Tuesday, April 29, 2014

Is the "social justice" of ABIMF and ACP what John Rawls had in mind?

The stated reason for the existence of the American Board of Internal Medicine Foundation (ABIMF) is to further medical professionalism.,the three principles of which are patient welfare,patient autonomy and social justice. By social justice they seem to mean the " just and cost effective distribution of finite [medical] resources ".

The Choosing Wisely campaign is promulgated by ABIMF and in its original version was an seemingly innocent and well intentioned suggestion that physicians and patients have a frank discussion about medical procedures and treatments to the end of trying to minimize those that might be wasteful and/or harmful. Of course,everyone want to do away with waste and harm.but it is morphing into something much more than that. Suggestions are being made and gaining momentum that lists should be made of those procedures and treatments that are "low value" which will be defined as falling below some threshold of quality adjusted life years (QALY) per amount of money. A figure  of  $150,000 per QALY is being proposed.Further, there are suggestions that CMS enforce the dictates of the Choosing Wisely campaign.

Note-if it is "determined" that something's value is  "low" i.e  if less than some dollar amount per QALY then physicians should not recommend that procedure and third party payers might just not cover it. So patients dependent on third party payers to obtain  that procedure would not receive it while more affluent folks who  are free to pay for their own treatments would be able to obtain this so called  low value procedures.

Social justice is a slippery term and its ambiguity may serve promotion of a given social movement  but it is generally recognized to be redistributive justice.Rawls said that redistribution would be acceptable only if the most disadvantaged members of society would benefit.

If the plan to suggest that "low value" treatment should not be done, then no one should receive it , at least in theory. But in practice it may well mean that those who cannot afford to pay for it on their own would not receive it, and such a group certainly would include the most disadvantaged members of society. Not a very Rawlian outcome.

Further, Rawls did not support decisions made on utilitarian grounds. The cost effectiveness analysis of the QALY calculus is clearly based on the dictum greatest good for the greatest number. Rawls believed that this approach did not support the autonomy,the individual rights and dignity of the individual.

Dr. Christine Cassel and Dr. Virginia Hood,both leaders of  the American College of Physicians spoke of "parsimonious care". Social justice a la Rawls would champion more care for the most disadvantaged .Parsimonious care is less care for everyone in theory but in practice the affluent may get it anyway. so who gains from that? Third party payers comes to mind.The ACP and ABIMF and others are going on a full court press to convince physicians that they are population doctors and to conserve resources they should follow guidelines. This will achieve the re-defined, non-Rawlian , social  justice imperative that they have said is required of physicians .Adherence to guidelines it is argued will improve the health of the collective though some individuals will suffer but the bottom line of the third party payers and ACOs will not suffer  and the medical elite mandarins will also do well.

Minor spelling,grammar and punctuation changes made on 7/11/14.

Thursday, April 17, 2014

Another chapter in the never endling clash between the collective and the individual regarding health care

The following comments were inspired by this insightful and very well written commentary by Margarit Gur-Arie entitled "Is the Nuremberg Code Obsolete?" After reading about where the cronies at IOM and the ideologues at Hasting Institute want to take us, I have to shout "It sure as hell better not be obsolete and do you people even know anything about the events that took place in Europe (or Macon county,Alabama for that matter)  in the 20th century and why we have the Code in the first place."

One of the more troubling developments in recent years in medical care is the seemingly increasing acceptance of the notion of the importance of the health of the collective even if sometimes to the determent of the welfare of the individual and that the latter seem to exist for the welfare of the former.

One of the latest twists here is that some are arguing that certain types of clinical research can be done without getting consent of the participants or even informing them about what it going on.

Quoting Gur-Arie:

" The Office for Human Research Protections (OHRP) held a public hearing in August 2013 regarding the nature of informed consent for randomized clinical trials...., two very distinct opinions regarding consent emerge from reading the various testimonies before the committee. The traditional opinion argues that there is a difference between treatment and research and that informed consent is required for both, including study of “standard care” interventions, CER and QI; that randomization always deprives research subjects of the judgment of their physician and that these issues are governed by law (e.g. the Constitution and such). The progressive view, presented by testimony from members of the Institute of Medicine (IOM), its Clinical Effectiveness Research Innovation Collaborative (CERIC), NIH and other research establishments, posits that randomization of “standard care” interventions poses no additional risks to patients, since doctors’ decisions are essentially like flipping a coin anyway, and therefore patients in this new learning system may be subjected to randomized CER and QI experiments without explicit consent and with minimal, if any, information (e.g. “something posted on the door”)."

 Related is this Hasting Center  report which speaks of   (with my bolding):

"The obligation of patients to contribute to the common
purpose of improving the quality and value of clinical care
and the health care system.
Traditional codes, declarations,
and government reports in research ethics and clinical ethics
have never emphasized obligations of patients to contribute
to knowledge as research subjects. These traditional presumptions
 need to change. Just as health professionals and
organizations have an obligation to learn, patients have an
obligation to contribute to, participate in, and otherwise facilitate learning.
This obligation is justified by what we call a norm of
common purpose. This norm of common purpose is similar
to what John Rawls calls the principle of the common good."

Wow, here is a group composed mainly of several ethicists from Johns Hopkins who presume to define an obligation for everyone and redefine the ethics of medical research, a goal they openly admit to in the first paragraph of their report.Everyone has an obligation to work for the common purpose of better health care.

Once all the health care providers and all the patients work together to participate in and gather the data about various medical tests and treatments the very smart people will be able to analyze it all and determine what is best for the collective. Utopian health care is within the reach of the  very smart people with ideas.

Thursday, April 10, 2014

More internists are failing the MOC exam-why could that be? Resistance to ABIM's MOC grows.

Why are more internists failing the Maintenance of Certification (MOC) exam? Kevin Pho on his medical blog offers two suggestions. See here. One reason is what I call the economically driven bifurcation of internists into hospitalists and officists and the disuse atrophy of hospital care skills in the office bound docs and the lack of familiarity with the preventive care changes and routine treatment of non acutely ill patients on the part of the hospitalists. If you don't treat respiratory failure,sepsis and acute heart failure on a regular basis you might just not do as well on the boards. The second reason Pho suggested is that the hassle factor in office care is now so high , with insurance,computer,and quality measures documentation  ever increasing that the fire in the belly to try and keep up with everything may be burning too low to try and keep current on conditions  you no longer are called upon to manage.

The suggestion that there should be one test for the hospital based internist and another for the officist has some merit but what about the dwelling number of dinosaurs who still try to do both. Of course that group is rapidly dying out.

And the more I read and hear about the absurd hoops internists are expected to jump through to try and satisfy the ever onerous non-test aspects of the ABPM's MOC process, the happier I am that I retired.See here for a great presentation of the clown-designed MOC program authored by the leadership at the American Board of Internal Medicine (ABIM).

I am pleased to see that there is at least some organized,as well as much unorganized, effort to resist or maybe even boycott the latest MOC affront imposed by the well paid folks at ABIM. See here and here. Further, mega kudos to Dr. Paul M. Kempen for his efforts to resist the MOC movement. Read what he has to say here. See here for Dr. Wes Fisher's comments re the big business that testing physicians has turned into.

Also of interest are the questions posed by Dr. Marc S. Frager to Dr. Richard J. Baron as well as Dr. Barron's reply.See here.

If you want to sign a petition to urge the ABIM to rescind their latest edicts regarding MOC ,go here

It is easy to find much anger and indignation directed towards the ABIM and recent revelations about possible conflicts of interests regarding its leadership has fanned the flames even more.