avoid  the Gnome paradigm can be avoided by actually proposing an alternative payment system .In that regard a often discussed method is the bundled payment system (BPS).Some have described the BPS scheme as being somewhere between fee for service and a capitation plan. I have had some experience with a plan promoted by Dr. Denton Cooley and his Texas Heart Institute.In this Texas Heart  Institute offered various cardiac services and procedures at a pre agreed upon price to various corporations who self insured.As the employees then had no co pay and the company costs per procedure seemed cheaper- it appeared to be a win win situation. I have not seen the books of Texas Heart but it seems reasonable that that arrangement may have increased their volume even if the charge per encounter was decreased.  However, it is not clear how the purported asymmetrical information problem was abrogated. Would not a cath cardiologist not have the same incentive to recommend a procedure as he would under a straight FFS arrangement?

The anti FFS information asymmetry dates back perhaps to the often quoted article by Nobel prize winning economist Kenneth Arrow. However, to the extend that the asymmetrical argument is salient in regards to medical care, does that not increase the stakes for the patient to have her physician acting as her fiduciary and not as a part time patient advocate and part time steward of society's medical resources which is what the New Medical Ethics seems to advocate..If medical ethics was the protection for patients against the more knowledgeable  physician,does not weakening that ethical imperative  by imposing a co duty to to society to the physician's obligations   leave the information challenged patient even more vulnerable.

Taking a wider view we see that for the most part what passes as fee for service -as least as it  applies to Medicare and Medicaid  is really a system of price controls the negative effects of which are well explained in Eco 101.

Saturday, November 21, 2015

Merger of high sounding ideals and narrow self interest yields new medical ethics

Cui Bono. Follow the money or who profits. Ask the question who profits form  what appears to be a sea change in medical ethics in the last decade? What is the sea change? The change is from a basic fiduciary duty of the physician to the patient to the physician now ethically tasked with both doing what is best for the patient and  somehow conserving "society's medical resources". One master less chance of conflict- two masters conflict lurking much of the time and loss of trust.

The new medical ethics is the ethics of the progressive. The progressive ethic is that much of society's affairs ( meaning an individual's affairs) should be managed by an elite.Medical decisions that in the past have been the bailiwick or purvey of the patient in consultation with his physician will in the world of the new medical ethics become decisions that will be made by wise leaders with ideas who pass their wisdom down in the form of guidelines adherence to which is now an ethical imperative. Here we have the merging of the high sounding ideals with the narrow self interests of the third payer payers.Does this not resonant with the notion of the Baptist and the Bootlegger?

Dr. Paul Hsieh discuses certain aspects of the new medical ethics here on PJMedia Blog.

Interestingly this 2012 article by Mark Daniels which reviews certain historical development in medical ethics and discusses various categorical approach to ethics in general ( duty based versus utilitarian etc) makes no mention of a duty of the physician to be a steward of society's medical resources.

The new ethics has been promulgated and promoted by the American Board of Internal Medicine and its foundation and fellow travelers in the American College of Physicians a number of whom have held positions in both organizations. This new duty is manufactured out of whole cloth largely by these two organizations.Their  Choosing Wisely campaign and the Medical Processional for the New Millennium publication have served as vehicles to bamboozle both the medical profession and the public.

Who profits? the third party payers and a number of the progressive medical elite who have positioned themselves to be the movers and shakers in the governmental and quasi governmental
structure that aims to control the practice of medicine and importantly attempt to control the expenditure of the private and public third party payers.

Wednesday, November 18, 2015

head trauma and football-What we know and what we do not know as another high school season ends

What do we know about head trauma in high school and college football?.

Mild Traumatic Brain Injury ( mTBI) encompasses the clinical entity of concussion. Concussion is defined as a trauma induced alteration of mental status with or without loss of consciousness.

Considerable research has been published regarding concussion and recently more research has been published about the multiple blows to the head that occur in all levels of football in  the absence of a recognized concussion. These "sub-concussive blows" have become the target for various types of brain imaging and cognitive function testing and the results have raised concern about the long term effects on the brains of highs school and college players.

 Some of what we know is :

1.While conventional MRIs and CTs in concussed high school and college football players are normal , Diffusion Tensor Imaging (DTI) and functional MRI have shown abnormal findings some of which may persist for weeks or months. Additionally subtle impairments of verbal memory and other cognitive tests have been reported in concussion cases persisting past the time during which the player has any symptoms.

2.Similar imaging findings and cognitive testing results are being reported in high school and college players after a season of participation in football even thought the players had no reported concussive event.

3.We know that football helmets do not prevent concussions.

4.We know that at least  some  college level contact sport athletes decades later show abnormal white matter by Diffusion tensor imaging and lowered test results on neurocognitive testing

 Some of  what we don't know is :

1.We do not know what pathological changes underlie the imaging findings. Do the scan results indicate transient damage and tissue repair without likely long term sequelae? Is there a recognizable subset of these players with these findings who if  they continue to be exposed to multiple head blows over many years will develop Chronic Traumatic encephalopathy (CTE)? How can those who may be destined to develop CTE be distinguished from the vast majority of players who never will  have those problems

From  the wide range of head hit exposures in those NFL players who have been diagnosed with CTE the obvious implication is that there must be a fairly wide range of thresholds. There are reports of NFL players with as little as five years of play showing  typical pathological findings at autopsy. Further there has been at least one case of a college player diagnosed with CTE.

2.the long term cognitive and brain imaging demonstrated results in  contact sport athletes in college and high school who did not experience a concussion.

 Another high school football season is ending and so far we have reports of11 fatalities. This is about average for the years following the meaningful changes made in the rules and the techniques of blocking and less dangerous ways to tackle. Better helmets probably prevent skull fractures but not concussions.

You see the same parents who carefully made sure their kids did not ride tricycles without  wearing helmets are some of the same ones watching and yelling at Friday night football games and do not see the irony of the common practice of there being an ambulance at the stadium. If their son is the victim of the second hit syndrome, probably an ambulance won't help.

addendum: Change made on 11/20/15 on the Numbers of high school football reacted deaths.

Tuesday, November 17, 2015

Sarcopenia the largely neglected "penia"

There are now at least four classes of medications that have received FDA approach for the treatment of osteoporosis and, according to various guidelines, for certain instances of " high risk"  cases of osteopenia.Family practitioners,internists and gynecologists have all joined the crusade to detect by using a questionnaire based risk tool and by bone  density scans  those patients thought to be at high risk" for fragility fractures and thousands of prescriptions for the bisphosphonate  category of anti osteoporosis drugs have been written.

In regard to the other age related loss of tissue integrity ,sarcopenia, there are no medications proven to help and no popular screening test.Only resistance exercise along with an adequate protein intake have been shown to mitigate the loss and in some relatively short periods of time in clinical trials have actually increased muscle mass and strength.

In regard to quantification of the loss of muscle size and strength a number of clinical papers have been published.Here are the stylized facts: From abut age 40 to age 70 there is about a 1-1.5% annual loss of strength as least as measured by the leg extension tests. Then  things get worse around  age 70 where losses of 2.5% or more per year have been documented. Men have been shown to show a greater proportional loss than women and in one study Afro Americans showing a greater loss than Caucasians.

There is a  proportionally greater loss in type 11, ( fast twitch)  muscle fibers  than the slow twitch type 1 fibers. Some of the muscle loss is due to a loss of anterior horn cells with aging. with more type 11 muscle cell loss.Some of the type 11 are replaced by type 1 cells.There is also evidence of qualitative  changes in muscles in the elderly among which there is the deposition of fat within fibers and possibly changes in the angular or spatial arrangement of fibers. Walking , cycling and other aerobic type exercises are largely powered by the slow twitch fibers and a  reasonable anti sarcopenia regimen would include aerobic and resistance exercises,the latter to try a preserve some type 11 fivers. .

The age related decline in maximal oxygen uptake can also be blamed in part on loss of muscle function. About half of the loss of max 02 is due to stroke volume of  the heart and about half to decrease in  a-v o2 uptake which is driven by loss of muscle mass with the associated decrease in the capillary density and mitochondrial mass.

Sarcopenia and osteopenia are related in several ways.The prevention of sarcopenia by resistance exercises also can increase bone density.The sarcopenic person is more likely to fall and sustain a fracture.No randomized trials  are likely to be done to compare a program with resistance exercise and weight bearing excise versus any one the anti-osteoporosis medications.