Saturday, November 12, 2011

Physicians have group data but treat individual patient-

Physicians are informed by studies which examine group data but deal with individual patients. How to apply the group data in clinical setting is not as easy as it might appear at first glance.
I blogged about this general topic several years ago.See here.

The term "Heterogeneity of treatment effects" (HET) is the translation into the jargon of the statistician of the basic fact that everyone does not respond the same to a particular treatment. Can the patient in the doctor's office be assumed to have the average response to a given treatment reported in a medical journal article? In a given group treated with a certain medication some subjects will fare better than average along some parameter of interest while others respond not at all and some in either group may have adverse effects,some serious some minor.You cannot expect every patient receiving a given treatment to do well let alone better than average which only occurs in the statistically impossible world of the children highlighted by Garrison Keillor.

RL Kravitz,N Duran and J Braslow authored the classic article on the issue of HET. See here for full text of the article which should be part of every medical student's education.

Dr. Michel Accad in his Blog Alert and Oriented discusses a recent paper that offers suggestions for ways to tame the problem of HET. The suggestions are aimed as those who carry out the clinical trials . See here for Accad's discussion entitled "Dealing with variable risk" and see here for a link to the full text of the article by Kent et al that he references.

Friday, November 04, 2011

Is retainer medicine unethical?

Drs Thomas S. Huddle and Robert M. Centor answer that question with a well reasoned and emphatic "no". Surprising to me was that their commentary appeared in a prominent medical journal,Annals of Internal Medicine, that generally has been the site of a number of commentaries and articles promoting the notion of social justice and inserting into the basket of medical ethical principles the obligation of the physician to promote social justice. The "New Medical Professionalism " was introduced to U.S. medical audiences in the Annals.See here for abstract of the Huddle-Centor article.

A dual premise criticism of the retainer practice model is that is damages the furtherence of social justice as it applies to health care and that physicians have a ethical obligation to act to further social justice. Social justice is a usefully elastic concept and reasonable people may differ as to what it means in a given situation . It is also a key arrow in the quiver of those who favor a progressive and re-distributional agenda. It was inserted into the area of medical ethics by the New Professionalism by a small group of energetic and prolific medical "thought leaders" whose views may or may not be representative of the group whose thoughts they were leading.Nevertheless , many professional organizations accepted the package deal giving at least lip service to the notion and in my opinion without fulling vetted the concept or thinking through the consequences.To convince many medical professional organizations that to be "professional" a physician had to work for social justice was a very significant propaganda accomplishment.

Huddle and Centor cut to the chase with this:

..we should not assume that the pursuit of social justice is an integral aspect of physician identity,despite numerous assertions to that effect.We contend that social justice is a civic virtue that makes its claims upon physician as citizens.If we are obligated to further health care access for every member of society,we have that obligation as members of society,not as physicians.Promoting nonprofessional virtues or ethical imperatives is not the province of professional ethics.

Yes and amen. The authors of the New Professionalism did simplify assert that medical professionalism should include the obligation of the physician to strive for social justice.

Three years ago I wrote about the issue of social justice and retainer practice and framing the debate.See here. Once the nose of social justice was in the ethics tent we could expect that it would be used to rhetorically justify a given agenda or criticize opposition to it.It seems that some critics of retainer medicine are proposing banning the practice as they allege it decreases access to health care and is socially unjust. Well, a little coercion and restriction of individual freedom in name of social justice is occasionally necessary.

Previously I have suggested that the new professionalism project was a way,and increasingly it seems a successful way to high jack medical ethics for a social agenda.See here.