When I published the essay found below in 2015,there was considerable chatter in the medical blog space about the dangers posed to the traditional physician-patient relationship. Now little is written about that topic. The dogs bark and the caravan moves on.
The following was originally posted on 3/24/2015 and a lightly edited version appears below in the hope that there may be some physicians who still care .
H.L. Mencken defined Puritanism as that haunting fear that someone,somewhere may be happy.
The Medical Progressive Elite's haunting fear is that someone,somewhere is making their own medical decisions with input from their private physician.This fear is shared by the third party payers. In recent years,there appears to be considerable progress in alleviating their fear.
The last thing that the third party payers and the medical progressive elite want is that medical decisions be made a physician- patient "dyad".This situation is ripe for a classic Baptists and Bootleggers scenario,some of the medical elite sincerely believing that medicine is too complex and expensive to be left to the judgment of patients with advice from their physicians and the third party payers striving to decrease the cost of doing business and increasing profits share holder value.
This medicine-is-too important-to-be left-patients-and-their- physicians view is made crystal clear in the following quote from the book,"New Rules" written by Drs. Don Berwick and Troyen Brennan:
"Today, this isolated relationship[ they are 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."
Dr.Berwick went on the be the head of CMS for a while and Dr. Brennan went on to be the chief medical office of Aetna insurance company and then CVS Caremark.Sometimes the line between the Baptists and the Bootleggers gets a bit blurry.
Destroying the physician patient "dyad" or relationship has been a strategic goal of the progressive elite for years and a major initiative to that end was the 2002 publication "Medical Professionalism in the New Millennium:A physician charter".That was a joint effort by the ACP Foundation,the ABIM Foundation and the European Federation of Internal Medicine. The project chair was Troy Brennan and, in my opinion, importantly in terms of future funding and promotion of the "charter" a member of the project was Dr. Risa Lavizzo-Mourey of the Robert Wood Johnson Foundation.The RWJF has been a major source of funds for the ad campaign for the Professionalism project. CEO and . Dr. Harry Kimball ,president of ABIM from 1991 to 2003, was also a project participant.
The Professionalism 's theme is to downplay the fiduciary role of the physician to the patient and insert a nebulous co-duty of the physician to be a steward of society's limited medical resources and to work for social justice. A particular political agenda was inserted into medical ethics. For physicians who wondered how that role was to be played out, later the ABIMF clarified things by explaining that one could be a steward of the [collectively owned] medical resources and social justice would be achieved by providing efficient health care.In one document the authors changed the nature of traditional medical ethics and also rewrote the meaning of social justice which was now efficient care as opposed to the widely accepted meaning of social justice as redistribution. In a bait and switch move they have redefined social justice as efficient health care attempting to aggregate the values that individuals might place on a treatment with some collective metric allegedly representing the greatest good to the greatest number.They then further simplified things for the practicing internists (actually all physicians) by gratuitously asserting that following guidelines would be the road to social justice.
Disappointingly, the AMA went along with this flim flam sophistry of the physicians as stewards of society's collectively owned medical resources.See here.
In the ACP-ABIM world no longer would the patient and the physician be the primary determiners of a test or treatment value but value would be designated as high or low primarily on a cost effectiveness calculus.Rather than treating each patient as an independent moral agent an aggregate utilitarian metric would be imposed in which "high value care" is not in the eye of the patient but rather defined by a third party and expressed in quality adjusted life years per dollar spent The only or at least determinate value is economic efficiency.
Of course, the medical professional elite is a subset of the larger progressive community whose operational credo is that most things are too complex and complicated to be left to average people and if they will not listen to the delivered wisdom they should be compelled while the progressive's polar star and major talking point is to fight against inequality. The poster child for the stick approach has be the comments of Dr. Robert Benson Jr.,the emeritus president of ABIMF,writing on the blog of the ABIMF:
" 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." (This would seem to be a rather severe penalty for not complying with a "recommendation" which Benson thinks should be an edict.)
Consider how important the Choosing Wisely rules would be if Benson's wishes were enacted.Consider how much of a target the Choosing Wisely decisions would be to various lobbying groups.Third party payers would relish such a situation.
If you want to know what the ABIM and its foundation are about, just read the ABIMF blog.
The combination of mega hubris and libido domini spells trouble in health care as it does pretty much everywhere.
