The Prospect Study give some more insight into mechanisms for ACS recurrence after PCI

See here for the Prospect study published in the NEJM.

This multi-institutional study involved a follow up of 697 patients who presented with an acute coronary syndrome (ACS) treated with an invasive catheter procedure ( percutaneous coronary intervention or PCI). The patients underwent coronary angiography and coronary artery intravascular ultrasound imaging.

Over a three year period 20.4 % had another adverse coronary event . The authors analysis indicated that about half of these events were due to obstruction at the location of the culprit lesions ( i.e the obstructive lesion that was treated by PCI) and half were due to non-culprit lesions. Most of the non-culprit lesions were considered angiographically mild (typically with an obstruction less than 70%) and were described as "thin-walled fibroatheromas" with a large amount of plaque . I suppose if those lesions were not thought to be mild by the cardiologist that they would have been "fixed".

According to the authors, a lesion with a thin wall, a lumen area of less than 4 mm,and a plague burden of 70% has a three year risk of causing a coronary event of 17%.

Potentially useful information not provided in the article would include to what extent patient with these non-obstruction lesions were treated with medications thought capable of stabilizing plaques, e.g. clopidogrel, aspirin, and statins. You have to believe (hope?) that the percentage would have been higher if patients had not been treated with drugs that "pacify the platelets" and decrease inflammation.

The authors emphasize that the intravascular imaging techniques used in this study are not ready for prime time, everyday clinical use because the specificity of lesions with the most predictive risk characteristics is low and there were serious side effects (including rupture of a cornoary artery) .Further, data was only obtainable on the proximal portion of the major epicardial coronary arteries ( about 6-7 cm) so what was going on more distally is unknown.

Everybody knows that thiazides are clearly the best anti-hypertensive. On the other hand..

All seven versions of the recommendations of the Joint National Committee for the Prevention, Detection,Evaluation and Treatment of High Blood Pressure (JNC 1 through 7) made it quite clear that thiazides were the drugs of choice for the treatment of hypertension. See here for JNC 7 which says, in part:

"Thiazide-type diuretics should be used for most patients with uncomplicated hypertension either alone or in combination with other drugs."

The ALLHAT trial has been used in support of that recommendation although that trial has generated hundreds if not thousands of pages of rebuttal and re-rebuttal. See here for an ALLHAT summary.We reassured later that the diabetes that sometimes might be precipitated by thiazides is a different and really benign type of diabetes, so not to worry about that.

The European approach is arguably less dogmatic that JNC's emphasis on diuretics.Here is the ESH/ESC 2007 update on hypertension treatment.

Now we have this meta-analysis ( yes, I am very skeptical of MAs in general but when they suit my biases, I shamelessly quote them).See here.

The authors included 14 studies that used 24-hour blood pressure monitoring and concluded"

Conclusions: The antihypertensive efficacy of HCTZ in its daily dose of 12.5 to 25 mg as measured in head-to-head studies by ambulatory BP measurement is consistently inferior to that of all other drug classes. Because outcome data at this dose are lacking, HCTZ is an inappropriate first-line drug for the treatment of hypertension.

Their last sentence could not be more in opposition to JNC. Let the games begin again.

Dr.Buz Cooper's continuing battle with the Dartmouth Atlas dogma

I have written about Dr. Buz Cooper before ( see here).Very well worth reading is his latest salvo that further strengthens his position that the reason for geographical variation in health care cost is poverty.Here he reviews the latest MEDPAC data.

I think he is saying in part that the "problem" isn't some mysterious regional variation in how doctor practice medicine ( i.e greed seems to distributed geographically by some as yet undiscovered mechanism); the problem is it costs more to care for poor sick patients. Changing doctor's practice patterns won't fix poverty. Somehow, I think electronic medical records (EMRs) won't either.

Here is his nutshell paragraph:

"MedPAC, the IOM and countless other organizations are on a quest to explain geographic variation in health care. Yet the puzzle has been solved, and it is solved again here. Geographic variation in health care is a manifestation of geographic variation in poverty. The logic is obvious to all of us in our every day experiences. Poverty is associated with more disease, and poor people cope with disease more poorly. And poverty is geographic. So it should not be surprising that health care utilization and spending are geographic."

More pile on the band wagon of demonizing the obese

DrRich has written this essay on the topic of demonizing the obese. Now the legendary and feared (feared at least by employees whose boss hires them to "help cut costs") McKensey group has joined the chorus singing the horrors of the obesity epidemic.They have determined the real cost of obesity which is supposed to be in the U.S.450 billion per year which is three times the direct medical costs.So what are the other costs?

They include in the overall cost of obesity the increased cost of food and of purchasing extra sized clothing. somehow they consider purchases of food and clothing to be some mythical "cost to society". I wonder if someone at McKensey actually sat in on economics 101 and learned that one person's cost is another's stream of income. Buying food, regardless of one's BMI, is not a cost to society but just a market transaction just as it is when the thin person buys a car. However, economics can be such a subtle and counter intuitive discipline.Apparently giving folks money to buy new cars was thought to stimulate the economy (remember cash for clunkers) but some "incremental" money spent by the obese on extra food and big shirts is a cost to society.

McKensey speaks obesity as a pandemic, the whole world is getting more obese and they contend that the problem is so vast and important than "governments must lead the fight against obesity" Well at least they didn't call it a war.

The McKensey group has been knee deep in health care policy matters for some time. Dr. Robert Kocher has been in and out of the group serving in between with President Obama's Council of Economic Advisers. He was a co-author of this fluff piece promoting Obamacare that appeared in the Annals of Internal Medicine and will be long remembered for this incredible quote; "It (Obama care) guarantees access to health care to all Americans."

While it has become dogma that the obese increase health care costs because of their increased incidence of such things as heart disease and arthritis and that by mitigating obesity there will be cost savings ,one should be aware of a attractive counterargument .Simply put that argument is that the obese will die at a younger age and therefore it is at least logically possible that they will consume less health care service overall. This is exactly what this article from Dutch authors concluded based on a series of simulation mathematical model scenarios. Here is a quote:

As with all mathematical models such as this, the accuracy of these findings depend on how well the model reflects real life and the data fed into it. In this case, the model does not take into account varying degrees of obesity, which are likely to affect lifetime health-care costs, nor indirect costs of obesity such as reduced productivity. Nevertheless, these findings suggest that although effective obesity prevention reduces the costs of obesity-related diseases, this reduction is offset by the increased costs of diseases unrelated to obesity that occur during the extra years of life gained by slimming down.

Over ten years ago I did some consulting to a large intentional petrochemical company. One day a group came by hawking their employee wellness packet .After their presentation, a Human Resources manager asked will not their pension expenses go up if we keep future retirees healthy longer. A refreshingly honest presenter said yes- that was probably so and added that the best thing for a pension plan would be for employees to be healthy productive workers, then retire and die the next day without a prolonged expensive illness .Of course we would never want to do that.

So if cost to "society" is behind the movement to fix the obesity problem maybe we should at least keep the topic on the drawing board even if anti-obesity advocates aren't ready to consider going back to the drawing board.

A public health initiative that improves people's health is a goal many would support but the claim that prevention necessarily saves money is one that is based more on faith than sound empirical evidence.

Can psychiatry differentiate disease from everyday suffering?

That question seems to be asked by not just one but two former chairman of the committees who authored editions of the fabled DSM. Dr. Allen J. Francis has been very critical of the currently being written DSM 5 ( Yes, they changed from Roman to Arabic numbers). An interesting family feud is depicted in this article from Wired on line.

The first time I came across this general thought was when I was discussing a case with a psychiatrist to whom I had referred a patient I thought might be chronically depressed.He said she was not depressed but in his view she was just a very unhappy person. I can't recall if he then proposed to treat her with the antidepressant flavor of the day or just talk her out of being unhappy or what.

While non psychiatry medicine which I will refer to as "real medicine" (somewhat tongue in cheek) sometimes uses a symptom counting method of diagnosis ( e.g use of a number of symptoms in the a major or minor category to reach a diagnosis) it has the cognitive luxury of being able to rely on physical findings, imaging techniques, sometimes fairly definitive blood tests and often definitive biopsy results.

However, our psychiatry brethren- as best I can tell as an outsider- depends on a symptom counting based diagnostic paradigm outlined in excruciating- to- read- details in the powerful DSM. For example,if a patient has five out of the nine official symptoms of depression over a two week period then they are diagnosed with major depression.Apparently for a while there was a "bereavement exclusion" for depression diagnosis but with the newest classification that has been removed, exemplifying how fluid the definition of a given disease can be.This descriptive diagnosis system was heralded as a marked improvement over the situation in the old days in which psychiatrists of different psychoanalytic schools would differ as to the diagnosis of a given patient.

Symptom listing,counting and matching was considered more scientific and importantly became available to non-psychiatrist physicians ( or any clinical health care provider). With a check list type diagnostic paradigm generally available and multiple psychiatric drugs being promoted by big pharma, primary care docs might conclude that "this psychiatry stuff is easier than I thought" and I suspect many did.Numerous dinner CMEoid sessions with primary care docs featured as the "thought leader"showing their fellow PCPs ( and NP and PAs) that psychiatric diagnoses were not something to be afraid of probably paid off for the sponsoring drug companies.

More "Social Justice" surprises for the middle class-more taxes

This article from Investor's Business Daily explains one of the counter-intuitive quirks of the tax increases which are part of PPACA.

New taxes kick in in 2013 for households with incomes over 250K ( 200 for a single filer); a 0.9% wage and salary tax and a 3.5% tax on some investment income.The article's authors walk the reader through what happens to families in three income ranges and oddly enough those in the middle of the three ranges are taxed more than the higher range group for an increase in their income, as might occur if one of the two spouses receives a job promotion or work extra. Nothing like a good partially regressive tax to sock folks in the face with some some hard hitting anti-productive social justice.Readers might recall that after PPACA was signed, we were told by Senators and some medical organizations ( you know who you are) that social justice was served.

A broader analysis of taxes and PPACA is offered by the Harvard economist,Greg Mankiw. His plan to decrease the deficit is for the government to give him one billion dollars and increase taxes by three billions.This reduces the deficit by 2 billion. He then relates this scheme to the arguments made about PPACA.

"Healthcare reform, its advocates tell us, is fiscal reform. The healthcare reform bill passed last year increased government spending to cover the uninsured, but it also reduced the budget deficit by increasing various taxes as well. Because of this bill, the advocates say, the federal government is on a sounder fiscal footing. Repealing it, they say, would make the budget deficit worse."

Professor Mankiw, in a more serious moment, refers readers to this article that explains how repeal of PPACA will not increase the deficit.That a repeal will increase the deficit is the latest argument from some of those who continue to support PPACA, the social justice argument getting a bit stale,now that the bill is passed and we are finding out what is in it.

It seems hard to believe that Internists are asking what is an internist?

Two of my favorite bloggers have recently taken up the questions " what is an internist?". Both Dr. RW (see here) and Dr. DB (see here) have written about this. My speculation is that orthopedists and neurosurgeons are experiencing less of an identity crisis.

My hunch is that both would have much less trouble with that question when they were in their Internal Medicine training programs. ( in fact Dr. RW made that point in his commentary ).

I know I had little doubt about what an internist was and what an internist did when I was a resident in IM. An internist was someone who was respected and called upon to deal with the diagnosis and management of complex medical problems and of critically ill patients. That was what a general internist did.General practitioners would consult with an internist for difficult cases and their expertise and knowledge was respected by both the GPs and surgeons.

Major changes in medical practice has brought about the current ambiguous nature of the internist's identity.

The general internist's role has been bifurcated into an office doctor and a hospitalist, with a rapidly decreasing number of internists playing both roles. While the hospitalist role more closely resembles the internist of 30-40 years ago the office internist is becoming harder and harder to be distinguished from the family practice physician.They both spend a significant part of their day doing preventive medicine,an activity particularity suited to guidelines and flowsheets and readily adaptable to delegation to nurse practitioners and physician assistants and likely ultimately to NP assistants or PA assistants.

The family practice physicians has evolved from the GP s of years ago and while the GPs were a source of referrals to the internist the Family Practice docs are more often than not competitors in the fairly recently defined world of what has become to be known as "primary care practice" . Both FP and IM docs will face more competition from NP and PAs if and when Obamacare plays out as demand from the number of insurance card carrying patients increasingly outpaces the supply of FPs and general IM docs and likely NPs as well.

The earlier version of the internist practiced in a very different world. He took call at night and would go to the hospital to see his patients in the ED and if they had problems in the hospital and some went to nursing homes.

The modern version so often now signs out at five o'clock with a telephone answering device informing the caller to call back during regular hours or if "an emergency" go to the Emergency Department.

I found the following paragraph from Dr RW's commentary as on target as it is depressing to someone who spend many years training to be an internist and more years practicing internal medicine as it used to be and now watching it change almost to the point of being unrecognizable.

The American College of Physicians slogan “Doctors for Adults” is unfortunate because it defines Internal Medicine as Family Practice without Pediatrics. This view has led to a proposal, published in the Journal Academic Medicine, that IM and FP be merged. It would mean the dissolution of general IM as a specialty. It's little wonder so few trainees want to go into general IM anymore. Who in their right mind would sign up for a specialty that's slated for dissolution in the next decade.

I know I would not.

More on how Electronic Medical Records will fix mostly everything

If you read this entry from Health Care Renewal you will realize how stupid and counterproductive electronic health care records can be.I say "can be" and sometimes are , not they have to be.

AND this entry from the same blog gives some very revealing insights as to who can get what from electronic medical records.Hint- it won't always be the patient or the physician. Dr. Scot Silverstein deserves much credit for his seemingly untiring efforts to educate us all about some of the really harmful ( and hypocritical) things going on in the EMR business.

Obamacare poster child for "growing autonomy of the regulatory state"

George Will, in his recent Jan. 16,2011 essay, " A Congress that reasserts its power", comments on the eclipse of Congress by the executive branch and the various federal agencies .
See here for the entire column.

Will says in part:

"The eclipse of Congress by the executive branch and other agencies is Congress' fault. It is the result of lazy legislating and lax oversight. Too many 'laws"actually are little more than pious sentiments endorsing social goals-environmental,educational,etc.-the meaning of which are later defined by executive-branch-rule-making."

The "etc." could well include the recently passed health care bill. The phrase "the Secretary (of HHS) shall determine" occurs repeatedly in the bill.If ever the phrase " the devil is in the details" applies it is in Obamacare.

Federal bureaucrats will write the rules that will be the very essence of the program. Congress endorsed a social goal ( health insurance for all-well, all but some 14-23 million, depending on whose estimate you believe) and abrogated the defining details to various federal agencies .

Will points out that the Federal register is a more important guide to governance than is the Congressional record.

To describe the belief that health care in this country will be improved by thousands of federal regulations patched together by scores of agencies, each subject to lobbying pressures and the risk of regulatory capture, requires a modifier stronger than the word "panglossian".

The antibiotic pendulum for treatment of Acute Otitis Media swings back

In the antibiotic era, the complications of acute bacterial otitis media (AOM) largely disappeared. One of the complications,mastoiditis, became a rare entity.Antibiotic treatment for AOM was standard treatment but in recent years the practice became challenged.

Several clinical research papers concluded that a number of children recovered from AOM without antibiotic treatment and seemingly without sequelae. Those findings were amplified by a couple of meta-analyses which derived the number needed to treat with antibiotic (NNT) and claimed that at least 7 children need to be treated (NNT) to shorten the illness of one child.

Perhaps encouraged by policies regarding antibiotic treatment in Europe and the growing concern about bacterial resistance caused by widespread and at times imprudent antibiotic use, several medical professional bodies issued guidelines that said antibiotics need not always be given to a child with AOM.

Now, two articles in the January 13, 2011 issue of NEJM present evidence from which one may reasonably conclude that antibiotic treatment is a good thing after all.An accompanying editorial supports a pull back from the current guidelines. The editorialist and authors of at least one of the two NEJM articles point out serious flaws in the clinical trials which lead to the current guidelines including ; imprecise criteria for the diagnosis of AOM,inclusion of children with minimal disease,ambiguous endpoints,small sample size and improper choice and dosing of the antibiotics used.

If the trials were as poorly done as implied about you have to wonder how repacking them in the fancy wrapping of meta-analyses strengthened the argument that lead several medical organizations to recommend a watchful waiting approach to AOM.A meta-analysis is only as good as the underlying studies that are included in the data set. I have repeatedly argued that meta-analysis should not rest at or near the top of the hierarchical structure of doctrinaire Evidence Based Medicine.

The specter of antibiotic resistance or rather the concern over the resistance may have played a role there. It is interesting that in regard to the treatment of AOM, it seems that resistance has not actually become a major factor.Apparently there has been a unexplained shift in the bacteria that cause AOM.Previously beta-hemolytic streptococcus was the major player and now the less invasive Hemophilus influenza ( H.Flu) and Moraxella catarrhalis are more common.

Although dissenting views were offered in 2003 by Dr. E.R. Wald ( one of the authors of one of the two NEJM articles) from the pediatrics department at the University of Pittsburgh in 2003, both the AAP and the AAFP issued guidelines in 2004 recommending initial observation in some cases ( described as nonsevere) rather than immediate treatment with antibiotics.Other groups joined the parade as well.

It will be interesting to see if these two publications lead to changes in recommendations and if so how much of a lag time there will be.

Does endurance exercise damage the heart?

Elevated heart muscle damage biomarkers have been reported in runners after completion of a marathon. Treponin has become the major biomarker used in the clinical assessment of a patient with acute chest pain and elevated levels have been reported in subjects immediately after completing a 26.2 mile marathon and other endurance athletic events.

Does the increase represent myocardial cell necrosis or could the increase be due to "leaky muscle membranes" also known as "cytosolic release". The authors of this recent article suggest the second mechanism may be responsible. I hope they are right as I have not given up running marathons just yet. See here for an abstract of that research.

A 2009 paper by Knebel et al investigated biomarkers and echocardiographic changes in 28 older marathon runners ( aged 60-72) and found no changes suggestive of systolic dysfunction but confirmed the finding previously reported of transient right ventricular diastolic dysfunction.These changes were no different from a group of younger marathoners. See here for abstract. So at least here the older runners were no worse off.

A 2002 paper by Shave,RE et al reported left ventricular systolic and diastolic dysfunction in 11 bikers after a 2 day mountain bike marathon.See here for abstract.

Twenty-seven athletes were studied with echocardiography after what was described as a ultra-endurance triathlon. In all, right ventricular dysfunction was demonstrated and while LV ejection fraction was normal and unchanged in most . However,in the 7 who demonstrated post exercise LV wall motion abnormalities there was a decrease in average LVEF from 57.8% to 45.9%. The authors described also that the "integrated systolic strain decreased from 16.9 to 15.1." I have no idea of the significance of that index nor if that degree of decrease mean anything.See here for abstract.

More elaborate cardiac echo testing was carried out on twenty 2003 Boston marathon finishers pre and post race and one month later. They used regular TTE (trans thoracic echo) but in addition used a technique called "spectal and tissue doppler (TD"). While systolic ejection fractions were unchanged, TD derived indices of LV and RV systolic function were said to be abnormal with at least some of the diastolic dysfunction indicators remaining abnormal one month later.See here for abstract.

Neilan and co workers published detailed results from extensive echo and biomarker studies on 60 finishers of the 2004 and 2005 Boston marathon. See here for full text. They reported elevations in cTnT and NT-ProBNP and similar echo findings to those reported in the previous article from the 2003 Boston marathoners.They noted more marked changes in biomarkers and echo changes in the group who trained less ( less than 35 miles per week in preparation for the race .) So maybe the better trained runners were less susceptible to whatever it is that long events bring about with heart function which is also suggested by the following reference.

A slightly optimistic note is sounded in this paper which describes echo findings of dysynchrony only in first time participants in a long distance event and not in more experienced distance runners and that a predictor of the echo changes was the type of ACE gene polymorphism.

More recently, a review also expressed an optimistic,reassuring note while a rebuttal letter to the editor offered the opposite view proposing the term " exercise induced right ventricular dysplasia" suggesting that the elevation in troponin post endurance events actually reflects tissue death and not just leakage. Both views lack the support on longitudinal follow up data. See here for the two letters.If troponin elevation does signal cell death would we see some type of clinically apparent cardiomyopathy in older endurance event participants after years of beating up their hearts or perhaps myocardial fibrosis noted on autopsy. I wonder if anyone has investigated cardiac function or reported autopsy data on the prolific running Tarahumara Indians.

At least so far there do not seem to be cases of what might represent endurance exercise induced cardiomyopathy.

Three commnentaries and a synthesis on central planning of health care

I strongly recommend this entry on the blog roadtohellthcare by Dr. Douglas Perednia .

He discusses three commentaries on the same broad subject, two by physician bloggers and one by a health care insurance industry executive. The physicians are Dr. Richard Fogoros, aka DrRich of Covert Rationing Blog and Dr. Scot Silverstein of the blog Health Care Renewal and of another blog devoted to issues involving medical information systems.see here.

The important message ( there are other messages as well and all three blog entries are well worth reading) from these blogs is best summarized by a concluding paragraph from Dr. Perednia;

Together these articles cover an enormous amount of ground, but the central message is that we’re making a big mistake if we think that coercing our doctors into using expensive and complex information technology and following the edicts of centralized “panels of experts” is going to get us where we want to go as patients. These are the obsessions and grand managerial plans of people who really don’t know much about doctors, patients and the real-world of delivering and receiving healthcare services. People in government bureaucracies, insurance companies, think tanks and academic medical centers, whose livelihoods depend upon claiming to be smarter, better informed and more creative than clinicians who actually deliver the care. These regulators and technocrats have now been in charge and working their will on healthcare for over 20 years.

More Social InJustice revealed as we find out what is in store with Obamacare

More than one observer commented after the passage of PPACA (Obamacare) that social justice has been served. This included at least one U.S. Senator and spokesmen for both the AMA and ACP. As more and more of the thousands of pages are deciphered and given operational meaning and are jiggered with by Congress we find at least some aspects speak more of injustice than justice.

One case in point was elucidated in this commentary by Reason Foundation Senior Policy analyst,Shika Dalmia. She tells the reader about something called the "exchange recapture subsidy".

Under this provision, the government will go after low-wage families to return any excess subsidies they get under the Patient Protection and Affordable Care Act...

When the government hands out subsidies, it will use a household’s income in the previous year as the basis for guessing what the household is qualified to get in the current year. But if the household’s income grows midyear, the subsidy recapture provision will require it to repay anywhere from $600 to $3,500, compared to the $450 that the law originally called for.

So, if a poor working family manages to somehow increase its income higher than the number which the government guessed to be their income for the purpose of handing out a subsidy they are hit with higher taxes with the result being that the marginal tax rate on their incremental gain in income is insanely high. If much or most all or economics is about incentives, what will that do to efforts to move up to the next level of income.

In the interest of fairness, it has been pointed out (see here) that this recapture mess was apparently added on to the last minute doctor-fix in an effort to scrounge up money to help pay for the subsidies and was part of an amendment authored by Republicans. So, maybe Obamacare set up the subsidies and Republicans tried to help pay for it and that was enacted by a legislature nominally controlled by Democrats and made it even worse. In any event, it is a bad deal thanks to those darn unintended consequences. Central planning might not be as easy as its advocates claim.

More and more to come on the concept of "value" in medical care

I have commented about this general topic before . See here.

The December 23, 2010 issue of NEJM has two articles on this topic. The first is from a member of the faculty of the Harvard Business School, M. E Porter and the second by T.H Lee. Dr. Lee is one of the NEJM editors and is also the network President for the Partners Health System.

Dr. Porter (Phd,Harvard,Business economics) is a widely published and widely quoted author.Concepts that he has popularized include: the Five Forces,the Value chain and the National Diamond model. In 2006 he co-authored a book with Elizabeth Teisberg entitled Redefining Health Care: Creating Value based Competition On Results.


Porter defines value as outcome achieved per dollar spent or value = outcome/cost. He has stated that health care should be restructured to consist of interdisciplinary teams to provide the outcome with the best value across "the full spectrum of health care". Having said that I am puzzled when he says that value is not an abstract ideal.To me that certainty sounds like an abstract idea because as pointed out in the second article in a understatement :

"No one should expect the value framework to be easy to implement.The measurement of outcomes and costs,the organization of clinicians into teams focused on improving care for patient populations,the evolution of a payments system that rewards providers who are more effective in improving the value of their care-they are all formidable tasks."

Formidable indeed. A reorganization of much or most of the medical system to one that conforms with Dr. Porter's conception of how it should be would be required.

I cannot help but be reminded of Will Roger's prescription for fixing the German U-boat problem -boil the oceans. Supposedly, when pressed for details he replied, in typical consultant fashion, he was an idea man and the engineers would have to work out the details. With the value framework model many details would have to worked out and then we could see how it would work and compare real world stuff with academic theorizing. We need to do it to see how it works.I've heard that somewhere before. Is there somewhere in the value framework some input from how much the patient values the service?

Waiting times in Canada for doctors-getting worse

During the last half of 2010 both my wife and I developed some ocular symptoms at different times. I developed more floaters and flashing lights and my wife developed some wavy lines in her visual fields. She called around 10Am to a local Eye group and was seen that day about 4PM by a retinal specialist-Diagnosis ocular migraine. When I called at 8am to the same group I was able to see a retinal specialist at 2PM-diagnosis posterior vitreous detachment with no signs of retinal detachment. Both were not actually emergencies but we were both glad we could be seen so soon and reassured.

Granted we live in a large metropolitan area with no shortage of medical specialists but even so the ease of seeing not just an eye doctor but retinal specialists was impressive.

It is an interesting contrast with recent data published by the Frazier Institute in Canada regarding wait times there to see medical specialists. See here.

Much data is presented and the entire report can be accessed. Here are some samples.
Wait time varies by specialist. For orthopedic procedures there was 35.6 week wait but happily "only" a 4.9 week wait before getting oncology treatment started. There was some good news the wait for psychiatry consultation nominally decreased from 16.8 weeks to a prompt 16 week wait.

h/t to the blog westandfirm

Does Obama care mean Medicaid type care for most-except the rich,

Tyler Cowen, economist from George Mason University,gives his views in this commentary which describes the effects of different payment schemes for medical services.


"Wealthy people will always be able to buy most of what they want. But for everyone else, if we stay on the current course, the lines are likely to get longer and longer.The underlying problem is that doctors are reimbursed at different rates, depending on whether they see a patient with private insurance, Medicare or Medicaid. As demand increases relative to supply, many doctors are likely to turn away patients whose coverage would pay the lower rates.

Since private insurance pays more per service than Medicare which pays more than Medicaid, physicians will increasingly attempt to structure their practices so that they can see more of the higher paying patients and less of the lower paying ones. This trend will increase with the pressures on demand for medical services brought about by ACA. Millions more patients will have insurance cards, more on Medicaid and more receiving cards from the insurance pools but there cannot be a corresponding increase in the number of physicians available to treat the new patients.

Simply put, more docs will restrict the number of Medicare patients they will treat. In fact, as the numbers of Medicare patients in a given internists practice increases the less viable is his practice from an economic viewpoint.I can illustrate that point with an anecdote from personal ( well second hand) experience.

My brother, also a retired doc, was recently told by his internist ( who also is approaching retirement ) that one of his partners "has to retire" because his Medicare patient load in his practice has reached the level at which he can no longer meet the income volume requirements of the practice. This, according to the back of the envelope calculations for that particular practice setting, is 42%.A recent survey by Merritt Hawkins quoted here, reports that 87% of physicians surveyed indicated that they will close or restrict the number of Medicare patients in their practice with a slightly higher number reported in regard to Medicaid patients.

Cowen continues saying:

Most people would end up with low, Medicaid-like reimbursement rates, and would endure long waits and low-quality service. But wealthier people could jump the line by paying more. Think of “Medicaid for everyone” but the rich.

Someone described Obama care as "robbing Peter to pay Paul" with Medicare patients playing Peter and Paul being the previously uninsured who gain insurance cards from the legislation. But with the effects of the looming shortage of primary care physicians it looks like both Peter and Paul can look forward to longer lines and poorer quality care. So while Peter gets robbed, Paul is paid little or nothing.

Price Controls in Medicine-Reality tends to support theory

What is the theory? Answer-price controls tend to 1)cause shortages,2) decrease the quality of the good or service controlled 3) increase demand and 4) encourage the development of black markets,bribes and other "work-arounds"

I am aware of all but number 4 happening in regard to Medicare in the U.S. Now we have apparent examples of black markets (or at least bribes) happening in the setting of the price control health care in Canada. See here for a discussion by Canada born economist, David R. Henderson writing at the blog Econolog.

The news story in the Montreal Gazette describes OB docs in Canada taking side money to guarantee that they will be available at the time of the delivery.

One commenter to the blog entry wondered if U.S. patients, after Obama Care really gets going,will be able to go to Canada to offer side payments to get their treatments there sooner than they could here due to the long lines that will develop when millions of more insurance card carrying patients compete for what will be a vastly too small supply of primary care docs. Actually the problem is already worse as seniors struggle in some areas to see physicians. See here for comments regarding that.

Dr. Don Berwick "answers questions" from senators

Due to Obama's interim appointment of Dr. Donald Berwick to lead CMS, before last week he did not have to appear before a Senate committee.Now he has. I had planned to pontificate about the encounter which seemed typically void of content but Dr. Doug Peredina at the Road to Hellth Blog has already offered an excellent commentary.See here. If you need a sleep aid and have no Ambien on hand you might go here and read and see the video of the prepared comments of the two lead Senators and Dr. Berwick.

What are the plans of Don Berwick's "leaders with plans"?

Dr. Don Berwick,head of the Center for Medicare/Medicaid Services (CMS),has made clear his views on how medical decisions should be made and on what kind of health care system the United states should have.This quote from a book he co-authored with Dr. Troyen Brennan,entitled New Rules leaves little room for ambiguity:

"Today, this isolated relationship[ he is 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.
Berwick in a laudatory address to the British NHS said that we need "leaders with plans" to design and reform the U.S. health care system. He said that"excellent health care is by definition redistribution". See here for a portion of speech praising the British NHS for in which the "redistribution " quote appears.

A likely candidate for such a leader with plans is Dr. Robert A .Berenson.

I first became aware of Berenson's ideas in an important and to my mind- startling at the time- commentary in the Annals of Internal Medicine published in 1998. ( M Hall,and R. Berenson, Ethical Practice in Managed Care.A dose of Realism. Annals Internal Medicine 1998, 395-402.) Here is a quote from that article:

"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."

Berenson and his law professor co-author were proposing a complete revision of the medical ethics that existed from hundreds of years.This fiduciary duty to the individual patient should be replaced by a nebulous co- duty to the collective to which the individual patient belonged. As outrageous as that appeared to someone trained in the traditional medical ethics, an obligation to serve the greater needs of society and to balance that against the individual patient's welfare has appeared to be widely accepted by various medical organizations. See here the New Professionalism as promulgated by the American College of Physicians.

Dr. Berenson's resume includes considerable work in the area of public policy regarding health care and he has served on a number of policy committees for the American College of Physicians. He served in one capacity or another in the Carter and Clinton administrations and was a member of the transition team for President Obama. He held a position with HCFA (April 1998 to October 2000) and according to his resume posted on the website for the ECRI Institute, see here , he was a vice president at the Lewin Group from 1997 -1998 before joining HCFA.

The Lewin group is part of Ingenix which is a subsidiary of United Health Group.That seems to place him at the Lewin Group in the general time frame of the Annals article publication referenced above. It is of interest that the authors' affiliations listed on the article included only a position at Wake Forest Medical School for both Hall and Berenson. ( I could not determine the exact timing of the article as relates to his time with Lewin so at the time of the publication he may well have not been affiliated with Lewin.)He was appointed as a commissioner for MedPac in July 2009 and in July 2010 became a vice-chairman of that organization. The role of MedPac after the-likely-to- be -very- powerful Independent Payment Advisory Board (IPAB), created by PPACA , becomes operational is unclear.

He is clearly a leader and certainly one with ideas and plans. A recent commentary published in the NEJM gives insight to some of his current ideas. In the Perspective section of the July 8,2010 issue of NEJM he submitted a piece entitled "Implementing Health Care Reform-Why Medicare Matters." ( NEJM,vol 363,no.2,p101-103).

While discussing the issue of medical costs and cost controls he talks about the "growing power of [medical service ] providers" (ask most physicians how much market power they have) and since Medicare price controls, already in place now for almost 20 years, won't control total medicare expenditures " we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now".

The operative words there are "at least for now".

More on that appears in the next commentary in the same issue. ( "The Independent Payment Advisory Board : by Timothy S. Jost, J.D.) He says in part that as long as the gap in reimbursements between private insurers and CMS continues to grow physicians will increasing abandon Medicare. He closes with this:

"In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers,it may well be the most revolutionary innovation of the ACA".

Price controls for private medical care would do what economics 101 says price controls do generally. There will be shortages, decreased quality and black markets and other methods to evade the restraints. We have seen the first two in the price controls for Medicare/Medicaid.

I wonder which is worse- a medical policy  leader recommending price controls out of ignorance of basic economics or being aware of the likely outcomes and make that recommendation anyway?

 addendum: Minor editorial change made 5/3/15

Could there really be a down side to the availability of inexpensive generic medications?

A recent commentary in the NEJM talks about unintended consequences of the 4 dollar generics that are becoming increasingly available. Go here for a news report about the concerns expressed by two researchers from Harvard and an audio interview with one of the authors.

Their concern is that with low cost medications often paid for in cash that the data bases used for various purposes will be even less reliable that they are currently . These data bases are used for such things as pay-for-performance and various programs which purport to be quality improvement efforts .Apparently with these cheap prescriptions many pharmacies do not file claims with the pharmacy management companies and insurance companies.

This might translate into less control by the pharmacy management companies and could possibly diminish the value of the services they sell to large insurance companies and the companies that self insure.

I find myself with little sympathy for what they claim is a dark lining in an otherwise silver cloud of cheaper medications and will have even less for the "solutions" that may fix the "problem". It seems to be a problem for the pharmacy management companies and not so much for the patients who spend less on their prescription medications.

At least some of the secrecy of the mysterious RUC is revealed

See here for an enlightening article from WSJ that goes -at least to some degree- behind the veil of the powerful AMA brain child, the RUC.Well, at least we are told who is the current chairman of the RUC and that she gave out baseball hats with "RUC" on the front and organized bowling for team building. This is encouraging to those who felt a major problem with the RUC was lack of baseball hats and bowling.

Once again kudos to the tireless Dr. Roy Poses for his continuing efforts to shine light on the AMA's RUC which plays a key role in dividing up the Medicare physician payment money which itself is limited by the price controls in place since 1991. Go here for his latest review of that situation and information about some recent efforts that have been somewhat successful in revealing what goes on behind the RUC veil.

We have had central planning in place for Medicare physician payments for almost a decade and we continue to see the consequences,both intended and unintended,not the least of which is a shortage of primary care physicians.

Pay for performance (P4P)-Goodhart's law aside is it unethcial?

This is a re-edited and lightly re-written version of a posting I made several years ago. Several years have passed and P4P has gone from a trial balloon to a more and more generally accepted fact of medical life, even though there continues to be cogent arguments in opposition to it and the broader bogus concept of "quality" measures.

Dr. Edmund Blum, an internist from Brooklyn makes the argument that pay for performance (P4P) involves a "irresolvable conflict " with the ethical standards of the medical profession.( American Medical News,Nov. 6,2006 issue in their "Professional Issue Section.) My bolding.


He says that P4P rests on 3 flawed premises or fallacies the most important of which is that P4P is consistent with medical ethics. He argues that it is not. (The other 2 fallacies are:P4P rests on a valid statistical foundation and P4P will improve the safety and quality of patient care). To those I would add a 4th namely that Goodhart's law would not be operable in the medical care setting.It has definitely been shown to operate there as well.

I quote:

"[medical] standards derive from a core of fiduciary responsibility, in which one person, the patient, depends on the superior knowledge and skills of another, the physician, and places complete confidence in that person in regard to a particular transaction-in this case, medical care."

"The fiduciary is held to a higher standard of legal and moral conduct and trust than a stranger or a business person...[This] obligates the physician to do his or her best for the patient regardless of reward.The duty goes beyond the 'due care' standard or tort law to a higher level of loyalty and commitment that is not contingent or rewards or penalties."

The idea of P4P involves an assumption that "the fiduciary relationship is insufficient motivation for the physicians to do their best."

To accept P4P is to accept the notion that physicians have not already been obligated to do their best for the patient and to place patient welfare above financial rewards and that they have to be giving a tip or a bribe to do their job. Dr. Faith Fitzgerald was on target when she said

" We must not servilely accept gratuities for doing our duty."

A few decades ago,I began the transformation from a lay person to a physician. Part of what was branded into my limbic cortex in that several year long process was the responsibility physicians have for their patients, a responsibility to do what is right for the patient,a responsibility to place their welfare above personal financial concerns. That responsibility cannot be canceled by a purported imperative to somehow also act as a steward of "society's resources" and work for social justice as the New Professionalism Charter implores.(See here for DrRich's comments on what that Charter has done to medical ethics).The prime directive was-and still should be- an individual physician's responsibility is to the individual patient .

The acceptance of P4P is so antithetical to the basic medical ethical tradition that I cannot believe professional organizations of physicians are supporting it, but they have -almost all of them have at least expressed written support. Tacit support of and advocacy for for P4P is equivalent to saying the ethics and culture of physicians are not adequate and to provide good clinical care it is necessary for third parties to proscribe behavior and reward and sanction accordingly. To sanction such thinking, in the words of Dr. Blum, is to "push us farther down the slippery slope to professionalization".

I am more pessimistic.We may already be at near the bottom of the slope and I see effort being made by relatively few physicians to try and climb back up.

Not what Dr. Berwick might want but more market based health care

More clinics are appearing in drug stores and groceries across the country providing quicker and cheaper health care with much shorter wait times for appointments. See here. ( h/t to economist Mark Perry's blog,Carpe Diem)
There are said to be about 8,700 of these urgent care clinics in the country.


These are not exactly the ACOs that are being heralded by some of the self appointed medical elite, the "leaders with ideas". The mini-clinics business models is somewhat simpler and more transparent than the Under Ware Gnome business plan of the ACOs.

ACO and HMO,A distinction with or with/out a difference -Are ACOs an example of Underware Gnome economics?

The current concept of an Accountable Care Organization (ACO) seems to have arisen at a 2006 meeting of MedPac and Dr. Elliot Fischer of the Dartmouth Atlas.See here for the 400 page transcript of the meeting.

A good place to begin an inquiry into HMOS v.ACOs is this entry by Jason Shafin,Phd Economics,on his blog Health-care Economics who discusses three difference between the two.

Dr. Robert Berenson,of the Urban Institute and of the Center for Studying Health System Change (HSC) and now a vice chair of the soon-to-be a very important player in health care ,namely the IPAB) co authored this article which is barely luke warm in its support of the ACOs and is even skeptical. See here for more on this center for HSC.

A later article he co-authored with two colleagues from the Center For Study of Health System Change went further and issued the warning that large vertically integrated organization such as ACOs can actually drive up health costs and offered the suggestion that price caps ( aka price controls) might be necessary.ACOs are, of course,said to be a means of increasing quality and decreasing costs at the same time.


A terse characterization of ACOs was offered by Dr. John Goodman in a comment to Dr. Shafin's above mentioned blog entry - " An HMO on steroids"

Two big issues with ACOs are market power and anti-trust concerns.So Far the FTC is still mulling over the rules of the game. See here.

I suggest a major difference between HMOS and ACOs is that the legal aspects of HMOs are well defined as are the regulatory rules while the rules for ACOS are yet to be written. There is so much uncertainty around almost every aspect of ACOs I am reminded of the South Park 's Underwear gnomes whose business plan is as follows:

Step 1.collect people's underwear
Step 2.???
Step 3.Make money

with ACO's business model being

Step 1.set up ACO
Step 2.???
Step 3.save money and increase quality of care

or perhaps

this version of the business plan of ACOs from WebMd is a more accurate description:

Step One: 'Provide connectivity and a full suite of services to the healthcare industry that improve administrative efficiencies and clinical effectiveness enabling high-quality patient care.'

Step Two:

Step Three: Profit.

Yes, step two is blank.

"The Secretary (HHA) shall determine"...can we all have a waiver?

According this editorial from Investors Business Daily, about one million workers have been spared a loss of their employer sponsored"minimedical" insurance, at least for the next year or so, until long after the November 2010 elections.

That is number whose insurance coverage has been "saved" by the waiver given by the Secretary of HHS.This includes 115,000 from McDonalds and 350,000 from the United Federation of Teachers Welfare Fund and according to IBD some 28 other companies or entities.

Quoting from IBD:

"How do you get a waiver from a law, anyway? This law was passed by elected representatives of Congress. How can unelected bureaucrats say some must obey this law but some don't have to?

Well, in lieu of specific guidelines in the law, it is riddled with the phrase "the Secretary shall determine." Which means we serve at the whim of the secretary of health and human services, currently Kathleen Sebelius."

Rule of law or rule of whim or of political expediency. This is likely just a sample sample of the many determinations that will be made by the HHS Secretary as ACA unfolds.

More welcome light shined on the problems with the"New Professionalism"

Kudos to Doug Peredina over at the blog roadtohellth with this commentary on medical nannies,the activities of CVS Caremark alone those lines and the broader topic of the problems with the new medical professionalism, also known as the "new ethics", a topic of considerable concern to me and one about which I have ranted repeatedly.See here and here.

Dr. Peredina discusses a lawsuit filed against CVS . Dr. Troyen Brennan is the CMO and executive vice-president of CVS Caremark. The following is a quote from the book "New Rules" which was written by Dr. Brennan and the current head of CMS Dr. Donald Berwick. They are discussing the physician patient relationship and say the following:

"Today, this isolated 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.”

In 2007,Dr. Brennan,then the executive vice president of Aetna cowrote an article in JAMA entitled "Managing Medical Resources. A return to the medical commons" which I blogged about ( see here) and I said in part:

"They speak of an abstract hypothetical " medical commons" and how the current emphasis by the physician on the welfare of the individual patient will spoil the commons much as the farmer who selfishly grazes his cattle on public land without regard for depleting the resource will destroy the resource.Physicians are implored to "reconstitute the medical commons" and think in terms of resource conservation and allocation so at the end the greatest medical good can be done for the greatest number of patients.They admit there is not currently such a commons. There never has been so I am unsure how a return is possible."

With this increasing constraint of decentralized individualized decision ( translation-individual docs advising individual patients about a course of action) someone else must make those decisions. Do you think the folks at insurance companies and pharmacy management companies might enjoy that role? Isn't it interesting that the head of CMS and the vice-president of a pharmacy management company share the same view of the "proper"role of the physician?

Also kudos to DrRich at his blog Covert Rationing Blog with this thoughtful and important criticism of the new medical ethics, in which the traditional physician patient relationship with its fiduciary duty of the physician is being replaced with a nebulous duty to society . Also DrRich-in his real life persona of Dr. Richard Fogoros- hosted a discussion on Sermo which from my vantage point was well received and he did an admirable job in fielding a variety of questions. It is instructive and worrisome that a number of the physicians writing in had not even heard about the New Professionalism. If you have not, go here to read about it in the original.

Also kudos to Dr. Beth Haynes at the blog Blackribbonproject for this entry concerning various aspects of the attack on the traditional physician-patient relationship.

This important topic deserves all the attention it can get.

Is government by whim the social justice that Obama advocates congratulate themselves about?

Obamacare mandated a percentage of premiums be used by health insurance company for patient care. Several large employers ( McDonalds and others) complained that would not allow them to continues to offer low premium health coverage to their lower paid employees.( It should be noted that there is some controversy if McDonald really complained or not, but that is not the major point).

The point is that the Secretary of HHS, Kathleen Sebelius waived the requirements for one year for certain employers and one large union welfare fund.

Ed Morrissey made this comment regarding this incident:

The Rule of Law depends on an environment with clear regulation and unbiased enforcement. From the start, ObamaCare lacked any clarity in regulation. Congress filled the bill with the phrase "The Secretary shall determine" in place of establishing rules and regulations for the massive regulatory regime Congress created. Now, the White House has added arbitrary enforcement to uncertain regulation and opaque processes. This is not the Rule of Law, but the Whim of Autocracy.

Obamacare contains hundreds of pages with anything but clear regulation and to expect unbiased enforcement is to believe in the power of fairy dust so much power being given by the four little words found throughout the bill "the secretary (of HHS) shall determine".

Both the AMA and ACP have congratulated themselves for their support of the bill because it served "social justice".

Are the actions of the HHS secretary an example of this social justice? Social justice by favoritism (catalyzed by the proximity of the upcoming election in this instance) is what they got.

What else they ( and all of us) may have gotten is more regime uncertainty. This is a term or concept developed and emphasized by the economist Robert Higgs. Higgs's thesis is that at least an important element in the prolongation of the great depression was the business uncertainty brought about by the actions of FDR. Simply put they were afraid to invest because they didn't know what the administration in Washington would do next. See here.

Higgs suggest a similar situation exist now. We have had some but not all major financial institutions bailed out with tax payers money,we have had some auto manufacturers bailed out and we now have some employers exempted for some provisions of a massive new law with powers so sweeping that one of its major effect is a deep and wide uncertainty.

Nancy Pelosi's comment that we have to pass the bill to find out what is in it was only partly true.When enforcement or administration of law is arbitrary we will be finding out piece by piece what it means with no way of predicting what will happen next.

Dr. Don Berwick addresses leaders of ACP, Tells them top-down government mandates won't work

Some would find that headline hard to believe. I do.While I believe the message I am surprised by the messenger.

It is hard to believe that the head of large government entity (CMS), which is noted for its top down mandates would express such a view. It is hard to believe that someone who heaped praise on the British National Health Service,also well known for its well known history of mandates, would hold such a view.

It is hard to believe that someone who has said that a health care system must,he emphasized the word "must", involve redistribution would say that. To achieve redistribution there must,now I emphasize the word "must", involve government mandates.


Berwick's address to the American College of Physicians Board of Governors was discussed in a blog entry by Bob Doherty,ACP's man in Washington, in his blog "The ACP Advocate Blog" See here for that entry.

There is much in Dr. Berwick's writings that strongly suggests his high regard for "rules with authority" and low opinion for the traditional doctor-patient relationship . The following is a quote from the book,"New Rules" which he co-authored with Dr. Troyen Brennan.

"Today, this isolated 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.”


He advocates regulation,rules with authority, constraint of individualized decision making and reformulating medical ethics. Clinical decisions, in this view, should not be in the hands of the patient and his physician. These views are clearly those of someone who believes in authoritative control over those clinical decisions, so if he believes that government top down rules won't work then he must envision some other,non-governmental system of controls.

Indeed, he has talked about vertically integrated medical systems which can seek out cost effective treatments and coordinate care referring to such things as accountable care organizations,and medical homes.So could he possibly think that they will be the source of the mandates rather than the federal government? The promotion of such organizations was a major theme of a recent article in the Annals of Internal Medicine by three member of the current White House staff which I blogged about here.

With the passage of the health care remake bill and the birth of scores of federal entities with the power to issue mandates and the unprecedented power given to the secretary of HHS to make mandates what else could possible happen but that medicine as it will be practiced will be medicine by federal mandate?

Mr. Doherty's interpretation of what Dr. Berwick has written is that Berwick believes that change must come from the bottom up. It is true that Dr. Berwick has earned an excellent reputation for working towards and catalyzing grass roots innovations to improve patient care and much of his rhetoric is consistent with that effort and promotion of that idea.

However, he is not leading a organization devoted to grass roots solutions but rather one whose history and thrust and machinery has and will continue to issue and enforce orders from the top.

Have we heard from Dr. Berwick any plans to dismantle the current CMS system of command and control?What will be the relationship of these vertical organizations to the central control systems of CMS and those created by the health care bill? Will they be the administrative arms of the central controllers?

Whatever vertically integrated entities emerge and regardless of the relationship of the accountable care-type organizations to the government particularly troubling to me is that the "bottom" of Berwick's bottom up solutions is not all the way down, namely to the level of the individual patient and the individual doctor as he has made it clear that the traditional doctor-patient relationship needs to be replaced."This relationship is no longer tenable or possible".

It is hard to say it better and simpler than the following questions posed by Dr. Edmund D. Pellegrino (JAMA,May 24/31/1995,Vol. 272,no 20)

" Is medical ethics a social, historical, or economic artifact? Or are there some universal , enduring principles?

Was the traditional physician-patient relationship with the strong and controlling fiduciary duty to the patient's welfare merely an artifact of an earlier economic time which was largely free of the third party payer hegemony? Fee-for-service and the traditional physician fiduciary duty are the two major enemies to centralized (private or public) control over medical care.

Avandia just barely hanging on and now Actos accused of increasing risk of bladder cancer

The TDZ's seem always to be in the news,the bad news. First, Rezulin was taken off the market because of liver toxicity.Next, the issue of Avandia increasing the risk of heart attack arose and arose and arose and seemingly the issue will never be settled. Now Actos is being accused of increasing the risk of bladder cancer.

Most recently the FDA has taken action to strictly limit its use and make it fairly difficult for a new patient to be prescribed that drug. In Europe, apparently it will be taken off the market and folks currently taking that medication will have to be switched to something else.

An interesting action taken by the FDA is to require GSK to commission an independent "re-adjudication" of the RECORD study. This was the clinical trial with 4447 patients in which rosiglitazone (Avandia) was compared with the combination of metformin and a sulfonylurea and concluded that results was inconclusive in regard to what everyone was interested, namely cardiovascular outcomes. Somehow the FDA expects more analysts looking at the data will turn the inconclusiveness into some conclusions. More likely it won't but then maybe everyone can move on and worry about some other adverse effect of something else.

FDA's reasoning seems to be that if these new adjudicators can get an answer then the TIDE trial ( still another trial that the optimists think will settle the issue) will not have to be taken off of hold. The FDA put TIDE on full clinical hold.

Several years ago when one attended the infomercials with food ( AKA drug company sponsored CME -dinners) several speakers could talk about little else but the PPAR receptors and after much time and money was aimed at doing something really good therapeutically with those receptors little was accomplished. See here for some comments by a research insider about the PPAR story.

Early on in the Avandia kerfuffle I went on and on about the issue of "small"increases in relative risk and how is relatively easy to tell a big thing from a little thing but how difficult it is for epidemiology to tell a little thing from nothing at all. The original Nissen and Wolski paper talks about a relative risk of 1.43. With risks of 3 and 4 there is typically little to argue about. With RRs less than 2 it seems we go round and round for a long time before the combatants run out of stream.

What is fate of physician-patient relationship in a Don Berwick designed health care system ?

The following quote from the book Dr. Berwick authored with Dr. Troyen A. Brennan,which is frighteningly entitled , "New Rules" answers the headline question. (see here for a review of that book published in the NEJM)

H/T to the blog " Black Ribbon Project"

“Today, this isolated 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.”

I have expressed my concern abut Dr. Berwick views before and one such commentary was re-e-published by Kevin,M.D. with my permission. One of the replies to that entry on his web site accused me of taking his remarks " out of context". While it is true that remarks and words and phrases can be cherry picked to give an impression contrary to the speaker's intentions I offer a friendly, rhetorical challenge to anyone who can propose a context in which Berwick's words could be said and not mean anything other than their obvious meaning. OK, I can think of one and it is trivial. The author precedes that paragraph with the words "I do not believe the following".

Berwick's and Brennan's views dovetail with the ground work constructed by the "New Professionalism" (see here for the details of that project ) which implores physicians to somehow balance their duty the patient with some nebulous responsibility of stewardship to take proper care of society's limited medical resources and strive for social justice. Dr. Troyen Brennan was the chair of the Professionalism project. In fact Dr. Brennan name crops up more than once in a narrative of the transformation of medicine in which medical care is taken from the hands of individual physician and into the control of various organizations.

In 2002, Dr. Brennan's new Professionalism was revealed to the world in the Annals of Internal Medicine ( see the above link). (OK, it wasn't just Brennan's,others played a role.)Physicians were admonished to work for the good of society and not just be concerned with the parochial concern for their own patients.

In 2006 Brennan and Berwick published the book, "New Rules". The operative word is "rules".

In an Article in 2007 (JAMA,Vol 208,#6,p 670) Drs J. Cohen, ,S. Cruess, and C. Davidson report their " discovery " that individual docs basically could not resolve the ethical dilemma posed by balancing their efforts for the patient's welfare with their duty to work for the good of the herd. ( see here for my comments on that article) What was needed was a "Medical Societal alliance" which could be made manifest through large vertically integrated organization such as something called an "Accountable care organization (ACO). Note, the old medical ethics had no major, crisis -level conflicts it was the New Ethics that posed the problem that the author purport to remedy with their nebulous alliance between collective abstractions.

Another article in JAMA in 2007 carried this theme further. The article was written by the then President of the American College of Physicians, Dr. Christine K. Cassel and the then executive vice-president of Aetna Insurance, Dr. Brennan. (JAMA ,June 13, 2007, Vol 297, no. 22, p. 2518, "Managing Medical resources.Return to the Commons")

They speak of an abstract hypothetical " medical commons" and how the current emphasis by the physician on the welfare of the individual patient will spoil the commons much as the farmer who selfishly grazes his cattle on public land without regard for depleting the resource will destroy the resource.Physicians are implored to "reconstitute the medical commons" and think in terms of resource conservation and allocation so at the end the greatest medical good can be done for the greatest number of patients.They admit there is not currently such a commons. There never has been so I am unsure how a return is possible.

The medical commons figure of speech seems bizarre and lame.While a grassy knoll for the villager's sheep can be defined by a specific surveyor description, the "medical commons" is a extremely large amorphous array,the elements of which defy enumeration, and is every changing, with some elements growing ,others contracting and innovations cropping up constantly. Various entities own various elements of this array-society owns none.The skills,and knowledge of thousands of physicians are aggregated and then allocated as if somehow society own them.There is no easily defined entity called "medical resources". Rather,it is an amorphous abstraction.Further, to speak of allocation means some one or some elite group will be the "allocator in chief ". Decisions will not be made by thousands of individual physician-patient pairs, since those individual physician-patient pairs plans to spend money are the worse nightmare an officer of a health care insurance company could have. Is anyone surprised that an officer on a large medical insurance company would propose a plan to eliminate the pesky problem of physician-patient "dyads" scheming to spend the insurance company's money simply because the two agreed such expenditure would be in the patient's interest?

The old follow-the-money strategy continues to have explanatory power. but why would the leadership of the ACP take part in that philosophical sham?