Friday, March 21, 2014

Adam Smith's Men of Systems and the progressive medical elite

Adam smith spoke of the men of system- men with a dangerous mixture of hubris and naivete  who presumed to know what is best for every one  and how to plan to bring that optimal state into being.

The following commentary highlights the views of some physicians who might be considered the medical men of system.

The following quote from Drs Don Berwick and Troyen Brennan in their appropriately named book, "New Rules" captures the essence of the fundamental nature of how men of system would arrange medical care.
 
"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

 

Dr. Robert Berenson strikes a  seemingly different but clearly related note in a commentary in the Annals of Internal Medicine , 1998,pg 395--402.  in which he promotes the health of the collective rather than the individual patient :

"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."

Berenson recommends a replacement of the fiduciary duty of the physician to the patient with a duty to a group while Berwick and Brennan talk about dissolution of the physician patient relationship and moving the locus of medical decision making  away from the physician and his patient to a reliance of authoritarian rules.

More recently Berenson has this to say:

 "we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now"

A series of articles in JAMA in 1994 (Rationing Resources while improving Quality) by Dr. David Eddy also recommended a utilitarian type medical care structure in which funds would be  spent on medical tests and treatments that were most likely to benefit some majority subset so that in the aggregate there would allegedly be a greater good for the greatest number.

Dr. John Benson is the former CEO of ABIM and ABIMF and had this to say recently on the ABIMF's website:

"  ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

So, for candidates for certification or the ABIM's Maintenance of Certification to even be allowed to take the tests they would have to recite,perfectly, the catechism of the brainchild of ABIMF ,the "Choosing Wisely" guidelines.

This alone, in my opinion,should qualify Dr. Benson for membership,along with the aforementioned doctors,in the Medical Men of System hall of fame.  

The recommendations of Berwick,Brennan,Berenson and Eddy were met by some vocal resistance as least as documented by letters to the editors in JAMA and the Annal of Internal Medicine . These authors were advocating a paradigm shift ,arguing for a 180 degree reversal of traditional medical ethics for which , I believe, physicians at the time were not ready and I hope are not ready now but...

But there is another way to gather support for a sea change in medical ethics and practice behavior,one that will also bring about greater concern for the collective and aggregate outcomes and that will to a large and ever increasing degree move the locus of medical decision making from the individual dyads to a central decider .

This other way is to nudge physicians and later shove them a bit into the acceptance of the notion that physicians have a duty to work for social justice and to act as stewards of the nation"s finite medical resources.To strive for social justice is a political position, one that does not necessarily have any professional links. To declare, or assert gratuitously , as was done the in the  publication known as the Medical Charter that physicians have an obligation to strive for social justice represented a audacious move,one that I am afraid has been at least nominally successful.

To close with a quote from Adam Smith's "Theory of Moral Sentiments" :

"The man of system, on the contrary, is apt to be very wise in his own conceit; and is often so enamored with the supposed beauty of his own ideal plan of government, that he cannot suffer the smallest deviation from any part of it. He goes on to establish it completely and in all its parts, without any regard either to the great interests, or to the strong prejudices which may oppose it. He seems to imagine that he can arrange the different members of a great society with as much ease as the hand arranges the different pieces upon a chess-board. He does not consider that the pieces upon the chess-board have no other principle of motion besides that which the hand impresses upon them; but that, in the great chess-board of human society, every single piece has a principle of motion of its own,"


addendum: Minor editorial changes made 9/12/14


2 comments:

Paul Kempen said...

Hey, Welcome back to the 1940s and Nazi Germany or 50s and US McCarthy era thinking. Then we had governments that wanted to dictate the ability to think and desired to create, manipulate and control society and Medicine in particular. When physicians stop treating to benefit the patients then all ethics are lost.
It is foolish to think the rich and powerful will be unable to still maintain that separate RIGHT to whatever they want-congress still remains separate from Obamacare restrictions. European medicine is available for those with assets to go there.
To comply to ABMS/ABIM corporate programs out of FEAR is extortion nothing less! ABIM/ABMS continues to insist still that Certification is voluntary again emphasizing that maintaining it out of fear is extortion.

Troglodytum Brachiandum said...

My political prejudice is that tyranny and fascism are bad. My Evidence-Based Conclusion is that they do not work for very long.
I tend to like "George Orwell's" line of reasoning; it is my pleasure that he seemed to be right. It has been tried - it does not fall into Best Practices.