retired doc's thoughts
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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 ...
Friday, May 12, 2023
What retired doc learned from economics
humans are pattern seeking story telling creatures.
Economics cannot provide the level of certitude that the experimental sciences provide.The best it can do is look for patterns and then tell stories.
What if physics were like economics From Jim Manzi Uncontrolled:The surprising payoff of trial-and-error for business, politics and Society.
And how those stories vary-eg Milton Friedman and there is no free lunch versus the better than a free lunch claim that fiscal stimulus in an economy which has less than full employment will give a free lunch and will generate stillmore free lunches.(This from the advice that arose fromthe work of Lerner and Hansen taking Keynes thought and turning them into just about the coolest tool a politician or elected official could have ever received.)
It began with Ayn Rand and may have ended up on life support with Covid19 and how humans have reacted
can recent innovations in health care delivery be explained in the context of Baumol's disease
Covid 19 2022 101 -the basics
New data on angio invasive follicular thyroid cancer necessitates change in ATA guidelines
Thursday, May 11, 2023
Thyrotrophin suppression to prevent thyroid cancer recurrence
Sunday, May 07, 2023
Was the old time medical ethics just an artifact of economics?
Monday, May 01, 2023
How reliable are tissue diagnosis of follicular thyroid carcinoma
Monday, April 03, 2023
I did not go to medical school to practice population medicine but maybe medical students do now
Those were pillars of medical ethics and of the medical culture.
However, in recent years we have seen a major effort ,with varying degree of success, by prominent medical organizations and foundations to change medical ethics and the culture of medicine.This is not just my interpretation of recent trends but direct quotes from leaders of several medical organizations say that is exactly what they wish to do.
While a number of organizations including foundations and think tanks have taken part in this effort my focus in this commentary is on two such organization-the American College of Physician (ACP) and the American Board of Internal Medicine (ABIM) and its affiliated foundation the ABIMF.
Basically the proposed change is the shift from the medicine of the individual wherein the physician acts in the interest of the patient ,that is as his fiduciary agent to the concern for the health of the population or the collective which is referred to by its advocates in the less emotionally charged term "population medicine".
ABIM and ACP have orchestrated two major initiatives; the Physician's charter and the Choosing Wisely Campaign. the later of which I believe which functions as a Trogen horse.
The 2002 publication of Medical Professionalism in the New Millennium: A Physician Charter played a major role in the movement toward the practice of population medicine .It was the result of a collaboration of the ABIM Foundation,the ACP Foundation and the European Federation of Internal Medicine. The Charter described three fundamental principle of medical professionalism.
Principle of primacy of patient welfare.
Principle of patient autonomy
Principle of social justice. Physicians must promote social justice in the health care system, including the fair distribution of health care resources.
Although the Charter said " physicians must reaffirm their active dedication to the principle of professionalism.".The third principle,social justice, had not been a feature of traditional medical ethics so it could hardly be reaffirmed. The authors gratuitously added a new principle to medical ethics and then in their concluding remarks pretend that physician must reaffirm a principle not previously part medical ethics .
The Charter also presented a "set of Professional Responsibilites", one of which was:
Since the Charter was proposing a sea change in medical ethics,voices were raised in opposition.
A particularly articulate critique was made by Dr. Richard Fogoros, who was blogging under the name DrRich on the blog The Covert Ratoning Blog . Quoting from his January 18,2010 blog commentary:
"The New Medical Ethics,...(Annals of Internal Medicine, February 5, 2002, vol. 136, pages 243-246), is deficient in the following ways:
- it undermines the foundation of the doctor-patient relationship,
- it threatens to fundamentally destroy medicine as a legitimate profession, and
- it places patients at grave personal risk whenever they encounter the healthcare system"
The second major initiative to change the medical culture began as what seemed to be a very reasonable and non controversial suggestion. Physicians and their patients were encouraged to have a dialogue and discuss various tests and treatments as they applied to a given patient in regard to the elimination or at least reduction in the number that were thought to be unnecessary,possibly dangerous and costly. This initiative is known as the choosing wisely campaingn.
This quote for Wikiipedia summarizes the relationship between the Charter and Choosing Wisely :
...The charter states that physicians have a responsibility to promote health equity when some health resources are scarce.[1] As a practical way of achieving distributive justice, in 2010 physician Howard Brody recommended that medical specialty societies, being stewards of a field, ought to publish a list of five things which they would like changed in their field and publicize it to their members.[1][17][18] In 2011, the National Physicians Alliance tested a project in which it organized the creation of some "top 5 lists".[1][19][20] Analysis of the National Physician's Alliance project predicted that the health field could save more than US$5 billion by cutting waste.[1][19][21]"
So the basic principles are : physicians are stewards of medical resources and that they need to work for health equity and that by cutting waste and saving money distributive justice would be furthered.
Dr,Cassel in an August 2012 talk about Choosing wisely at Universality of California recalled that the CW program really begin a year earlier when she and others, including Dr. Berwick and leaders of the not for profit publication Consumer rRports met.
Consumer Reports,though purportedly non political supported Obamacare and the presidential appointment of Dr. Don Berwick to lead CMS.
Population Medicine as a form of utilitarianism based on on some nebulous impossible to quantify notion of utility or happiness based on the purportedly objective measure of QALY.
I did not go to medical school to work to maximize or optimize the overall health of some population based on some metric and some ultimately subjective value judgment of a planner but times have changed and my generation of physicians is retiring and dying off.The dogs barked and the caravan moved on.
Friday, March 17, 2023
Will long term endurance exercise really keep a youthful heart
Willl longtime endurance exercise really preserve ( help preserve) a compliant left ventricle (LV) and mitigate the age related stiffening of the LV and the aorta?
Is the only solid evidence for that thesis the extensive work of Dr. Ben Levine and his coworkers at the Institute for Exercise and the Environment?
Some longitudinal studies have shown that active exercise achieve grater preservation of 02 max than do sedentary people but there are studies that contradict those findings.
Possible mechanisms by which long term exercise might preserve a compliant LV include:
animal work showing that rats with long time exercise develop elongated muscle fibers
improvement in calcium transport during relaxation 'increase in myocytes and improve fatty acid oxidation decreasing lipotoxicity Bhella , Impact of lifelong exercise dose on left ventricular compliance and distensibiity J Am Coll Cardio. 2014 vol 64 no 12
Beware- CHATGPT 's references sometimes are fabrications
Saturday, February 18, 2023
Here is how a physician can be a steward of health care resources
As the years went by medical school, residency, fellowship all had their share of difficulty concepts to master and there was always something else to learn - always the perception that you needed to known all you could as you had people's health and lives in your hands.The rewards could be great but so were the challenges and the continuing obligation.
But then with the publication of the Physician Charter,the new medical professionalism,things seem to get even harder as a new daunting task appeared on the scene. Now doing your best for your patient to live up to your fiduciary duty was not enough, you also had to work for social justice and be a steward of society's finite medical resources.
Wow, that certainty didn't sound easy. In fact I had no clue as to how to live up to that new obligation nor understood exactly what these those terms even meant and was it not the case that sometime an individual's best interests conflicted with those of society assuming that the later interests could even be appropriately defined.
It was years later when I finally realized how I could live up to these new ethical obligations an exemplify the traits expected and demanded of a professional in the new milimeum and now it seems very easy.
It is easy because the medical progressives,the elite,the thought leaders , the hierarchy of various medical professional organizations will make it easy for the rank and file medical practitioners in the field. These leadesr will determine what is of value not only to the patients but to society. So based on what is high value guidelines will be forthcoming and the field docs will only have to adhere to them to do what is right for the patient which will also be what is in the best interests of society.
Any concern that I might have had about some conflict between the interests of the individual patient and society will vanish because as Victor Fuchs has told us what is good for the group will necessarily have to be good for your patient as well as he is a member of the group which is benefited. It gets better. The tests or procedures that you deny your patient is now understood to not be rationing at all. This is the case because some of the members of ACP elite has wisely redefined rationing as restricting the use of effective,high value care. So restricting lower value are is not by definition rationing at all.
This important role of determining what is high and what is not high value care is not the slam dunk that some members of the USPSTF task force said in regard to their pronouncement of no need to do any PSA screening. No this type analysis requires specialized expertise and training and is "typically performed by investigators", ( such as those writing the above referenced Annals article)