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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, January 19, 2018

Has the modern electronic medical record made many physicians accomplices to lying?

In the last few  years I have the opportunity to read my medical records  and those of  some extended family members. After reading these documents, I wondered- has the electronic medical record (EMR)  made doctors liars? When they sign off on a record that filled with erroneous statements and claims that something was done and it was not done and the physician knew it had not been done ,why would not lying be an accurate description ? I suggest it would be.

When I reflect back on the emphasis of the importance of accurate medical records that was  embedded into my nascent physician  mind as a medical student and house officer and  as I read the repetitive useless information, erroneous entries and pages of useless cut and past repetitions  and even fabrication of what transpired I cannot believe what the medical recored has become. So in some ways this is one of the saddest and most disillusioned  blog entries I have ever posted. In some cases the medical record has been useless and misleading and often inaccurate garbage and certainly potentially capable of harming the patient and likely a fertile field for plaintiff attorneys.

I read the medical records ( fairly easily obtained through the clinic's patient portal). I read that the patient had a physical exam ( describing normal finding for various parts of this phantom exam which she never had). No one listened to heart or lungs. Reading the medical history I find that she was said to have hyperthyroidism ( she had hypo) said to be on Armour thyroid  ( she is not) .Reading another orthopedics record ( again from the patient portal ) I learn that the summary sheet described the wrong leg bone as having the issue of concern i.e. tibia rather  than femur.

A few years ago I read on my own  colonoscopy report that my physical exam was normal. This was another phantom exam, this was being signed off by one of my former partners.

So would it be fair to describe this type things as publishing a false medical record or simply put lying. Court room scene. Doctor, your records on Mrs X indicate you performed a physical exam prior to her endoscopy?. Did you in fact do such an exam? Mrs X has testified that she did not have such an exam.

Do the physicians even know what is contained in the medical record that they sign? Is that any excuse if they sign the record?

Addendum:  2/8/18 Still more. Having  a pacemaker in place I take part in a "remote interrogation" of the PM every three months.This includes a summary done by a PM tech at the PM center at a local hospital. Each report ends with "the patient had no complaints". At no step in this process has anyone ever asked me how I am doing.

addendum 5/6/18 After remote interrogations every 3 months for two and one half years,at last the technician actually asked me how I was doing  and if I was having any problems.

Addendum 6/30/21 I write about further instances of phantom exams in as blog post about the Cures Act.

Wednesday, January 17, 2018

Mayo study: higher cardiorespiratory fitness associated with lower risk of atrial fibrillation

Data and analysis continues to address the issue of exercise level and risk of atrial fibrillation (AF)-sometimes referred to as the U-shaped curve controversy.

Hussain et al (1) published a follow-up study on 14,094 selected subjects who had been referred to Mayo Clinic for exercise stress testing. These were from a much larger group from whom those with a history of heart failure, atrial fibrillation or flutter or stroke were excluded.The average follow-up was 14 years and the outcomes of interest were incident atrial fibrillation ,stroke and death.
They divided the subjects into 4 groups based on functional cardiorespiratory capacity as estimated by their performance on the Bruce protocol stress test.

Those subjects in the highest exercise performance category showed no increase in the risk for AF.

The authors concluded:

"...better cardiorespiratory fitness is associated with lower risk of incident AF, stroke and mortality. Similarly risk of stroke and mortality in patients with AF is also inversely associated with cardiorespiratory fitness."

They also commented that the reduction in these risks with increasing exercise capacity  "may be a direct physiological effect of exercise and physical activity or a consequence of a lower burden of cardiovascular risk factors" I would add "or both".

This is  another coarse grain study which will not settle the U shaped curve argument.I think often these "controversies " just dwindle away rather than get settled. The etiology of AF and stroke with AF involves a complex array of numerous possible  and possibly interacting input variables and here we look at the effect of  only one such variable ( exercise capacity-as a surrogate for exercise level) on the outcome (s) but at least  long time endurance exercisers may find some solace here. Critics can justifiably point out that a number of potentially confounding variables were not available  for analysis including, smoking history,alcohol use,and actual exercise habits.

Again quoting  Simon (2) ".. a man hears what he wants to hear and disregards the rest"

1) Hussain,N Impact of cardiorespiratory fitness on frequency of atrial fibrillation , stroke,and all cause mortality. AJC Jan 1, 2018. vol 121 issue 1, p 41-49

2) Simon, P .Lyrics from the song ,The Boxer, 1969

H/T "notes from DR RW"

Monday, January 15, 2018

Not your father's internist any more

This a very lightly edited version of a commentary that I made 12 years ago. Nothing has happened in the last 12 years to change my views and from the point of view of a very over the hill internist, things are even worse and are not likely to get better.

"The current data are clear.There are fewer docs going into general internal medicine.Lower pay and  less prestige are two of the reasons offered and an increasing amount of onerous,often counter productive computer driven requirements may for some be the final straw.

A  "op-ed" like piece in the ACP Observer by the President D. Anderson Hedberg is entitled "Finding the Art within the science of internal medicine". My gut reaction to it is " wouldn't it be nice if it were [still] true.?"The internist he portrays does resemble the internist I thought I was training to be. But I doubt if it is possible to be that type physician today.(see end note )

Dr. Hedberg quotes a 1998 article by Dr. Robert L. Wortmann, chair of IM at the U. Of Oklahoma in Tulsa. Dr. Wortman said the four distinguishing characteristics of internists are: 1) the ability to be a diagnostician ( internists were once called that) who can practice the deductive scientific process that leads to therapy. 2) the ability to provide care of complex acute and chronic problems. 3) the ability to be a consultant for generalists, specialists and subspecialists and 4) curiosity. One comment he made re "curiosity" does resonate with my IM training. He said that to the internist it is important to consider the "links between disease and pathophysiology as well as between the therapy and its mechanism of action"

These comments definitely had more currency at a time when: 1) there was no competition in primary care save for GPs. and there was a clear distinction between GPs and internists. There were no family doctors-from whom the distinction between them and internists is harder now to draw- and no competition from nurse practioners. 2) there was the reasonable likelihood of being able to spend enough time with a patient to play out those characteristics and patients did not have to be seen every 10-15 minutes to either meet the clinic or HMO quota or generate enough income to keep the practice going. 3) there was no need to worry and try and determine if the recommended therapy was approvable by the HMO, Insurance company or pharmacy management company.4) there was no hospitalists to compete with you. You were the hospitalist. 5) there was time and opportunity to pursue efforts to satiate your curiosity.

Only about 25 % of internists consider themselves general internists and more and more subspecialists refer back to the general IM doc or the FP problems not clearly linked to their subspeciality.Hospitalists are growing in numbers and the arrow points in the direction of at least some general IM docs pulling back from their roles in the hospitals making them more like FPs than internists.

In short, in today's environment how realistic are the comments of the two physicians quoted above? I think not very. I am afraid their comments were more relevant in an earlier era.It is hard to say what are the distinguishing characteristics of internists in the current practice of medicine.
I believe it is a confluence of factors and forces that are leading to the demise of the general internist.

Another major determinative factor is the following:A few decades ago the internist (there was no "general" preceding the designation) was the recognized expert in diseases of the heart, lungs, and kidneys as well as the expert in endocrinology and hematology. Tremendous growth and development of the subspecialist domains of expertise has changed the landscape. Cardiologists are now called in to treat coronary syndromes, pulmonary docs for respiratory failure, etc etc. Oncologists take care of the cancers, kidney doctors the ESRD cases and it is the rheumatologists now giving the disease modifying treatments for rheumatoid arthritis .When emergent or semi-emergent medical issue arise after hours the patient is likely seen in the ER by an ER doc and if hospitalized, then seen by a hospitalist who more likely than not calls in specialists.In short, the areas in which the internist was the expert have largely disappeared and the experts are the IM subspecialists and it is the ER docs and hospitalists who sort out the problems of sick patients summoning subspecialists as needed.

To a large degree many internists are left with office treatment of the same conditions managed by FPs and nurse practitioners ( hypertension, type 2 diabetes,annual check ups, elevated cholesterol,URIs etc, annual "check ups" )

How many internists would want their myocardial infarction treated by an internist? I want a cath cardiologist.

end note: I do not deny there are exceptions. I have been a big fan of the blog ," db's medical rants" by Dr. Robert Centor,an academic internist who as best  I  can tell from his writings continues to function in the manner described by Dr. Worthmann.However he does not seem to  work primarily  in a private practice setting the landscape of which , in the last few decades ,has become a completely different game.

Addendum: 2/9/18 My own internist who is also my former partner finally decided to find a internist for his medical care.The one he chosen has an excellent CV board certified,good med school,good residency site etc. He said he liked him, he seemed nice  but it was "sorta funny" that he did no physical exam at all.

Saturday, January 13, 2018

LBBB associated non ischemic cardiomyopathy -more favorable remodeling if CRT started early

 An article by the electrophysiology group at the University of Pittsburg highlights the importance of early CRT in cases of left bundle branch induced non-ischemic cardiomyopathy with heart failure.

 First some background:

The effect of LBBB on ventricular function has been recognized at least since the 1980s and abnormal septal movement  described as  early as 1973 (4). See here for my review of the abnormal cardiac function observed in LBBB.

LBBB induced cardiomyopathy and its potential reversibility by CRT was described at least as early as 2005 in an article by Jean-Jaques Blanc(1). In 2008 Blanc co-authored a chapter on that topic in Barold and Ritter's book  "Devices for Cardiac Resynchronization" (pg 139-145)

In 2013, Vaillant et al (2) described 6 patients with so-called isolated LBBB who developed heart failure and in whom a marked improvement in cardiac function was documented following the institution of CRT.

Wang and Saba et al (3) from Pittsburg studied 123 patients with LBBB-associated idiopathic non-ischemic cardiomyopathy. About half were treated with CRT in less than 9 months after diagnosis and half received CRT after 9 months.

Improvement in left ventricular ejection fraction to greater than 35% was more likely in those who received earlier treatment. The author concluded in part " Delaying CRT may miss a critical period of halt and reverse progressive myocardial damage"

I suggest the importance of this paper is not that earlier is better than later (which seems expected) but rather that,to my knowledge, this is the first paper describing a  large number of patients with  LBBB induced cardiomyopathy   and their response to CRT. To my knowledge ,only a handful of patients had been described previously and this article should perhaps serve to make this entity better recognized.

The patients were treated with CRT which, so far, has been virtually synonymous with bi-ventricular pacing (Bi-V). Now , however, more patients are being paced with His Bundle pacing. There is some developing evidence that His Bundle pacing is  at least equivalent in terms of efficacy to Bi V pacing. His bundle pacing certainly seems more physiologic. His bundle pacing is capable of making the abnormal LBBB QRS complex normal or nearly so in the majority of  cases.Alberti et al  (5) from the University of Florence make the case for His Bundle pacing as an alternative to Bi-ventricular pacing in CRT and note sthe ongoing clinical trial (the HOPE_HF trial)  using His Bundle pacing in CRT eligible patients.Actually in 2015, Lustgarten et al(6) demonstrated an equivalent CRT response
of Bi-V pacing  in a cross over trial with His Bundle pacing in 29 patients.

All of Wang's patients were treated for 3 months with the  standard heart failure regimen but responded poorly and then with CRT. What about patients who develop "lone" LBBB and have a history of decreased exercise tolerance but ejection fractions still within the normal range? Should the patient be required to have overt HF and poor response to medication before  CRT is considered?

Again a personal note in this regard.  Two years ago  I developed LBBB and my exercise capacity decreased immediately . My echo showed a EF in the normal range ( lower limit) and mitral Doppler flow indicated impaired relaxation and stress echo showed abnormal septal movement. I had also developed an exercise induced high grade second degree heart block and on that basis was a candidate for a pacemaker. I was fortunate to have an EP cardiologist who was doing His Bundle pacing (few were at that time  at least in my area) and after a series of  uncommon post procedure complications (including pulmonary embolus,and pocket hematoma) were resolved I was able to enjoy a return to a level of exercise ability indistinguishable from my pre conduction problems status and I believe avoided the likelihood of a progressive LBBB induced cardiomyopathy.

Three cheers for His Bundle pacing.

1)Blanc J, Evaluation of left bundle branch block as a reversible cause of non-ischaemic dilated cardiomyopathy  with severe heart failure . A new concept of left ventricular dyssyncrhony-induced cardiomyopathy Europace. 2003  7 (6) 604-610

2)Vaillant et al. Resolution of left bundle branch block induced cardiomyopathy by cardiac resynchronization therapy.JACC 2013 vol 61 no 10  pg 1089

3)Wang,NC et al New onset left bundle branch block-associated idiopathic nonischemic cardiomyopathy and time from diagnosis to cardiac resynchronization therapy. The NEOLITH II study PACE 2018 Jan 4

4)Breithandt,G. Left bundle branch block,an old-new entity.J. Cardiovas Tranal Res2012 ,Apr 5 2 107. (authors reference the work of Curtius and of McDonald.

5)Alberti, L Hemodynamics of His bundle pacing. J of electrocardiology 50 (2017) 161-168

6)Lustgarten DL et al His-bundle pacing in cardiac resynchronization therapy patients.a crossover design comparison.Heart Rhythm 2015;12 1548-57

Wednesday, January 10, 2018

The ABIM Foundation, "a foundation dedicated to what?"

Following a revealing blog post regarding the ABIM  by DRWes, a  comment was made by Keith:

" This is what happens when a non profit organization loses site of it's true mission and becomes more focused on the dollars. Looks like they are generating so much loot from their plundering of physicians that they needed somewhere to hide it. Why not create a foundation (the ABIM Foundation) dedicated to what ????"

 So what is it dedicated to?

The key document which outlines the purported current missions of the  ABIMF is the 2002 publication of "Medical Professionalism in the New Millennium:A Physician Charter" .

According to the ABIMF's website: "The Fundamental principles of the charter are primacy of patient welfare,patient autonomy and social justice. "

The first two are long established principles of medical ethics about which there is little controversy  ,but the third is another matter

From a tactical point of view the use of term social justice" has a number of selling points.First, while everyone who would consider themselves progressive (or modern liberals) would support social justice, many of a conservative or libertarian mind set would not. The term social justice is loose and indeterminate and therein again lies is rhetorical value. To many social justice connotes helping the disadvantaged.and  conservative and libertarians are not going to be speaking out against helping the poor etc but differ from progressives in the permissible techniques to bring that about.But to the founders of the Charter helping the disadvantaged  may not be  the driving force.

 We are told that new new medical professionalism is about a "fair and equitable distribution of finite medical resources" and that physicians have an obligation to move toward that goal. At this point readers of the charter might well wonder how, as practicing physicians, how would they accomplish that move.  Well, we are told that physicians can practice cost effective medicine and that may well be best done by following guidelines.In that way they can be the stewards of the finite resources.So it seems that " fair and equitable" corresponds to "cost effective" which for an individual physician that translates to " follow the guidelines"

So  now the bait and switch, the bait is a obligation to promote social justice and the switch is to follow guidelines which is claimed to bring  about  fair and equitable distribution of resources.

Yet you have to ask is this striving for purported social justice the reason for the existence of the ABIMF or  is it to save money for third party payers?ABIM accumulated a significant amount of money by testing internists for board certification and found themselves holding many millions of dollars . This was profit in the sense of receipts greatly exceeding their costs but a non profit does not make a profit by definition even if their monetary intake greater exceeds their monetary output. ABIM itself is a non profit.

Monday, January 08, 2018

The long term trend of how and where decisions are made

I continue to be impressed by the depth of the insight found in Thomas Sowell's "Knowledge and Decisions".

Here is my attempt to discuss some part of it that.

One of the major constraints facing human is lack of knowledge for making the many decisions they have to make in the business of living and just getting by.But decisions have to made and analysis of how and where these decisions are made offer meaningful insight into a lot of which transpires.

We can speak of decision making units (DMU) ( my abbreviation) and attempt to examine the processes involved .Much can be learned about that by looking at the incentives and constraints under which the DMUs operate and the extent to which their (its?)decisions and actions are subject to feedback.The DMUs also may vary in the extent to which they engage in incremental trade offs as opposed to categorical solutions.Sowell correctly emphasis that for analytic purposes one should not look at an organization's purported "mission statement" but rather at their incentives and constraints

Sowell contends that over time in the United States there has been a shift in the locus of the decision making.There has been a shift from decisions traditionally made in the home to the school, from businesses to various governmental agencies and to the courts. Further, within government there has been a major shift from decisions made by the legislative branch,concerning which voters have at least the chance of influencing the decisions, to the executive branch with its too numerous to list agencies and departments which are much more immune to the power of the vote and more insulated from public feedback and often given much difference by the courts.

These administrative entities  have  " .... political initiatives and its own external constituencies developed as a results of initial mandate, constantly pushing for an expansion of its activities and benefits." ( from page 318 Sowell, "Knowledge and Decisions" Basic Books, 1980,)

Medical decision making has also migrated from the decisions made by the individual patient physician "dyad" to more central decision making directly and/or indirectly by insurance companies,large medical  practices, pharmacy management companies and HHS.

addendum: 1/20/18 The title was changed. The title was appropriate for a much earlier version of the post written in regard to a particular piece of legislation ,reference to which was deleted in the final version. My apologies for sloppy editing.

Sunday, January 07, 2018

"..how little they really know about what they imagine they can design" -Mega medical hubris

Frederick Hayek was talking about the "curious task of economics " That sentiment can as easily be applied to the central planners of medicine. Dr. Donald Berwick has written about the "need" medicine has for "[wise] leaders with plans".

Five years ago I blogged about the need for a lecture for medical students to underline the dangers of hubris.The type of hubris exhibited by the recently minted expert typically is a self limited affliction as growing experience overwhelms earlier exaggerated estimates of one's knowledge and medical expertise.

Nowhere is hubris more highlighted than it is in those intellectuals who profess to know what it best for others, everyone.This is not the  usually limited hubris of the novice but rather a permanent more exuberant hubris typical of the self appointed philosopher leader who profess to know what is best for everyone as is the case with the self appointed spokesmen for population medicine.

The notion of wise leaders with plans ( for others) finds historical precedence in Plato and his advocacy of philosopher kings.

Friday, January 05, 2018

Echocardiography in the elite athletes of the NBA

The stylized athlete's heart is described as having an increased left ventricular end diastolic volume,a thickened left ventricular wall and increased  left ventricular mass.

Electrocardiograph studies have been reported in soccer players and cyclists largely from Europe.It has been recognized for years that different patterns of cardiac remodeling result from various forms of athletic activities typically depicted as the dichotomy between patterns described in  endurance athletes and in  resistance trained athletes.

Recently (1) a large amount of data has been published on US professional basketball players.These were players on the active rosters of all the NBA teams from the 2013-2014 and 2014-2015 seasons. Testing was done at several locations and sent to the cardiology department at Columbia for analysis.

That publication should be of value to cardiologists faced with issues involving cardiac evaluation of basketball players as regards HCM and Marfan's Syndrome.  Sudden cardiac death is most common among basketball players and HCM is the leading cause.

1) Engel , DT Athletic cardiac remodeling in U.S. professional basketball players.JAMA Cardiology 2016:1(1), 80-87

Wednesday, January 03, 2018

How traditional medical ethics got highjacked and why?

For as long as the dominant medical ethical precept and prime directive was do what it right for the individual patient,third party payers were challenged to control medical costs to the degree they desired because they could not control the folks whose hands were on the cost levers. That just might be the answer to the why.

Traditional Medical ethics stood in the way of the third party payers efforts to control costs and in regard to the private health insurers  to maximize profits.

With the why out of the way, lets move on to the how.

First, we look at an early trial balloon of the plan to disabuse physicians of what to the third party payers was a very dangerous notion namely that the physicians had a fiduciary duty to their patients.

The following gives a flavor of several publications from major medical publications that launched the trial balloon and does not claim to be an exhaustive literature review of medical article promoting that theme.

In 1988 Dr. Robert A. Berenson and M. Hall, a law professor, writing in the Annals of Internal Medicine said that "the traditional ideal" [the traditional doctor patient relationship in which the doctor's duty was to the patient] was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians."

They were explicit when they said : (my bolding)

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.

The authors were saying that insurance companies and managed care companies were defining the physician's role and that physicians needed to simply change their ethical precepts and get with the program.Some may recall that one of the characteristics of a profession (which medicine once was) was that it defined its ethics not an outside party. So the old ethics just does not work any longer.

Berenson and Hall proposed a complete revision or negation of the medical ethics that existed from hundreds of years.This fiduciary duty to the individual patient should be replaced by a nebulous co- duty to medical collective to which the individual patient belonged. As outrageous as that appeared to someone trained in the traditional medical ethics, an obligation to serve the greater needs of society and to balance that against the individual patient's welfare has subsequently appeared to be widely accepted ( at least by many medical society  leaders and spokesmen) by various medical organizations. See here the New Professionalism as promulgated by the American College of Physicians. But I get ahead of the narrative.

Dr. David Eddy authored a series of articles in JAMA ( Eddy DM. Rationing resources while improving quality.How to get more for less.JAMA.1994:272,817-824) promising to teach physicians how they could increase quality and save money at the same time.

The trick was the utilitarian imperative-do the greatest good for the greatest number. In his moral calculus it was not only appropriate but it was ethically demanded that, for example, one would not waste money by for example offering yearly mammograms to women between 40 and 50 if a greater bang for the buck could be achieved by offering smoking cessation session to pregnant women. Cost effectiveness analysis was to guide what was offered to the group It was the health of the collective that mattered and that was true even if the collective was a thrown together bunch of strangers whose employers happened to sign up to a given HMO. The traditional fiduciary duty of the doctor to the patient as well as the legal manifestations of that relationship and the aspect of human nature that says I want what is best for my health and my family's health not for some alleged aspect of a fictional collective would have to moved past.

Doctors were admonished by Eddy to not be "hoarding resources" for their patients.Note his approach went past cost effectiveness concerns and even past comparing the cost and benefits for alternative approaches to the same disease. He was suggesting making judgment about what disease money should be used for and what sub-group of members of the collective should benefit and which should not.

Another significant shot across the old medical ethics bow was offered by Dr. Donald Berwick and Dr. Troyen Brennan with their book, "New rules" published in 1996. The authors were as explicit as was Dr. Berenson when they wrote:

"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The
primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.

Dr. Berwick later received a recess appointment to head CMS while his co-author later become CMO and VP for Aetna (2006-2008) and subsequently CMO and EVP of CVS Caremark.Dr. Berenson has held several positions in federal government icluding vice chair of the Medicare Payment and Advisory Committee (MED PAC).

Next we look at the charter for the New Medical Professionalism which was published in the Annals of Internal Medicine in 2002 as internists on both sides of the Atlantic offered a faux solution to the problems that medical practitioners faced in the new century .Dr. Brennon played a major role in that effort.

The authors listed various problems facing physicians and then gratuitously offered the mother of all non sequiturs namely that presumably these multiple problems (a barrage of new drugs and technology,changes in market forces,etc) could be solved by physicians working for social justice and an equitable distribution of society's medical resources as well as working to promote and respect patient autonomy and the principle of the patient's welfare.Social justice was bundled with the other two non controversial principles. Think about that "solution", to mitigate the myriad of problems the proposal was to maintain principles physician had upheld for a long time and add on an obligation to work for social welfare. As if physicians did not already have have enough to do. This was not an ethics handbook ( that would come later ), rather this was a "charter" , a set of commitments for medical professionalism which they defined as the basis for medicine's imaginary contract with society.

In 2007 the same or very similar theme was played again , this time by Dr. Brennan , who by this time had become VP of Aetna in an article entitled "Managing Medical Resources, A return to the Medical Commons" , coauthored by the then President of ACP Dr. Christine Cassells.(JAMA,June 13,2007,Vol 297,#20,pg 2518.

Here,the authors speak of an abstract, hypothetical " medical commons" and lament that the current emphasis by the physician for the welfare of the individual patient will spoil the commons much as the farmer who selfishly grazes his cattle on public land without regard for depleting the resource will destroy the resource.Physicians are implored to "reconstitute the medical commons" and think in terms of resource conservation and allocation so at the end the greatest medical good can be done for the greatest number of patients.They admit there is not currently such a commons. There never has been so I am unsure how a return is possible.

The medical commons figure of speech seems particularly lame.While a grassy knoll for the villager's sheep can be defined by a specific surveyor description, the "medical commons" is a extremely large amorphous array,the elements of which almost defy enumeration, and every changing, with some elements growing ,others contracting and innovations cropping up constantly.There is no easily defined entity called "medical resources";it is an amorphous abstraction.Further, to speak of allocation means some one or some elite group will be the "allocator in chief ". Decisions will not be made by thousands of individual physician-patient pairs.

Cassell and Brennan assert that a market based on a regulatory approach will allocate resources without the caring and wisdom that clinicians can bring to the endeavor. In their analysis the only choice is a medical commons with physicians and patients moving hand in hand willing to put aside the petty concerns of the individual when necessary for the greatest good of the group.

This is not the only publication wherein an officer of a large insurer found a friendly home either with a ACP officer as co-author or in a ACP journal to espouse a similar theme.

The journal of the American College of Physicians (ACP), the Annals of Internal Medicine, in 2006 featured a five page article in which the former CEO, and then current board member of Aetna, Dr. John W. Rowe, pontificated on the "moral basis for physicians..to participate in...[P4P]." I commented on that article at the time and noted that Aetna's reputation among practicing physicians was such that Dr. Rowe might not have been the most credible witness to present the case for P4P , a movement which the ACP has tended to favor. In a comment to my blog entry Dr. Roy Poses pointed out more details concerning Dr.Rowe's association with Aetna , namely that he owned 6 million shares and that he was actually chairman of the board of Aetna and that , of course, Rowe has a fiduciary duty to act in the interests of the company.

Then in 2012 came the new ethics manual of the American college of Physicians ( Published as a supplement to the Annals of Internal Medicine Jan. 2012,
American college of Physician ethics Manual, sixth edition;) Here is one quote:

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.

In this document there was no longer dancing around the edges or causing the reader's eyes to glaze over with absurd fairy tales of patients and physicians working together for some nebulous common and conservation of commonly owned resources. Now we are told doctors need to conserve medical resources and get over the archaic obligation to the be patient's advocate.

quoting from Table 1 ( pg 74) Principles that Guide the ACP Ethics Manual recommendations

principle description

Beneficence The duty to promote good and act in the best interest of the patient
and the health of society

Non Maleficence The duty to do no harm to patients

Respect for patient The duty to protect and foster a patient's free uncoerced choice

Justice The equitable distribution of the life-enhancing opportunities
afforded by health care

Quoting from page 74 of a supplement to the Annals of Internal Medicine, entitled "American college of Physicians Ethics Manual,sixth edition.

Comment: Right at the beginning the ancient bedrock of medical ethics is quietly altered. Now Beneficence is expanded beyond its traditional meaning altered to include "the health of society"
How has the term been used in the past.

Wikipedia states:
The term beneficence refers to actions that promote the well being of others. In the medical context, this means taking actions that serve the best interests of patients. However, uncertainty surrounds the precise definition of which practices do in fact help patients.

James Childress and Tom Beauchamp in Principle of Biomedical Ethics (1978) identify beneficence as one of the core values of health care ethics. Some scholars, such as Edmund Pellegrino, argue that beneficence is the only fundamental principle of medical ethics. They argue that healing should be the sole purpose of medicine, and that endeavors like cosmetic surgery, contraception and euthanasia fall beyond its purview.

Considerations of justice must inform the physician's role as citizen and clinical decisions about resource allocation. The principle of distributive justice requires that we seek to equitably distribute the life-enhancing opportunities afforded by health care. How to accomplish this distribution is the focus of intense debate.More than ever,concerns about justice challenge the traditional role of physician as patient advocate.

A box insert is found on page 87 of the manual:

Box 4  "Patients first and stewardship of resources.

The physician's first and primary duty is to the patient.

Physician must base their counsel on the interests of the individual patient, regardless of the insurance or medical delivery setting.

This physician's professional role is to make recommendations on the basis of the best evidence and to pursue options that comport with the patient's unique health needs,values and preferences."

Ed. OK so far no problem but now

"Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available."

In 2002,  a major offensive against the old ethics appeared in the form of the "Charter for the New Professionalism in the New Millennium "Then things are firmed up in the ACP's new ethics manual

June 2012 AMA joins the bandwagon.

Dr.Richard Fogoros said the following: on his blog the Covert Rationing Blog:

To summarize, by the turn of the millennium doctors were being coerced to withhold healthcare from their patients at the bedside, and thus to violate their time-honored primary professional directive. The intent of the 2002 Charter on medical professionalism was to repair the problem (i.e., to cure the “frustration”), not by confronting the forces of evil doing the coercion, but rather, by simply changing medical ethics to make bedside rationing OK. And that’s just what the document did, though only after careful re-editing to make this radical change to medical ethics sound as benign as possible.

Here we had the great non sequitor which was that  physicians are frustrated by many current forces and situations so to relive their angst we propose they not only worry about the welfare  of their individual patients but they also are responsible for everyone's welfare and the conservation of society's resources.

But how to do that-simple- later we are told simply follow the guidelines.