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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 ...

Thursday, March 31, 2016

Population Medicine is faith based - without logic or emperical support

Here are the comments of Apu,owner of the Kwik e Mart after Homer Simpson quite his job there:

"He slept,he stole,he was rude to the customers.Still, there goes the best damned employee a convenience store ever had. "

In a way a free , market based society is something like that. With freedom and capitalism , property rights and rule of law , there are booms and busts, there are demonstrable inequalities  among various parameters,there is information asymmetry, externalities, and apparent market failures. Still it is the best damned economic, social system a country ever had.

The economist and historian,Dierdre McCloskey,put it this way:

"How do I know that my narrative is better than yours?  The experiments of the 20th century told me so.  It would have been hard to know the wisdom of Friedrich Hayek or Milton Friedman or Matt Ridley or Deirdre McCloskey in August of 1914, before the experiments in large government were well begun.  But anyone who after the 20th century still thinks that thoroughgoing socialism, nationalism, imperialism, mobilization, central planning, regulation, zoning, price controls, tax policy, labor unions, business cartels, government spending, intrusive policing, adventurism in foreign policy, faith in entangling religion and politics, or most of the other thoroughgoing 19th-century proposals for governmental action are still neat, harmless ideas for improving our lives is not paying attention."

 The proponents of a population medicine approach have not been paying attention.

The population medicine approach is a faith based movement whose rhetorical support is largely gratuitous assertion and is strikingly lacking in logic and empirical support. It takes a great act of faith to believe that very wise medical leaders will be able to determine what medical conditions should be treated, what  preventive measures should be carried out and how in the "era of limited resources" of which they speak the correct allocations of resources will be made.

Population Health Approach (PHA)or more concisely population medicine is the antithesis of individual medicine which is and has been for centuries the interaction of the individual patient with a physician whose fiduciary duty is to the patient  acting to the best of his ability and judgment in that patient's best interests . It is the medicine of the individual  versus the medicine of the aggregate  or the group..It pits the sanctity of the individual against the alleged aggregate benefit of some group.

It is the tension of Plato and Aristotle.

It is basically the fable story tale saga of the baptist and the bootlegger. the bootlegger being the third party payers. The baptists are various members of the progressive medical elite lobbying for a system in which the elite can decide what is best for the rest of us, this time in terms of medical care.

Let's look at some of content of the sermons .The bootleggers usually leave the rhetoric to the baptists but there may be the occasional exception.See the final paragraph below.

A revealing and amazingly explicit explication  of some of the principles is found in this sermon by one of the preachers of the religion of population medicine.  Dr. Harold Sox expresses the view of the doctrine espoused by the Church of the ACP and ABIMF,( Reference: JAMA November 13,2013 vol 310 number 8).

"Throughout history,codes of professional conduct have called on clinicians to make each patient's interests their highest priority.If resources becomes limited,clinicians will find themselves unable to adhere to that standard of practice for all patients.In 2002a new code of conduct ,the Charter for Professionalism ,addressed this conflict by calling of physicians to consider the needs of all when treating the individual. While meeting the needs of individual patients,physicians are required to provided health care that is based on wise and cost-effective management of limited clinical resources.The provision of unnecessary  services not only exposes patient to avoidable harm and expense but also diminishes the  the resources available to others."

This remarkable passage indicates that the physician has an ethical imperative to balance the needs of the individual patient with the needs of society.With this foundational  principle of the population health approach, the Charter, in effect calls on clinicians to allocate resources. However, it does not provide specific advice. Recent programs such as the American Board of Internal Medicine  Foundation's Choosing Wisely campaign, are beginning to fill this knowledge gap, as do some practice guidelines." 

It is an astonishing passage ,filled with both hubris and naivete, as it seeks to completely overturn centuries of medical ethics in which the physician had a fiduciary  duty to the patient and rewrite the role of the physician and shift the decision making process from the patient and her physicians to central planners..

A sometimes evoked fable in the religion of the medicine of the collective  is that of the Medical commons. A example of that type sermon is found in JAMA  in a joint effort by Drs. Troy Brennan and Christine Cassel in which the authors urge both physicians and patients to forgo their own limited self interest and work together for the good of the group.At the time of the publication of this 2007 article, Dr. Cassel was an officer of the American Board of Internal Medicine (ABIM) and Dr. Brennan was a executive at Aetna Inc. (Managing Medical Resources,return to the commons, JAMA June 14 2007,vol 297 p 2518

addendum:Reference added 5/30/2016

Wednesday, March 30, 2016

The progressive medical elite-nothing wrong with P4P that being smarter (and learning the latest buzz words)- won't fix

The professional medical elite have had to admit that yes, sometimes in the past the P4P projects haven't worked out very well but we can all learn from past mistakes and with a fresh set of administrative buzz words and by being really smart this P4P thing will work really well regardless of what past experience and human nature tell us.

That seems to be the view expressed by a spokesman for the American College of Physicians (ACP) who is  masterful in his fluency of  medical management buzz words the use of  which along with being really smart, and catalyzing cooperation between the various stake holders will lead to a new enlightened era of amazing P4P rules abrogating Goodhart's law and revoking human being's strong tendency to respond to incentives.

Quoting from The ACP Advocate Blog written by Bob Doherty,VP of governmental affairs for the ACP  in regard to rules for P4P

  "..we should figure out what works to help physicians achieve the Triple Aim, including better ways to organize and deliver care, and then judiciously apply a core, harmonized, and improved set of measures to track progress, while always being on the look-out for unintended adverse consequences." Also we need to "reimagine" things. Why does that remind me of Will Roger's  solution to the German U-boat problem?

It is always good to throw in the bogus  feel-good and pious Triple Aim phrase and "harmonizing" has a nice vague group think ring to it and who is the "we" to which Doherty refers.There was once a time when there were only two people in the exam room that could be considered stakeholders, the patient and the physician. Now the way medical care is discussed  and is practiced seems to find others in the exam room who have some stakes to hold. These invisible stake holders include  , of course, the third party payers and now more than ever the health care entity that employs the physician . 

 Dr. Christine K. Cassel, formerly head of the ABIM and the ACP and the National Quality Forum (NQF), expressed her  opinion  in the New England Journal of Medicine ( "Getting More Performance from Performance Measurements" Cassel, CK et al , NEJM 371,23 2014). I quote.

"All stakeholder groups are now invested in getting more  performance out of measurements ,which should ultimately drive the care improvements that patients need and deserve."

 Two professors from the University of Zurich, Frey and Osterloh present four major arguments against the use of P4P  ( see here for a summary).I quote some excepts:

"It would be na├»ve to assume that the persons subjected to variable pay-for-performance would accept the respective criteria in a passive way and fulfill their work accordingly. Rather, they spend much energy and time trying to manipulate these criteria in their favour.(  Ed:This is one of mechanisms underlying Goodhart's Law).

 ......Variable pay-for-performance tends to crowd out intrinsic work motivation.".

Don''t look to the opinion pieces by Cassel or Doherty for cogent analysis of these and other critiques of P4P.Boil the oceans.

Friday, March 25, 2016

Population medicine-the poster child for the hubris of the progressive medical elite.

 Note: the core ideas expressed below originally appeared in a blog post  published 1/16/15 under the title " Are patients pawns on the chessboard of population medicine?"

 So are patients the pawns on the chess board of population medicine?

They would seem to  be- at least so it appears to be in the presentation of the "population medicine approach"  by Dr. Harold Sox,former editor of the Annals of Internal Medicine, former president of the American College of Physicians (ACP) and former chair of the U.S. Preventive Services Task Force, offered in the November 13 ,2014 issue of  the Journal of the American Medical Association (JAMA).

Here is my thumbnail summary of Dr. Sox's description of  how the population medicine approach would work.

The major important diseases would be identified as would methods for their prevention. With that knowledge in hand , then funds could be transferred across patients and disease processes so that the maximal overall health benefit could be achieved.In this process it might well be that sometimes funds would be diverted away from the testing and treatment of some so that the preventive measures could be funded and then  " in a few generations" the benefit would be fully realized.He is explicit regarding the fact that in the short run some people would be harmed although he does not seem to explain why it would be only the short run as would not new preventative measures always be formulated and have funds diverted to their execution

If that does not exemplify the mega-hubris and naive utopian view of the progressive mind set  possessed by someone  who somehow knows what is best for everyone,I do not know what does. First they determine what the important diseases are,then they glibly state they can discern how to prevent them and then they presume to have the wisdom, authority and power to "transfer" funds for one patient treatment to another person's prevention program so that the overall benefit is maximized though some pawns may have to be sacrificed.

.The population medicine advocates claim the approach to  each patient strictly as a individual is "obsolete" and  are promoting a statistical medicine that claims to be capable of provided the greatest health benefit to the greatest number.Practicing physicians know how difficult it can be to recommend what might be best for the individual patient,the "populationists" glibly claim to know what is best for everyone.Individual freedom and autonomy also is obsolete in this world view. Of course,the presumption of the knowledge of what is best for everyone,irrespective of the wishes and autonomy of the alleged beneficiary of  that betterment, is characteristic of the progressive ( AKA modern liberal).The medical progressive elite is just a subset of the larger category of progressives.

In chess, pawns or for that matter any piece ( except the king), might be sacrificed in executing a strategy of placing the opponent 's king in checkmate. In the case of the population medicine approach the individual patient might be sacrificed in executing a strategy of maximizing the health of the specified population as measured by some metric such as quality adjusted life years  (QALY) per dollar spent ?

I closed another earlier article on Dr Sox's frightening essay with this paragraph:

"...the principles involved in treating patient who requests help from a physician and  and proposing preventive measures for a population are not the same. The population has not requested help and may have not even authorized the "treatment"  A key principle in treating the individual is to respect his/her values. How can one determine the values of a population? Do all member of the population have to agree.? Is disease prevention is only principle to value, do liberty, and avoidance of coercion not matter? Who is to judge what is the fair allocation? Is disease prevention more important than treating the sick which historically is what physician basically did ?What about the possible harms of a preventive program?Should the population members have to agree to the preventive measures? Is informed consent not to be part of population medicine? "

I know-  I have written about this more than once before but I find the concept so antithetical to hundreds of years of traditional medical practice  and ethics and to basic concepts of individual freedom and individual autonomy that I cannot get over those ideas being given voice in one of the country's major medical journals and few voices raised in opposition.  

Monday, March 07, 2016

Is transient increase in pulmonary artery pressure one reason why older runners take a while to "warm up"

Most  older folks who jog,run or cycle probably experience a sluggish,hard to get going period when they first start out on their exercise session.

Dr.SP Wright and colleagues have published data demonstrating that in the group they studied (men and women age 55+-6 years ) there was transient increase in pulmonary artery  wedge pressure (PAWP) pressure as determined by right side heart characterization.

PAWP increased  from baseline at 11+-3 to 22+- 5 with light exercise.and then declined back to 17+-5.

This information needed to be considered in light of what was already known about pulmonary artery and pulmonary artery wedge pressure at rest and on exercise.Kovacs et al reviewed data from 1187 subjects who underwent right heart catherterization  at rest and with exercise.( ref 1 below). ( I continue to be amazed at the number of people who agree to let doctors put  catheter  is the veins and snake them through the heart chambers and into the pulmonary artery)

 Current guidelines state that pulmonary artery hypertension (PAH) can be diagnosed when PAP exceeds 25 mm hg at rest or 30 with exercise. However  exercise levels of pulmonary artery pressure increase with age while pressure levels at rest do not and as is discussed below the 30 cutoff may be misleading in older patients..

During low levels of exercise in subjects less than fifty years of age the PAP was 19.4 +-4.8 while in those greater than fifty pressure were 29.4 +-8. So in older apparently normal subjects the PAP may exceed 30 .( In one review 20/97 normal subject over 50 years of age exceeded the  pulmonary artery hypertension diagnostic threshold of 30 . There will be a number of false positive diagnosis of pulmonary artery hypertension if the  exercise30 mm hg criterion  is used.

So in older humans the exercise pulmonary artery pressure is higher and then increases further with the onset of exercise but then returns to lower levels after about 5-10 minutes of exercise.

This transient increase in the wedge pressure could explain how some of us breath a little heavier when we first start to run. Further this  transient increase should be considered when doing clinical  research work regarding pulmonary artery pressures. So why is this transient increase occurring?

Although Wright's subjects were considered normal it is possible that they had some degree of exercise  induced diastolic dysfunction ( their resting echocardiograms were said to be normal). Impaired ventricular relaxation and decrease in left ventricular compliance seem part of the aging process.But if the transient increase in pulmonary artery related pressure is an indirect manifestation of diastolic dysfunction , why is it transient?


1) Kovacs, et al "Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review"European respiratory Journal , vol 34, issue 4 ,Oct 2009

2)Wright,SP et al. "The pulmonary artery wedge pressure response to sustained exercise  is time-variant in healthy adults"Heart 2016, Mar 102(6) 438