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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Monday, October 11, 2010

More welcome light shined on the problems with the"New Professionalism"

Kudos to Doug Peredina over at the blog roadtohellth with this commentary on medical nannies,the activities of CVS Caremark alone those lines and the broader topic of the problems with the new medical professionalism, also known as the "new ethics", a topic of considerable concern to me and one about which I have ranted repeatedly.See here and here.

Dr. Peredina discusses a lawsuit filed against CVS . Dr. Troyen Brennan is the CMO and executive vice-president of CVS Caremark. The following is a quote from the book "New Rules" which was written by Dr. Brennan and the current head of CMS Dr. Donald Berwick. They are discussing the physician patient relationship and say the following:

"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.”

In 2007,Dr. Brennan,then the executive vice president of Aetna cowrote an article in JAMA entitled "Managing Medical Resources. A return to the medical commons" which I blogged about ( see here) and I said in part:

"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."

With this increasing constraint of decentralized individualized decision ( translation-individual docs advising individual patients about a course of action) someone else must make those decisions. Do you think the folks at insurance companies and pharmacy management companies might enjoy that role? Isn't it interesting that the head of CMS and the vice-president of a pharmacy management company share the same view of the "proper"role of the physician?

Also kudos to DrRich at his blog Covert Rationing Blog with this thoughtful and important criticism of the new medical ethics, in which the traditional physician patient relationship with its fiduciary duty of the physician is being replaced with a nebulous duty to society . Also DrRich-in his real life persona of Dr. Richard Fogoros- hosted a discussion on Sermo which from my vantage point was well received and he did an admirable job in fielding a variety of questions. It is instructive and worrisome that a number of the physicians writing in had not even heard about the New Professionalism. If you have not, go here to read about it in the original.

Also kudos to Dr. Beth Haynes at the blog Blackribbonproject for this entry concerning various aspects of the attack on the traditional physician-patient relationship.

This important topic deserves all the attention it can get.


Doug Perednia, MD said...

Dr. Gaulte,

Thank you very much for your positive comments, but I must point out that you're a far better reporter than I am. I had no idea that Dr. Brennan is the CMO and EVP of CVS/Caremark, and had not tied this at all to his association with Dr. Berwick, who is now running CMS. This has some rather profound implications for the integrity of those pushing the "new medical ethics". Since the CVS/Caremark "healthcare nanny" program is clearly a medical intervention, it seems inconceivable that Dr. Brennan was unaware of its use of data which should have been protected and privileged information. He also could, should or ought to have been aware of the anti-competitive nature of CVS' healthcare nanny campaign. The implications are astonishing. This gentleman is insisting that 3rd parties have a place in the physician-patient relationship, only to immediately abuse that seat for private commercial purposes at the first opportunity.

Why shouldn't we now assume that the government, corporations or any 3rd party won't abuse their seat in the exam room at EVERY opportunity?

You can't make this stuff up. Thanks for putting 2 and 2 together!

HaynesBE said...

Thank you for continuing to write on this very important topic--and congrats on your publication at KevinMD.
Thanks also for the recognition--although the link appears to be broken.
Beth Haynes

Andrew_M_Garland said...

Mike:  What treatment will I have?

Assigned Doctor:  There is no need to bother you with the details. Rest assured that it balances your needs against those of Society and the limited resources available.

james gaulte said...

Dr. Haynes-thanks for the comment.sorry about the link I think I may have fixed it now.

Anonymous said...

Perhaps much of this is relevant and timely. However, the 500 pound gorilla that remains lurking over the head of every physician is an unrestrained tort system. Use of centralized decision-making does not guarantee universally positive outcomes. Without centralized protection from individual professional liability, physicians will never take these "new medical ethics" very seriously.

james gaulte said...

Anonymous 8:42 You are right. A jury in a malpractice case may well not be convinced by some save money on your wife to benefit the ACO argument.Even less likely is that argument going to convince the patient's husband.

James Gaulte

Anonymous said...

And the same Dr. Brennan was a committee member on the recent (Oct 5th)IOM report calling for the expansion of independent nurse practitioners. Here is a link to that report: