What retired doc learned from economics

From Leamers book on Maco
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

It (my general political-philosophical set of beliefs) really did begin with Ayn Rand, first reading

"Capitalism, the Unknown Ideal " and then devouring Atlas shrugged and Fountainhead.

By late adulthood

my political-philosophical beliefs were fairly well settled in to be.

1)Strong belief in the importance of private property and rule of law and contract law and limited government and that central planning was for the most part a bad game plan

2)support for the kindergarten lesson of "don't mess with other people or their stuff". 

3)Individual freedom was important and the libertarian non-aggression axiom seemed like a good maxim;

4) The history of the 20th century made it quite clear that economic central planning as in communist USSR and China was a disastrous idea leading to the death of millions of people. 

I generally felt fairly comfortable in my self chosen set of reassuring voices in a my echo chamber

consisting of various blogs,books and podcasts and U tube sites until recently. 

 Coincident with the Covid pandemc,Some of the web sties, and  blogs which over the year s have been reliable dispensers of Austrian economic dogma  and general libertarian thought have with an alarming frequency published pseudo-scientific hogwash in regard to the covid 19 pandemic. 

One such posting denied the validity of current concept of viruses putting forth instead the bizarre notion that what are called viruses are actually waste products of cellular damage brought about by various type of  electromagnetic waves. All of the pseudoscientific is not quite as bat-sh**t

crazy as this denial of basic biologic knowledge but some are very close. For example, the claim that wearing a mask will lead to carbon dioxide retention and that mask wearing will lower your immune response , both claims lacking in scientific proof .

The covid pandemic has spotlighted the conflict between the common good and individual freedom.  

Nicholas Talib's comment seemed to an effort to  settle the apparent conflict when he said to remember that the principle underlying libertarian ,axiom , is the non aggression axiom

. If you believe that there is asymptomatic transmission of   a potentially serious  and potentially fatal disease the transmission of which can be significantly  mitigated by wearing a mask, then you need to wear a mask to conform with libertarian basic axiom if  you cannot socially distance .To not wear a mask with those assumptions in mind is to disregard or dismiss the non aggression  moral imperative as you are taking an aggressive act against strangers and or friends. 

However, it seems that there a number of vocal libertarian and libertarian leaning conservatives who do not agree with some or all of the following assumptions

1) There is a Covid 19 pandemic

2)Covid 19 is spread by respiratory droplets and aerosols and fomites

3) Masks will mitigate the spread of covid 19 

4)social distancing will mitigate the spread of covid 19

5) Viral vaccines have been shown to be safe and effective and have provided a "herd immjnity" for a a number of viral illnesses

 There is are a number of vocal libertarians and libertarian leaning conservative who believe or at least espouse some or all of he following:

1.The pandemic is a hoax

2 covid vaccine is a means of population control

can recent innovations in health care delivery be explained in the context of Baumol's disease

Note this blog post is the first of a joint authorship with chatgpt and me. Can recent innovations in health care delivery be explained in the context of Baumol's disease? the following is what chatgpt said in regard to the title question "While there is no single solution to address the cost disease in healthcare, several strategies have been proposed and implemented to mitigate its effects. Here are a few examples: Technological innovation and telemedicine: Advancements in technology, such as telemedicine and digital health solutions, can improve the efficiency and accessibility of healthcare services. Telemedicine allows for remote consultations, reducing the need for physical visits and lowering costs associated with in-person care. Task-shifting and delegation: Healthcare providers can optimize their workforce by delegating certain tasks to other healthcare professionals or utilizing non-physician personnel, such as nurse practitioners or physician assistants. This helps to improve productivity and reduce costs by efficiently utilizing the skills and capabilities of different healthcare professionals. Preventive care and chronic disease management: Emphasizing preventive care and proactive management of chronic diseases can lead to better health outcomes and reduced healthcare costs in the long run. By focusing on early intervention and preventive measures, healthcare resources can be allocated more efficiently, potentially mitigating rising costs associated with advanced or emergency care. Health information technology (HIT) adoption: Widespread adoption of electronic health records (EHRs) and health information exchange systems can enhance coordination and reduce redundancies in healthcare services. Efficient data sharing and interoperability can help healthcare providers make more informed decisions, reduce medical errors, and improve overall productivity. Payment reforms and value-based care models: Shifting from fee-for-service reimbursement models to value-based care models incentivizes healthcare providers to focus on quality and outcomes rather than the volume of services provided. These models promote efficiency, care coordination, and cost containment while aiming to improve patient outcomes. Collaboration and integration: Encouraging collaboration and integration among healthcare providers, such as forming accountable care organizations (ACOs) or healthcare networks, can improve coordination, reduce duplication of services, and streamline healthcare delivery. This integration can help optimize resource allocation and improve overall productivity. . Note chatgpt's strategies should be considered in most instances as aspiration. .

Covid 19 2022 101 -the basics

Three  basics emerge as we enter year three of a pandemic that has claimed 900.000 lives in the United States"

 Covid 19 is a respiratory virus that spreads by aerosols and there is asymptomatic spread as well as symptomatic spread and a significant amount oif the spread is from high spread events aa super spreader events 

1) Effective Masks prevent infection (N 95 or equivalent )

2)Vaccines prevent serious disease and death to a large degree but vaccines do not prevent infection.

3)vaccine effectiveness wanes over a period of months and booster are required as does immunity acquired by infection 

Corollaries. Vaccines do not prevent infection. To the extent masks prevent spread of infection they will naturally prevent death and serious illnesses. Mask effectiveness does not wane.

The protection afforded by vaccines and by contracting covid 19 wanes over time. Boosters are necessary.

Unless and until a vaccine that prevents infection is developed the human experience with covid will depend on the mutations that occur with covid and the development and availability  of safe and effective treatments given promptly after a rapid diagnosis. If covid mutates to a gentler affliction no more than a bad cold or mild to moderate severe flu,,, great.  But If the mutation history of covid continues as it has so far , we are not through with covid no matter how much folks pretend that is the case. Mutations will continue , infection and  surges will continue and boosters will be needed. Mutations may arise as they have so far that have varying degrees of  vaccine escape and varying degrees of virulence. 

The polio vaccine prevented infection by blocking GI tract mucosal invasions and until humans develop a vaccine that protects against covid invading the nasal mucosa or develop a vaccine that is effective against all corona viruses we are not going to say that we are through with covid.

New data on angio invasive follicular thyroid cancer necessitates change in ATA guidelines

With the publication of an article from Japan involving study of 303 cases of encapsulated angioinvasive FTC the current ATA risk classification of angioinvasive into those with four or more instance of angioinvasion ( deemed high risk) and those with three or less (deemed low risk) needs to be revised. The ATA risk classification is low, intermediate and high and the recommendations for each vary considerably.The current guidelines indicate that a patient with 4 or more angio invasions is high risk and a patient with 3 0r less foci of angioinvasion is consdiered low risk and therfore not needing remant ablation. Yamazaki et (1) reviewed 290 cases of FTC with angioinvasion (AI).These patients were free of metastasis at presentation and were seen at the Ito hosptial from 2005 to 2014. Disease free survival in those with one AI had a 94.9 % 10 year DFS while a patient with 4 or more had a 83% DFS, Those with AI of 1-3 had a DFS of 86.3 while patients with 4 or more had a DFS of 83.3 This is not statistically significant. Patients with angioinvasion of less than 4 are consdiered low risk by the ATA criteria Yamazaki' data show there is not a prognostic difference between a patient with three and a patient with four foci of AI . Yamazali et al Encapsulated angioinvasive follicular thyroid cancer.Prognostic impact of the extent of vascular invasion.Ann Surg Oncol 2022 feb 25

Thyrotrophin suppression to prevent thyroid cancer recurrence

Fron reading the Amercan Thyroid Association;s thyroid cancer guidlines I had assumed that the notion that TSH supression to reduce risk of cancer recurrence was both widely accepted and clearly demonstrated by underlying mechanistic studies and by emperical clinical data. The notion is widely accepted but a mechanistic rational is controversal with their being in vito data that both support and deny the role of TSH in cancer growth and emperical data are contradictory. A 1998 report from the NTCTcs (Cooper DS,THyroid 1998)TSH was independly associated with disease progression in high risk patients but only in univariate analysis and not in multivariant models. A 2007 report from NTCTCS (Jonklass j, et al ) which was said by the authors to be the first to show superior outocme with THST They reported improved outcomes in high risk patients ( stage 111 and iv) The 2015 report (Carhill, AA etd al ) from NTCTCS recomended "moderate" but not " aggresssive therapy" Moderate was defined as a TSH level 2 -2.9 with aggresssive 1.0 to 1.99,.They found no additional benefit with the aggessive therapy and recommended at least three years of THST in high risk patients Kekebew et al have published data that challenged the paradigm which indicates suppressive therapy for thyroid cancer patients with either high or intermediate risk. The issue becomes a more high leverage decision ( a currently popular basevball jaron term ) in elderly patients as .as the cardiac risks are of concern and in women the bone loss issue .Basically TSH supression means the iatrogenic generation of subclinical hyperthroidism,a condition that is not comletely benign. Klubo-Gwiezdzinske et al studied retrospectively 1012 cases of DTC (41 with follicular) treated with near total thyroidectomy and remnant ablation and found no improvement in PFS ( authors state their study was under powered to detect a difference in OS) in intermediate and high risk DTC with TSH suppression.( Association of thyrotropin suppression with survival outcomes in patients with interemediate and high risk differentiated thyroid cancer. JAMA opoen network oncology 2019 2 (2) e 1187754

Was the old time medical ethics just an artifact of economics?

This is a redo of an earlier essay with minimal editorial change. I repeat it now with a nagging thought that "that ship has sailed some time ago" The concern I espressed several years ago has increased as medicine has become corporatized and a target for private equity. __________________ Can the traditional, medical-ethical prime directive of placing the individual patient's interest first survive in a financial environment in which physician autonomy is greatly diminished and income for most physicians is controlled by third party payers. not to mention the heavy hand of venture capital buying medical practices. More broadly put, Dr. Edmund D. Pellegrino asked in 1995 (JAMA,May 24/31,1995,Vol 273,no 20,) " Is medical ethics a social, historical, or economic artifact? Or are there some universal , enduring principles?" In 1988, Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional [ethical ] ideal" was no longer compatible with the changed practice reality that "existing insurance contracts and manged care arrangements define for physicians." 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." Incredibly, the authors claimed that this shift in ethical focus would actually increase patient trust, an attribute that even in the late 80's was in decline as patients tried to live (sometimes literally) with the HMO's restrictions to medical care. Incredibly, they claimed that by not having the patient's interest as the prime directive there would be increased trust in their physician. The expected wave of letters to the Annals editors expressed the belief that advocacy for the individual patient was the prime directive and what it was all about and to replace it was to effectively do away with medical ethics as it had been known and practiced for a very long time. This is what would be expected from an audience of internists who had grown up medically inculcated with an ethic which was the polar opposite of what the authors proposed. Practicing internists at that time were reared to believe that the physician was completely and ultimately responsible for their patients and that their primary duty was to the patient. The average practicing internist if they read the article at all may have thought this was the contrived advocacy of someone who was attempting to make manged care appear ethical. All that was required was to turn medical ethics on its head.When I read that article I thought "you've gotta to be kidding me". A few years later ,I saw no one was kidding as the ACP, ABIM and the European Federation of Internal Medicine joined forces to formulate what was called the New Professionalism in which physicians were admonished to do more than maximize the health of all the patients in their HMO, which was as far as the Annals authors went. Now, physicians were told that they had an ethical obligation to strive for Social Justice. This joint effort by several medical organizations was said to be necessary as the "old ethic" needed to be revised to align itself with the new economic environment in which physicians now lived and "medicine's commitment to the patient was being challenged by external forces of change within our society". While the 1988 article's authors stopped short of suggesting physicians should conserve resources for others in society at large and not just concern themselves with their own HMO's population, the new ethics or professionalism as it was now called, headlined social justice raising it to the level of the big three ethical precepts-patient welfare, patient autonomy and social justice.More than one observer has asked does precept three conflict with precept one? The era from 1963 to about 1990 has been termed the time of "retail medical care". Physicians and patients enjoyed the situation in which a patient's insurance followed the patient so that he could choose any physician and the physicians' fees were not set by the insurer but largely were set by what the physician considered and the payer agreed to be "reasonable,customary,and prevailing". Things were good for physicians in those days as not only was physician autonomy largely unchallenged,but also Medicare had brought about a large influx of money to be spent largely at the discretion of the doctor and their patients and exciting new diagnostic and therapeutic tools were available. More could be done for your patients and more patients could afford medical care. Referrals could be based on the physician's knowledge of the area consultants and prescriptions were written without concern for some third party's list of permissible choices. But soon things were to change as the era of "wholesale medicine" replaced the old ways with the HMO now being a middleman-a very powerful middleman- and Medicare imposed wage and price controls on medical services. A series of articles was published in 1995 in JAMA authored by Dr. David Eddy that discussed the metrics and merits of decision analysis which he hailed to be a mechanism that could perform magic. The magic was to increase quality of medical care while reducing cost. But it was all merely playing with words and defining words to suit the argument. Eddy defined quality as the greatest medical good for the greatest number within the eco-medical collective (aka HMO). It did not go unnoticed to the skeptical reader that Dr. Eddy listed his affiliation as "Kaiser Permanente of Southern California") Pellegrino in 1995 also asked ...can physicians change the ethics of the profession at will ( as proposed by Berenson and Hall) or is there a more fundamental and universal foundation for the ethics of medicine in the special nature of the physician-patient relationship? Pellegrino's quotes are found in an article entitled "Guarding the Integrity of Medical Ethics-Some Lessons from Soviet Russia" . The subversion of medical ethics in Russia suggested to Pellegrino two lessons. 1) corruption will afflict any health system not designed with care of the patient as the its primary driving force. 2) medical ethics must be independent of political exigency. "... a morally responsive profession is an indispensable safeguard for the sick against the statistical morality of utilitarian politics, even in democracies." The statistical morality of utilitarian analysis seems to be increasingly unopposed as the group outcome derived data plays an increasingly large role in the decisions regarding the individual patient exhibited in part as guidelines executed by mid level practitioners as well as physicians. In this new day, the physician has more to worry about that just her patient, she must be concerned for everyone (as allegiance to social justice would demand) but at least she has been removed from the impossible role of being responsible for every aspect of his patient's well being as she is now (merely) a member of a team or perhaps the host of a medical home and part of a system of health care. It takes a village now to treat a patient. ______________ With increasing pressure for a single payer health care system and talk about a federal health board to determine what should/shall be done, the statistical morality of utilitarianism seems more and more on the ascendancy. As much as I do not want to believe it, more and more I am afraid that the old medical ethics may well have been and is now the "artifact of economics" about which Pelligrino speculated.

How reliable are tissue diagnosis of follicular thyroid carcinoma

In a study by Cipriani et al (1) in 2011 a pathology review of 66 follicular thyroid carcinoma (FTC) by three pathologists the diagnosis of 47 was changed (71 %).24 cases were reclassified to papillary carcinoma,18 to follicular adenoma, and five were reclassifed to poorly diffferentiated thyroid carcinoma ... A change from FTC to PTC (to follicular variant of papillary) is an order of magnitude less serious that changing the diagnosis from FTC to poorly differentiaed thyroid carcinoma.Further the change from Carcinoma diagnosis to thyroid follicular adenoma occured in 18 cases ,a change with obvious therapeutic implications.So in 23 cases (five plus eighteen ) the incorrect diagnoses have major and serious impact in almost half of the cases. FTC specific survival forthe reclassifed cases was 77% at ten years and 33.7 at 20 years. There are two major issues in which disagreement frequently occurs:1) whether or not there are areas of atypia as seen in papillary thyroid cancer and 2)whether or not there is invasion either of the capsule or angioinvasion. In some cases the reviewing pathologist believed that the invasion criteria used by some of the of pathologists were not sufficent and therfore the diagnosis was follicular adnoma. The cases were from well known and higly respected institutions ( MGH and University of Chicago) from 1965 to 2007 and all cases had undergone surgery and /or RAI treatment.The slides were reviewed by three pathologists from those institutions.You have to wonder what the error rate might be at the thousands of less pretigious institutions in the country and what the impact might be on patients whose diagnosis was wrong. .... If almost 3/4 of the diagnoses of FTC are on review found to be incorrect with with almost half being reclassified to papillary and around 10% being reclassifed to undifferentiated and about 30% not being carcinoma at all ( i.e. reclassified to adenoma) how accurate are the prognosis made on that basis and similarly how accurate are the data regarding effectivenss of various therapies. The recommendations of the American Thyroid Association as well as all other therapy recommending organizations begin with the implcit assumption that the diagnosis are correct, that is FTC is really that and not an adenoma with a excellent prognosis or a poorly differentiated carcinoma with a extremely bad prognosis regardless of therapy.You have to wonder how many patients with a benign adenoma underwent thyroidectomy and I 131 remnant ablation. If this study is representative of the general stratus of the pathological diagnosis of thyroid cancer how accurate could prognostic statements be ? 1 )Cipriani NA et al Follicular Thyroid carcinoma.How have histological diagnoses changed in the last half century and what are the prognostic implications? Thyroid, vol 25 number 11, nov 2015

I did not go to medical school to practice population medicine but maybe medical students do now

First do no harm,primum non nocere and do what what is right for the patient.Those were the core principles taught to me and my medical school classmates. In the more formal language of ethics, the driving principles were non-maleficence and beneficence.

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:
 

"Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources."

 Further in the same section of the paper physician are admonished to work to "minimize overuse of health care resources"

So under the rubric of " social justice" the authors instruct physicians  to provided health care that is wise,cost-effective and fair.The Charter was silent,however, in regard to how would the practicing make operation the principle of social justice . Later ACP and ABIMF would give instructions in that regard. Spoiler alert-it relates to following guidelines based on cost effectiveness criteria.


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"

  Acceptance of the Charter by scores of other medical professional organization.

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.<sup>[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.</sup> 

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.

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

In recent weeks there have been numerous internet compliants about ChatGPT.Some of them are regarding erroneous references or citations, I had an expereince with that. I was chatting with this system about a medical case of peripheral neuropathy.It said that distance running was a recognized casue of periphral neuropathy.I asked for references and three were provided. I tried to find the references on PUbMED and they were not found.I asked for three more references.Same result.I then asked ChatGPT if the refereces were made up. It replied that It was sorry for "misunderstanding my question" The six references given were all bogus.They had title and journal names that seemed real but the actual reference was bogus. Several people have made comments on various internet sites that the references or citations provided in a ChatGPT essay were fictitious.This behavior had been referred to a "hallucinations" More recently I questioned ChatGPT about certain aspects of conduction system cardiac pacing.The discussion seemed reasonalbe as least to the level of my non EP level of knowledge but one of the references could not be confired.I asked for another referece and this time the reference was correct-that is it was a real reference but not quite what I had asked far. So if it is the case that sometimes the references are valid and sometimes not may be even worse that if they were all fabrications.At least so far it did not try to lock me out of the space ship.

Here is how a physician can be a steward of health care resources

I knew from the first day of medical school that this doctor business was not going to be easy. We were told how many newwords and and concepts we had to master in the next few months,how some of us would not make it and how as physicians -if we even made it that far-would continues to have to work hard to continue to master new information and techniques.

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)