I did not go to medical school to practice population medicine but maybe medical students do now

First do no harm,primum non nocere and do what what is right for the patient.Those were the core principles taught to me and my medical school classmates. In the more formal language of ethics, the driving principles were non-maleficence and beneficence.

Those were pillars of medical ethics and of the medical culture.

However, in recent years we have seen a major effort ,with varying degree of success, by prominent medical organizations and foundations  to change medical ethics and the culture of medicine.This is not just my interpretation of recent trends but direct quotes from leaders of several medical organizations say that is exactly what they wish to do.

While a number of organizations including foundations and think tanks have taken part in this effort my focus  in this commentary  is on two such organization-the American College of Physician (ACP) and the American Board of Internal Medicine (ABIM) and its affiliated foundation the ABIMF.

Basically the proposed change is the shift from the medicine of the individual wherein the physician acts in the interest of the patient ,that is  as his fiduciary agent to the concern for the health of the population or the collective which is referred to by its advocates in the less emotionally charged term "population medicine".

ABIM and ACP have orchestrated  two major initiatives; the Physician's charter and the Choosing Wisely Campaign.  the later of which I believe which functions as a Trogen horse.


The 2002 publication of Medical Professionalism in the New Millennium: A Physician Charter played a major role in the movement toward the practice of population medicine .It was the result of a collaboration of the ABIM Foundation,the ACP Foundation and the European Federation of Internal Medicine. The Charter described three fundamental principle of medical professionalism.
 Principle of primacy of patient welfare.
Principle of patient autonomy
Principle of social justice. Physicians must promote social justice in the health care system, including the fair distribution of health care resources.

Although the Charter said " physicians must reaffirm their active dedication to the principle of professionalism.".The third principle,social justice, had not been a feature of traditional medical ethics so it could hardly be reaffirmed. The authors gratuitously added a new principle to medical ethics and then in their concluding remarks pretend that physician must reaffirm a principle not previously part medical ethics .

The Charter also presented a "set of Professional Responsibilites", one of which was:
 

"Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources."

 Further in the same section of the paper physician are admonished to work to "minimize overuse of health care resources"

So under the rubric of " social justice" the authors instruct physicians  to provided health care that is wise,cost-effective and fair.The Charter was silent,however, in regard to how would the practicing make operation the principle of social justice . Later ACP and ABIMF would give instructions in that regard. Spoiler alert-it relates to following guidelines based on cost effectiveness criteria.


Since the Charter was proposing a sea change in medical ethics,voices were raised in opposition.
A particularly articulate critique was made by Dr. Richard Fogoros, who was blogging under the name DrRich  on the blog  The Covert Ratoning Blog . Quoting from his January 18,2010 blog commentary:

"The New Medical Ethics,...(Annals of Internal Medicine, February 5, 2002, vol. 136, pages 243-246), is deficient in the following ways:

• it undermines the foundation of the doctor-patient relationship,
• it threatens to fundamentally destroy medicine as a legitimate profession, and
• it places patients at grave personal risk whenever they encounter the healthcare system"

  Acceptance of the Charter by scores of other medical professional organization.

The second major initiative to change the medical culture began as what seemed to be a very reasonable and non controversial  suggestion. Physicians and their patients were encouraged to have a dialogue and discuss various tests and treatments as they applied to a given patient in regard to the elimination or at least reduction in the number that were thought to be unnecessary,possibly dangerous and costly. This initiative is known as the choosing wisely campaingn.

This quote for Wikiipedia summarizes the relationship between the Charter and Choosing Wisely :


...The charter states that physicians have a responsibility to promote health equity when some health resources are scarce.^[1] As a practical way of achieving distributive justice, in 2010 physician Howard Brody recommended that medical specialty societies, being stewards of a field, ought to publish a list of five things which they would like changed in their field and publicize it to their members.^[1][17][18] In 2011, the National Physicians Alliance tested a project in which it organized the creation of some "top 5 lists".^[1][19][20] Analysis of the National Physician's Alliance project predicted that the health field could save more than US$5 billion by cutting waste.<sup>[1][19][21]"


So the basic principles are : physicians are stewards of medical resources and that they need to work for health equity and that by cutting waste and saving money distributive justice would be furthered.</sup> 

Dr,Cassel in an August 2012 talk about Choosing wisely at Universality of California recalled that the CW program really begin a year earlier when she and others, including Dr. Berwick and leaders of  the not for profit publication Consumer rRports met.

Consumer Reports,though purportedly non political  supported Obamacare and the presidential appointment of Dr. Don Berwick to lead CMS.

Population Medicine as a form of utilitarianism based on on some nebulous impossible to quantify notion of utility or happiness based on the purportedly objective measure of QALY.

I did not go to medical school to work to maximize or optimize the overall health of some population  based on some metric and some ultimately subjective value judgment of a planner but times have changed and my generation of physicians is retiring and dying off.The dogs barked and the caravan moved on.