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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, May 12, 2023

What retired doc learned from economics

From Leamers book on Maco
humans are pattern seeking story telling creatures.

Economics cannot provide the level of certitude that the experimental sciences provide.The best it can do is look for patterns and then tell stories.

What if physics were like economics From Jim Manzi Uncontrolled:The surprising payoff of trial-and-error for business, politics and Society.

And how those stories vary-eg Milton Friedman and there is no free lunch versus the better than a free lunch claim that fiscal stimulus in an economy which has less than full employment will give a free lunch and will generate stillmore free lunches.(This from the advice that arose fromthe work of Lerner and Hansen taking Keynes thought and turning them into just about the coolest tool a politician or elected official could have ever received.)

It began with Ayn Rand and may have ended up on life support with Covid19 and how humans have reacted

It (my general political-philosophical set of beliefs) really did begin with Ayn Rand, first reading
"Capitalism, the Unknown Ideal " and then devouring Atlas shrugged and Fountainhead.

By late adulthood
my political-philosophical beliefs were fairly well settled in to be.

1)Strong belief in the importance of private property and rule of law and contract law and limited government and that central planning was for the most part a bad game plan
2)support for the kindergarten lesson of "don't mess with other people or their stuff". 
3)Individual freedom was important and the libertarian non-aggression axiom seemed like a good maxim;
4) The history of the 20th century made it quite clear that economic central planning as in communist USSR and China was a disastrous idea leading to the death of millions of people. 

I generally felt fairly comfortable in my self chosen set of reassuring voices in a my echo chamber
consisting of various blogs,books and podcasts and U tube sites until recently. 

 Coincident with the Covid pandemc,Some of the web sties, and  blogs which over the year s have been reliable dispensers of Austrian economic dogma  and general libertarian thought have with an alarming frequency published pseudo-scientific hogwash in regard to the covid 19 pandemic. 

One such posting denied the validity of current concept of viruses putting forth instead the bizarre notion that what are called viruses are actually waste products of cellular damage brought about by various type of  electromagnetic waves. All of the pseudoscientific is not quite as bat-sh**t
crazy as this denial of basic biologic knowledge but some are very close. For example, the claim that wearing a mask will lead to carbon dioxide retention and that mask wearing will lower your immune response , both claims lacking in scientific proof .

The covid pandemic has spotlighted the conflict between the common good and individual freedom.  

Nicholas Talib's comment seemed to an effort to  settle the apparent conflict when he said to remember that the principle underlying libertarian ,axiom , is the non aggression axiom

. If you believe that there is asymptomatic transmission of   a potentially serious  and potentially fatal disease the transmission of which can be significantly  mitigated by wearing a mask, then you need to wear a mask to conform with libertarian basic axiom if  you cannot socially distance .To not wear a mask with those assumptions in mind is to disregard or dismiss the non aggression  moral imperative as you are taking an aggressive act against strangers and or friends. 

However, it seems that there a number of vocal libertarian and libertarian leaning conservatives who do not agree with some or all of the following assumptions

1) There is a Covid 19 pandemic
2)Covid 19 is spread by respiratory droplets and aerosols and fomites
3) Masks will mitigate the spread of covid 19 
4)social distancing will mitigate the spread of covid 19
5) Viral vaccines have been shown to be safe and effective and have provided a "herd immjnity" for a a number of viral illnesses

 There is are a number of vocal libertarians and libertarian leaning conservative who believe or at least espouse some or all of he following:
1.The pandemic is a hoax
2 covid vaccine is a means of population control

can recent innovations in health care delivery be explained in the context of Baumol's disease

Note this blog post is the first of a joint authorship with chatgpt and me. Can recent innovations in health care delivery be explained in the context of Baumol's disease? the following is what chatgpt said in regard to the title question "While there is no single solution to address the cost disease in healthcare, several strategies have been proposed and implemented to mitigate its effects. Here are a few examples: Technological innovation and telemedicine: Advancements in technology, such as telemedicine and digital health solutions, can improve the efficiency and accessibility of healthcare services. Telemedicine allows for remote consultations, reducing the need for physical visits and lowering costs associated with in-person care. Task-shifting and delegation: Healthcare providers can optimize their workforce by delegating certain tasks to other healthcare professionals or utilizing non-physician personnel, such as nurse practitioners or physician assistants. This helps to improve productivity and reduce costs by efficiently utilizing the skills and capabilities of different healthcare professionals. Preventive care and chronic disease management: Emphasizing preventive care and proactive management of chronic diseases can lead to better health outcomes and reduced healthcare costs in the long run. By focusing on early intervention and preventive measures, healthcare resources can be allocated more efficiently, potentially mitigating rising costs associated with advanced or emergency care. Health information technology (HIT) adoption: Widespread adoption of electronic health records (EHRs) and health information exchange systems can enhance coordination and reduce redundancies in healthcare services. Efficient data sharing and interoperability can help healthcare providers make more informed decisions, reduce medical errors, and improve overall productivity. Payment reforms and value-based care models: Shifting from fee-for-service reimbursement models to value-based care models incentivizes healthcare providers to focus on quality and outcomes rather than the volume of services provided. These models promote efficiency, care coordination, and cost containment while aiming to improve patient outcomes. Collaboration and integration: Encouraging collaboration and integration among healthcare providers, such as forming accountable care organizations (ACOs) or healthcare networks, can improve coordination, reduce duplication of services, and streamline healthcare delivery. This integration can help optimize resource allocation and improve overall productivity. . Note chatgpt's strategies should be considered in most instances as aspiration. .

Covid 19 2022 101 -the basics

Three  basics emerge as we enter year three of a pandemic that has claimed 900.000 lives in the United States"
 Covid 19 is a respiratory virus that spreads by aerosols and there is asymptomatic spread as well as symptomatic spread and a significant amount oif the spread is from high spread events aa super spreader events 

1) Effective Masks prevent infection (N 95 or equivalent )
2)Vaccines prevent serious disease and death to a large degree but vaccines do not prevent infection.
3)vaccine effectiveness wanes over a period of months and booster are required as does immunity acquired by infection 

Corollaries. Vaccines do not prevent infection. To the extent masks prevent spread of infection they will naturally prevent death and serious illnesses. Mask effectiveness does not wane.

The protection afforded by vaccines and by contracting covid 19 wanes over time. Boosters are necessary.

Unless and until a vaccine that prevents infection is developed the human experience with covid will depend on the mutations that occur with covid and the development and availability  of safe and effective treatments given promptly after a rapid diagnosis. If covid mutates to a gentler affliction no more than a bad cold or mild to moderate severe flu,,, great.  But If the mutation history of covid continues as it has so far , we are not through with covid no matter how much folks pretend that is the case. Mutations will continue , infection and  surges will continue and boosters will be needed. Mutations may arise as they have so far that have varying degrees of  vaccine escape and varying degrees of virulence. 

The polio vaccine prevented infection by blocking GI tract mucosal invasions and until humans develop a vaccine that protects against covid invading the nasal mucosa or develop a vaccine that is effective against all corona viruses we are not going to say that we are through with covid.

New data on angio invasive follicular thyroid cancer necessitates change in ATA guidelines

With the publication of an article from Japan involving study of 303 cases of encapsulated angioinvasive FTC the current ATA risk classification of angioinvasive into those with four or more instance of angioinvasion ( deemed high risk) and those with three or less (deemed low risk) needs to be revised. The ATA risk classification is low, intermediate and high and the recommendations for each vary considerably.The current guidelines indicate that a patient with 4 or more angio invasions is high risk and a patient with 3 0r less foci of angioinvasion is consdiered low risk and therfore not needing remant ablation. Yamazaki et (1) reviewed 290 cases of FTC with angioinvasion (AI).These patients were free of metastasis at presentation and were seen at the Ito hosptial from 2005 to 2014. Disease free survival in those with one AI had a 94.9 % 10 year DFS while a patient with 4 or more had a 83% DFS, Those with AI of 1-3 had a DFS of 86.3 while patients with 4 or more had a DFS of 83.3 This is not statistically significant. Patients with angioinvasion of less than 4 are consdiered low risk by the ATA criteria Yamazaki' data show there is not a prognostic difference between a patient with three and a patient with four foci of AI . Yamazali et al Encapsulated angioinvasive follicular thyroid cancer.Prognostic impact of the extent of vascular invasion.Ann Surg Oncol 2022 feb 25

Thursday, May 11, 2023

Thyrotrophin suppression to prevent thyroid cancer recurrence

Fron reading the Amercan Thyroid Association;s thyroid cancer guidlines I had assumed that the notion that TSH supression to reduce risk of cancer recurrence was both widely accepted and clearly demonstrated by underlying mechanistic studies and by emperical clinical data. The notion is widely accepted but a mechanistic rational is controversal with there being in vitro data that both support and deny the role of TSH in cancer growth and emperical data are contradictory. A 1998 report from the NTCTcs (Cooper DS,THyroid 1998)TSH suppresion was independly associated with disease progression in high risk patients but only in univariate analysis and not in multivariant models. A 2007 report from NTCTCS (Jonklass j, et al ) which was said by the authors to be the first to show superior outocme with THST They reported improved outcomes in high risk patients ( stage 111 and iv) The 2015 report (Carhill, AA etd al ) from NTCTCS recomended "moderate" but not " aggresssive therapy" Moderate was defined as a TSH level 2 -2.9 with aggresssive 1.0 to 1.99,.They found no additional benefit with the aggessive therapy and recommended at least three years of THST in high risk patients Kekebew et al have published data that challenged the paradigm which indicates suppressive therapy for thyroid cancer patients with either high or intermediate risk. The issue becomes a more high leverage decision ( a currently popular basevball jaron term ) in elderly patients as .as the cardiac risks are of concern and in women the bone loss issue .Basically TSH supression means the iatrogenic generation of subclinical hyperthroidism,a condition that is not comletely benign. Klubo-Gwiezdzinske et al studied retrospectively 1012 cases of DTC (41 with follicular) treated with near total thyroidectomy and remnant ablation and found no improvement in PFS ( authors state their study was under powered to detect a difference in OS) in intermediate and high risk DTC with TSH suppression.( Association of thyrotropin suppression with survival outcomes in patients with interemediate and high risk differentiated thyroid cancer. JAMA opoen network oncology 2019 2 (2) e 1187754

Sunday, May 07, 2023

Was the old time medical ethics just an artifact of economics?

This is a redo of an earlier essay with minimal editorial change. I repeat it now with a nagging thought that "that ship has sailed some time ago" The concern I espressed several years ago has increased as medicine has become corporatized and a target for private equity. __________________ Can the traditional, medical-ethical prime directive of placing the individual patient's interest first survive in a financial environment in which physician autonomy is greatly diminished and income for most physicians is controlled by third party payers. not to mention the heavy hand of venture capital buying medical practices. More broadly put, Dr. Edmund D. Pellegrino asked in 1995 (JAMA,May 24/31,1995,Vol 273,no 20,) " Is medical ethics a social, historical, or economic artifact? Or are there some universal , enduring principles?" In 1988, Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional [ethical ] ideal" was no longer compatible with the changed practice reality 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." Incredibly, the authors claimed that this shift in ethical focus would actually increase patient trust, an attribute that even in the late 80's was in decline as patients tried to live (sometimes literally) with the HMO's restrictions to medical care. Incredibly, they claimed that by not having the patient's interest as the prime directive there would be increased trust in their physician. The expected wave of letters to the Annals editors expressed the belief that advocacy for the individual patient was the prime directive and what it was all about and to replace it was to effectively do away with medical ethics as it had been known and practiced for a very long time. This is what would be expected from an audience of internists who had grown up medically inculcated with an ethic which was the polar opposite of what the authors proposed. Practicing internists at that time were reared to believe that the physician was completely and ultimately responsible for their patients and that their primary duty was to the patient. The average practicing internist if they read the article at all may have thought this was the contrived advocacy of someone who was attempting to make manged care appear ethical. All that was required was to turn medical ethics on its head.When I read that article I thought "you've gotta to be kidding me". A few years later ,I saw no one was kidding as the ACP, ABIM and the European Federation of Internal Medicine joined forces to formulate what was called the New Professionalism in which physicians were admonished to do more than maximize the health of all the patients in their HMO, which was as far as the Annals authors went. Now, physicians were told that they had an ethical obligation to strive for Social Justice. This joint effort by several medical organizations was said to be necessary as the "old ethic" needed to be revised to align itself with the new economic environment in which physicians now lived and "medicine's commitment to the patient was being challenged by external forces of change within our society". While the 1988 article's authors stopped short of suggesting physicians should conserve resources for others in society at large and not just concern themselves with their own HMO's population, the new ethics or professionalism as it was now called, headlined social justice raising it to the level of the big three ethical precepts-patient welfare, patient autonomy and social justice.More than one observer has asked does precept three conflict with precept one? The era from 1963 to about 1990 has been termed the time of "retail medical care". Physicians and patients enjoyed the situation in which a patient's insurance followed the patient so that he could choose any physician and the physicians' fees were not set by the insurer but largely were set by what the physician considered and the payer agreed to be "reasonable,customary,and prevailing". Things were good for physicians in those days as not only was physician autonomy largely unchallenged,but also Medicare had brought about a large influx of money to be spent largely at the discretion of the doctor and their patients and exciting new diagnostic and therapeutic tools were available. More could be done for your patients and more patients could afford medical care. Referrals could be based on the physician's knowledge of the area consultants and prescriptions were written without concern for some third party's list of permissible choices. But soon things were to change as the era of "wholesale medicine" replaced the old ways with the HMO now being a middleman-a very powerful middleman- and Medicare imposed wage and price controls on medical services. 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 that could perform magic. The magic was to increase quality of medical care while reducing cost. But it was all merely playing with words and defining words to suit the argument. Eddy defined quality as the greatest medical good for the greatest number within the eco-medical collective (aka HMO). It did not go unnoticed to the skeptical reader that Dr. Eddy listed his affiliation as "Kaiser Permanente of Southern California") Pellegrino in 1995 also asked ...can physicians change the ethics of the profession at will ( as proposed by Berenson and Hall) or is there a more fundamental and universal foundation for the ethics of medicine in the special nature of the physician-patient relationship? Pellegrino's quotes are found in an article entitled "Guarding the Integrity of Medical Ethics-Some Lessons from Soviet Russia" . The subversion of medical ethics in Russia suggested to Pellegrino two lessons. 1) corruption will afflict any health system not designed with care of the patient as the its primary driving force. 2) medical ethics must be independent of political exigency. "... a morally responsive profession is an indispensable safeguard for the sick against the statistical morality of utilitarian politics, even in democracies." The statistical morality of utilitarian analysis seems to be increasingly unopposed as the group outcome derived data plays an increasingly large role in the decisions regarding the individual patient exhibited in part as guidelines executed by mid level practitioners as well as physicians. In this new day, the physician has more to worry about that just her patient, she must be concerned for everyone (as allegiance to social justice would demand) but at least she has been removed from the impossible role of being responsible for every aspect of his patient's well being as she is now (merely) a member of a team or perhaps the host of a medical home and part of a system of health care. It takes a village now to treat a patient. ______________ With increasing pressure for a single payer health care system and talk about a federal health board to determine what should/shall be done, the statistical morality of utilitarianism seems more and more on the ascendancy. As much as I do not want to believe it, more and more I am afraid that the old medical ethics may well have been and is now the "artifact of economics" about which Pelligrino speculated.

Monday, May 01, 2023

How reliable are tissue diagnosis of follicular thyroid carcinoma

In a study by Cipriani et al (1) in 2011 a pathology review of 66 follicular thyroid carcinoma (FTC) by three pathologists the diagnosis of 47 was changed (71 %).24 cases were reclassified to papillary carcinoma,18 to follicular adenoma, and five were reclassifed to poorly diffferentiated thyroid carcinoma ... A change from FTC to PTC (to follicular variant of papillary) is an order of magnitude less serious that changing the diagnosis from FTC to poorly differentiaed thyroid carcinoma.Further the change from Carcinoma diagnosis to thyroid follicular adenoma occured in 18 cases ,a change with obvious therapeutic implications.So in 23 cases (five plus eighteen ) the incorrect diagnoses have major and serious impact in almost half of the cases. FTC specific survival forthe reclassifed cases was 77% at ten years and 33.7 at 20 years. There are two major issues in which disagreement frequently occurs:1) whether or not there are areas of atypia as seen in papillary thyroid cancer and 2)whether or not there is invasion either of the capsule or angioinvasion. In some cases the reviewing pathologist believed that the invasion criteria used by some of the of pathologists were not sufficent and therfore the diagnosis was follicular adnoma. The cases were from well known and higly respected institutions ( MGH and University of Chicago) from 1965 to 2007 and all cases had undergone surgery and /or RAI treatment.The slides were reviewed by three pathologists from those institutions.You have to wonder what the error rate might be at the thousands of less pretigious institutions in the country and what the impact might be on patients whose diagnosis was wrong. .... If almost 3/4 of the diagnoses of FTC are on review found to be incorrect with with almost half being reclassified to papillary and around 10% being reclassifed to undifferentiated and about 30% not being carcinoma at all ( i.e. reclassified to adenoma) how accurate are the prognosis made on that basis and similarly how accurate are the data regarding effectivenss of various therapies. The recommendations of the American Thyroid Association as well as all other therapy recommending organizations begin with the implcit assumption that the diagnosis are correct, that is FTC is really that and not an adenoma with a excellent prognosis or a poorly differentiated carcinoma with a extremely bad prognosis regardless of therapy.You have to wonder how many patients with a benign adenoma underwent thyroidectomy and I 131 remnant ablation. If this study is representative of the general stratus of the pathological diagnosis of thyroid cancer how accurate could prognostic statements be ? 1 )Cipriani NA et al Follicular Thyroid carcinoma.How have histological diagnoses changed in the last half century and what are the prognostic implications? Thyroid, vol 25 number 11, nov 2015