Thursday, September 23, 2010

What is fate of physician-patient relationship in a Don Berwick designed health care system ?

The following quote from the book Dr. Berwick authored with Dr. Troyen A. Brennan,which is frighteningly entitled , "New Rules" answers the headline question. (see here for a review of that book published in the NEJM)

H/T to the blog " Black Ribbon Project"

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

I have expressed my concern abut Dr. Berwick views before and one such commentary was re-e-published by Kevin,M.D. with my permission. One of the replies to that entry on his web site accused me of taking his remarks " out of context". While it is true that remarks and words and phrases can be cherry picked to give an impression contrary to the speaker's intentions I offer a friendly, rhetorical challenge to anyone who can propose a context in which Berwick's words could be said and not mean anything other than their obvious meaning. OK, I can think of one and it is trivial. The author precedes that paragraph with the words "I do not believe the following".

Berwick's and Brennan's views dovetail with the ground work constructed by the "New Professionalism" (see here for the details of that project ) which implores physicians to somehow balance their duty the patient with some nebulous responsibility of stewardship to take proper care of society's limited medical resources and strive for social justice. Dr. Troyen Brennan was the chair of the Professionalism project. In fact Dr. Brennan name crops up more than once in a narrative of the transformation of medicine in which medical care is taken from the hands of individual physician and into the control of various organizations.

In 2002, Dr. Brennan's new Professionalism was revealed to the world in the Annals of Internal Medicine ( see the above link). (OK, it wasn't just Brennan's,others played a role.)Physicians were admonished to work for the good of society and not just be concerned with the parochial concern for their own patients.

In 2006 Brennan and Berwick published the book, "New Rules". The operative word is "rules".

In an Article in 2007 (JAMA,Vol 208,#6,p 670) Drs J. Cohen, ,S. Cruess, and C. Davidson report their " discovery " that individual docs basically could not resolve the ethical dilemma posed by balancing their efforts for the patient's welfare with their duty to work for the good of the herd. ( see here for my comments on that article) What was needed was a "Medical Societal alliance" which could be made manifest through large vertically integrated organization such as something called an "Accountable care organization (ACO). Note, the old medical ethics had no major, crisis -level conflicts it was the New Ethics that posed the problem that the author purport to remedy with their nebulous alliance between collective abstractions.

Another article in JAMA in 2007 carried this theme further. The article was written by the then President of the American College of Physicians, Dr. Christine K. Cassel and the then executive vice-president of Aetna Insurance, Dr. Brennan. (JAMA ,June 13, 2007, Vol 297, no. 22, p. 2518, "Managing Medical resources.Return to the Commons")

They speak of an abstract hypothetical " medical commons" and how the current emphasis by the physician on the welfare of the individual patient will spoil the commons much as the farmer who selfishly grazes his cattle on public land without regard for depleting the resource will destroy the resource.Physicians are implored to "reconstitute the medical commons" and think in terms of resource conservation and allocation so at the end the greatest medical good can be done for the greatest number of patients.They admit there is not currently such a commons. There never has been so I am unsure how a return is possible.

The medical commons figure of speech seems bizarre and lame.While a grassy knoll for the villager's sheep can be defined by a specific surveyor description, the "medical commons" is a extremely large amorphous array,the elements of which defy enumeration, and is every changing, with some elements growing ,others contracting and innovations cropping up constantly. Various entities own various elements of this array-society owns none.The skills,and knowledge of thousands of physicians are aggregated and then allocated as if somehow society own them.There is no easily defined entity called "medical resources". Rather,it is an amorphous abstraction.Further, to speak of allocation means some one or some elite group will be the "allocator in chief ". Decisions will not be made by thousands of individual physician-patient pairs, since those individual physician-patient pairs plans to spend money are the worse nightmare an officer of a health care insurance company could have. Is anyone surprised that an officer on a large medical insurance company would propose a plan to eliminate the pesky problem of physician-patient "dyads" scheming to spend the insurance company's money simply because the two agreed such expenditure would be in the patient's interest?

The old follow-the-money strategy continues to have explanatory power. but why would the leadership of the ACP take part in that philosophical sham?

1 comment:

HaynesBE said...

Thanks for the link...and great expansion on this very important topic.
I had no idea they actually referred to what they are attempting as a "medical commons." I have thought about how this is exactly what is happening, even in the way it is discussed. Health care resources are thought of as "national"--and this turning them into a commons brings with it all of the well known tragedies which accompany a commons of any significant size.

I have added links to 3 of your related posts an an update on my blog.

Thank you for alerting me to your excellent writing.
Beth Haynes MD
www.TheBlackRibbonProject.org