Saturday, May 31, 2014

Wanted: Men of System to manage the Population Medicine Approach and maximize society's health


 Let's begin with explaining Men of System and Population Medicine Approach (PMA)

 Adam Smith , in his first book, The Theory of Moral Sentiments spoke of the "man of system"

"The man of system, on the contrary, is apt to be very wise in his own conceit; and is often so enamoured 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, altogether different from that which the legislature might chuse [sic] to impress upon it. "

  Dr. Harold C. Sox, , former President of the American College of Physicians (ACP) and former editor of the Journal of that organization, The Annals of Internal Medicine  explains and seemingly recommends the PMA in a commentary in JAMA (November 33,2013) entitled 'Resolving the Tension Between Population Health and Individual  Health Care ".

In this formulation  it is claimed that  one treats the population much as a physician would treat an individual patient.One uses the same "value metric" and the same few decision making principles. For example one would screen a given patient only if that would maximize that person's welfare and similarly in considering applying  a screening procedure to a group would involve screening only those who would gain QALYs. Cox admits we don't really have all that information yet but "the challenge would be to develop models of the principal high stakes decisions of clinical medicine, perhaps starting by identifying these decisions and developing the evidence to inform them"We would need to determine the frequency,causes and consequences of the common medical conditions in a population and devise strategies for dealing with them over the life span.  The public health system and the health care system  and community leaders need to plan together.

Then resources could be allocated between disease-specific programs so that they would be moved from groups of patients less likely to benefit to groups more likely to benefit.

Sox  then seems to admit there may be some growing pains with this approach but in the long run there will be benefit,. That is my paraphrasing now a quote :

"It will take several generations to realize the full benefit of investments in disease prevention. In the short run, these investments may draw resources away from tests and treatment for some sick people. In the long run,disease prevention and better low cost technology could reduce the outlay for treatment. In the interim, skillful clinical decision making can make the most of limited resources. 


To make the population medicine approach operational it would be necessary for physicians to consider themselves practitioners of population medicine and support a system that "fairly allocates resources between the healthy many and sick few:" The Charter for Professionalism paves the way for that by admonishing physicians that they are the stewards of medical resources and that cost effectiveness is the new polar star.As long as physicians considered themselves to be fiduciary agents of their individual patients the scheme would not work. The publication of "Medical Professionalism in the New Millennium:A Physician charter" in 2202 was an important step in the movement to further the dogma of medical collectivism..

To achieve this medical  utopia the Men of System of whom Adam Smith wrote will be required ; some one will be needed to move the different  members of society around the chess board of utilitarian health care with its fair and cost effective allocation of health care resources. And while only a few physicians can be the Platonic Guardians ,some of whom will likely expend their energies on IPAB, the rank and file docs can work for the common good by adhering to guidelines. 


addendum: Minor grammar and spelling corrections made 7/31/14

No comments: