Wednesday, August 06, 2014

The crusade to change medical ethics,custom and practice gains momentum

The mega-thought leaders,the established leadership of some of the major,influential professional medical organizations, and an alarming numbers of fellow travelers are on a quest to change the thinking of the worker-bee physicians,and the general public (who are either now patients or potential patients) from the long established model of the physician as an advocate and fiduciary to the patient to one in which the physician is a steward  of "scarce medical resources" which are characterized as being owned by society.But the physicians who are tricked into acting in that way are not preserving "society's resources" but rather they are boosting the bottom line of some vertically integrated health care entity.

Early explorations  and exhortations of this theme in the major medical literature are exemplified by one article in the Annals of Internal Medicine and a series of articles in the Journal of the American Medical Association (JAMA).I chose these articles because the authors were quite explicit about their recommendations.

A series of articles was published in 1995 in JAMA authored by Dr. David Eddy that discussed the metrics and merits of decision analysis which he hailed to be a mechanism to increase the quality of medical care while reducing costs. Eddy defined quality as the greatest medical good for the greatest number within the eco-medical collective (aka HMO now this might be an ACO) It did not go unnoticed to the skeptical reader that Dr. Eddy listed his affiliation as "Kaiser Permanente of Southern California")

In 1998 M.A. Hall,a law professor, and Dr. Robert A. Berenson writing in the Annals of Internal Medicine said that "the traditional ideal" [the prime duty to the patient ] was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians."
"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 and Hall  justified this  ethical sea change because the role that insurance contracts would  define for the physicians.Medical ethics must change to accommodate the bottom line of the third party payers.If traditional ethics were in the way,just change the ethics and that is exactly what the ACP and the ABIMF are attempting to do.Never mind that for the most part one of the characteristics of a profession is that it and not a third party defines its ethics.They seemed to either rewrite the definition of a profession or declare that the practice of medicine was not really a profession at all.

 Dr.Berenson Joined HCFA in 1998.His biography found at the ECRI website indicates that from 1987 to 1997 he was a Vice President at the Lewin Group.Lewin is part of Ingenix which is owned by United Health Care Group.Ingenix changed its name to Optuminsight in early 2011.(See here for details.)He is a fellow at the Urban Institute and in  2010 he became vice of  the Medicare Payment Advisory Commission (MEDPAC)

 In a recent NEJM roundtable, Dr. Atul Gawande, summed it up with this reference to "a new culture in practicing medicine"  in which physicians will "prioritize our responsibilities as shepherds of scare social resources  to the same extent that we've historically prioritized our responsibilities for providing benefits to our specific patients"  This, or course, is nothing new. The American Board of Internal Medicine Foundation (ABIMF) and the ACP has been promoting this notion of  physicians as stewards of resources as part of the new Medical Professionalism which debuted in prime time in 2002 in a well funded campaign. ABIMF received some $ 13 million from the ABIM  which apparently represented receipts well in excess of costs of the various testing programs ABIM administers to internists. Another $ 5 million was in the form of a grant from the Robert Wood Johnson Foundation,

 The Choosing Wisely campaign is well funded and is in part funded ironically by thousands of internists who sent off their checks to take a certification exam not to support a political, philosophical campaign  whose mission appears to be to usher in the medicine of the collective.

It gets ever worse.Consider the following comments of Dr. John Benson Jr,former CEO of ABIM and ABIMF: (my underlining)

" 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."

If a candidate does not learn the Choosing Wisely catechism or some other subjective view of what is and is not high value to the letter she would not even be "allowed" to take the certification exam. 

 You have to wonder  how the typical patient would  feel if he knew that his physician  was devoted to the best interests of some statistical aggregate, perhaps those who found themselves in some or other ACA or HMO or being treated in some large hospital system.It is not clear to me how many physicians have adopted that perverse devotion but it is clear that the caravan of the medical progressives is expending much effort and money to that end and I am afraid while some dogs  are barking objections the caravan will move on.

I still remember the elation and pride that I had when I learned I has passed the Internal Medicine examination ( I became board certified so long ago there was still a written and a oral exam). Now as I look at the efforts of the ACP and the ABIM to destroy the traditional medical ethics of devotion to the patient, pride is not the emotion I feel.

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