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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Thursday, March 31, 2016

Population Medicine is faith based - without logic or emperical support

Here are the comments of Apu,owner of the Kwik e Mart after Homer Simpson quite his job there:

"He slept,he stole,he was rude to the customers.Still, there goes the best damned employee a convenience store ever had. "

In a way a free , market based society is something like that. With freedom and capitalism , property rights and rule of law , there are booms and busts, there are demonstrable inequalities  among various parameters,there is information asymmetry, externalities, and apparent market failures. Still it is the best damned economic, social system a country ever had.

The economist and historian,Dierdre McCloskey,put it this way:

"How do I know that my narrative is better than yours?  The experiments of the 20th century told me so.  It would have been hard to know the wisdom of Friedrich Hayek or Milton Friedman or Matt Ridley or Deirdre McCloskey in August of 1914, before the experiments in large government were well begun.  But anyone who after the 20th century still thinks that thoroughgoing socialism, nationalism, imperialism, mobilization, central planning, regulation, zoning, price controls, tax policy, labor unions, business cartels, government spending, intrusive policing, adventurism in foreign policy, faith in entangling religion and politics, or most of the other thoroughgoing 19th-century proposals for governmental action are still neat, harmless ideas for improving our lives is not paying attention."

 The proponents of a population medicine approach have not been paying attention.

The population medicine approach is a faith based movement whose rhetorical support is largely gratuitous assertion and is strikingly lacking in logic and empirical support. It takes a great act of faith to believe that very wise medical leaders will be able to determine what medical conditions should be treated, what  preventive measures should be carried out and how in the "era of limited resources" of which they speak the correct allocations of resources will be made.

Population Health Approach (PHA)or more concisely population medicine is the antithesis of individual medicine which is and has been for centuries the interaction of the individual patient with a physician whose fiduciary duty is to the patient  acting to the best of his ability and judgment in that patient's best interests . It is the medicine of the individual  versus the medicine of the aggregate  or the group..It pits the sanctity of the individual against the alleged aggregate benefit of some group.

It is the tension of Plato and Aristotle.

It is basically the fable story tale saga of the baptist and the bootlegger. the bootlegger being the third party payers. The baptists are various members of the progressive medical elite lobbying for a system in which the elite can decide what is best for the rest of us, this time in terms of medical care.

Let's look at some of content of the sermons .The bootleggers usually leave the rhetoric to the baptists but there may be the occasional exception.See the final paragraph below.

A revealing and amazingly explicit explication  of some of the principles is found in this sermon by one of the preachers of the religion of population medicine.  Dr. Harold Sox expresses the view of the doctrine espoused by the Church of the ACP and ABIMF,( Reference: JAMA November 13,2013 vol 310 number 8).

"Throughout history,codes of professional conduct have called on clinicians to make each patient's interests their highest priority.If resources becomes limited,clinicians will find themselves unable to adhere to that standard of practice for all patients.In 2002a new code of conduct ,the Charter for Professionalism ,addressed this conflict by calling of physicians to consider the needs of all when treating the individual. While meeting the needs of individual patients,physicians are required to provided health care that is based on wise and cost-effective management of limited clinical resources.The provision of unnecessary  services not only exposes patient to avoidable harm and expense but also diminishes the  the resources available to others."

This remarkable passage indicates that the physician has an ethical imperative to balance the needs of the individual patient with the needs of society.With this foundational  principle of the population health approach, the Charter, in effect calls on clinicians to allocate resources. However, it does not provide specific advice. Recent programs such as the American Board of Internal Medicine  Foundation's Choosing Wisely campaign, are beginning to fill this knowledge gap, as do some practice guidelines." 

It is an astonishing passage ,filled with both hubris and naivete, as it seeks to completely overturn centuries of medical ethics in which the physician had a fiduciary  duty to the patient and rewrite the role of the physician and shift the decision making process from the patient and her physicians to central planners..

A sometimes evoked fable in the religion of the medicine of the collective  is that of the Medical commons. A example of that type sermon is found in JAMA  in a joint effort by Drs. Troy Brennan and Christine Cassel in which the authors urge both physicians and patients to forgo their own limited self interest and work together for the good of the group.At the time of the publication of this 2007 article, Dr. Cassel was an officer of the American Board of Internal Medicine (ABIM) and Dr. Brennan was a executive at Aetna Inc. (Managing Medical Resources,return to the commons, JAMA June 14 2007,vol 297 p 2518

addendum:Reference added 5/30/2016

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