Thursday, September 19, 2013

Don Berwick on the NHS ..."unique example for all to learn from and emulate""-after examing the Mid Staffordhire horror show

Here is the entire sentence from which part of this posting's title derives:

"You are stewards of a globally important treasure: the NHS. In its form and mission, guided by the unwavering charter of universal care, accessible to all, and free at the point of service, the NHS is a unique example for all to learn from and emulate."

 That quote is from a letter from Dr. Berwick to officials of the NHS as part of the report from the committee he chaired to investigate the egregious treatment of patients at a NHS hospital,the Mid Staffordshire.

See here for Greg Scandlen comments in a  blog entry entitled "The Real Don Berwick"

In Scandlen's commentary there is a description of the horrible things to which patients were subjected and excerpts from the committee's report.

I cannot resist one other quote, this one from Paul Krugman.

"In Britain, the government itself runs the hospitals and employs the doctors. We've all heard about how that works in practice .Those stories are false."

The following is  from Berwick's  book written with the current Vice president of CVS Caremark (Troyen Brennan)

 "Today, this isolated relationship[ he is speaking of the physician patient 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.

So how did those appropriate rules with authority work out for those victims of the NHS? Was there too much residual "decentralized decision making"

Maybe one lesson to learn from the NHS tragedy is when no one is accountable or responsible, some really terrible things can happen. Berwick's committee did find that no one was really at fault."NHS staff were not to blame".

OK,one more quote, this time John McEnroe's  "you gottta be kidding me"

Another lesson all can learn from the NHS is how incredibly bad their electronic record system worked. See here for a report of what some have called the biggest IH foul up ever.

Tuesday, September 17, 2013

Obamacare-"Law of the Land"except those parts that the administration Postpones or exempts the favored from

As opposition to Obamacare grows even as deadlines loom for its implementation,the dwindling numbers of defenders issue increasingly strident and lame defenses.

Members of the administration as well as Paul Krugman  blatantly proclaim Obamacare is the "law of the Land" and is no longer a political matter. The administration that has done much damage to the rule of law in the way it has selectively enforced, or postponed  or issued exemptions to the law has the audacity now to claim it is the law. As least those parts they it deems to be politically expedient."No longer a political matter"- really, the way it has been arbitrarily administered has been nothing but politics.

The ACP Advocate blog has recently  questioned the ethics of physicians who would refuse to help their patients to sign up for the plan and of those physicians who bring their anti-Obamacare views into the examination room. No, the blog did not say it was unethical but just raised the issue and used the term "borderline unethical".(I wonder if saying they were unethical would be libel per se.Further, the blog writer, Bob Doherty ,ACP's  Executive VP and governmental affairs man in Washington, challenged the claim that Obamacare will damage the physician-patient relationship  with the astonishing counter claim that  Obamacare might actually strengthen the physician-patient relationship.See here for that blog entry and a series of  related commentaries.

 I argue that this relationship is not a function of insurance or its lack  but rather it is based on the patient's belief that the doctor is acting in the best interests of the patient, treating him with respect, respecting his autonomy  and maintaining confidentiality. To the degree that Obamacare encourages physicians to join ACOs there may well be a tendency for the patient's trust to diminish as has been the case in some HMOs if and when the patients sense that the organization's interests  clash with his own and that his physician's income depends of adhering to the policies of the HMO-ACO-vertically integrated health care entity. Does anyone believe that HMOs have strengthened the physician-patient relationship?

I find it interesting that a ACP sponsored blog raises the issue of physician-patient relationship in  in regard to Obamacare.IMO it has been the efforts of ACP,along with  the ABIM foundation, to promulgate the new medical ethics and the "professionalism for the new millennium" that has damaged the physician-patient relationship by sneaking into medical ethics the concept of the physician having a co-duty to the patient and to society to the determent of the traditional physician's fiduciary duty.

ACP proposed ( and now seems to assume it is accomplished) a major change in medical ethics ( adding social justice and physician obligation to conserve "society's resources" ) and then with an apparent straight  face claimed there was really nothing new there at all. See here for a detailed discussion of this disingenuous tactic.

Thursday, September 12, 2013

The new medical ethics and professionalism is good news for the viability of the ACOs

If most physicians believed and acted as if they were the fiduciary agent of their patient ( as was once their primary ethical imperative ) the new highly touted Accountable Care Organizations (ACOs) would be doomed to failure. They may fail anyway because the new ethics is not a sufficient condition for ACO and maybe not be necessary either but it sure won't hurt.

The new ethics has paved the ethical road for bigger medicine -in the form of ACOs and other vertically integrated health care entities..What was needed to be done was to change the role of the physician from steadfast advocate for the patient, which often put him in opposition to the insurance company,to a more compliant worker working with the suits to "conserve society's medical resources" and thereby enhance the bottom line of the organization.

   To accomplish that, long standing  medical ethical principles had to revised. These venerable precepts were welfare of the patient and preservation of patient autonomy. The new ethics architects did not launch a honest frontal attack on primacy of patient welfare but rather sneaked in a new element , namely social justice and added to the concern for the individual patient's welfare a co duty to preserve society's resources.

A facile veneer of ethical sounding verbiage serves to justify a localized, utilitarian statistical approach to clinical decision making in which the aggregate "good" or statistically defined utility-perhaps measured in quality adjusted life years- will trump the utility or good of any given individual patient.

This approach was raised to its most specious,arrogant level by a well known medical economist,Victor Fuchs writing in the New England Journal of Medicine. See here for my previous comment regarding Dr. Fuch's sophistry.

Fuchs tells his readers about a dilemma.

"How can a commitment to cost-effective care ( as physicians have been "committed" to that since the Physician charter and the New Professionalism) be reconciled with a fundamental principle of primacy of patient welfare"

He argues that  if all the physicians in a given health care collective(as in Accountable care Organizations) practice cost effective medicine, the resources saved can be used for the benefit of the defined population which includes the patients of the physician who seemingly may face a conflict. So, if all the physicians act in the same way all patients benefit.

 Here, Fuchs conflates the good of group as indicated by some aggregate number with the good of each individual in a particular situation in which a particular individual may not enjoy the benefit and may actually be harmed. In fact cost effectiveness analysis involves aggregate data. With any outcome in a group some may benefit and  some may be harmed.Years earlier, Dr David Eddy offered the same basic recipe for " increasing quality while decreasing costs" but, unlike Fuchs had the honesty to admit in such an arrangement there would be winners and losers. Fuchs maintains,apparently with a straight face,everyone wins.

The old medical ethics clashed with what is needed from physicians to make the collective a financial success. The medical progressive elite believe they have solved that problem by changing medical ethics .Many in the older generations of physicians do not buy in to the
stewards of society's resources concept but as waves of younger docs hear nothing else from the day they enter med school, the concept of fiduciary duty to the patient will be of fleeting historical interest.Certainly, that will be the case if the activities of the ABIM Foundation with its generous funding from the Robert Wood Johnson Foundation has its way.

If you wonder how big and bigger medicine will affect patient care see this excellent discussion by  Dr.Paul Hsieh.