Monday, April 26, 2010

Another Medical blogger worried about erosion of physician's duty to the individual patient

I should have noticed Dr. Doug Perednia's blog, Road to Hellth, sooner. See here. I was aware of the "competition "between Dr Richard Fogoros's blog, Covert Rationing Blog and the ACP advocate blog authored by a senior vice president of the ACP for a blog of the year award.

The following is a quote from Dr. Perednia advocating votes for DrRich. Unfortunately, the ACP blog won out.

Dr. Rich's blog has been nominated for an award for the Best Health Policy/Ethics Blog on the Internet. His chief competitor is the blog of the massive and politically powerful ACP - the American College of Physicians. The most important difference between these two competitors is their attitude toward the physician-patient relationship. The ACP has decided to endorse a "new set of ethics" in which "social justice" considerations (whatever the hell they are), should be taken into account along with the personal welfare of the patient when making medical decisions and dispensing medical advice. Specifically, physicians should engage in "parsimonious care", that is designed to minimize the use of medical resources and "ensure that resources are equitably available".

To put it bluntly, the ACP is saying that when you're lying there with a potentially fatal or crippling condition, your doctor has an obligation to think not only about what's best for you, but also about what's best for "society" in terms of what tests to perform, what medications to prescribe and what procedures to undertake. They don't actually say who actually gets to dictate the needs of "society", but it's a reasonable guess that your insurance company, government regulators, Medicare, the AMA or ACP, or some other "official" entity will be making the call. "Normally Mr. Jones, I'd recommend that you get a CT or MRI test to make sure that you aren't having a stroke or a tumor that we would treat immediately, but a 'panel of experts' has decided that it's best for society that we order these tests parsimoniously. So I'm going to have to think about this one for a while. I'm sure you understand. Tell me if you develop any further weakness and we'll reconsider at some point in the future."

I would strongly encourage you to read Dr. Rich's discussions of these differences in perspective and their implications here, here, here and here. I would point you to the ACP's responses to Dr. Rich's arguments, but they've declined to publish any on their own websites.

The issue of the primacy of the physician-patient relationship, the fiduciary duty of the former to the latter and its erosion by the "new" medical ethics has been something talked about much on this blog (see here for a recent comment). I am heartened to see another voice in fray.

3 comments:

Doc D said...

Hi, my first visit here.

I don't disagree with Dr's Ferogo or Perednia on most of the concerns they have, and I frequently write from a similar standpoint. I'm afraid the train has left the station on the status quo. It might be better to get out in front of "Change" and develop alternative frameworks for choice and standards of care that keep the individual's health and welfare at the core our practice. Many of us want to be left alone to do the best for each patient, but that strategy will leave no opportunity to manage the doctor-patient encounter in the face of government intrusion. I've been part of hospital staffs and clinical groups that got together and said "here's our standards" for care (ie., one statin is too little, but twelve are too many, and the like) and stood up to the centralized planning approach. With the help of our patients (who write their Congress member), it works. Also, we got with the outliers in our professional community, who are giving us a bad name, and said "knock it off."

I really hate politics, but the AMA and other organizations have become progressive conclaves. and I see no alternative, unless we want to just keep griping while the national process unfolds.

I apologize if all this has appeared before. Thanks for the opportunity to comment.

james gaulte said...

Doc D

Thanks for your comments.I welcome others.

James

Doug Perednia, MD said...

Doc D and Dr. Gaulte,

Thanks so much for reading. There is no question that the AMA and other "traditional" organizations that doctors would expect to use to argue for reason have become part of the problem rather than part of the solution. Money and power corrupt over time. The AMA receives over $70 million per year from CPT licensing rights tied to the RBRVS. It's become financially rational for them to perpetuate the entire system that it represents.

Ironically, the upcoming healthcare disruptions knowingly or unknowing built into the new reform law might provide and opportunity for new patient/physician organizations to come to the fore. The trick is going to be: (1) defining the desired end result in a clear and unambiguous way; and (2) creating and educating the public and medical communities about simpler, market-based solutions that will get us there. I've tried to set up a mechanism to do this at http://www.ushealthcareconstitution.org, and would welcome any ideas thoughts that you and others in the patient and medical communities might have to advance the process.

Ultimately, it's all going to be a question of defining a clear goal, simple, sustainable solutions, and "marketing" them until the country is aware. Sadly, it reminds me of a billboard I used to see driving to the VA every day. It said: "A terrible thing happens without advertising - Nothing". Thus far, the medical community is not very sophisticated or skilled in this regard. We're too busy training taking care of patients.