Transformation from "layperson" to physician

In the ten  years since I began blogging  much  of what has been written about medical professionalism, I find alarming. The New Professionalism  as promulgated by the American College of Physicians and the ABIM attempts to transform the basic medical obligation of the physician to the patient to a nebulous,operational vague co-duty to serve society by conserving resources and furthering social justice.

The following is taken  from an earlier blog entry with light editing and additions.


Dr. Lawrence G.Smith, writing in the April 3, 2005 issue of the American Journal of Medicine speaks of this transformation. from lay person to physician. Professionalism has been written about extensively as it relates to doctors. Smith maintains the core of professionalism is the "personal transformation of self that takes place in stages during the early years of medical training and practice" When transformed the person now interacts with society in a new and different manner ).Dr. Smith was not speaking of professionalism in terms of being a steward of collectively owned resources,that distortion of basic medical ethics was not  then widely written about.

I have no doubt that transition happened to me. I can still remember comments made by teachers now over 50  years ago which were part of that process. I remember the attitude of respect and seriousness that was passed to me from the professors of gross anatomy as it related to behavior to the cadavers and behavior in the lab. I remember the pathology professor who told us that when we saw patients at night in the hospital how important it was for us to look and behave like physicians.I remember the chief of surgery who insisted that his residents wear shirts and ties in the hospital and clean coats and that his definition of a surgeon was a physician who knew how to operate.I remember how the clinical faculty typically treated the patients in the county hospital always with courtesy and respect, even though at times residents might have not.

 Soon after I completed residency and fellowship training I was doing a locum tenens and had the occasional to call the chief of medicine, with whom I had trained, to see a private patient at 3 am. She had end stage lupus and he had seen her several years before and her parents insisted that he see them. I called him at home and  he arrived soon after .. He was well shaven and well dressed in a suit and tie.. He spent over a hour with the patient and family,taking a detailed history and ding a physical examination , completed a page and half note and spent another 10 minutes with me.The family was greatly relieved that all that could be done was being  done. I was greatly relieved and felt that the chief had taught me another lesson;how a physician can do things the way that should be done in the real world.

These are just a few snap shots of the many  events and attitudes that lead to my transition from a college kid who really had no idea what to expect in med school or beyond to a person who felt he was trained to do serious, often difficult, important work and that it all was a privilege and a great obligation and that doing the right thing for the patient was what it was all about. Much of what my high school friends had done while I was in training, I had missed and in the years of training much of transpired in the world I had also missed. And much of the everyday concerns of relatives seemed to be so much less important.I believe part of that transformation process is the isolation from the daily events of the world that seems required by the intense study and training lasting for years past the usual time an adult joins the work force. Part of that transformation occurs because most of your waking hours are spent with other physicians and professionals doing what doctors do and talking about things doctors talk about.Role models are everywhere.

I might add  my classmates and I made that transition with the "benefit" of the trophies- for- everyone -before- the- game white coat ceremony.

As Dr. Smith said, once the transformation occurs you cannot think of being a physician as just a job.And it is difficult to think of yourself as any thing but a physician.


And because of that transformation it becomes very hard for a physician to retire or to be forced to leave practice because of illness. Are you transformed back into a lay person or are you still a physician who ...?

Quality adjusted life years is not even argued about any more-

We don't debate  the merits of quality adjust life year determinations any longer, we just do them.

 But, there was a time a few years ago when there was thoughtful criticism of the concept of quality adjusted life years (QALY) but the dogs barked and the caravan moved on.

One  such  analysis  appeared in 1990.I (JAMA 199:263(21):2917-2921), John LaPuma et al  said that the QALY concept was :

"founded on six ethical assumptions:
 quality of life can be accurately measured and used, utilitarianism is acceptable, equity and efficiency are compatible, projections of community preferences can substitute for individual preferences, the old have less "capacity to benefit" than the young, and physicians will not use quality-adjusted life-years as clinical maxims."

In their article they offer valid critiques of each of those assumptions.


Now it seems that the notion of QALY is firmly established in the practice of " determining" the cost effectiveness of medical procedures and treatments. Why is the word determining placed in scare quotes? Because my argument is that the idea of determining QALY is, in the words of the founder of utilitarianism, which is what QALY is all about, a fiction.

Jeremy Bentham did not discuss QALYs since the term was not invented in his day but he did consider the idea of adding up individuals happiness or utility as it was essential to his philosophy.

Bentham's famous principle is "the greatest happiness of the greatest number is the foundation of morals and legislation". To him happiness was the balance of pleasure over pain and this would be summed up somehow for everyone affected by the policy proposal and was known as the principle of utility and is the essence of utilitarianism.

Those who favor a utilitarian approach to public policy issue will not be pleased to learn than Bentham himself admitted that summing happiness or utilities or some measure of quality of life did not make sense. Bentham wrote:

"Tis vain to talk of adding quantities which after the addition will continue distinct as they were before,one man's happiness will never be another man's happiness:a gain to one man is no gain to another;you might as well pretend to add 20 apples to 20 pears,which after you had done that could not be 40 of any one thing but 20 of each as there were before. This addibility of the happiness of different subjects , however, when considered rigorously it may appear fictitious, is a postulatum without the allowance of which all political reasoning is at a stand.."

So Bentham realized that adding up everyone's happiness did not make sense (when considered rigorously) but we need to do it to make policy.

The economist, Anthony de Jasay ,said that scientifically speaking aggregating the utilities of different persons, e.g. to subtract from the gains of some the losses of others,is just as nonsensical as taking four apples out of seven oranges.So nonsense that is "useful" for some analysis is still nonsense.

Cost effectiveness analysis as applied to medical procedures does not exactly sum happiness over many individuals but sums instead quality adjusted life years. The QALY ( or the simpler concept of life years) is foundational in the current efforts to determine cost effectiveness.


John Rawls' A Theory of Justice proposes a redistribution scheme different from utilitarianism about which he said "[it] ( utilitariansim )does not take seriously the distinction between persons".Thomas Nagel,a critic of utilitarianism said of it that it treats the needs and satisfactions of multiple individual beings as if they were the features of some hypothetical mass person.

Nonsense or not it is a handy tool for the elites who would make their value judgments determinative of what the rest of us are allowed to have in terms of medical care.

 Woody Allen tells the following joke. A guy walks into a psychiatrist' office and say  "doc, my brother is crazy, he thinks he is a chicken." The doc replies you should get him in a mental hospital.The guy say I should but we really need the eggs.

The third party payers and their fellow travelers need the eggs.


note: Minor editorial tweeks made on 8/16/12 and joke and other addtions made on 4/8/16

The Tenth Commandment and Hayek were right about envy

Quotes for the day From FA Hayek and PJ O'Rourke bring a year-end message about envy and social justice.

Quoting  the economist, Anthony de Jasay quoting Hayek.

"No effort to make society drabber will make it drab enough to relieve envy. Hayek,invoking Mill, pleads that if we value a free society, it is imperative 'that we not countenance envy, not sanction its demands by camouflaging it as social justice, but treat it.. as the most anti-social and evil of all passions' "

PJ O'Rourke, whose scholarly credentials include having actually read  Smith 's Wealth on Nations in the original English, has this to say about the envy and coveting things:

"The Tenth Commandment sends a message to all the jerks who want redistribution of wealth, higher taxes, more government programs, more government regulation, more government, less free enterprise, and less freedom. And the message is clear and concise: Go to hell."




References:

Page 198. The State, Anthony de Jasay
An Alternative Inaugural Speech" (18 January 2005) by PJ O'Rourke

The authoritarian coercive aspect of the progressive medical elite

George Will has commented on the recent authoritarian  activity of of attorneys general and  the justice department to go after climate change "deniers", (a derogatory term to suggest a similarity to round earth deniers and Holocaust deniers.)

Will talks about the authoritarian facet of progressives. I submit the subset of progressives in the medical elite has the same frightening characteristic.

Here are some  examples;

1) Dr Robert Benson ,former CEO of the ABIMF,writing on the blog of the ABIMF is explicit about what he desires in regard to the Choosing Wisely initiative of the ABIMF. ( It should not go unnoticed that the funding for this program , the motive of which I have ranted about before, comes largely for fees charge to internists for their certification and recertification  exams and for other time consuming  programs that have been made  part of their MOC ( Maintenance of certification program).

Benson wants the Choosing Wisely guidelines rules  to be determinate of Medicaid payments and memorizing of the Choosing Wisely  suggestions orders to be a requirement for being eligible to that the Certification exam for internal Medicine.See here for more details and my earlier comments on that.

quoting Dr. Benson : boldings added


" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."...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."

2) Like minded thoughts are expressed in the NEJM by Dr. Nancy Morden of the Dartmouth Institute for Health Policy and Clinical Practice:

"..linking the lists ( of tests and procedures not to do ) to specialty specific maintenance of certification  activities such as practice audits and improvement tasks could also advance their dissemination and uptake at very low cost."

"...Choosing Wisely items should also be incorporated into quality-measurement efforts such as Center for Medicare and Medicaid Services Physician Quality Reporting  ...linking low value service use to financial incentives ( translate penalties )  .. should accelerate ...into practice changes."


3) Drs Don Berwick and Troyen Brennan in their book "New Rules" are not subtle in the following quote:

"Today, this isolated relationship[  speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.

When one talks about constraining and reformulation and "rules with authority" , the coercive aspect is obvious. Of course the progressive medical elite is authoritarian, they are progressives. 

The ethics of the medical progressives

 Hubris is the belief that one is intellectually superior to his fellow human being.That can be manifest as just an air of superiority , sort of a know-it-all  who might offer gratuitous advice.Such folks tend to be irritating but not necessarily dangerous.. Add that mind set to a belief that folks of that statue should be in charge of well most everything and you have the two basic principles of the progressive mind set and then things can get to be dangerous.Add to that mindset the notion that if folks do not accept your blindingly brilliant plans there should be some mechanism of enforcement of your wisdom.


Cui Bono. Follow the money or who profits. Ask the question who profits form  what appears to be a sea change in medical ethics in the last decade? What is the sea change? The change is from a basic fiduciary duty of the physician to the patient to the physician now ethically tasked with both doing what is best for the patient and  somehow conserving "society's medical resources". One master less chance of conflict- two masters conflict lurking much of the time and loss of trust.

The new medical ethics is the ethics of the progressive.  I call the medical progressive the medical progressive elite. In Joe Kotkin's taxonomy found in his book America's New Class System they would be a subset of the clerisy who function to provide cover for the oligarchs and for the ever growing and increasingly powerful governmental bureaucracy.

The progressive ethic is that much of society's affairs ( meaning an individual's affairs) should be managed by an elite.Medical decisions that in the past have been the bailiwick or purvey of the patient in consultation with his physician will in the world of the new medical ethics become decisions that will be made by wise leaders with ideas who pass their wisdom down in the form of guidelines adherence to which is now an ethical imperative. Here we have the merging of the high sounding ideals with the narrow self interests of the third payer payers.Does this not resonant with the notion of the Baptist and the Bootlegger?

Dr. Paul Hsieh discuses certain aspects of the new medical ethics here on PJMedia Blog.

Interestingly this 2012 article by Mark Daniels which reviews certain historical development in medical ethics and discusses various categorical approach to ethics in general ( duty based versus utilitarian etc) makes no mention of a duty of the physician to be a steward of society's medical resources.

The new ethics has been promulgated and promoted by the American Board of Internal Medicine and its foundation and fellow travelers in the American College of Physicians a number of whom have held positions in both organizations. This new duty is manufactured out of whole cloth largely by these two organizations.Their  Choosing Wisely campaign and the Medical Processional for the New Millennium publication have served as vehicles to bamboozle both the medical profession and the public.

Who profits? the third party payers and a number of the progressive medical elite who have positioned themselves to be the movers and shakers in the governmental and quasi governmental
structure that aims to control the practice of medicine and importantly attempt to control (i.e. minimize) the expenditures of the private and public third party payers.

Former ACP presdient asks "must the population health approach compromise the needs of the individual"

Dr. Harold Sox in a JAMA viewpoint commentary ( see here for link) addresses  three questions regarding 'Population health approach" which he defines as  " a aim to improve and maintain health across a population"

1.Can the population health approach improve the outcome of US health care? 2.For this approach to succeed ,must it reconcile the need of the individual with the community  3.How might these needs be reconcilable?

"Must the Population Health Approach Compromise the Needs of the Individual to Benefit the Community?

  " It will take several generations to realize the full benefit of investments in disease prevention.In the short run,these investments may draw resources from tests and treatments 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. "

 This IMO is an incredible paragraph on several grounds .First of all the author admits that some sick people may  be harmed as funds are diverted to prevention programs.So the answer to the question that introduces the paragraph is "yes" and is presented in a matter of fact manner. The distinction between short run and long run seems spurious. If limiting funds for  treatment for some sick people is used to for prevention, why would that be a one time occurrence. Would not funds continue  to be  used for prevention as the expense of some sick people if there is some purported advantage to that based on the currency of QALY? One can only guess what "skillful clinical decisions" might be that somehow mitigates the issue of denying treatment to some for some purported future aggregate benefit from a prevention program? Here putative preventive measures trump the need to treat a sick person which for centuries has been the essence of the physician's activity.Oh well to make a omelet..The omelet here would be improved health of the community as judged by some aggregate statistic and judged by some central entity.


Earlier in the article Sox speaks of making decisions regarding allocation of resources across patients and programs.The program that would be favored at  the expense of another would be based  on comparison of QALY ( quality adjusted life years). "One reasonable principle is to move resources from groups of patients less like to benefit to groups more  likely to benefit" The author does not specify who it is that will "move resources" and whose permission, if any, would be necessary for such rationing. or who will make that type decisions.This shift of resources might involve removing resources of value to some for putative somehow measured greater benefit to others.

 Individuals make trade-offs in many areas of their lives including health care. This utilitarian approach is based on a third party making trade-offs between lives. It treats people as means of reaching some social end, in this case "maximizing health" and in the process fails to respect the "discreteness of the individual"

Earlier in the commentary the author says :

"Planning to optimize population health will mean determining the frequency,causes and consequences of the common medical condition in a population and devising strategies for dealing with them over a life time" Wow, no hubris there.

Sox speaks of the health care system and the public health care system planning together, as if the health care system is a unitary entity capable of acts appropriate to a sentient being,such as planning and cooperation. and could  cooperate with another abstraction as if it were also a sentient  entity.He seemingly realizes something major will be required to force this cooperation and the answer is "global spending limits".This will "force the community  to cooperate in deciding how to maximize the health of the people?"

It is hard to make sense out of that last quote so riddled as it is with  reifications , regarding abstractions as concrete existential entities capable of  thought and action.Are you forcing the community which is the people to decide how  to maximize their own health? How will that decision making process be carried out? Voting,town hall meetings for every one in the country? What measure of health maximizing  would be used? Who would decide? Does this conflate community or society with  with government? The two are not the same.

A number of members of what I call the progressive medical  elite have apparently received the memo that says to push the concept of "global medical spending limits:. In the same issue of JAMA, Dr. Don Berwick and Dr. Zeke Emanuel  both recommend very specific limits. eg.for medical  spending to  increase no more than the increase in the GDP.
 

So are the needs of the individual and the population reconcilable? They are in the specific sense in which he uses the term, i e reconcilable in the sense of " using the same metric of value (QALY) and the same decision making principles.

But the answer to the question "Must the Population health approach compromise the needs of the individual to benefit the community?" is yes as demonstrated in the example he offered.

As if to camouflage the brutal reality of the "draw[ing] of resources" away from the sick, Dr Sox closes with the platitude that the basics of patient centered care have not changed. The hell they have not changed-they certainly have  in the population health world he envisions.

The progressives in general as well as subsets such as the medical progressive elite learned nothing from the history of the 20th century - nothing in terms of the outcome of central planning, nothing in terms of the slippery slope of sacrificing the individual to the collective.

The alleged demise of the internist-is it just the money?

A blog  entry, now several years old,by one of my favorite medical bloggers, DB aka Dr. Robert Centor, offered an important insight into some of the current problems with the specialty of internal medicine which include few medical graduates opting for general internal medicine and the low level of general satisfaction of many internists.It is clearly not your grandfather's internist anymore.

 Dr. Centor was commenting specifically on the suggestion by one of his colleagues that the training of internists needed to be revamped with more emphasis on outpatient issue and less on inpatient matter.He seemed to believe and I agree that that was not the answer. Rather DB's key message,in regard to the decreasing popularity of general internal medicine as a choice of medical students, I believe was the following:

"...I believe the problem is money – and that has impacted everything else."


As long as the internists "reimbursement" was what was known as "reasonable, customary and prevailing" the classical internist type practice thrived and "those were the days my friend and we thought they would never end" but they did. The beginning of the end of that type practice can be traced to the imposition of price controls on physician fees by Medicare. Soon after the other third party payers clamped down as well in part with the largely now defunct mechanisms subsumed under the rubric "managed care" whose effects still linger although the programs were rejected by the patients.

With managed care the collegial and self reinforcing relationships that grew up in the pre-managed care era disappeared. Now longer could the internist refer to the physician of his choice it was typically necessary to refer only to someone on the patent's plan.No longer could the family practice physician or the surgeon or ObGyn send a patient to the internist she knew she could trust to take good care of the patient.

With the new payment system ( ever decreasing fees from governmental and non-governmental payers) and the breakdown of the old informal, ad hoc but very useful referral systems, satisfaction for the internists began to fall.Importantly,with decreased fees per patient encounter the incentive was to increase patient encounters and spend less time with each patient.

Further, internists 's practices gradually became a game not of his choosing. Guidelines proliferated and the internist's attention turned more the care of the worried well and a check list practice evolved making sure your patient flossed,wore seat belts and had her colonoscopy and five fruits and veggies a day. Much of it became trivialized to the point where it really began to actually make sense for an assistant (PA nurse practitioner) to do much of what somehow had become expected. And then there is the "existential angst" brought about by the conflict of the old with new medical professionalism.See here for my earlier rant on that and for DrRich's very similar views in his comment to the post.

With decreasing fees per patient encounter it became harder and harder for the traditional internist to care for patients in and out of the hospital and see patients after hours in an emergency room and make the ends of his practice meet with enough left over to make it all seem worthwhile. The notion of a hospital-only practice with regular hours offer many discouraged and burning out internists an out and for younger internist to spend their time taking care of sick patients, i.e. the complex problems that traditionally internists dealt with.  

Of course, there is more to the origin of the hospitalist than the angst of the internist and the dwindling pay schedules but I still marvel a bit at the readiness of the internist to change roles to become a physician whose stock and trade was episodic care with little if any chance for the type of long term care through the course of a chronic illness that was once typical of an internist's practice .

So even though the internist turned hospitalist gained more time off, probably better income, and less business type hassles and a chance to deal with the type of serious , complex, medical problems that internists train to manage, but it was only part (although a major part) of what an internist used to be. And of course, the internist who remained with a truncated medical practice had to forgo much of what his training was all about.  More and more, I am convinced that the type practice that an internist had was largely dependent on the economic environment of the times and when that environment changed so did the internist and to the degree the new professionalism is the currency so has the medical ethics.




addendum: typo corrected 4/12/16

Federalization of MOC program and Choosing Wisely is moving closer to reality

Dr. Wes on his blog gives an update on the alarming progress ABIMF and fellow travelers have made in their program to exert control of medical practice.

 The folks associated with ABIMF have told us what they want to do and now it looks like they are making alarming progress towards those goals.

\
On the ABIMF blog ,former CEO of ABIMF, Dr. John Benson made these comments,telling us what they want. ("The Necessity of Stewardship"Feb.20.2014)

"The time is well past exhortation. The issue has been recognized for decades. Hard choices and penalties must go beyond training the next generation. 2020 is closing in."

He continues

" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."  (note the current President of ABIM and ABIMF is Dr. Richard Baron who left a post at CMS through the revolving door to assume his duties at ABIM and ABIMF)

and it gets worse

" 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." (Maintenance of Certification)

 Benson seems to want Choosing  Wisely to literally become the law of the medical land and recent events at the federal level should give him satisfaction.Very alarming developments.

Statistical independence does not mean causal

   An article in the Jan 24, 2005 issue of the Archives of Internal Medicine(vol. 165 p138-145) made important points regarding the concept of "independent risk factors". Basically, Dr. Brotman and co-authors remind  (or more likely inform) the readers that ( my bolding): statistical independence does not mean causality, is context dependent ( ie in that particular data set) and risk factors may be causal even if not statistically independent. Independence is a statistical concept relying on a particular statistical model.

  I once downplayed the significance of elevated triglycerides as a risk factor for coronary disease because  I had read triglycerides were not an independent risk factor. Now, or course, clinical studies have shown the opposite- at least for now. The point is that a risk factor can be "significant" i.e. important whether or not a medical publication's analysis indicates that is an "independent risk factor" .

Articles like this can be  are important antidotes to the faith that we tend to have in the black box magical output of multivariate analysis as well as less familiar techniques ( eg propensity score matching  and,instrumental variables methods which purport to make observational studies more like randomized trials).  Few physicians have plowed through the pen and paper process of doing a multivariate analysis or even understand generally what it all about.I don't claim to. That exercise might give one a real sense of what is being done and perhaps how small variations in data input can alter the answer- changing an independent risk into one that is not and vice versa.

In regard to heart disease, the authors assert that as more variables are linked to disease, no study will be able to properly model all the risk factors to enable them to say that X is an independent risk factor. This problem of residual confounding limits medicine's search for the causes and might make us more circumspect when we make pronouncements to patients about what causes what and what we should do about it and we cannot just rely on whether a  particular study did or did not show statistical independence.

William Barrett In his book "Illusion of Technique"(Anchor Books, 1979) says that Logic is the only modern science that has shown its own limits by showing the limits of formal systems(through the work of Godel and others).

We might tend to forget when we read " X is an independent risk factor for disease Y" that we are dealing with "provisional conclusions " extracted from "fragmentary" data and working within a particular statistical  model with a  particular data set.

 Some have make a distinction between "faith based" medicine with "evidence based medicine". Considering the faith required to believe the output of mysterious mathematical models about which most physicians readers know little , this distinction begins to fade away.Maybe we need a medical version of Godel's theorem as an antidote to hubris or faith based believe in technique. I eagerly await more articles,such as Brotman's,pointing out the limits of medicine's knowledge generating techniques.

note: This theme appeared in  comments  in a different venue by me about ten year ago and have not appeared  before on  RDT and has been lightly revised and edited.