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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, July 12, 2018

How well do the Echo guidelines work to estimate cardiac filling pressures ?

Elevated filling pressure is thought to define heart failure as it is thought to be the driver for exercise intolerance and shortness of breath.

Filling pressures can be invasively determined by catheters in either the pulmonary artery wedge position or in the left ventricle.

One of the major aims of echocardiography is to provide reliable estimate of filling pressures .It is generally accepted that echocardiographic indices are more effective in determining  filling pressures in patients with reduced ejection fraction (EF) and is more problematic in patients with preserved EF

The 2009 echo guides  for determination of diastolic function were revised in the 2016 guidelines and both  have been the target of some criticisms.

IMO a 2015 article ( 2) from the Cleveland Clinic offers data that raises reasonable concerns about the estimation of filling pressure in patient with preserved EF.It should be noted that the classification system of degrees of diastolic dysfunction (DD) used by the authors is not the exact system proposed by the 2016 guidelines. but rather those of the 2009 guidelines.(1) and the athors criticism relate specifically to the 2009 system.However I believe their conclusion ( see below) regarding the basic underlying paradigm holds regardless of tweeks made to the 2009 guidelines.

The authors reviewed 460 consecutive patients who underwent echocardiography within 24 hours of elective left heart catheterization.

Their figure 5 plots left ventricular diastolic pressure (LVEDP) against normal and the 3 grades of DD in patients with EF greater than 50 % and those with EF less than 50%.In both groups there was no difference in LVEDP between normals and those with Grade 1 and Grade 2. The only statistically significant difference was that between normals and those with grade 3  DD who had EF less than 50%.

The authors conclude: "the findings of this study question the notion that DD is a predictable, progressive process beginning with impaired relaxation followed by reduced compliance and increased filling pressures. The prognostic value of echo graded DD may relate more to its reflection of intrinsic properties of the left ventricle, or to exercise hemodynamics  than to its correlation with resting hemodynamics alone. "A Mayo Clinic study  of 467 patients ( 3) by Kane et al found that
reported no higher pulmonary artery systolic pressure at rest  or on  exercise in those patients with the echo diagnosis of impaired relaxation.



 1) Nagueh, SF Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echo 2009, 22, 107


2) Grant A, Grading diastolic function by echocardiography:hemodynamic validation of the existing guidelines. Cardio Vascular Ultrasound 2015.


3)Kane, GC et al Impact of age on pulmonary systolic pressure at rest and with exercise.Echo Research and Practice, 2016,3(2) 53-61

Sunday, July 08, 2018

The great social justice bait and switch courtesy of ACP,ABIM and RWJF

Certain members of the leadership of the American College of Physicians,the American Board of Internal Medicine and the Robert Wood Johnson Foundation authored a manuscript designed to permanently change the physician patient relationship.The paper is entitled "Medical Professionalism in the new millennium: A Physician Charter.",.which I will refer to in this commentary as "The Charter" .  It was a project of  the  foundations of the ABIM and ACP and the European Federation of Internal Medicine.See here for the document.

The documents simply asserted that physicians are the stewards of a [collectively owned] store of medical resources and that physicians have a professional obligation to work for social justice. While they did not explicitly deny the fiduciary role of the physician to the patients in effect  they declared that there was a co duty to conserve the "limited" medical resources as well as the duty  to the individual patient.Contrary to the biblical warning about serving two masters the Charter's authors urge a stewardship of medical resources which subsequent publications by ACP,ABIM and others  said will best be made operational by physicians  following guidelines.

In my opinion this publication is a poster child for the use of gratuitous assertions.

Quoting from the Charter" essential to the contract [medicine's contract with society] is the public trust".


The Charter was published in the Annals of Internal Medicine  and Dr. Harold Sox, the then editor of the Annals of Internal Medicine, offered an introductory commentary. He said in part "the condition of Medical Practice are tempting physicians to abandon their commitment to the primary of patient welfare....the Charter call physicians to promote fair distribution of health care resources"

 I suggest that the choice of the words "primacy of patient welfare" is significant in the omission of the modifier "individual" in front of the word patient. Subsequent promotion of the Charter has made it clear that patient welfare will be defined in terms of the aggregate not in terms of the individual patient.  A subsequent publication ( JAMA: November 13,2013) by Dr. Sox advocating  "population Medicine " made it clear what type of patient welfare Dr Sox favored. See here.

A brief quote from Sox; "

"Perhaps the de facto organizing principle for US health care,approaching each patient strictly as an individual is obsolete.The population health approach is an alternative." (I have added the bolding)

Dr. Sox makes explicit what is hinted at and glossed over in the charter,namely the sacrifice of the individual to the group, the individual patient to the aggregate, or at least  to some aggregate metric claimed to represent the good of the group.

 The charter promised social justice and operationally that has been translated to following guide lines based on alleged aggregate benefit.







Friday, July 06, 2018

Medicine is increasingly dominated by collectivist ideology.

This commentary title is an truncated and slightly altered version  of the following quote from the brilliant essay by Dr. Michel Accad. "Medicine today is dominated by the collectivist ideology" . See here for the reference to his 2009 contribution. 

This is a theme I have thought and fretted about far too much.Many of the thoughts I have mulled over and occasionally expressed in this blog are far better expressed in Dr. Accad's essay. Here is a sample;

"In the broadest sense, medical collectivism is the belief that medicine cannot be left to voluntary and unrestricted transactions between individual patients and individual healers but must be improved, directly or indirectly, by the hand of government."

and another.

" Individuals and populations ,patients and society are conveniently conflated as a matter of fact."

And here is the real money quote.

"..hoodwinking physicians into practicing population medicine is of course the essential means to confuse practitioners into thoughtlessly carry out sweeping interventions whose primary benefit is the profit of third parties."

Docs who were trained in my era ( I know that was a long time now-MD-64) learned that the principle ethical precept was do what was right for the patient and there was ,with few exception.s no other obligations.  What was definitely not on the table was the notion that physicians had an obligation to conserve the nation's medical resources. Social justice was not on the table.


I believe the metaphor of the Bootlegger and the Baptist captures an important aspect of what is happening in  medical practice in the United States.

I do not envision a wide spread plot or conspiracy of third party payers and academic physicians and leaders of major medical professional organizations meeting regularly to further their long term dream of finally taming the physicians and disabusing them of their traditional role as a fiduciary of their patients. However, the third party payers certainty welcome the efforts of the academic medical elite in that regard and some times welcome them into their ranks .

The Baptists in this conception are those physicians who sincerely believe that in the age old conflict between the interests of the individual and those of society as a whole that the trump card would be held by society.The Bootleggers are the third party payers whose bottom line increases in proportion to the acceptance of those views.

Thursday, July 05, 2018

Is the Choosing Wisely campaign a giant flim flam benefitting the thrid party payers?

Is the choosing wisely initiative (CW) just a clever ploy to save money for the third party payer?
 or Is it just about a sincere effort by physicians who really care to eliminate to the extent feasible fraud and waste?

Is CW an extension of the New Professionalism movement?

I  argue that CW is a flim flam and a power grab jointly shared by the third party payers and the medical progressive elite who provide the academic cover and propaganda. I  argue that it is in fact about much more that elimination of fraud and waste and that it is a logical outgrow of a major element of the change in medical ethics that the New Professionalism movement is attempting to bring about.

It is a story about the ACP the ABIM and a foundation ( the ABIMF) established with money obtained from internists taking certifying exams whose fees greatly exceeded any reasonable cost of providing those examinations and about  another foundation  , the Robert Wood Johnson Foundation (RWJF)

I  argue that it is not just the CW ad campaign funded by ABIMF and RWJF but it is larger namely The New Professionalism-Choosing wisely-high value care flim flam.

The New Professionalism authored by folks from ACP,ABIM and the RWJF  provided the cover or alleged philosophical foundation for CW and the push for high value care.The follow the money rule continues to have great explanatory value.