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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, June 19, 2019

Is the integrity of the doctor-patient relationship still a topic?

When I published the essay found below in 2015,there was considerable chatter in the medical blog space about the dangers posed to the traditional physician-patient relationship. Now little is written about that topic. The dogs bark and the caravan moves on.

The following was originally posted on 3/24/2015 and a lightly edited version appears below in the hope that there  may be some physicians who still care .

H.L. Mencken defined Puritanism as that haunting fear that someone,somewhere may be happy.

The Medical Progressive Elite's haunting fear is that someone,somewhere is making their own medical decisions with input from their private physician.This fear is shared by the third party payers. In recent years,there appears to be considerable progress in alleviating their fear.

The last thing that the third party payers and the medical progressive elite want is that medical decisions be made  a physician- patient "dyad".This situation is ripe for a classic Baptists and Bootleggers scenario,some of the  medical elite sincerely believing that medicine is too complex and expensive to be left to the judgment of patients with advice from their physicians and the third party payers striving to decrease the cost of doing business and increasing profits share holder value.

This medicine-is-too important-to-be left-patients-and-their- physicians view  is made crystal clear in the following quote from the book,"New Rules"  written by Drs. Don Berwick and Troyen Brennan:

"Today, this isolated relationship[ they are 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 went on the be the  head of CMS for a while and Dr. Brennan went on to be the chief medical office of Aetna insurance company and then CVS Caremark.Sometimes the line between the Baptists and the Bootleggers gets a bit blurry.

Destroying the physician patient "dyad" or relationship  has been a strategic goal of the progressive elite for years and a major initiative to that end was the 2002 publication "Medical Professionalism in the New Millennium:A physician charter".That was a joint effort by the ACP Foundation,the ABIM Foundation and the European Federation of Internal Medicine. The project chair was Troy Brennan and, in my opinion, importantly in terms of future funding and  promotion of the "charter" a member of the project was  Dr. Risa Lavizzo-Mourey of the Robert Wood Johnson Foundation.The RWJF has been a major source of funds for the ad campaign for the Professionalism project.   CEO and . Dr. Harry Kimball ,president of ABIM from 1991 to 2003, was also a project participant.

The Professionalism 's theme is to downplay the fiduciary role of the physician to the patient and insert a nebulous co-duty of  the physician to be a steward of society's limited medical resources and to work for social justice. A particular political agenda was inserted into medical ethics. For physicians who wondered how that role was to be played out, later the ABIMF clarified  things by explaining that one could be a steward of the [collectively owned] medical resources  and social justice would be achieved by providing efficient health care.In one document the authors changed the nature of traditional medical ethics and  also rewrote the meaning of social justice which was now efficient care as opposed to the widely accepted meaning of social justice as redistribution.  In a bait and switch move they have redefined social justice as efficient health care attempting to aggregate the values that individuals might place on a treatment with some collective metric allegedly representing the greatest good to the greatest number.They then further simplified things for the practicing internists (actually all physicians) by gratuitously asserting that following guidelines would be the road to social justice.

Disappointingly, the AMA went along with this flim flam sophistry of the physicians as stewards of society's collectively owned medical resources.See here.

In the ACP-ABIM world no longer would the patient and the physician  be the primary determiners of a test or treatment value but value would be designated as high or low  primarily on a cost effectiveness calculus.Rather than treating each patient as an independent moral agent an aggregate utilitarian metric would be imposed  in which "high value care" is not in the eye of the patient but rather defined by a third party and expressed in  quality adjusted life years per dollar spent The only or at least determinate value is economic efficiency.

Of course, the medical professional elite is a subset of the larger progressive community whose operational credo is that most things are too complex and complicated  to be left to average people and if they will not listen to the delivered wisdom they should be compelled  while the progressive's polar star and major talking point is  to fight against inequality. The poster child for the stick approach has be the comments of Dr. Robert Benson Jr.,the emeritus president of ABIMF,writing on the blog of the ABIMF:

" 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." (This would seem to be a rather severe penalty for not complying with a "recommendation" which Benson thinks should be an edict.)

Consider how important the Choosing Wisely rules would be if  Benson's wishes were enacted.Consider how much of a target the Choosing Wisely decisions would be to various lobbying groups.Third party payers would relish such a situation.

If you want to know what the ABIM and its foundation are about, just read  the ABIMF blog.

The combination of mega hubris and libido domini spells trouble in health care as it does pretty much everywhere.

Monday, June 10, 2019

Why a non-cardiologist thinks generally ablation is bettter than medication for rhythm control

Of course the teaser tittle is misleading.You should ask "better for what".Remember the old auto ad that claimed Fords (or some brand) are better,again better than what and for what.

A  better,more focused claim is that ablation is better than drugs to convert atrial fibrillation to normal sinus rhythm.That issue arises only after the decision of rate versus rhythm control has been made.There is convincing evidence to that point that ablation works better. There is also general agreement that patients feel better with a sinus rhythm than when their atria are fibrillating.Atrial fibrillation is a bad method of running a cardiac pump.

What has not been proven with randomized clinical trials is that ablation results in longer lives and fewer strokes.

The recently presented CABANA trial (https://www.acc.org/latest-in-cardiology/clinical-trials/2018/05/10/15/57/cabana) was long awaited and was hoped to answer that question

This was a large (n=2204),multicenter trial  with five year followup comparing standard AF ablation procedure with either rhythm or rate control medication.When the data were analyzed by the venerable,preferred, orthodox method of analysis ( intention-to-treat or ITT) there was no difference in the combined end points of death,disabling stroke,or cardiac arrest nor was there for each component of the combined end point.

ITT is also referred to as "once randomized always analyzed". If 1,000 were assigned to medication and another 1000 assigned to ablation, all of the Medication group would be analyzed according to the group to which they  were assigned even if they switched over to the ablation group. This method is ,according to standard epidemiologic-statistical dogma, is the only analytic approach which will preserved the "integrity of the randomization process." Randomization is done in the first place to control for the effect of known and unknown variables so that the two groups are balanced in regard to prognostic variables. ITT has been called the de facto standard and it is "conservative", i.e it minimizes Type I error,  it is less likely to show a difference when there is no difference. In criticism of ITT one could say it is too conservative and more susceptible to Type II .

Per protocol analysis (PPA) compares treatment groups that include only those who completed the treatment as originally allocated.Whereas ITT makes the two treatments look similar PPA is more able to how differences.

When PPA was applied to the CABANA data there was demonstrated a decrease in mortality in the ablation group.So there are dueling conclusions based on the method of analysis.(1)

My argument is that regardless of there being no difference in mortality (or maybe there is a difference favoring ablation depending of what analysis you prefer) ablation works better to decrease atrial fibrillation and people feel better without AF and the procedure is safe. It is safe according to either way  you analyze CABANA and we already knew it was safe. The extensive data from Cleveland Clinic  (2) makes that clear. So you do not have to believe that ablation save lives or decreases strokes to favor ablation over rhythm control medication, but of course ablation is not for everyone.

After the data were presented the predictable flurry of spin emerged touting the results  of the PPA and of the "as treated "data.But the EP folks did not really need an alternative analysis to continue with business as usual as ablation is safe,it works better and when successful in decreasing or eliminating the atrial fibrillation "burden" there is better quality of life.

This is certainty not a recommendation to treat everyone with af with ablation but rather an argument in favor of ablation over medication for rhythm control.For  many patients for various clinical reasons, rate control may be the better choice and  a trial of rhythm control meds before ablation is a reasonable and common approach.

1) "...a man hears what he wants to hear and disregards the rest".The Boxer, Simon  and Garfunkel.1982

2)Rehman,KA Life-threatening complications of atrial fibrillation ablation. 16 year experience in a large tertiary care cohort. JACC,March2019, vol 5 no. 3, p 284
(fifteen year period,10,278 patients, no deaths, 100 life threatening complications (mainly pericardial effusions and stroke),no aorto-esophageal fistulas,

Addendum: 10/30/19 This article from the Nov.2019, Journal of American College of Cardiology by Cheng et al presents data suggesting that the Cleveland Clinic experience may not be universal.