This really nails it

Sometimes you read something that nails it so good , that condenses so many killer insights into one long sentence that you go way past wishing you had said it (the important thing someone said it) that you just want to shout it out to whoever will listen.And that is what I will do now to my tiny band of regular readers and the more readers who wander in from a Google hit on whatever.

That something (I know I have quoted this before but I want everyone to read it) is from The Covert Rationing Blog by DrRich who said this:

These reverse incentives, we’ve seen (we being readers of this site), are aimed at actively stamping out, eradicating, and punishing any self-motivated physician who tries, despite all obstacles, to deliver excellent
healthcare. Among these are the mandate that primary care doctors spend only 7.5 minutes per patient encounter; invoking the magic of P4P to determine exactly what must and must not take place during that 7.5 minutes; grabbing the right to interpret clinical science in order to formulate the “guidelines” that inform P4P; coercing doctors to agree to egregious adhesion contracts that any sane person would find unconscionable; forcing doctors to practice under a set of coding “guidelines” that prevent good patient care and serve as traps for “fraud;” and in general, making every patient encounter subject to a web of regulatory speed traps that force doctors to concentrate on keeping the OIG at bay rather than on what the patient needs. In short, in their efforts to gain control of physicians’ behavior in order to covertly ration healthcare, American Wonkonians are creating insurmountable, systematic disincentives for excellence and penalties for non-mediocrity. They have placed doctors in the untenable position of being utterly unable to fulfill their professional, traditional, legal, and ethical obligations.

The only way doctors have a realistic chance of attaining excellence under such a system, so as to service at least the rich, the connected and the quick-witted, is to abandon the system altogether.

The more I read and think about it and discuss it with colleagues (active and other retired docs) the more I agree with DrRich's analysis and his conclusion. One route to abandon the system may well be the various versions of a retainer system that are sprouting up and in that regard if you want to learn more go here to hear from Dr. Chis Ewin who does more than talk about it.

Off the grid or black market medicine

I have written before about the expected effects of rationing health care and listed the usual outcomes-shortages,poor quality etc. The rise of a black market is another well known outcome but I did not think that we had reached the point in the the U.S. where there was actually a black market. I had to rethink that position after reading this entry by DrRich in which he talks about the off the grid medical activities.

If you accept the classical economic definition of a black market (An illegal market, in which something is bought and sold outside of official government-sanctioned channels)
then it seems that what DrRich is discussing is not really black market because it is not illegal to do most of what he describes. But this is really pedantic quibbling over definitions ( I think black market activities is a sub set of off the grid) and the issue is that we have still another consequences of the de facto medical rationing about which DrRick speaks so eloquently. Here patients choose to spend their money for various reasons to buy medical care outside of the insurance hegemonic universe even though they have health insurance.

I should not have been the least bit surprised by tales of off the grid medicine.My son while "insured" with a large nameless HMO in California fractured his radius at the elbow, was pinned and then began his battle with the HMO. He couldn't get PT ( ok he did get a handout sheet ) and later the wires began to almost push through the skin when he flexed his arm. The docs at the HMO said they did not take out hardware in "older patients"- he was 24. They were adamant and refused to accept calls from me or my wife,also a physician.We were told that Dr. X, head of orthopedics, did not talk to physicians on the phone .I had him come back home to Texas and he had the hardware removed by an orthopedic friend who did not charge him and the hospital discounted the facility fees a bit as I was on staff at the time ( that type of professional courtesy is, of course,history now).

The retainer medicine movement could be considered an off the grid activity at least off the insurance grid but at least so far is not illegal in the U.S. However, as the movement grows- as it seems to be doing- I predict we will be hearing more arguments to limit it or restrict it entirely by legislation if necessary. The anti retainer practice propaganda mill is already at work . See DB for examples.The insurance industry will bray about it as will those who believe that social justice principles trump individual freedom and choice.

ACP recent comments of P4P-sounds more like it but ...

I have not been one to sing the praises of the American College of Physicians and usually have offered my share of criticism. However, their recent comments which are critical of P4P , at least the way it seems to be playing out, appears to me to be more on target but unfortunately stops short of complete categorical condemnation which is what the concept deserves.

Here is a quote as found on a recent Medscape article which quotes from a recent piece in the Annals of Internal Medicine.

"Current incentives could result in deselection of patients, 'playing to the measures' rather than focusing on the patient as a whole, loss of trust between physicians and patients, unnecessary care, reduced access to care and continuity of care, and worse care for patients with complex chronic conditions. These consequences are avoidable, but only if the architects of the health care system try to avoid them."

I agree with all of the above except the comment about the consequences being avoidable. I believe paying or bribing doctors to do their job is a bad plan on its face and cannot be fixed by modifying this or that aspect of it. I find it a bit hard to reconcile these comments with the recent editorial in the Annals of Internal Medicine which urged physicians (and appealed to their professionalism) to work with insurers who strive to make medical practice lean and efficient.

Stochastic and epistemic uncertainty and the ecological fallacy

A recent comment made to a posted essay by DB of DB's Medical Rants spoke of a term I had not heard before, namely aleatoric uncertainty. But with the web one can quickly learn that it is merely another term for our old friend- random or stochastic uncertainty or variation.

One can talk abut two types of uncertainty. Stochastic is the random or some would say inherent or irreducible uncertainty. The other is Epistemic uncertainty which is that related to incomplete or inadequate information.

At least some of the former type of uncertainty can disappear as knowledge becomes more complete and adequate.

This introduction  gives me a chance to quote one of my favorite insights borrowed from others namely the thought experiment described by Dr. Steve Goodman of Johns Hopkins which I have talked about before.

Here is my paraphrased version of it which is crafted to elucidate the difference between the stochastic and the deterministic:

Mr. Jones is faced with the need for surgery.The particular procedure is generally accepted to pose a 15% risk of death. Let us magically produce 100 clones of Mr. Jones. When they all undergo surgery, what will happen? In the random process model ( stochastic interpretation) , 15 will die but we cannot tell beforehand who they will be. In the deterministic model, either all 100 will live or all 100 will die depending on whether Mr. J. and all his clones have or do not have some biochemical or physiological condition(s) that is/are in fact what causes the mortality risk of the procedure.

If we learn the reason for the death some or all of the uncertainty vanishes.Before it was learned that about 1 out of 300 people have a single nucleotide polymorphism (leading to TMPT deficiency, and toxic accumulation of 6MP type drugs) no one could predict which child with ALL treated with 6MP would experience catastrophic bone marrow failure. Now with at least this mechanism in our knowledge base, patients can be tested for TMPT deficiency and those who are deficient can be safely treated with a lower dose. Knowledge of the mechanism shrinks the level of stochastic or random uncertainty. The more we know, the fewer are the circumstances that appear to be random. But even as we learn more "mechanisms" we still have the issue of how to apply aggregate data to the individual even though more and more we hear about genetic perturbations that strongly influence and sometimes apparently even determine the response of various tumors to chemotherapy.

The British physician- author, Kieran Sweeney, writes about this age old problem of "balancing the general with the particular" in his book "Complexity in Primary Care".

In this balancing act, a force that may push the clinician in the wrong direction is the lure of the "ecological fallacy". Sweeny writes"

With the advent of evidence-based medicine, clinicians were encouraged to interpolate from population data to individuals. In so doing, however, we were at the mercy of the ecological fallacy-assuming that any and all conclusions derived from population data could be applied to individuals in the data set.

No where did (does) this appear more glaring than in the large number of drug company driven, medical education company arranged "CMEoid" dinner experiences in which practitioners (docs and mid-levels alike) are exhorted to treat to goal, whether this be blood pressure or HbA1C or whatever else. Previously the big guns that were hyped to get the blood sugar down were the glitazones now less so and I see invitations coming in for drugs that are attempting to favorably harness the integrin family. For an interesting and thoughtful take on the basis ( or lack of same) for treating cholesterol to goal see this recent essay by Dr. Howard Body.


addendum: Minor spelling and syntax changes made 10/21/2014

Everyone agrees -hospitalists are here to stay

With the publication of a recent observational study published in the NEJM which seems to indicate that hospitalists save a little money ( read the latest by the Happy Hospitalist and you just might conclude it is more than a little money- see below for link) and do not seem to have proven harm to the patients,several prominent medical bloggers ( Dr. Wes, The Happy Hospitalist, and Dr. Wachter) all seem to agree that we have a win-win situation. It is win-win at least as far as the doctors now known as hospitalists ( and sometimes noturnists) and the hospitals are concerned and sometimes for the internists and family docs who now no longer manage their patient's care when they are hospitalized. There is always at least one sour note.

In this posting, Dr. Rob expresses no little dissatisfaction that he can't find out in anything like a timely fashion what the heck the hospitalists et al did with his patient in the hospital.Further, I am becoming more and more of the opinion that patients tend to be in the win column as well except when they go back to their primary care doc to find out what happened to them in the hospital. I hasten to point out that this is not be case with every hospitalist-patient-PCP encounter set but obviously sometimes it does happen.

Dr. Wes points out that when we go to the hospital we now have the doctor rather than our doctor. That is ,the primary care doctor who attends the patient when he is not in the hospital hands off the patients to the hospitalist who in the course of the patient's stay in the hospital may himself hand off the patient a number of times. The recurrent discontinuity of care at least so far has not been proven to cost anything in terms of cost to the hospital or morbidity of mortality of the patients. One might argue that the loss of one aspect doctor-patient relationship could be lost but no dollar value is typically assigned to that. And as Dr. Happy Hospitalist points out , there was no shortage of hand offs on weekends between docs in the same group anyway, so what's different now.

As Dr. Wes states and as the Happy Hospitalist has explained clearly the current economics of medical care is such that the dichotomy of "officist" and hospitalist makes sense and the former practice of an internist playing both roles perhaps was only possible in a long gone economic environment.

I chafed against the concept of a hospitalist and mourned the apparent terminal condition of the type of internist that I enjoyed being for a number of years but now if I were just entering into a medical life as a general internist I believe I would have to take the road of either the hospitalist or the physician with a retainer practice. As pointed out by DB the retainer doc can have the time to do a good job in the office .We all know that the time pressured doc is a prefect recipe for missed diagnoses, poor judgment calls, pride and sometimes ethical damage to the physician and loss of respect of the patient. The retainer doctor has the time and the hospitalist practice -as least of the type that Dr Happy Hospitalist lives- does also.I think as far as general internists are concerned. Mr. Dylan's advice might be heeded.

..you better start swimming or you'll sink like a stone.For the times they are a changing

The high jacking or corruption of EBM

The following quote is taken from DBs Medical Rants which he quotes from a BMJ article which apparently requires a subscription so I can't access it but it so good I have to feature it here.

Evidence based care was never meant to be a substitute for clinical judgment but, combined with the inducements of the quality and outcomes framework, it becomes so. Mechanistic blanket management strategies, embedded into computer software, become fixed and static with the danger that innovation will be stifled. Interventions become routine, and practitioners are no longer required to grapple with the innate uncertainty of each different clinical situation. Most randomised trials systematically exclude patients’ symptoms, functional status, comorbidity, severity of illness, ideas, and preferences. Yet these are the factors which should fundamentally affect decisions about appropriate treatment.2 Within large study populations, there will be smaller populations sharing different characteristics whose response to a given treatment will differ from that of the larger group. Such groups could be systematically harmed by the intervention, and there are currently no robust systems in place to measure or monitor this.3

The "insight/word" ratio is that paragraph is about as high as it can get.

Not only will innovation be stifled, individualized, proper thoughtful patient care will be worse than stifled it could almost die out. Of course with blanket management strategies, or pathways or algorithms or recipes patients could be harmed. And the innate uncertainty of each different clinical situation is what it is all about.Two patients with chest pain often have different underlying diseases, two patient with the same disease label have different symptoms, two patients treated with the same dose of the same medication for the allegedly same disease have greatly different responses,two patients with the same disease label react differently to the suggestion that they even take a medication.In a given randomized clinical trial some patients get much better, some a little better, some not at all and some get worse.

The lure of the mantra of evidence based pathways or guidelines is exactly what third party payers can use in their rational quest to control physicians to control costs to control their profit stream. Control is the operative word. Recognition of this innate uncertainty is the last thing they want to admit to or deal with.

The lure of the mantra of evidence based pathways and guidelines works well for the academics and others who "partner" with the third party payers to control the working stiff docs in their rational quest to be members of the ruling class , to be first among equals , to be the animals that are more equal that the others or for whatever reason they have.

The lure of the mantra of evidence based medicine (EBM) fits nicely with those whose philosophical mind set includes the notion that medicine is too important to be left to the individual physician and the individual patient and that wiser heads must prevail so that people will do the right things for themselves.

The lure of evidence based medicine could not be better for some drug companies whose skilled epidemiologists and statisticians are able to stack the deck and cook the books to make the overworked, over regulated, over hassled physician in her quest to do the right thing for her patients believe that their latest entry into the medication market is clearly what she should prescribe yesterday whether that is true or not. It should be said that deck stacking and book cooking is not the monopoly of drug companies but are the seductive tools of anyone with an ax to grind.

The lure of evidence based medicine even offers apparent salvation for the over worked, over regulated, over hassled physician who sometimes thinks "Hell, just tell me what to do, give me the latest guidelines."

The lure of evidence based could not be better for the third payers who would decrease payments generally and then reward these compliant with the guidelines with part of the money they took away.

The lure of evidence based medicine could not be better for the newly minted MPH who can now crank out a meta analysis or a quick and dirty case-control study with software that is so much easier to run than to understand that can flash across the rapidly cycling news cycle, bag an interview and add to their CV, whether the study makes sense or not.

The lure of evidence based guidelines could not be better for those believe the way to go is the mid-level route. Arm a NP or PA with electronic access to the right guidelines for efficient, evidence based care and then only the complicated cases would need the physician's input and I suppose the guidelines would include guidance as to when a case is complicated.

The manipulative value of the evidence based medicine label has meant so much to so many that it has become harder and harder to separate the valuable contributions of valid, well done clinical trials and analytic thought from the hijacked, counterfeit versions that serve to control the narrative dialog and ultimately to control much more. Reference to EBM can serve as a talisman.To say that such and so is evidence based is to ignore the real question which is what is the nature of the evidence.

"Total responsiblity to our patients"

Dr. Robert Centor in his DB's Medical Rants hits a home run. Read his essay here. He reminds us that physicians have responsibility to patients and not to systems. When I am sick I want a physician who cares about his patient; I do not want to be embraced by an efficient,evidence based,EMR facilitated system that like a pig with lipstick calls itself my medical home.

He speaks of the crisis in internal medicine. Clearly there is one. The crisis is bigger than that though, all of U.S. medicine is in crisis or nearly so. The primary care folks are the ones currently most affected, but the radiologists and surgeons et al who are fairing relatively better might be as concerned as the forces battering primary care have their addresses as well and the big single payer (CMS) influences more than Medicare fees for the office visit.

Dr. Centor is referring to the fiduciary duty of the patient which I believe is in danger not only from the hegemonic strength of the third party payers but from the self destructive rhetoric of many of the professional organizations and academics who strongly influence the emerging generation of physicians.A glaring example is the "new professionalism" as pushed forward by the ABIM foundation and the ACP- and mindlessly or perhaps innocently accepted by many other professional organizations- which eviscerates the duty of the physician to the patient replacing it with some type of impossible balancing act where in physicians are cajoled into being instead stewards of the finite medical resources that seem to be owned by everyone and no one and advancing the cause of a nebulous social justice. Recently an editor of the Annals of Internal Medicine seems to equal professionalism with the imperative to meet the third party payers in their effort to improve "quality and efficiency." See if you can find a general internist in private practice who believes that the third party payer are interested in real quality.

Physicians take care of their patients and are responsible for them. Systems do what systems do and cannot care or be responsible for individuals.

A commentor writes DB asking to begin at the beginning and tell what is broken with internal medicine.

I offer this great summarizing quote from DrRich. which speaks of what is wrong in general and which I believe disproportionately impacts primary care folks including internists. The links are his.

These reverse incentives, we’ve seen (we being readers of this site), ( the reference here is to DrRich's website "Covert Rationing Blog")are aimed at actively stamping out, eradicating, and punishing any self-motivated physician who tries, despite all obstacles, to deliver excellent
healthcare. Among these are the mandate that primary care doctors spend only 7.5 minutes per patient encounter; invoking the magic of P4P to determine exactly what must and must not take place during that 7.5 minutes; grabbing the right to interpret clinical science in order to formulate the “guidelines” that inform P4P; coercing doctors to agree to egregious adhesion contracts that any sane person would find unconscionable; forcing doctors to practice under a set of coding “guidelines” that prevent good patient care and serve as traps for “fraud;” and in general, making every patient encounter subject to a web of regulatory speed traps that force doctors to concentrate on keeping the OIG ( Office of Inspector General)at bay rather than on what the patient needs. In short, in their efforts to gain control of physicians’ behavior in order to covertly ration healthcare, American Wonkonians (You will need to read more from Dr.Rich to learn what a Wonkonian is ) re creating insurmountable, systematic disincentives for excellence and penalties for non-mediocrity. They have placed doctors in the untenable position of being utterly unable to fulfill their professional, traditional, legal, and ethical obligations.

The only way doctors have a realistic chance of attaining excellence under such a system, so as to service at least the rich, the connected and the quick-witted, is to abandon the system altogether.

Is not gradually disabusing physicians of the notion that their prime duty is to the patient part of the package deal (the above mentioned disincentives plus watering down their fidelity to the patient) to control physicians?

Would internists be better off without the ABIM?

More and more I am beginning to think that is the case. Dr. Faith Fitzgerald,who I love to quote when she said regarding P4P doctors do not need to bribed to do their jobs (paraphrased), has criticized the ABIM recent moves regarding certification and re-certification.

Her essay can be found here.

She finds a disconnect between the notion of certifying a "comprehensive general internist" and their recent proposal to certify a type of cardiologist who treats severe heart failure and cardiac transplantation. OK transplant medicine is another world but has treatment of heart failure not been a regular activity of internists since forever.

She really nails it saying :

It is disingenuous of the ABIM, I think, to feign support for the so-called “comprehensive internist” while simultaneously depleting the general internist's portfolio of certified legitimacy in some of the more highly valued components of recognized expertise, such as management of heart failure and of hospitalized patients. This threatens to further shift the work of general internists to a support function not only for the classic subspecialists of medicine but also for the “certified modular” subspecialists. It potentially leaves the so-called comprehensive internist, already beset and underappreciated by payers and systems, to do predominantly triage, health information technology, social services, counseling, prevention, screening, and general organizational and secretarial functions for the “experts.” I doubt that many young internists in training will aspire to this role, especially because its many components can be done better and more efficiently by nonphysician personnel.

The good doctor worries about his patient

When I began private practice of pulmonary disease and internal medicine in the late 1970s I had spent the previous one year doing research at a medical school and before that two years in the army. The thing that impressed most in my first three weeks of work in a moderately large group of internists was how much my partners seem to really care about their patient and how they actually worried about them.

A recent essay by Dr. Philip R. Alper entitled "Being a good doctor" reminded me of those thoughts.He writes a regular column in the Internal Medicine World Report and I have quoted him before.

In this essay he is reminded of a comment made to him many years earlier by a colleague of his who said "You know good doctors worry about their patients".

Alpert continues:

Doctors who worry about their patients keep up-to-date, listen to their patients and think about not only what they say but also what they haven't said.They second guess their own impressions because they are aware of the potential for error. More than adherence to clinical guidelines or being paid for performance and recertification, the combination of good medical training and worrying abut one's patients is likely to lead to highest quality care.

Worrying about the patient puts the patient first not the doctor.

The 70s and early 80s were a time when we didn't worry about coding so much or E &M games. We spent more time talking about our patients and what was wrong with them medically and what we should do and attended no seminars on the best way to code. We did not use templates to treat the charts and we didn't worry abut how to game the system so as to get pay for performance. Being bribed to do our job was not a concept that in our universe of discourse or of thought. We could worry about our patient because the economic reality of time allowed us to do that.

I feel sure-or at least hope-that the good doctor still worries about their patients but it seems all the other worries -like how to keep the practice viable and not be audited by CMS and somehow be stewards of the limited medical resources , or if you prescribed the "wrong "drug according to the patient's prescription plan, or if you had enough patients with a low enough Hb A1 C to not be delisted by the patient's insurance plan-may well encroach on the available worry time and energy . You can only worry about so much.

The Medicare E & M System and enforcement is even worse than I thought

If recent posts by prominent medical bloggers ( see here and here) have not stirred up enough anger and fear and astonishment at the Medicare E & M system for coding clinical activities for payment, you should read the latest entry by DrRich .

Draconian is too mild a descriptor what the auditors can do and apparently actually do.DrRich correctly points out that it is a game the doc cannot win if he plays it at all. Opting out of the system seems to be the only way not to loose. It seems to be a world of Kafka inspired bureaucrats wherein if you consistently down code to avoid trouble with the man you can be accused of upcoding.

Read DrRich's essay and see what this powerful single-payer does and see if you still believe a single party payer for the country is the way to go.

Some docs opt to not "work on Maggie's farm no more"

Thanks to Kevin for this reference. Several groups California seem to be opting out of the third party payers hegemony.

Dr. Harold Sox in the Dec 4,2007 issue of the Annals of Internal medicine gives a brief history of the medical "guild" ending with this sentence:

"...by the mid-1960s the [medical] profession has become increasing subservient to the principal purchasers of health care;business and government."

In somewhat understated prose he nails it.

However, later he suggests that the third party payers have made an effort to make make medicine more lean and evidence based and he cajoles the internist readers of the Annals to meet "our partners"at least halfway. As expected he makes the obligatory genuflect to the concept of of the medical profession's obligation to work to conserve finite medical resources. For physicians to live up to the tenets of professionalism as defined by the ACP and the Annals folks private practice docs have to cooperate fully ( or at least halfway) with the altruistic efforts of third party payers to conserve resources and practice evidence based medicine.

The docs in California realize meeting them half way is worse than impossible it is probably suicidal.

Dylan wrote

"Well, he hands you a nickel ,he hands you a dime
he asks you with a grim if you're having a good time"

Many internists in private practice and their patients have long since stopped enjoying a good time.

Hats off to the physicians with the courage to say no.They have realized a simple fact.

The third party payers will not control medicine if the physicians do not contract with them.

The Avandia scrum and the art of war and narrative control

The Executive Physician (EP) has an excellent and interesting take on several aspects of what went on ( and maybe why) in regard to the Avandia saga. I say "scrum" as in rugby because , in a way, I am reminded of a bunch of strong forces all pushing in different directions for their own ends.

Drug companies are not unique in their desire to do things for their own self interest and explain their actions in terms other than the obvious. Researchers may write articles to further their own reputations and academic careers. Federal agencies actions, as so well explicated by Thomas Sowell, can be best understood and explained by looking at the incentives and constraints they are subject to and the feedback they receive. It seems that EP gives us a view of the Avandia narrative in terms of power relationships and natural incentives a knowledge of which he attributes in part to his reading of "The Art of War" and "The Prince".

After the publication of the bomb-shell meta-analysis in the NEJM we witnessed a battle of words,data manipulation or analysis-depending on how you look at it-to determine who would control the narrative.

EP tells us that actions of the various players in the Rosi saga are natural and that "indignation is laughable".

I continue to be impressed with how much influence an article in a high impact medical journal can have. Not only has Avandia suffered a major sales slump and a relative advantage accrued to Actos but I believe that the current recently revised diabetes guidelines reflect a growing disenchantment with the glitazone family not just with Avandia. The touring Joslin Clinic traveling dinner, diabetic CME roadshow was once described by one of my ex-partners as a glitazone love-fest.I doubt if it will seem so now. The glitazone advocates no longer control the narrative.

It has not gone unnoticed how quickly the "gliptins" move on the stage. The guidelines already include one of them,sitagliptin, band name Januvia as an alternative for second line treatment ( i.e after metformin and life sype changes are unable to drive the HbA1c to under 7.)With the glitazone story still playing out you have to wonder why the movers and shakers of the diabetic treatment world are so eager to latch on to another diabetic wonder drug. Could the manufacturers of that group of medications already be scurrying to control the narrative? Duh.