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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 ...

Wednesday, May 28, 2008

The philosophy supporting the "diabetes police" is more than frightening

I have written before about the movement of at least some of the public health community into areas not traditionally thought to be within their purview such as local public health departments monitoring the hemoglobin A 1 C levels. I was not aware of the degree to which the philosophy animating this movement was developed and being expounded in very explicit terms.

Thanks to Sandy Szwarc of Junkfood Science . Her entire piece should be read but below are some of the comments made by exponents of what you might call "the new public health ethics".

In a nutshell,the basic notion is that an individual's health and health related behaviors are too important to be left to the individual as they poise a threat to society and government must act for the good of society.

Ms. Szwarc quotes from a "thought leader" in this field of public health ethics, Dr. Angus Dawson who is at the Centre for Professional Ethics at the University of Toronto as he discusses his approach to the problem of obesity.

[the educational approach to battle obesity] "will fail as it wrongly assumes..that we ought to respect an individual's existing preferences " and "an ethical obesity policy ought to focus on collective interventions [ in which] the individual will not be able to opt out.

If people will not do what we know to be best for them and society we will make them do it.This seems to be the core of the public health ethics.

Lest you think that we are dealing with the relatively, unheard voice of a fringe philosopher in the wilderness (or at least in Canada),essentially the same theme is expressed by Dr. VJ Guillory who served on the AMA Expert Committee on Obesity when he wrote in the Journal of Public Health , "The mandate to ensure and protect the health of the public is an inherently moral one...and it implies the possession of an element of power to carry out that mandate."

In this age of supposedly evidence based medicine it is interesting to read one of the comments from a report about a meeting of the AMA Expert Committee on Obesity : "The magnitude of the obesity is too great to wait for evidence-based guidelines before increasing efforts focused on prevention and intervention." So it is ready, shoot, aim- all with very generous funding from the Robert Wood Johnson Foundation and it is individual freedom and autonomy the targets.

Tuesday, May 27, 2008

Will the options for internists be even fewer as time goes by?

Had retirement not worked out to be better than I had hoped for, I had thought that a concierge practice or being a hospitalist would be the way for me to go. The retainer practice might allow me to escape from the clutches of the third party payers whose ever tightening of the control and payments screws sucked much of the joy of patient care and the threat of things getting even worse casting a pale over the future. The hospitalist gig offered the relief of no call and a opportunity to attend the type of complex,often very ill patients which seemed to be what an internist was trained to do.

But now we hear that perhaps the hospitalist role may not be a safe haven for the internist for very long. Dr. RW tells us about that scenario here.

Even as the future for hospitalist might appear less rosy, we should not forget that the safety and quality movement leader guru, Dr. Donald Berwick still has much for them to do as they become the change agents and integrators of a new medical system that will provide quality care, reduce costs and improve public health. I guess it is better that I did not become a hospitalist as all I could do on a good day was to take as good of care of my patients as I could leaving the problems of maximizing public health and obtaining universal medical coverage to someone else.

Tuesday, May 20, 2008

The diabetes police concept moves to Texas

Thanks to Sandy Szwarc of the blog Junk Food Science for this alert.

The Metro Health District in San Antonio is creating a "surveillance program" to identify diabetics. Earlier I had written about a similar program in New York. Hemoglobin A1C levels will have to be reported by the clinical labs to the public health folks.

The project is described as a pilot program which came into being by actions of the Texas Legislature.If successful(those sorts of program are very likely to be judged successful by the folks who administer it)it will be transplanted into other metro areas in Texas.

The notion that medical care ( health care) is too important to be left to individual physician and the individual patient gains more traction as the nanny state move on, privacy being a quaint concern of an earlier era.

Safe drinking water and mosquito control are considered to be legitimate concerns of public health authorities, my blood sugar level, hemoglobin A 1C and blood pressure level are not.

Saturday, May 17, 2008

Peri-operative beta blockers-quality measure or risk factor for stroke and death

The now published results of the POISE trial raises the question that the rush to make peri-operative beta blockers a quasi-mandatory quality measure may have lead to a number of deaths from stroke . Could that possibly be right?

In the words of at least one of the trial investigators the answer is yes.Dr. P.J. Devereaux's comments can be found here in Medscape news report describing the trial and various commentators' reactions to the results.

POISE was a large ( 8000 plus subjects) randomized trial designed to determine the effect of the peri-operative use of Metoprolol-XL. 100 mg was given 2-4 hours preop and again 0-6 hours post op and then 200mg daily for thirty days.

Total mortality was increased in the treatment arm (3.1% versus 2.3%,Hazard ratio 1.33,p=03) while myocardial infarctions were decreased but strokes were increased.Strokes occurred in 1% of the treatment arm patients versus 0.5 5,Hazard ratio 2.17. Hypotension was also significantly increased in the treatment arm while the incidence of atrial fibrillation was decreased.

Critics of the trial might argue that the dose of Metoprolol was simply too high and too much of this putative good thing might well cause more hypotension. They might argue that POISE only demonstrated that if you give an inappropriate dose of a beta blocker you cause harm. But I do not believe that the results of the trial will be dismissed based on different experts differing on dosing details of the trial.More likely major changes in guidelines will be made.(I will have to admit that if I took 200 mg of metoprolol a day, I would move like a turtle and have a heart of 12.)

If there is a lesson here it is not just that a large randomized clinical trial gives results opposite to earlier smaller trials-that is a story we have heard more than once before. The lesson is not that expert committees sometimes have to revise their recommendations as new information becomes available.The lesson I think that should be emphasized is that overzealous quality rule writers and enforcers can be a hazard to your health ( and I have said that before). Read Dr. Devereaux's comments regarding how many patients may have been harmed by taking peri operative beta blockers and then wonder how many patients received them simply because premature quality guidelines were in place and physicians were caught up in the rush to treat even though it seems clear now that the evidence for such zealous efforts was inadequate.

Dr. DB (AKA Dr. Robert Centor) nailed it when he recently spoke about in this regard " the performance and quality movement which has a 'ready,fire, aim' philosophy".

Thursday, May 08, 2008

Still more on Medical Home AKA medical utopia

Yesterday, I signed up for a new, free newsletter, The Medical Home Monitor. This is apparently aimed at those who are interested in this latest version of managed care and its new packaging and how this bogus concept can be sold to the public.

Its advocates promote the Medical Home as a revolutionary sea change in medical care for which the term Utopian fails to properly denote both its purported magnificence and its absurdity.

The Medical Home Monitor uses 7 (count them,seven) back to back adjectives to describe the Home. They are: accessible,continuous,comprehensive,family centered (alternatively the term patient centered is used),coordinated,compassionate, and culturally effective. Not only that but there will be improved clinical outcomes and patient satisfaction and it will not increase health care costs. Think of it, provide many more services that the typical patient now receives and it will not cost more.

Sandy Szwarc in her consistently insightful blog, Junkfoodscience, explains clearly the difference between the hype of the Medical Home and the reality of what it is as envisioned the single payer called CMS. This CMS version of Medical Home as contrasted the warm fuzzy words imployed to hype it gives a new dimension of hubris to the concept of bait and switch.

The Happy Hospitalist explains in agonizing, mind boggling detail the particulars of how the Medical Home will be constructed in the regulation driven world of Medicare.Any doc or any patient who might be conned into taking part in this scheme should read these two blogs.Anyone who believes that Medicare should serve as the paradigm for a universal single payer just might be disabused of that belief by digesting these two essays.

Nurses and doctors, of course, will play a key role in this Medical Care Utopia but patients will be interested to learn that in the Medicare version as structured by the AMA's RUC committee the nurse will be allocated 3.5 minutes for a patient with one condition and 9.4 minutes if 4 or more conditions are present to provide the comprehensive,compassionate, culturally effective care it purports to deliver. Similar micro managed time allocations are given for physician's time. I am not kidding, the RUC wonks describe activities in term of tenths of minutes. Doctors will be allowed 12.5 minutes for those patient classified as "very sick". If anyone on the RUC task force actually took care of complicated, complex medical cases , he/she must have slept through most of the sessions.12.5 minutes should be more than enough to evaluate a elderly person with heart failure,COPD, diabetes and new onset severe back pain who is living alone and taking nine different medications, leaving time to ask about dental flossing and seat belt use and immunization status and to make a few well chosen culturally sensitive comments and hand out three health care educational booklets and allow time for the patient to proudly show the latest photos of her grandchildren.

Dr. Roy Poses takes on this issue in his latest posting on Health Care Renewal as has Kevin in his May 8, 2008 entry blog (see here) and Dr. Vijay Goel in his blog,Consumer-focused Health Care, as he heartedly seconds the analysis of the Happy Hospitalist. If you think-well this is just the government bureaucratic mind set at work and private entities will show everyone how the "Home" should be built- read this earlier entry by DrRich in his blog, Covert Rationing Blog, as he explains how United Health Group plans to do it. I made some comments about that also.

I have been critical of the American College of Physicians' position and role in the Home concept and I await their justification of the RUC 's plans and how they can possibly support what would be a disaster for primary care.Rather than their typical sound bites (quality evidence based, patient centered care,electronic medical records, medical home, blah, blah, blah), they should be saying to the RUC and CMS "Gentlemen , we have read your proposal and as internists we know more than a little about caring for complex medical patients and we know that you cannot attend a complicated patient in 12.4 minutes and if you think it can be done you have no business writing guidelines or rules."

Tuesday, May 06, 2008

Look who is going to write the compensation rules for the "Medical Home"

The American College of Physicians and others have been touting their solution to most (if not all) of the problems destroying primary care medicine under the banner of "Medical Home". One major obstacle to providing the accessible,continuous and coordinated care has been and is that physicians are not compensated to provide that type service.For example, how would Mediare compensate docs for those activities?

Now we learn that AMA's friend of the primary care doc,the RUC (relative value scale update committee) will play a major role in setting up the rules and ultimately the fee structure for the Medicare version of the Medical Home. The Tax relief and Health Care Act of 2006 mandated a demonstration project .

Here is a link to the AMA site with a description and from there a further link to the full set of recommendations from RUC. Anyone who thinks the Medicare funded Medical Home will be anything different from the morass of rules and tricks and traps of the fee structure and coding mysteries that typifies dealing with CMS should take a few minutes and read what RUC has authored. If you think the current coding games doctors have to play are onerous and irrational
(go to the latest from the Happy Hospitalist to get a flavor of that) wait until you see what the RUC thinks need be done to deliver the "coordinated continuous care" envisioned by the pie-in-sky Medical Home concept.