The Medical Matrix,the iPatient and does anyone remember the physical exam?

The December 25, 2008 issue of NEJM has a brilliant Perspective written by Dr. A. Verghese entitled "Culture Shock-Patient as Icon, Icon as Patient".

Dr. Verghese, a professor at Stanford Medical School, writes about the world of the computer screen patient or as he puts it so well- speaking of the world of internal medicine training- the iPatient.

"The patient is still at the center but more as an icon for another entity clothed in binary garments,the "iPatient".

He explains that after the ER docs work up or perhaps define the patient the " interns meet a fully formed iPatient long before seeing the real patient." Quoting the semanticist Alfred Korzbski, Verghese reminds us that the "map is not the territory".

The reality or virtual reality of the iconic patients may overwhelm the person from whom the iPatient is constructed. The CT report or lab test may not be correlated with the history or physical exam as neither may be done as the reality of the full developed iPatient arrives "on the ward".

"If one eschews the skilled and repeated examination of the real patients, then simple diagnosis are overlooked, while tests, consultations and procedures that might not be needed are ordered."

He speaks of two approaches, the traditional way where in the body is the text and the new way or the expedient or Ipatient way. The first approach is a needed remedy for the development of "chartomas"-which are disease labels that become the iTruth by "being cut and pasted into every note".

This is a great commentary and Dr. Verghese tells us that at Stanford an effort is underway to revise and strengthen bedside skills. Good for them. My medicine chief during training, George Burch, preached that if you are uncertain or uneasy as to what is going on clinically go back talk to the patient again and examine him again. When the house staff receives a patient fully iDefined patient, they may never know if that are uncertain or not and they probably would have no reason to be uneasy, but the patient may.

HL Mencken,National Health Coverage Council and Public Choice Theory

Recently, Dr. Donald J. Boudreaux in a commentary in his column,"Eonomics in Many Lessons", featured some quotes from one of my all time favoties, H.L. Mencken. Mencken's comments suggests that he understood the core thoughts illuminated by Tullock and Buchanan in their writings that informed us of what has become known as Public Choice Theory.

Mencken said:

"the survival into our enlightened age of a concept hatched in the black days of absolutism the concept, to wit, that government is something that is superior to and quite distinct from all other human institutions ... a transcendental organism composed of aloof and impersonal powers, devoid wholly of self-interest and not to be measured by merely human standards."

Mencken struck the key note of the ideas behind Public Choice Theory, namely that public officials-elected,civil service or appointed- act, at least in part in their own interests. These people, members of the same species as those not in government employment, tend to be motivated by salaries and other perks,lust for power and prestige and easy of managing their bureaucracy.The ideal from our eight grade civics class of a selfless public official wisely acting for the good of society is seldom achieved.

With that in mind, the"independent Health Coverage Counsel" proposed in Max Baucus's health reform plan should scare the heck out you.See here for one critique of that plan.
The danger of placing the power to make economic decisions in the hands of a governmental or quasi-governmental organizations should be obvious to all.

In fact, it scares me so much that I awoke from my blogging hiatus.

Time for retired doc to retool,meditate and do the sabatical thing

What with the downtime imposed by a hurricane and the confluence of a bunch of other family and personal stuff, I think it best to-at least for a while-take blog writing off the table.I probably can't resist posting a few wonderfully cogent comments on some of my favorite medical blogger sites but little more than that for a while. I have beaten to death a number of my favorite themes and I need to re-fire the belly. I promise not to reappear in a new role as a political pundit.That market is super saturated anyway. So for a while, so long and thanks for all the fish.

Power outage from Hurrican Ike

Now 12 days since Hurricane Ike and still no power to my part of the Houston area. So no blogs for a while and for a short while to come. I only have access to a friend's computer or the wi-fi at a mall. Maybe next week things will be up and running again. Hopefully, my three readers will be patient.

More news on the fall out from restricted house officer work hours

Every time I mention there may possibly be some problems with the work hours restriction regarding house officers, I receive a barrage ( OK, 1 or 2 comments) from folks who consider me to be a old jerk who just wants a return to the good old days and that I want nothing more than to deny house officers time with their families so to better achieve the nebulous work life balance.

Thanks to Kevin for alerting me to this news item. In part, it seems like some surgery residents have been caught working too much in their misdirected efforts to try and learn to be good surgeons. Shame on them.

To disabuse these rebellious surgeon in training from their anachronistic aversion to shift work for physicians, efforts should begin earlier, i.e. in medical school. Rules should be implemented to limit the hours of study allowed for medical students.

work-life balance,shift worker physicians and paradigms lost

Sometime in the 1980s the term "work-life balance " ( which I will abbreviate as "wlb" to save key strokes) began to seep into the universe of conversational and literacy discourse. I suggest the term itself may be a bit of a self contradiction or at least a poorly constructed notion. Work for the great majority of human adults is part of life so would not "work-non-work balance" be more to the point.

And the point seems to be basically that there is said to be some appropriate distribution of the hours in a week or day so that the proper of amount of time is spent working and in the other various domains of existence, which would including family time,recreation,and you fill in the blank with religion or community service or duck hunting.WLB had become a buzz word particularly in the business world wherein it is widely believed that companies must make some highly visible effort to help their employee achieve this wlb or at least appear to do so.

It is a modern concept and a concept that makes sense only when folks achieve a certain degree of affluence. It would have made no sense to talk to our ancestors who worked the land from dawn to dusk and then collapsed in bed to talk about balance. Pretty much every thing was work. Similarly millions of people who eek out a barely adequate living in those parts of the world now call developing (formerly known a underdeveloped) are not too concerned with discussion about the best way to balance their lives. In the 1970s and before medical students and house officers did not lobby their trainers, teachers and exploiters for a better balance in the work and non work lives.I don't know why we didn't , maybe we just were not that evolved yet or maybe we thought we could not get away with it.

When I did consultation work for a large international corporation, I frequently did examinations for overseas travel and executive physicals for the top small percentage of the employees. One such person was tasked to consult with high level managers to work out ways in which those managers could make it to happen that their employee would achieve this wlb. This individual traveled around the world visiting various general managers and vice presidents and noted that most could be fairly described an "workaholics". He told several of them that they would never achieve the alleged goal of more wlb without the leaders serving a role models. Almost to a man (or woman), the reply was basically : Look if I slow down or work less, some sob will take my job." The wlb manager soon retired early and moved to a ranch in Montana ( I am not making this up ).

Government officials and politicians who get into some type of hot water such as accusations of wrong doing often decide to retire and give as reason " spend more time with my family". Nothing like getting caught to convince one to balance their work and life.

For some, their work is their life even though their position is such that they could opt to fish more, be ushers at church or have regular meals with their spouses. For them the balance is heavily shifted to the work side. Consider the degree to which physicians in their training shift much of their lives to the studying and working for a prolonged period of time. Do they accumulate a great unmet need for other activities so that when they finally finish training they are ready to catch up and re balance their wlb ratio, in part by becoming shift workers? Maybe so. Or since the income rewards are getting less and less and the prestige of physician work is diminishing and the autonomy is getting harder and harder to even find and when the pride of being physician gets to some personally determined tipping point maybe it is more politically correct to say you need more time on the life side of work life balance than to say screw it.

More reason to be wary of meta-analyses

A tip of the blogging hat to DB's Medical Rants for this reference.

This article by Ian Shrier and others from McGill investigated the subjectivity of meta-analyses and concluded the following:

The interpretation of the results of systematic reviews with meta-analyses includes a subjective component that can lead to discordant conclusions that are independent of the methodology used to obtain or analyse the data. And things get even more mushy when the statistical experts differ as to what methodology should be used.

In their discussion this paragraph says it well :

Our results suggest that a systematic review with a meta-analysis must be viewed with the perspective that it represents one study conducted by specific investigators with a specific methodology. At each step of the methodology (defining the general criteria, search strategy, inclusion/exclusion criteria, data abstraction, and analysis), subjective decisions are required that could affect the validity of the study; the relative importance of each will likely depend on the topic of inquiry and the data acquired. Our study demonstrates that disagreements in the conclusions of systematic reviews with meta-analyses can also be due to subjective interpretations of the results and not only of the methodology. The inclusion-exclusion criteria often are determinative of the outcome.Meta-analyses can be thought of as observational studies in which the subjects are trials.

Of course meta-analyses involve subjective judgment calls and various type of personal bias that the investigators bring to the table. How could it possibly be otherwise?

This gives me still another opportunity to reference the classic editorial in the Annals of Internal Medicine by Steve Goodman of Johns Hopkins which I discussed at some length here. To sum it I can do no better than to quote Goodman:

Judgment determines what evidence is admissible and how strongly to weigh different forms of admissible evidence. When there is consensus on these judgments and the data are
strong, an illusion is created that the evidence is speaking for itself and that the methods are objective. But this episode[ the mammogram controversy mentioned above] should raise awareness that judgment cannot be excised from the process of evidence synthesis and that the variation of this judgment among experts generates uncertainty just as real as the probabilistic uncertainty of statistical calculations.

I never tire of repeating my rant that meta-analyses should never have been placed at the top of the evidence based medicine evidence hierarchy.And for that matter biological plausibility should never have relegated to lower rings of the ladder.

Merck replies to the criticism of the Advantage trial

Dr. Jonathan M. Edelman, Director of Scientific affairs for Merck, has offered this reply to the charges leveled in the Annals of Internal Medicine article which had characterized the Advantage trial as a "seeding trial".

Dr. Edelman denies that it was, in fact, a seeding trial and that it was designed to answer a significant, scientific question describing the trial as one in which Vioxx was compared with a widely used drug Naproxen in a "real life" setting and involving patients who were allowed to take aspirin as well and - as such- answered questions that were relevant and pertinent to practicing physicians. He also denies that participants were not properly informed about the purpose of the trial.

Edelman also says that the trial "was designed, conducted, analyzed and interpreted by the scientific department of Merck." I had implied otherwise in my comments in an earlier entry on this subject perhaps inappropriately embellishing this following statement from the Annals article, "Merck's marketing division, ...handled the scientific and marketing data including collection, analysis and dissemination." However, which group or groups within the company designed the trial does not settle the question of if this a seeding trial or not.

Dr. Carlat has also taken up this topic and interviewed one of the authors of the Annals article.See here for the interview. The WSJ.Com Health Blog also writes about this issue here. The Med Page Today blog tackles this topic also.

Details of how much and what was disclosed to the patients and the participating physicians is not made clear by either the Annals article or the Merck reply.

Annals Internal Medicine article dissects the "seeding trial" aka "Marketing trial"

A number of e-mails and other internal Merck documents became fair game for analysis and critique when they became available as part of the discovery process of a civil suit involving the cardiovascular safety of Vioxx and this analysis is published in the August 19,2008 issue of the Annals of Internal Medicine . (The Advantage Seeding Trial: A review of Internal Documents, Hill KP et al, Annals Int Med. 2008;149;251-258).

The documents discussed in this article are concerned with a trial called ADVANTAGE which was said to assess the differences between Vioxx and Naproxen regarding side effects and effectiveness in the treatment of osteoarthritis.The trial involved 600 investigators and 2785 patients and was ultimately published in the Annals of Internal Medicine giving the results of a 3 month followup.

The current Annals article(needs subscription) takes the reader into the real life example of the world of a clinical trial that is designed and executed by the marketing ( not the research) division of a pharmaceutical company. This type of trial has been referred to as a "marketing trial" or a "seeding trial". The term " seeding trial" is actually used by involved employees although one company e-mail advised against the use of the term even in in-house writings.Although it has been suspected and alleged that drug companies sponsor these marketing trials this article is said to be the first documentation of at least some of what goes on in the company as the trial is planned and carried out.

Perhaps new to some physicians the seeding trial is nothing new at all in the world of marketing as explained in great detail in this reference which puts the idea in the context of opinion leaders, the Hawthorne effect and the tipping point. (for some reason I could only pull up the cached version.)

If the idea worked for Post-Its-as the above reference explains-why not for prescription drugs?

Psaty and others have decried the use of these low quality ( from a scientific or statistical point of view) trials and I wrote about in 2006 with some fairly unkind words about the physician opinion leaders who participate and make these marketing trials possible.

Doctors Harold Sox and Drummond Rennie wrote the editorial in the August Annals entitled "Seeding trials: Just say "no" " They wrote that the key to a successful seeding trial is deception. I would like to believe that many or most of the physician investigators were deceived as the alternative is that they knew it was wink-wink-nudge-nudge pretense of a trial and the term co-conspirator would apply.

Sox and Rennie said the Annals published the trial because no one told them it was a seed trial.One has to wonder why the editors had to be told. A 1994 NEJM special article made clear the characteristics of such trials and the Advantage trial was published in the Annals in 2003.David Kessler and co-authors in their NEJM article said the following about these marketing trials.

Features that distinguish such trials from scientifically rigorous studies include the use of a design that does not support the stated research goals, the recruitment of investigators not because they are experts or leading researchers but because they are frequent prescribers of competing products in the same therapeutic class, disproportionately high payments given to "investigators" for their work (although the only work may be to write prescriptions for the drug), sponsorship of the studies by the company's sales and marketing division rather than its research department, minimal requirements for data, and the collection of data that are of little or no value to the company. Typically, these trials involve introducing a new drug in a crowded therapeutic class. The success of such a new product may depend on undoing physicians' comfortable habits of prescribing a competing, more established product.

Hopefully with the spotlight of the current Annals article and editorial, editors,review boards and potential physician investigators will be less likely to be deceived and will "say no"and protect the real victims of these trials namely the patients who often in good faith thought they were furthering science and helping other people with the disease under study while in fact they may put themselves at risk for side effects for no reason other than increasing the sales of the medication.

Physicians who are confused and mislead by drug companies can rest easy-maybe, the government is coming to help

Enticed by pizza and promotional pens and mugs, enchanted by attractive, tricky drug reps and hoodwinked by cleverly crafted medical articles that have been funded by Big Pharma the woefully undereducated and incredibly gullible and naive medical doctors may look forward to having help from the government . At least that is being proposed, see here for news about that.

The plan is for the government to hire unbiased docs who will go forth and detail the office docs but this time the detailing will be done by folks who know the truth. It has become very difficult for someone with only a college degree, four years of med school and from 3-8 years of further education to sort the truth from the hype in regard to medication use. Fortunately, once the government hires someone with similar educational background to disseminate the unbiased truth they apparently- through the magic of government funding- become able to pluck the nuggets of truth from the dung of pharma manufactured propaganda and the razzle-dazzle of the traveling hired guns.

There are some cynics who believe that government decisions themselves have an unfortunate but predictable tendency to be biased, confused and self interested but the high-school civics class notion of the governmental agency or agent who is free of self interest and serves only the public good has considerable currency in spite of overwhelming evidence to the contrary.

As suggested by "The Last Psychiatrist" blog -does it not worry anyone that Congress believes or claims that physicians are so clueless that the government has to send out "academic detailers" to instruct the docs as to proper patient care?

I also wonder how have they been able to practice medicine before without that help?

Were not the "academic detailers" hired by the medical education companies hired by the drug companies thought to be part of the problem? Well, with a different source of funding things will change.

Physicians learning to be shift workers?

In a recent Medscape edition (July 1,2008) we find a disturbing essay by a practicing academic pediatrician who expresses concern about some of the unexpected consequences of the restrictions placed on medical house staff work hours. I find it disturbing in part because what the author describes could not be further from the notion that the physician (house staff) should not leave until his patient is taken care of.

Dr. Jane R. Gilsdorf, from the University of Michigan Medical Center, pulls no punches with this sentence:

The current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.

In discussing this with a former partner, who taught internal medicine residents for over 30 years and retired one year after the work rule changes were implemented, he had this cynical comment to make:

"Maybe it is good that the residents learn that approach early on because it seems that most docs are becoming shift-workers. Consider how things often work. You have a primary care doctor who has defined office hours and when you call his number after hours you either get a "triage nurse" or a recording that basically says call back tomorrow if it is not an emergency or go to the ER if it is an emergency. At the ER you see an ER doc who is working a shift and if you are admitted you are likely seen by a hospitalist who also is a shift worker. The notion of a personal physician whose role transcends duty hours is dead in the water."

Dr. Gilsdorf opines that more funds are needed to help correct the problems brought about by the ACGME work restriction rules. Basically, someone needs to be paid to do much of what the house staff used to do and now cannot. Dr. R. Centor discusses some of the problems brought about by the ACGME work rules and suggests with good planning,teaching and hard work many of them can be at least to a significant degree mitigated and I believe he is probably right.

However,how the broader "shift-workerization" of physicians can be reversed is another matter.Major shifts in the economic forces regarding physician and hospital compensation have brought that about and that big ship will be hard to turn around.

Still more possible benefits from statins-the list goes on and on

Dementia prevention and statins are again in the news with this study. Previous studies offered contradictory data , some showing an benefit in risk reduction in the development of dementia from statin use while others did not.

The current study is a bit more robust than some of the previous ones as patients were followed over time and periodic tests of cognitive ability were performed and the statins users scored higher.

Another study (a meta-analysis-and thanks to Dr. RW for that reference) offered evidence that post operative onset of atrial fibrillation can be reduced by statins. I guess we could use something new now after those unpleasant, unintended consequences noted from giving almost everyone beta-blockers pre op.

I have marveled before about how many good things can be attributed to statins all of which make me feel good about taking one of them even though my LDL wasn't all that high anyway.

I have written before about the contradictory results regarding statins and risk of colon cancer and commented that another case-control study will not settle that issue (for that matter,any issue) but that is exactly what the NEJM published in the face of previously published dueling case controls studies addressing that issue.

The story of dementia and statins is still being written but maybe in the meanwhile we can keep exercising in the hope that it will keep our hippocampi big and healthy and our frontal lobes relatively free of white matter bright spots.Anyway it would be nice to think so.

The really, really dark side of P4P (maybe the only side)

Comments by an Hawaii physician,called to our attention by the prolific Sandy Suracz, should do more than raise a few eyebrows.I have characterized P4P as, among other things,bribing physicians for doing their job. It seems to be worse than that.There may be instances of docs being bribed to use certain medications.

Now we seem to have more reason to believe that some health plans are being bribed by drug companies to prescribe certain medications and then the health plans bribing and coercing the physicians in the plan to prescribe those medication under the feel-good facade of
quality care and guidelines.

Dr.Catey Shanahan from Hawaii is the whistle blower in this instance describing what went on in the plan for which she works and alleged comments from a management person in another plan where she interviewed for a position. Details can be found here in her letter to the editor of a newspaper. The guidelines that Dr.Shanahan found questionable involved the dictum that all type 2 diabetics should be treated with a statin medication to drive the LDL below some magic number.I hope the usual fate of whistle-blowers does not await Dr. Shanahan.

One can argue about the validity of the conclusion that all such patients be treated to that target with that class of medication and can question the robustness of the data that suggest that such treatment is both safe and efficacious, let alone effective. ( I'll admit I have/had firmly bought into that line of thinking but am rethinking that now) However, there is no argument, as far as any reasonable or even conceivable interpretation of medical ethics, about bribing physicians to prescribe certain medications. DrRich sent me (and everyone who reads his blog and book) the message that medical ethics and pride are in a downward spiral and if medical ethics is in a crisis, trust is next to fall.

Three years ago my brother-in-law received a prescription for simvastatin ( not the generic) because of his slightly elevated LDL. He was of the belief-without any specific supporting data- that the doctor was getting some type of "kick back" for using that medication. In my naivete,I told him in no uncertain terms that that sort of thing just does not happen.The conversation would have to be a bit different now.

This same general issue attracted a bit of attention when the "EPO" stories broke and the question of rebates for physicians and health care plans came to light at that time.I wrote about that here.

Fortunately the shattering of the trust in doctors which such activities will bring about will be mitigated by knowledge that no longer will pharma firms hand out the mind altering pens and mugs decorated by the names of medications. That should restore trust in physicians.

More deserved criticism of P4P

I welcome attacks on the dangerous and muddled headed concept and practice of P4P. There is so much wrong with it that I hardly know where to begin. A good place to begin is this most recent entry by Dr.Roy Poses of Health Care Renewal. He summarizes most of the problems with pay for performance in this posting. To his excellent essay I would only add never forget Goodhart's Rule, which tell us that once a measurement becomes a target or a goal it is no longer a valid measure or more accurately phrased

Once a measure is made a target for the purpose of conducting policy, it will loose the information content that would qualify it to play such a role.

Dr. Robert Centor in his blog sends us to an extremely well written article in JAMA. You need a subscription but he gives us at least a hint of the flavor of that satire here.Ridicule sometimes is a sharper sword than thoughtful critiques.

I am afraid that in spite of biting satire and the elucidation of valid arguments against P4P, too many of our fellow physicians continue to collaborate with this travesty that can only serve to further accelerate the downward spiral to the ethics and pride of the medical profession.

Critics of the gate-keeper version of managed care were often told that the train had already left the station and now critics of P4P are being told that as well. The gate-keeper train ultimately derailed and I believe docs should let the P4P express train leave without them being aboard.

More things too important for individuals to manage for themselves

I have ranted before about those who think and want everyone to think that medical care is far too important to be left to uninformed, selfish egotistical decisions that physicians and patients are likely to make when they meet secretly in the former's office away from the watchful eyes of third party payers and conspire to spend some one else's money.The last thing a rationing unit would want to happen is to allow the unfettered actions of doctors and patients to prevail. DrRich's writings have made that point with great literary skill.

That activity makes sense if you consider the "pay with other people's money principle" but groups other than third party payers also share in similar movements and I am less sure of their motives. Case in point are the activities of several local public health units in moving to monitor the blood sugar levels - as surrogated for by the Hemoglobin A1C levels-of citizens without their consent.They would have us believe that the public health imperative is so strong that diabetes treatment cannot be left to willy-nilly, half hearted efforts of individual physicians and their patients.

We are seeing more and more of that same type of thinking in regard to "managing" the food intake and other activities of children. There are major efforts out there by groups who believe that what a child eats and what activities they do are too important to be left to the uniformed,almost-negligence proclivities of parents.After all it is those parents who are to blame for the current ever growing epidemic of fat kids.

Great Britain and Canada seem to be a bit ahead of the U.S. in this nanny-state nutritional impetus but we are closing fast.Sandy Szwarc in her July 15,2008 entry give us this instance of how far it is going in one region of England where parents may not be "allowed" to send lunches to school with their children.

Hayek writes of the "Fatal Conceit" of those who not only believe they know what is best for everyone but also see fit to take measures to insure that their wisdom becomes operational even it means the power of the state will enforce it.

WSJ editorial carries foward theme of Medicare as a harbinger of what a single payer would be like

Recently, I wrote that if you wonder what a single payer for medical care in this country would be like, all you need to study is how Medicare is working now. This same idea is expressed in this editorial from the Wall Street Journal. If you want to look at a real life example in the U.S. of what you may have learned in your Economics 101 class about price controls, all you need to study in how Medicare works.

WSJ says this:

The fight over doctor fees [the current annual dance over cuts in Medicare physician payments] is merely an appetizer for such a system, where competing interest groups would clash for their share of the spending pie. Highly politicized Medicare-like price controls on providers and services would spread to every health decision. The result would be rationing and declines in quality of care.

The writer explains:

As a virtual monopoly, Medicare uses a complex formula to set reimbursement rates for thousands of services. In short, it controls prices. That's why doctors are supposed to eat a pay cut, even though everyone knows this would prompt more doctors to stop seeing Medicare patients. But price fixing is the way that an open-ended entitlement like Medicare – which gobbled up $432 billion in 2007 – tries to control spending.

Thomas Sowell said that ignoring basic economic ideas is about as realistic as ignoring gravity in this essay on price controls. Medicare is all about price controls and rationing.

Pediatric organization issues proactive recommendations re use of stains in children

Several years ago, Dr. Antonio Gotto, noted lipid researcher, jokingly suggested putting statins in the drinking water. While we are not quite there yet, we are closer to that facetious goal with the latest recommendations from the American Academy of Pediatrics. Go here to read their paper.

I found their recommendations more than a bit surprising in light of the following: 1) an apparent reversal from their earlier pronouncements, 2) the lack of evidence presented in their paper addressing the issues of long term safety and long term efficacy regarding decrease in clinical coronary artery disease events. The emphasis on surrogate measurements on which they had to rely given the paucity of long term outcome data is in contrast to the bad press surrogate measurements have recently received in diabetes drug trials.

So what group of children should be considered for prescription drug therapy.Here is what the AAP said:

7. For patients 8 years and older with an LDL concentration of 190 mg/dL (or 160 mg/dL with a family history of early heart disease or 2 additional risk factors present or 130 mg/dL if diabetes mellitus is present), pharmacologic intervention should be considered. The initial goal is to lower LDL concentration to <160> 110 mg/dL may be warranted when there is a strong family history of CVD, especially with other risk factors including obesity, diabetes mellitus, the metabolic syndrome, and other higher-risk situations.
   

After you read the Pediatric association's argument for their position go here and read what is ,in my opinion, a much more reasoned and scholarly assessment of this general issue by the prolific Sandy Szwarc.(Thanks to Dr. Wes for that reference).

How will a government single payer work?Go to the Happy Hospitalist to see how it did/does work for Medicare

Everyone who is a physician or is training to be one,everyone who is a patient or who might someday be one (that really is almost everyone) needs to go now and read and re-read one of the latest essays by the Happy Hospitalist. Physicians to whom the education of physicians is entrusted should either copy that post and hand it out or send all of their students to the the link on the web .Would anyone like to wager that it will not find its way into any publication from a major medical organization?

Physicians who are so fed up with what medical practice has become and are so desperate that they are now recommending a single payer should read his article and see if their views about a single payer will change.

Happy explains what the CMS system is. If he is right,and I believe him to be right, the ship will sink in a few years and there will be not enough primary care docs to care for those folks who will need their services. Of course, many have prophesied that as well but the professional organizations such as ACP who also forecast disaster have not offered a viable solution, in my opinion.

The die was cast in 1989 with the passage of the Omnibus Budget Reconciliation Act. Wage controls were enacted for Medicare services, something that was promised to not ever happen when the Medicare bill was passed. With price controls one can expect shortages, increased demand , poor service and even black markets. All of the expected consequences did not occur overnight, but most (I don't think there is much of a black market yet) are very evident now and are getting worse.

The system that HH expertly explains so far has damaged the primary care physicians most but one can see effects moving up the doctor food chain. We are seeing ob-gyns offering botox and selling vitamins and are told there it is easier to get a vascular surgery fellowship than a dermatology residency. We read that a nurse anesthetist (CRNA) is averaging higher incomes than an internist or family doc or peds doc. Orthopedists are using PAs to do some of the non-procedural stuff (e.g. actually talking to patients) so their time can be spent with the higher paying activities like sawing and sewing.When you read how the system works much makes more sense: why we suddenly can't get by without hospitalists while 20 years ago there were no such entities, why the old medical ethics of putting the patient first had to be replaced by social justice concerns and a utilitarian viewpoint.It is the covert rationing so cogently explained by DrRich.

We all should know what wage and price controls do but the CMS system is worse than that. It is structured so that it will self destruct. Go to HH's post to see how that works.It is a death spiral of ever increasing volume and decreasing payment per unit of service that is crushing primary care and those docs who do the procedures will survive only a little longer.

He references his proposed solution in his blog. I don't know if his cure is the right medicine or not but he sure has done everyone a great service by explicating the pathophysiology of the problem.

More on rivaroxaban trials

Recently, I referenced two clinical trials published in the NEJM which compared a new oral anticoagulant,rivaroxaban, with the low molecular weight heparin enoxaparin for thromboprophylaxis in patients undergoing hip arthroplasty and knee replacement surgery.Both studies showed an advantage for rivaroxaban over the comparison drug in terms of fewer thrombotic events and showed no real difference in bleeding.

Dr. RW pointed out that the dose of enoxaparin was lower than the standard recommended dose,that is the dose recommended in the United States. In both studies, the dose of enoxaparin was 40 mg. daily.This is in contrast to the 30 mg. every 12 hours which is the standard dose used. Could the use of the lower dose of the drug to which rivaroxaban was compared be an instance of "stacking the deck"? In the hip surgery study, there were 33 patients out of 1678 with major venous thromboembolism events versus 4 in 1686 patients in the rivaroxaban arm seemingly indicating the superiority of "riva".

Would the higher enoxaparin dose that is typically given resulted in fewer cases making the comparison less favorable to rivaroxaban? Maybe, but in a 1994 dose finding study the outcomes with 40 mg once daily and 30 mg twice daily were not statistically different.There were 27/199 (14%) patients with clots in the 40 mg dose and 22/208 (11%) in the 30 mg twice a day dose, a difference not statistically significant. Admitedly this was not a mega trial so a false negative could have occurred but the 40 mg dose has been used in other trials.The PDR gives the 30 mg. twice daily dose as the recommended dose but also suggests that in hip surgery patients the 40 mg regimen is reasonable alternative.After all of that, it seems to me that the 40 mg. used is not a unreasonable dose and has been used in other trials with enoxaparin .

In regard to the knee surgery study, the authors stated that the enoxaparin dose used was the dose approved in Europe and not the 30 mg twice daily dose approved in the U.S. for that application. Further, they started that a trail is currently in progress with the 30 mg. twice daily dose.

With those considerations in mind my speculation or veiled accusation that the deck was stacked has little evidential support.It may be best to shoot after aiming.

In a thoughtful followup to his first posting Dr RW makes the important fact that you need to look at the facts of how the trial was designed and executed rather than basing any decision regarding the validity of the trial by simply looking at who paid for it. With some of the drug trials scandals (the Ketex studies come to mind)and the possibility that some data has been withheld in some trials I have become so jaded and distrustful that my objectivity titer has diminished and his suggestion to look at trial critically and then look at the funding makes sense.

This time,new oral anticoagulants may well make it to the market

I had my hopes that ximelagatran would be the replacement for warfarin. That did not happen because of liver toxicity problems with the drug. Now several new drugs are traveling through the clinical trial pathways.Most of these are in a new class of anticoagulants known as Factor Xa inhibitors.

The medication leading the pack, in terms of being closest to approval, is rivaroxaban. Clinical trial results are found in the June 26,2008 issue of NEJM for the hip arthroplasty and total knee replacement studies. Both found fewer episodes of thrombosis in the rivaroxaban group and no statistical difference in bleeding when compared with enoxaparin. The liver toxicity that killed ximilagatran so far has not been a problem. Another Factor Xa inhibitor,apixaban, is in trials as is a direct thrombin inhibitor,dabigatran.

If and when the clinical trial(s) comparying "riva" with warfarin in chronic atrial fibrillation demonstrates similar good results we may finally have a new oral anticoagulant than does not require frequent blood test monitoring and may be free of much of the vexing vagaries of trying to get the dose of warfarin right and keeping it there.

More on end of Era of the Oslerian Internist

DB Rants takes on the issue of "what will happen to the Internist" in this entry and more and more internists are offering a pessimistic prediction of their future. It seems the internist has to choose between being a "office internist" and in the view of some being relegated to a position that seems little different from a Family Practice doc except that the FP doc can do more or being a internist who only sees patients in the hospital.

A third option may be the retainer practice in which maybe the internist doc can still do both but even that seems weighted to the out patient practice.

The Happy Hospitalist gives us this mini view of the economic environment that is a main driver for the changed world of the internist.

Help for the environment is on the way but maybe not for asthma patients

Fears of ozone depletion and the purported health effects of that should be soothed somewhat with knowledge that the CFC containing bronchodilator inhalers will be outlawed in December 2008. See here for The FDA message concerning the impending prohibition.

The new non-CFC inhalers (some contain HFA) will taste different, need regular priming and cleaning to prevent them from plugging and blocking delivery of medication to the lungs but that is the least asthmatics can do to help the environment. Additionally there are no generics for the non-CFC units so cost will increase. I wonder if we will see black market old fashion type albuterol inhalers.Again it is the least asthma patients can do to prevent sunburn and skin cancer in Australia.

Judging from how hard it may be to instruct someone to properly use an inhaler, I'll bet there will be more than a little trouble in switching over to the new units. There are 4 brand names and apparently the priming and cleaning directions vary by brand.Further, different pharmacy management companies may well favor one unit or another based on deals they make with the manufacturers .

Dr. Mintz in his medical blog does an excellent job of explaining the new inhalers here
Several of his readers replies are also instructive and I think a harbinger of the problems to come.I believe the confusion about them will lead to problems for asthma patients, in some- just inconvenience but for others- poorer control and more visits to the ER before everything is sorted out.

A huge number of skin cancers are alleged to be prevented by the CFC ban ( see here for a old CDC request for comments regarding CFC in asthma inhalers).Here is a link to an entirely different view on the issue which raises issues of the lack of proven safety of the new inhalers and other potential problems they may present and several presumed experts who maintain that any contribution of the CFC from the asthma inhalers is basically too small to have any effect on ozone depletion. The new HFA units have only been used for a relatively short time and recent events involving side effects that became evident long after all the clinical trials leading to approval were completed might give the FDA pause.

At least two questions are raised by the banning action of the FDA.Will the ozone zone recover faster when the CFC ban is completed or will it have any effect and it there any way anyone will even know. I claim no expertise in that area but my basic cynicism leads to think that the stratosphere will not really change much one way or the other long after asthma patients and others with obstructive lung diseases pay more for their medication.

The other interesting aspect is that I think this is the first time that the FDA bans a medication or group of medications not because they are thought or proven to be harmful to those who use but because they are thought to possibly harm folks who do not use it. (OK, the purported skin carcinogenic effect of increased sun rays from the purported decrease in ozone layer thickness would affect everyone- even asthmatics.) Since the task of determining harm to medication users has proven much harder that the FDA or anyone ever thought, it is admirable that the FDA will take on an even more difficult task.

Let us shift the risk factor paradigm-it is about time

The June 6,2008 NEJM published a very important editorial. This is one should be handed out to medical students and house officers. This insightful filled essay was authored by Drs. Harlan Krumholtz and Thomas Lee.Dr. Krumholz is prominent in the area of outcome research and hopefully his views will have a positive impact in reassessing and reining in the current risk factor modification craze which has neglected the fact that how one modifies the factor may change the disease outcome of interest. It might be added that in some instances we have little or no evidence that modifying a risk factor will matter at all as appealing as the pathophysiologic rational may appear.

From the essay we read:

It is increasingly apparent that the specific strategies used to modify them [the risk factors] make a critical difference in patient outcomes.

The now canceled ILLUMINATE trial illustrates dramatically the main point. Raising the HDL with a particular medication (torcetrapib) was associated with a higher mortality rate. How you raise the HDL may well matter.

What do the authors propose?

..we should no longer support the use of target without reference to the strategies used to achieve them....Second, guidelines and performance measures should incorporate more sophisticated and explicit considerations of the risk of the disease and the adverse consequences posed by the intervention.

A clinical trial is ultimately a test of strategy,and we should not be surprised that different strategies may have different effects on patients beyond their effect of risk-factor levels.

You would hope that publishing those thoughts in a high impact journal such as NEJM would have actually have an impact.

Guidelines-good suggestions or edicts or (sometimes) shameless self promotion

Two medical bloggers have recently made very cogent comments regarding medical guidelines,
Dr. Robert Centor and DrRich. Medical students and house officers would do well to read both because they have never lived in a medical world without the guidelines and physicians reading the blogs may get a different perspective on what is being done to them in the name of doing something for them and patients and to further the abstract goal of quality. (the 2 postings are highlighted below)

Both make the very important observation that guidelines that purport to be evidence based may be just as likely as the advice from your uncle Cyrus or your charming used car salesman to reflect their own personal and professional interests and are in word-biased. No, they all are not- at least not to the same degree- if there were things were that simple, you could just ignore all of them.

And of course, we should not forget Goodhart's Law, namely when a measure becomes a target it no longer functions as a measure.

Dr. Centor has informed us previously us about the nature of pharyngitis in adults, a subject he has studied and written about for a long time and in this recent entry delves into PSA screening. The bottom line is that there are numerous guidelines and they all don't agree with each other. Various guidelines writing groups begin their task with different world views.

The public health oriented wonks have a different perspective about PSA (or whatever screening procedure is at issue) screening that a practicing urologist might.The former group has to consider the total cost to society( which I believe is basically a bogus concept in that context) while the later wants to detect cancer earlier and yes, he has the economically advantageous opportunity to do more procedures ( from biopsy to surgery) if lots of men have their PSA values measured. If you believe that entities allegedly writing in the context of the greater good, really only have their nebulous goal in mind (this includes the prestigious USPSTF panels), you should read this entry.

DrRich takes us through the fascinating history of the rise and fall and rise of the concept of "metabolic syndrome" and what, if any, specialty medical group should promote and exploit it and coins (I think he coined it) the intriguing and thought provoking term of predatory guidelines.

Physician and lawyer ownership-interesting contrast

Hat tip to the Blog A Stitch in Haste for pointing out this interesting distinction.Physicians, in Mr. Pete Stark's view cannot or should not be trusted to own ,for example,a hospital because of the fear their avarice will overwhelm their fiduciary duty to their patients. ( I have written before about what I believe to be an erosion of that duty by the New Professionalism). Pete Stark has a penchant to introduce legislation to limit what a physician can do in terms of referring patients to various health care facilities. To get flavor of the "Stark Law" go to this analysis of the complexities involved in this statute.More on recent congressional efforts to restrict who can own hospitals can be found here.

By startling contrast-any one but a lawyer is legally not allowed to own a law firm.No one but a lawyer can own a law firm-others cannot be trusted.Of course, owning a law firm is one thing, owning a hospital or imaging center is something else but the disconnect between the general level of public trust for the two professions and the perceived need to control one group to a much greater extent than the other is something to think about.

New Asthma guidelines (again) and another meta-analysis re:LABAs and asthma

The National Heart,Lung and Blood folks have authored still another set of asthma guidelines-all you would ever want to know in 440 pages. (5.22 MB).Several links from the NHLBI site did not work and one version was only 3.88 MB. This one seemed to work, however.Physicians who treat asthma are obligated to plow through it but if you prefer to read the written page as opposed to the computer screen be prepared to replace your print cartridge.

In other asthma news,the issue of the safety of LABA use in asthma has been revisited in a recent issue of the Annals of Internal Medicine.I have written before about the candidate for the worse randomized clinical trial of the century,the memorably flawed SMART trial, and the subsequent impressively flawed meta-analysis (relying heavily on the results of SMART) unfortunately published in the Annals of Internal Medicine by the Salpeter team and the kurfuffle it generated. In an act of apparent contrition, the Annals has published another meta-analysis regarding the use of long acting beta agonists (LABAs) in the treatment of asthma and found LABAs innocent. (Since I have been so critical of certain aspects of meta-analyses,one could ask why I would believe this paticular one. The answer is I believe-or at least I quote- those that conform with my preconceived notions and biases about the subject.) Here is another meta-analysis that provides support for the widely held position and my notion that LABAs are beneficial in COPD.

Used properly LABAs add value to asthma treatment. They are to be added to the treatment program after inhaled corticosteroid (ICS) have been started but along with resuce beta agonist use appear to be inadequate for control. This is the role for LABAs according to the new guidelines. LABAs are not to be used for rescue therapy. Frequent use of a short or long acting beta-agonist in a poorly controlled asthmatic (one who should be on steroids) is a harbinger of ER visits, a required intubation and worse.

It is not your father's medical ethics any more

Can the traditional medical ethical prime directive of placing the individual patient's interest first survive in a financial environment in which physician autonomy is greatly diminished and income for most physicians is controlled by third party payers. More broadly put, Dr. Edmund D. Pellegrino asked in 1995 (JAMA,May 24/31,1995,Vol 273,no 20,) " Is medical ethics a social, historical, or economic artifact?Or are there some universal , enduring principles?

In 1988 Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional ideal" was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians." Their comments were not subtle when they said :

We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible.

Incredibly, the authors claimed that this shift in ethical focus would actually increase patient trust, an attribute that even in the late 80's was in a decline as patients tried to live (sometimes literally) with the HMO's restrictions to medical care. Incredibly, they claimed that by not having the patient's interest as the prime directive there would be increased trust in their physician.

The expected wave of letters to the Annals editors expressed the belief that advocacy for the individual patient was the prime directive and what it was all about and to replace it was to effectively do away with medical ethics as it had been known and practiced for a very long time. This is what would be expected from an audience of internists who had grown up medically inculcated with an ethic which was the polar opposite of what the authors proposed. Practicing internists at that time were reared to believe that the physician was completely and ultimately responsible for their patients.

The average practicing internist if they read the article at all may have thought this was the contrived advocacy of someone who was attempting to make manged care appear ethical. All that was required was to turn medical ethics on its head.When I read that article I thought "you've gotta to be kidding me".

A few years later ,I saw no one was kidding as the ACP, ABIM and the European Federation of Internal Medicine joined forces to formulate what was called the New Professionalism in which physicians were admonished to do more than maximize the health of all the patients in their HMO, which was as far as the Annals author went. Now, they had an ethical obligation to strive for Social Justice.This joint effort was said to be necessary as the "old ethic" needed to be revised to align itself with the new economic environment in which physicians now lived and "medicine's commitment to the patient was being challenged by external forces of change within our society".

While the 1988 article's authors stopped short of suggesting physicians should conserve resources for others in society at large and just concern themselves with their own HMO's population, the new ethics or professionalism as it was now called, headlined social justice raising it to the level of the big three ethical precepts-patient welfare, patient autonomy and social justice.More than one observer has asked does precept three conflict with precept one?

The era from 1963 to about 1990 has been termed the time of "retail medical care". Physicians and patients enjoyed the situation in which a patient's insurance followed the patient so that he could choose any physician and the physicians' fees were not set by the insurer but largely were set by what the physician considered and the payer agreed to be "reasonable,customary,and prevailing".

Things were good for physicians in those days as not only was physician autonomy largely unchallenged,but also Medicare has brought about a large influx of money to be spent largely at the discretion of the doctor and their patients and exciting new diagnostic and therapeutic tools were available. More could be done for your patients and more patients could afford medical care. Referrals could be based on the physician's knowledge of the area consultants and prescriptions were written without concern for some third party's list of permissible choices. But things were to soon change as the era of "wholesale medicine" replaced the old ways with the HMO being the middleman.

A series of articles was published in 1995 in JAMA authored by Dr. David Eddy that discussed the metrics and merits of decision analysis which he hailed to be the mechanism to perform magic. The magic was to increase quality of medical care while reducing cost. But it was all merely playing with words and defining words to suit the argument. Eddy defined quality as the greatest medical good for the greatest number within the eco-medical collective (aka HMO). It did not go unnoticed to the skeptical reader that Dr. Eddy listed his affiliation as "Kaiser Permanente of Southern California")

Pellegrino in 1995 also asked ...can physicians change the ethics of the profession at will ( as proposed by Berenson and Hall) or is there a more fundamental and universal foundation for the ethics of medicine in the special nature of the physician-patient relationship?

Pellegrino's quotes are found in an article entitled "Guarding the Integrity of Medical Ethics-Some Lessons from Soviet Russia" . The subversion of medical ethics in Russia suggested to Pellegrino two lessons. 1) corruption will afflict any health system not designed with care of the patient as the its primary driving force. 2) medical ethics must be independent of political exigency. "... a morally responsive profession is an indispensable safeguard for the sick against the statistical morality of utilitarian politics, even in democracies."

The statistical morality of utilitarian analysis seems to be increasingly unopposed as the group outcome analysis derived data plays an increasingly large role in the decisions regarding the individual patient exhibited in part as guidelines executed by mid level practitioners. In this new day, the physician has more to worry about that just her patient, she must be concerned for everyone but at least she has been removed from the impossible role of being responsible for every aspect of his patient's well being as she is now (merely) a member of a team and part of a system of health care.

The philosophy supporting the "diabetes police" is more than frightening

I have written before about the movement of at least some of the public health community into areas not traditionally thought to be within their purview such as local public health departments monitoring the hemoglobin A 1 C levels. I was not aware of the degree to which the philosophy animating this movement was developed and being expounded in very explicit terms.

Thanks to Sandy Szwarc of Junkfood Science . Her entire piece should be read but below are some of the comments made by exponents of what you might call "the new public health ethics".

In a nutshell,the basic notion is that an individual's health and health related behaviors are too important to be left to the individual as they poise a threat to society and government must act for the good of society.

Ms. Szwarc quotes from a "thought leader" in this field of public health ethics, Dr. Angus Dawson who is at the Centre for Professional Ethics at the University of Toronto as he discusses his approach to the problem of obesity.

[the educational approach to battle obesity] "will fail as it wrongly assumes..that we ought to respect an individual's existing preferences " and "an ethical obesity policy ought to focus on collective interventions [ in which] the individual will not be able to opt out.

If people will not do what we know to be best for them and society we will make them do it.This seems to be the core of the public health ethics.

Lest you think that we are dealing with the relatively, unheard voice of a fringe philosopher in the wilderness (or at least in Canada),essentially the same theme is expressed by Dr. VJ Guillory who served on the AMA Expert Committee on Obesity when he wrote in the Journal of Public Health , "The mandate to ensure and protect the health of the public is an inherently moral one...and it implies the possession of an element of power to carry out that mandate."

In this age of supposedly evidence based medicine it is interesting to read one of the comments from a report about a meeting of the AMA Expert Committee on Obesity : "The magnitude of the obesity is too great to wait for evidence-based guidelines before increasing efforts focused on prevention and intervention." So it is ready, shoot, aim- all with very generous funding from the Robert Wood Johnson Foundation and it is individual freedom and autonomy the targets.

Will the options for internists be even fewer as time goes by?

Had retirement not worked out to be better than I had hoped for, I had thought that a concierge practice or being a hospitalist would be the way for me to go. The retainer practice might allow me to escape from the clutches of the third party payers whose ever tightening of the control and payments screws sucked much of the joy of patient care and the threat of things getting even worse casting a pale over the future. The hospitalist gig offered the relief of no call and a opportunity to attend the type of complex,often very ill patients which seemed to be what an internist was trained to do.

But now we hear that perhaps the hospitalist role may not be a safe haven for the internist for very long. Dr. RW tells us about that scenario here.

Even as the future for hospitalist might appear less rosy, we should not forget that the safety and quality movement leader guru, Dr. Donald Berwick still has much for them to do as they become the change agents and integrators of a new medical system that will provide quality care, reduce costs and improve public health. I guess it is better that I did not become a hospitalist as all I could do on a good day was to take as good of care of my patients as I could leaving the problems of maximizing public health and obtaining universal medical coverage to someone else.

The diabetes police concept moves to Texas

Thanks to Sandy Szwarc of the blog Junk Food Science for this alert.

The Metro Health District in San Antonio is creating a "surveillance program" to identify diabetics. Earlier I had written about a similar program in New York. Hemoglobin A1C levels will have to be reported by the clinical labs to the public health folks.

The project is described as a pilot program which came into being by actions of the Texas Legislature.If successful(those sorts of program are very likely to be judged successful by the folks who administer it)it will be transplanted into other metro areas in Texas.

The notion that medical care ( health care) is too important to be left to individual physician and the individual patient gains more traction as the nanny state move on, privacy being a quaint concern of an earlier era.

Safe drinking water and mosquito control are considered to be legitimate concerns of public health authorities, my blood sugar level, hemoglobin A 1C and blood pressure level are not.

Peri-operative beta blockers-quality measure or risk factor for stroke and death

The now published results of the POISE trial raises the question that the rush to make peri-operative beta blockers a quasi-mandatory quality measure may have lead to a number of deaths from stroke . Could that possibly be right?

In the words of at least one of the trial investigators the answer is yes.Dr. P.J. Devereaux's comments can be found here in Medscape news report describing the trial and various commentators' reactions to the results.

POISE was a large ( 8000 plus subjects) randomized trial designed to determine the effect of the peri-operative use of Metoprolol-XL. 100 mg was given 2-4 hours preop and again 0-6 hours post op and then 200mg daily for thirty days.

Total mortality was increased in the treatment arm (3.1% versus 2.3%,Hazard ratio 1.33,p=03) while myocardial infarctions were decreased but strokes were increased.Strokes occurred in 1% of the treatment arm patients versus 0.5 5,Hazard ratio 2.17. Hypotension was also significantly increased in the treatment arm while the incidence of atrial fibrillation was decreased.

Critics of the trial might argue that the dose of Metoprolol was simply too high and too much of this putative good thing might well cause more hypotension. They might argue that POISE only demonstrated that if you give an inappropriate dose of a beta blocker you cause harm. But I do not believe that the results of the trial will be dismissed based on different experts differing on dosing details of the trial.More likely major changes in guidelines will be made.(I will have to admit that if I took 200 mg of metoprolol a day, I would move like a turtle and have a heart of 12.)

If there is a lesson here it is not just that a large randomized clinical trial gives results opposite to earlier smaller trials-that is a story we have heard more than once before. The lesson is not that expert committees sometimes have to revise their recommendations as new information becomes available.The lesson I think that should be emphasized is that overzealous quality rule writers and enforcers can be a hazard to your health ( and I have said that before). Read Dr. Devereaux's comments regarding how many patients may have been harmed by taking peri operative beta blockers and then wonder how many patients received them simply because premature quality guidelines were in place and physicians were caught up in the rush to treat even though it seems clear now that the evidence for such zealous efforts was inadequate.

Dr. DB (AKA Dr. Robert Centor) nailed it when he recently spoke about in this regard " the performance and quality movement which has a 'ready,fire, aim' philosophy".

Still more on Medical Home AKA medical utopia

Yesterday, I signed up for a new, free newsletter, The Medical Home Monitor. This is apparently aimed at those who are interested in this latest version of managed care and its new packaging and how this bogus concept can be sold to the public.

Its advocates promote the Medical Home as a revolutionary sea change in medical care for which the term Utopian fails to properly denote both its purported magnificence and its absurdity.

The Medical Home Monitor uses 7 (count them,seven) back to back adjectives to describe the Home. They are: accessible,continuous,comprehensive,family centered (alternatively the term patient centered is used),coordinated,compassionate, and culturally effective. Not only that but there will be improved clinical outcomes and patient satisfaction and it will not increase health care costs. Think of it, provide many more services that the typical patient now receives and it will not cost more.

Sandy Szwarc in her consistently insightful blog, Junkfoodscience, explains clearly the difference between the hype of the Medical Home and the reality of what it is as envisioned the single payer called CMS. This CMS version of Medical Home as contrasted the warm fuzzy words imployed to hype it gives a new dimension of hubris to the concept of bait and switch.

The Happy Hospitalist explains in agonizing, mind boggling detail the particulars of how the Medical Home will be constructed in the regulation driven world of Medicare.Any doc or any patient who might be conned into taking part in this scheme should read these two blogs.Anyone who believes that Medicare should serve as the paradigm for a universal single payer just might be disabused of that belief by digesting these two essays.

Nurses and doctors, of course, will play a key role in this Medical Care Utopia but patients will be interested to learn that in the Medicare version as structured by the AMA's RUC committee the nurse will be allocated 3.5 minutes for a patient with one condition and 9.4 minutes if 4 or more conditions are present to provide the comprehensive,compassionate, culturally effective care it purports to deliver. Similar micro managed time allocations are given for physician's time. I am not kidding, the RUC wonks describe activities in term of tenths of minutes. Doctors will be allowed 12.5 minutes for those patient classified as "very sick". If anyone on the RUC task force actually took care of complicated, complex medical cases , he/she must have slept through most of the sessions.12.5 minutes should be more than enough to evaluate a elderly person with heart failure,COPD, diabetes and new onset severe back pain who is living alone and taking nine different medications, leaving time to ask about dental flossing and seat belt use and immunization status and to make a few well chosen culturally sensitive comments and hand out three health care educational booklets and allow time for the patient to proudly show the latest photos of her grandchildren.

Dr. Roy Poses takes on this issue in his latest posting on Health Care Renewal as has Kevin in his May 8, 2008 entry blog (see here) and Dr. Vijay Goel in his blog,Consumer-focused Health Care, as he heartedly seconds the analysis of the Happy Hospitalist. If you think-well this is just the government bureaucratic mind set at work and private entities will show everyone how the "Home" should be built- read this earlier entry by DrRich in his blog, Covert Rationing Blog, as he explains how United Health Group plans to do it. I made some comments about that also.

I have been critical of the American College of Physicians' position and role in the Home concept and I await their justification of the RUC 's plans and how they can possibly support what would be a disaster for primary care.Rather than their typical sound bites (quality evidence based, patient centered care,electronic medical records, medical home, blah, blah, blah), they should be saying to the RUC and CMS "Gentlemen , we have read your proposal and as internists we know more than a little about caring for complex medical patients and we know that you cannot attend a complicated patient in 12.4 minutes and if you think it can be done you have no business writing guidelines or rules."

Look who is going to write the compensation rules for the "Medical Home"

The American College of Physicians and others have been touting their solution to most (if not all) of the problems destroying primary care medicine under the banner of "Medical Home". One major obstacle to providing the accessible,continuous and coordinated care has been and is that physicians are not compensated to provide that type service.For example, how would Mediare compensate docs for those activities?

Now we learn that AMA's friend of the primary care doc,the RUC (relative value scale update committee) will play a major role in setting up the rules and ultimately the fee structure for the Medicare version of the Medical Home. The Tax relief and Health Care Act of 2006 mandated a demonstration project .

Here is a link to the AMA site with a description and from there a further link to the full set of recommendations from RUC. Anyone who thinks the Medicare funded Medical Home will be anything different from the morass of rules and tricks and traps of the fee structure and coding mysteries that typifies dealing with CMS should take a few minutes and read what RUC has authored. If you think the current coding games doctors have to play are onerous and irrational
(go to the latest from the Happy Hospitalist to get a flavor of that) wait until you see what the RUC thinks need be done to deliver the "coordinated continuous care" envisioned by the pie-in-sky Medical Home concept.