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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 ...

Sunday, August 31, 2014

The effects of multiple sub-concussion head blows in football

Two research  groups have demonstrated brain imaging findings in collegiate football players over the course of a season.Importantly these abnormal findings occurred in players who did not experience a concussion..While concussions occurring at all levels of football competition has finally attracted some long overdue attention,more recently the significance of so called " sub-concussive" head blows is under scrutiny.

Bazarian et al studied 10 college football players over the course of one season. ( "Persistent Long Term cerebral White Matter Changes after Sports related Repetitive Head Impacts. Plos one 9(4),e94737)

 Head impacts were recorded and measured by helmet accelerometers and brain imaging was done preseason, immediately post season and six months after the end of the season. Imaging was done by the diffusion tensor technique (DTI).This MR technique can demonstrate abnormalities in the white matter and can visualize connections of fiber tracts between different parts of the brain.Current theory regarding traumatic brain injury is that axons are stretched with resultant micro damage.These changes are not detectable by conventional MR while DTI is capable of detecting abnormalities associated with so-called mild brain trauma.

White matter changes were noted in these players none of whom sustained a clinically evident concussion.
The changes in most players,but not all, were also seen in the six month followup images. Evidently in some cases the 6 month period with no head impacts allowed recovery or at least return to the pre season scan pattern.. There was a correlation between number of head impacts and DTI findings. The DTI changes were not correlated with changes in cognitive testing or tests of balance.The authors state that it is not known whether the changes noted represented damage per se or recovery and beneficial plasticity. The number of head impacts ranged from a low of 431 to 1850.Multiple head impacts occur regularly in lineman while quarterbacks and wide receivers are more at risk for more severe single hits and concussions.

A possibly encouraging  finding in the Bazarian study  is that none of players demonstrated any scan abnormalities at the beginning of the season.One would expect that if these findings were to persist for very long periods of time (longer than 6 months) that these players who likely played football for a number of years by this time would have shown some abnormality from repeated head blows.

Another TDI imaging study was published by TW McAllister ( Effect of head impact of diffusivity measures in a cohort of collegiate contact sports athletes, Neurol. 10:1212/01Dec 11 2013.) There was at least one important difference from Bazarian's results. Quoting the authors from this study which involved 80 varsity football and ice hockey players and 79 non contact sports participants:

 "The magnitude of change in corpus callosum MD (mean diffusivity) was associated with poorer performance on a measure of verbal learning and memory."

What are the underlying tissue changes corresponding to the DTI patterns? No one knows whether they represent damage to the axon and or the myelin  sheath and/or edema. See here for a comprehensive discussion of the DTI technique and findings in head trauma.

Regardless of the exact relationship between imaging findings and the tissue changes, it is difficult  to argue that subjecting (allowing) young brains to sustain multiple hits can be anything other than potentially harmful.Although recent emphasis on concussion and chronic traumatic encephalopathy (CTE) has lead to some rule changes in the direction of limiting to some degree head blows and rules regarding management of concussions ( when to be allowed to return to play etc) ,every Friday night tens of thousand of young men hit each other repeatedly in the head and are cheered on by hundred of thousands of football fans and parents. For now the dogs continue to bark while the caravan moves on.

ADDENDUM:9/4/14 and again on 9/24/14
Much to no one's surprise a similar study has been published involving measurement of head impact forces and DTI changes in a high school football team over the course of a season. (Devenport,EM et al, "Abnormal white matter integrity related to head impact exposure in a season of high school varsity football"
J of Neurotrauma 2014 Jul 14, published ahead of print) .There was a significant linear relationship between their measured impact force and DTI changes as well as relationship between DTI measurements and changes in a memory test.

Wednesday, August 13, 2014

What would happen if Choosing Wisely became the medical "law of the land"?

Choosing Wisely (CW) is an initiative or campaign lead by the American Board of Internal Medicine Foundation (ABIMF) to change the thinking of physicians and patients so that the choice of  medical tests and treatments are chosen  wisely in such a way as to greatly reduce waste of resources and harm to the patient.At least that is the way in which its proponents frame it.

It began as an apparent low-key program to simply have the physician and her patient sit down together and have a  conversation about what needed to be done in a particular patient's case and it continues in part to be marketed as such. So, if for example that a given test, e.g. MR of the lumbar spine,might not be ordered if it were the case that an MR in that stylized scenario had not been shown to be helpful.The patient would be subject to possibly harm of a false positive tests and the possible cascade of more testing,etc etc.

However in the two years since the launching of CW ( at the time of this writing) several policy experts and wonks have envisioned a much more full bodied, authoritative and coercive role  for the pronouncements announced under the CW brand.  It is this expanded role for CW that I refer to as the medical law of the land.. From simply reducing waste and  harm a second wave of CW is devoted to reducing "low value" services,however that may be defined.

So based on some of these experts' recommendations, what would the medical landscape look in the era in which the decisions of Choosing Wisely would be much more than the suggestions or recommendations,which is how they are sometimes presented  and  instead be  determinative in regard to the reimbursements of third party payers, private and public as well as  being used in decisions regarding medical specialty certification  and maintenance of certification and other mechanisms to decrease medical costs.

Consider the comments of Dr Robert Benson Jr.,President Emeritus of the ABIM and ABIMF  writing on the ABIMF blog with bolding of words added by me:

" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."...ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

So, a candidate for ABIM certification would have to properly quote the Choosing Wisely rules recommendations before he even gets to take the certification or MOC examination.

This recent commentary by Dr N.E. Morden and her co-authors from Yale and Harvard tells the same story.

"..physician-endorsed low-value labels will probably be leveraged to these purposes. [cost containment and quality measures]...We believe that if such efforts are designed and applied carefully they should be embraced as a promising method for reducing low-value services."

...linking the lists ( of tests and procedures not to do ) to specialty specific maintenance of certification  activities such as practice audits and improvement tasks could also advance their dissemination and uptake at very low cost."

"...Choosing Wisely items should also be incorporated into quality-measurement efforts such as Center for Medicare and Medicaid Services Physician Quality Reporting  ...linking low value service use to financial incentives ( translate penalties )  .. should accelerate ...into practice changes."

So payment for physician services,quality ratings,and maintenance of board certification are linked to adherence to the "recommendations" of  CW.

In this proposed choosing -wisely world the deciders at CW assume a very powerful position.Various special interest groups stake holders would have great incentive to lobby the CW leaders,to do what they could to direct the "recommendations". Physicians would have to follow the CW guidance or risk loosing certification let alone payment for services. As bound as physicians would be to the  dictates of the CW authority how much trust could a patient have that his physician is acting in his ( the patient's) best interests .Making CW the medical law of the land would be a giant step toward the collectivization of medicine and destruction of the traditional physician patient relationship.

Of course, all of those sky-is-falling comments are in stark contrast to what one would read on the websites promoting the CW campaign.. There we hear  marketing phrases such as "ensuring the right care at the right time" and doing reasonable, sensible things and involving the patients in the decision process. Mom and apple pie with ice cream on the pie is the image floating above  the CW advertising efforts, but when one reads the comments of Benson and Morden et al  that outlines what they want to do,a different, darker side of CW is visible.So what is it: an idealized physician-patient collaborative effort or advocacy for  an alarming  level of medical care hegemony lead by select members of the higher echelons of the progressive medical elite who seem to believe that carrots are not enough .The ABIMF ( financed largely by the ABIM) and the Robert Wood Johnson Foundation are spending millions of dollars convincing the public and members of the medical profession that Choosing Wisely is a collaborative,thoughtful movement that just wants to ensure that patients get the right care at the right time while the President Emeritus of ABIM(F) and some policy wonks from Yale and Harvard talk a markedly different game.

Today's trial balloons may well become tomorrow's policies and governing rules about how medicine is practiced and it will not be all about the right treatment at the right time.It will be about the most cost effective means of achieving quality adjusted life years as that is valued by someone other than those trying to live those years.

Addendum: Minor changes in grammar and style made on 10/8/14 and on 12/28/14 and on 2/20/15

Wednesday, August 06, 2014

The crusade to change medical ethics,custom and practice gains momentum

The mega-thought leaders,the established leadership of some of the major,influential professional medical organizations, and an alarming numbers of fellow travelers are on a quest to change the thinking of the worker-bee physicians,and the general public (who are either now patients or potential patients) from the long established model of the physician as an advocate and fiduciary to the patient to one in which the physician is a steward  of "scarce medical resources" which are characterized as being owned by society.But the physicians who are tricked into acting in that way are not preserving "society's resources" but rather they are boosting the bottom line of some vertically integrated health care entity.

Early explorations  and exhortations of this theme in the major medical literature are exemplified by one article in the Annals of Internal Medicine and a series of articles in the Journal of the American Medical Association (JAMA).I chose these articles because the authors were quite explicit about their recommendations.

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 to increase the quality of medical care while reducing costs. Eddy defined quality as the greatest medical good for the greatest number within the eco-medical collective (aka HMO now this might be an ACO) It did not go unnoticed to the skeptical reader that Dr. Eddy listed his affiliation as "Kaiser Permanente of Southern California")

In 1998 M.A. Hall,a law professor, and Dr. Robert A. Berenson writing in the Annals of Internal Medicine said that "the traditional ideal" [the prime duty to the patient ] was "not compatible with the role 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."

Berenson and Hall  justified this  ethical sea change because the role that insurance contracts would  define for the physicians.Medical ethics must change to accommodate the bottom line of the third party payers.If traditional ethics were in the way,just change the ethics and that is exactly what the ACP and the ABIMF are attempting to do.Never mind that for the most part one of the characteristics of a profession is that it and not a third party defines its ethics.They seemed to either rewrite the definition of a profession or declare that the practice of medicine was not really a profession at all.

 Dr.Berenson Joined HCFA in 1998.His biography found at the ECRI website indicates that from 1987 to 1997 he was a Vice President at the Lewin Group.Lewin is part of Ingenix which is owned by United Health Care Group.Ingenix changed its name to Optuminsight in early 2011.(See here for details.)He is a fellow at the Urban Institute and in  2010 he became vice of  the Medicare Payment Advisory Commission (MEDPAC)

 In a recent NEJM roundtable, Dr. Atul Gawande, summed it up with this reference to "a new culture in practicing medicine"  in which physicians will "prioritize our responsibilities as shepherds of scare social resources  to the same extent that we've historically prioritized our responsibilities for providing benefits to our specific patients"  This, or course, is nothing new. The American Board of Internal Medicine Foundation (ABIMF) and the ACP has been promoting this notion of  physicians as stewards of resources as part of the new Medical Professionalism which debuted in prime time in 2002 in a well funded campaign. ABIMF received some $ 13 million from the ABIM  which apparently represented receipts well in excess of costs of the various testing programs ABIM administers to internists. Another $ 5 million was in the form of a grant from the Robert Wood Johnson Foundation,

 The Choosing Wisely campaign is well funded and is in part funded ironically by thousands of internists who sent off their checks to take a certification exam likely unaware their payments to ABIM is used in part to  support a political, philosophical campaign  whose mission appears to be to usher in the medicine of the collective.

It gets ever worse.Consider the following comments of Dr. John Benson Jr,former CEO of ABIM and ABIMF: (my underlining)

" ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

If a candidate does not learn the Choosing Wisely catechism or some other subjective view of what is and is not high value to the letter she would not even be "allowed" to take the certification exam. 

 You have to wonder  how the typical patient would  feel if he knew that his physician  was devoted to the best interests of some statistical aggregate, perhaps those who found themselves in some or other ACA or HMO or being treated in some large hospital system.It is not clear to me how many physicians have adopted that perverse devotion but it is clear that the caravan of the medical progressives is expending much effort and money to that end and I am afraid while some dogs  are barking objections the caravan will move on.

I still remember the elation and pride that I had when I learned I has passed the Internal Medicine examination ( I became board certified so long ago there was still a written and a oral exam). Now as I look at the efforts of the ACP and the ABIM to destroy the traditional medical ethics of devotion to the patient, pride is not the emotion I feel.

Friday, August 01, 2014

Is "low value [medical] care like Justice's Stewart's definition of pornography?

In a 1964 obscenity case, Supreme Court Justice Potter Stewart admitted that he might not be able to specifically define the parameters of pornography but " I know it when I see it".

I wonder if a similar situation exists with the concept of low value medical care (LVC) which is  a main talking point in a campaign spearheaded by the American Board of Medicine Foundation (ABIMF).

Surely this term is not just a floating abstraction. I thought I had  simply missed the definition in reading about LVC. Off to Google to enter "definition of Low value care". Neither Google nor Bing lead me to a generally accepted definition of low value care or for that matter value in health care in general.

In fact the literature of health care value is bereft of a general consensus as described in this quote from Dr.Scott D. Ramsey writing in the Oncologist :

"one of the most enduring and controversial topics in medicine is the concept of what constituents value in health care"

The concepts of the business management  guru, Michael E. Porter are widely quoted and for him value is defined as "health outcome per dollar spent" but he spends considerable effort in explicating how elusive and difficult that is to put into meaningful operational use.

Given that the term value lacks a clear definition and defined operational boundaries, how did the American Board of Internal Medicine Foundation (ABIMF) expect many medical professional organization to conjure up a list of low value procedures? That initiative was part of their "Choosing Wisely " Campaign. Yet a list were generated  by some process or processes with some or other operational meaning of low value.I guest these medical thought leaders know it when they see it.

Professor Catherine MacClean of University of Pennsylvania gives this definition of low value health care, which seems to be close to if not on the mark and at least  is more substantive:

"any care for which there exists an alternative form of care this is both equally  effective and lower cost. In this regard no care or watchful waiting is eligible for the designation "alternative form" I wonder how many of the  "Choosing Wisely" campaign's wise choices  meet that definition.

 I think that more than a few writers who talk about low value care may be using  little more than Justice Stewart's ocular  technique.