Monday, October 24, 2011

The new PSA screening recommendation is not just a recommendation

What has mostly been neglected by the press in reporting the latest pronouncement of the USPSTF is that their conclusion that PSA measurements should not be done to screen men for prostate cancer is much more than a recommendation. Before the passage of ACA  it was merely a recommendation  but now the rules of the game have changed.

Dr. Rich at The Covert Rationing Blog  gives us his excellent analysis of the the panel's recommendations and the data they emphasized as well as the data they underplayed.Here is a quote from that commentary that explains why what the panel at the Task Force says really matters.


Obamacare, which is now the law of the land, makes the USPSTF the final arbiter of which preventive services are to be covered by private insurers (Section 2713), by Medicare (Section 4105), and by Medicaid (Section 4106). Only those that have achieved a grade of A or B by the USPSTF will be covered. And if you believe you will be able to purchase for yourself PSA screening (or any other medical service which Obamacare has decided not to cover) you have not been paying attention. Perhaps you can do so today (if you’re not on Medicare or Medicaid), but probably not for long.

  So CMS (Medicare and Medicaid ) will not pay for the tests.How long will it take private insurers to follow suit?The question remains can you pay for the test yourself.It is not clear that you cannot but I share Dr.Rick's concern  that prohibiting private choices paid for with private money for health care issue may become illegal.

Cato has recently published their report on economic freedom.  Freedom fans will not be pleased with the falling economic freedom indicators in the U.S. noted in their report. Health care freedom is incompatible with the vision that medical progressives have for the U.S.,namely that medical care is too important to be left in the control of individual physicians and individual patients. From the perspective of the progressives, Obamacare is a great step forward and has been heralded by certain medical organizations as promoting social justice while loss of  individual freedom to make one's health care choices seems to be part of the price of that "justice".

Friday, October 21, 2011

Two great blog commentaries on "Diagnostic skepticism" and why we are seeing less of that?

Dr. RW Donnell in this blog commentary  outlines some of the factors that are impeding  the diagnostic skepticism that traditionally internists had drummed into their heads during their training period.  Dr. Donnell carried forward and expanded comments made by Dr. Robert Centor in his recent blog offering.

Guidelines,the worse aspects of EMRs,time pressures and the metrics by which hospitalists are too often graded are some of the factors that make it more difficult than it used to be to  ask  "what else could the diagnosis be".


Tuesday, October 18, 2011

Have we seen the last of the CLASS act fraud?

The CLASS Act was a long term care plan appended to Obamacare to give the impression that the total cost would be less than one trillion dollars,which was a slight psychological barrier to its passage.It was a spending program that magically would reduce the defect.It was purported to contribute some 80 billion to the projected health care savings that the Obama health care plan would bring about.

See here for the economist Alex Tabarrok's commentary on this fraud that contributed to the passage of Obamacare. Now, the Secretary of HHS has admitted the plan can't work and will be dropped,but even later breaking news is that the White House hints maybe not yet.


Friday, October 14, 2011

Thomas Szasz's "define or be defined" and Physicians morphed in to health care providers

The husband and wife physician writing team of J. Groopman and P. Harztband make strong points in their commentary found in the Perspective section of the October 13,2011 issue of the NEJM. The title is The New Language of Medicine.

They relate certain changes in language related to health care to the movement to industrialize and standardize health care. These changes include the word "consumer" or "customer" for "patient" and lumping doctors,nurses,PAs,and NPs together under the designation of "health care provider".

The relationship and interaction between physician and patient fades out and is minimized by referring to the generic "health care", as if is in the words of the authors " fundamentally a prepacked commodity on a shelf that is "provided" to the "consumer".

What happens to considerations about the physician-patient relationship when you speak about providers and consumers.

Thomas Szasz wrote brilliantly about the power of language.

"The struggle for definition is veritably the struggle for life itself. In the typical Western two men fight desperately for the possession of a gun that has been thrown to the ground: whoever reaches the weapon first shoots and lives; his adversary is shot and dies. In ordinary life, the struggle is not for guns but for words; whoever first defines the situation is the victor; his adversary, the victim. For example, in the family, husband and wife, mother and child do not get along; who defines whom as troublesome or mentally sick?...[the one] who first seizes the word imposes reality on the other; [the one] who defines thus dominates and lives; and [the one] who is defined is subjugated and may be killed."

In short, define or be defined. There was a time not long ago when physicians in many ways defined their role.Their role was to act as a fiduciary to their patients,to do no harm and act in the interest of their patient.Now their role is being redefined as in part acting as stewards of resources.Yes, it has been members of the medical profession,largely a small group of internists, who have helped considerably in this effort to redefined medical ethics and have been able to implant those views in the medical school and post graduate curriculum. While I would not impugn the motives and sincerity of those physicians who have promoted that view and value system,I cannot resist applying the venerable Mafia Rule. Follow the money.Who gains from transforming physicians into health care providers and tasking them with saving money for the health care collective?

Their commentary closes with:

"We believe doctors and nurses,and others engaged in care should eschew the use of such terms (consumer,health care provider)that demean patients and professional alike and dangerous neglect the essence of medicine."

Amen.

Monday, October 10, 2011

Obamacare-A great opportunity for Medical Hubris

In 2005, I outlined a few thoughts about what I would include in a lecture to medical students about hubris and the practice of medicine. See here. At the time, I had no idea about the surge of exuberant hubris that the next few years would bring although I should have because of the strikingly hubristic five part series in JAMA which was a plea for utilitarian planning for allocation of health care resources.

Hubris is defined as excessive pride or self confidence.From Wikipedia we read that the word implies an overestimation of one's own competence and capabilities particularly as exhibited by someone in a position of power. In Greek tragedy it leads to nemesis, or the end result of harm or ruin. However,in the context of public health expert advice and edicts, it seems to be the beneficiaries of the edits that run into harm's way and not the expert.

Several thinkers have issued warnings to those who would take portions of the scientific wisdom of the day and go forward with hypertrophied self confidence and idealistic certitude to make the world (or their little sector of interest) better.

Boris Pasternak said; " What is laid down, ordered, factual is never enough to embrace the whole truth.Life always spills over the rip of every cup." The medical elite in the public health sector who would tell everyone how to eat, or treat all folks with a given medical condition think "Well, not my cup" and charge ahead as if the concept of unintended consequences had never been formulated and that individual variation , personal circumstances and values would not have to be contended with and progress in medical knowledge would be frozen in time so as to not make necessary changes in their determinations.

Morton Hadler ( J.O.M.,Vol 31, pg 823,1989) spoke of various categories of truth including the distinction between scientific truth and clinical truth,the latter informed in part by the former and is determined by the joint efforts of the physician and the patient.

Karl Popper said "We know a great deal but our ignorance is sobering and boundless.All things are insecure and in a state of flux."

Ian Stewart and Jack Cohen in their book "Figments of Reality" spoke of "what science offers is not facts but understanding, not answers but contingency plans"

Those type comments could be considered life advice to the newly minted practitioners of various discipline, and in particular, in this commentary to medical doctors.

The type of hubris often seen in novices is typically what I am calling the more benign form and is often cured by experience and seeing highly regarding paradigms and treatment plans replaced by others often 180 degrees from the discarded notion.This is what I call Type 1 hubris. It is an unwarranted and persistent belief in the correctness and permanence of contemporary consensus views.It is a failure to realize they are working with concepts that are often more contingency plans than permanent solutions.This type of hubris often dissipates as the practitioner gains more experience and sees the various ways disease patterns play out and how patient's disease scripts differ from the text book. Aristotle spoke of phronesis or practical wisdom which is the result of combining the lessons of experience with empirical knowledge (episteme) and technical knowledge (teche).

However, there is a second type of hubris, a more dangerous form, logically named Type 2. Type 2 includes the over blown pride and hypertrophied confidence in one's beliefs and idealistic certitude as is found Type 1 but in addition includes the internalized imperative to to bring about widespread practice (s) consistent with their version of current medical wisdom or truth. Starkly put" I'm know what should be done,everyone should do it " and when someone with Type 2 hubris is in a position of power ",let's make them do it".

The five part series of articles published in JAMA in 1994 by David Eddy is , in my opinion,a candidate for the most hubristic series ever published in a major medical journal.Reference is "Rationing Resources while Improving Quality", Eddy, DM, JAMA,1994:272,817-824)

Eddy's answer to the problem of how to save resources while improving quality was to employ the utilitarian maxim/imperative strategy to do the greatest good for the greatest number or make the herd healthier along some metric even though some cows might be worse off.The herd here was a medical collective such as a HMO.This also applies to the ACOs put into play by Obamacare to the extent those entities based as they are on an Underware Gnome type plan will survive .

Dr. Don Berwick speaks of the need for "leaders with ideas" and the need to replace the physician-patient "dyad" with a group outcome oriented decision process authored by the wise leaders with ideas. ( You have to worry when someone talks about "dyads"). Those views conform with the Progressive Medical Axiom of " medicine is too complex and too important to be be left in the hands of the individual physicians and patients."

For most physicians, the Type 1 hubris wears off or withers away after the realities of a few years of clinical experience bump up against the overly simplistic concepts of the novice. Type 2 is what we need to worry about and to fear those leaders in positions of authority (or advisers to those in power) who never caught on to the Hayekian notion of "how little men know about what they imagine they can design..." But no matter, being a public health expert or a medical planner means you have never say you are sorry.

With Obamacare and IPAB's unprecedented powers as well as CMS's control over Medicare,there are great opportunities for leaders with ideas and the requisite amount of hubris to do unprecedented damage to the practice of medicine.


Minor syntactic,spelling and punctuation change made 8/18/14.