Can long standing endurance exercise training mitigate the of age related loss of compliance of left ventricle?

With more evidence available to generate legitimate concern about an increased risk of atrial fibrillation with  many years of endurance exercise and papers about long time endurance athletes and the  much less likely risk of developing arrhymogenic right ventricular dysplasia (ARVD), some good news for the crazy, old long distance runners was very welcome.

Here is a link to summary of the paper by Dr. Paul Bhella et al. entitled "Impact of Lifelong Exercise "dose" on Left Ventricular Compliance and Distensibility"

Here is the authors'conclusion :

" Low doses of casual, lifelong exercise do not prevent the decreased compliance and distensibility observed with healthy, sedentary aging. In contrast, 4 to 5 exercise sessions/week throughout adulthood prevent most of these age-related changes. As LV stiffening has been implicated in the pathophysiology of many cardiovascular conditions affecting the elderly, this "dose" of exercise training may have important implications for prevention of cardiovascular disease."

Is there an age related decrease in left ventricular compliance.  According to a 1984 article by Rodeheffet et al the aging heart may be able to maintain cardiac output in the face of an age associated decrease in maximal heart rate by increasing stroke volume. See here for link. The older person relies more on an increase in end diastolic volume and riding the beneficial part of the Starling curve, but if the left ventricle become less compliant, which it is claimed it does as a function of age that adaptation would only work for a while.

Is the decrease in LV compliance due to just getting old or might it be due to lack of vigorous physical exercise. Dr. Armin-Zaeh and coworkers at the Dallas Based Institute for exercise and environment medicine  believe  it is the latter. See here.  My personal bias is obviously to agree with them. Here are the conclusions from the above linked article.

"In conclusion, a sedentary lifestyle is associated with a decline of ventricular compliance, leading to higher cardiac filling pressures and lower stroke volumes for a given filling volume compared with age-matched athletes or young individuals. Prolonged, sustained endurance training preserves ventricular compliance with aging and may be an important approach to reduce the probability of heart failure with aging."


A partial,apparent  counterpoint to the  above studies can be found here in this 2003 article by  P E Gates and co-authors whose analysis and summary minimized the importance of one of their own findings  ( namely that a standard measure of diastolic function (the e/a ratio) was higher in endurance trained subjects) and instead emphasized the value of the decreased arterial stiffness noted in long term exercisers.Either way, a less stiff ventricle and/or a less stiff aorta, it is  good news to long term endurance exercisers.

addendum: 10/1/14 Correction made on title, "Stiffness" changed to "Compliance"
addendum-1/22/14 Title reworded to a less awkward version 

addendum; 10/4/15 An article by Daniel Forman  entiltted "Enhanced left ventricular filling associated with long term endurance exercise." The title tells their conclusion . The link below is just for an abstract so I cannot comment on the data or how well their summary captures the data. or how old the masters were. The authors state "Early ventricular filling indices in master athletes more closely resemble transmitral flow patterns of health young adults." (Journal of Gerontology 1992, 47 2)

Another chapter in "were you wrong then doctor, or are you wrong now?" this time regarding stenting of non culprit lesions.

The American College of Cardiology recently retracted one of its magic five "Choosing Wisely" recommendations.In 2012 ACC had advised that in the setting of an acute coronary event one should only revascularize the "culprit artery".This is the artery thought to be responsible for the event and if other obstructions are detected the ACC said that there was evidence that the fix everything approach might be harmful.This advice was based on non randomized trials. Here is ACC's official statement.

Now apparently two randomized trials  suggest one should fix (place a stent in ) the other obstructions. Here is quote from ACC:

 “over the last two years, new science has emerged showing potential improvements for some patients in their overall outcomes as a result of complete revascularization.”

Larry Husten,prolific medical journalist whose Forbes article on this subject is linked above, really nailed it , quote:

" It seems to me that the medical organizations that produce guidelines should freely admit this lack of evidence for most recommendations. Then, instead of getting their panties all in a bunch trying to defend the indefensible– as we saw recently with the salt guideline– they could advocate for better evidence...So if they want to make the case for more data they will have to first acknowledge their ignorance.

Acknowledging ignorance seems the last thing  likely to emerge from the guidelines generating organizations.

In 1728, the three verdict system arose in Scottish Criminal cases.The accused could be found guilty,not guilty or not proven. So guilty, not guilty or admitting their ignorance and admitting we just can't say.


Being  a guideline author seems to confer immunity for having to say you are sorry.  The individual physician strives to do what is the right thing for his patient and hopes that what he does is right, the quality rule makers are able to summon up sufficient hubris to  presume to know what is good for everyone. Of course they frequently do not. Remember the beta blocker fiasco.



 

Are pediatric football concussions different from high school and college head trauma?

It would be nice to think so and a 2012 study by Maugans et al provides some data ( see here for full text) which suggests it may be the case. Eight young football players  (in a study of 12 athletes ) were studied early post concussion and at two subsequent times.The football players ages were : two 12 year olds,one thirteen year old,three 14 years olds and 2 aged 15.

Multiple Imaging techniques were used . The diffusion tensor imaging (TDI) tests were normal  as were conventional MRIs,and proton magnetic resonance spectroscopy.

 This is in contrast to two studies in college and two studies in high school football players, none of whom experienced a concussion ,which showed decreased fractional anisotropy (FA) in certain white matter tracts and/or functional MR  abnormality in the dorso-lateral frontal cortex.See here for Talavage's article regarding functional MR changes in high school players.

Further ,one study (Bazarian,  (see here for full text)) showed persistence of the TDI changes six months after the college football  season ended. Here is the authors' summary:

" we have demonstrated that a single football season of RHIs  [ repeated head impacts]without clinically evident concussion resulted in WM changes on DTI. These DTI changes correlated with multiple helmet impact measures and persisted despite 6 months of no-contact rest. This lack of WM recovery could potentially contribute to progressive, cumulative WM damage with subsequent RHI exposures. If this relationship is confirmed in longitudinal studies, efforts to limit the development of RHI-related WM changes by monitoring helmet impact measures, and further elucidation of modifiable factors that may influence WM recovery, could mitigate the long-term risk of CTE [chronic traumatic encephalopathy]."

Maugan's group did demonstrate decrease in  cerebral blood flow ( CBF) in the concussed subjects which tended to return to normal over a few weeks.The authors' conclusion;

"Pediatric SRC [sports related concussion] is primarily a physiologic injury, affecting CBF significantly without evidence of measurable structural, metabolic neuronal or axonal injury.(I am still trying to figure out what a "physiologic injury" means.)
 
What might account for the apparent differences in brain scan results in the college and high school players and the younger athletes studied by Maugan?

Possibly the younger players have a  threshold for CNS symptoms given a head blow  that is lower that the  threshold for whatever tissue changes take place that are reflected in DTI findings.There are contradictory data regarding the question of whether younger brain are more or less susceptible to damage for head trauma.

While it has been shown that  some head  impact levels ( as measured by accelerometers in helmets) in  youth football may approach those demonstrated in high school and college they are on average lower.(see here for full text of article by Cobb, 2013 for detailed data of head impact forces ) Further, the total number of impacts in a season of high school or college practice and game time may be considerably more than in a season of youth football and it may be the cumulative effects is what drives the DTI changes and whatever underlying tissue changes that may occur.Also as the years pile up, youth football and then high school and then college and then for a few professional football the total  number of head impacts grows and it may be the long term cumulative effect of multiple sub-concussive plus the occasional concussive blow that  leads to CTE in a minority of football participants.A definitive link between the imaging findings on active players and the pathological changes seen in chronic traumatic encephalopathy has yet to be established.

Although parents may feel some reassurance from Maugan's research, there is little to be reassured about in  the brain imaging studies of high school and college football players following a concussion free season as well as those studies on players with concussions.There is certainly little reassurance offered in this lengthy and detailed  article from Rolling Stone.There is an increasing about of research on the effects of football related head trauma ( as well as ice hockey) .One pundit, a retired football  player,commented  that it is the parents who really need their heads examined.

Addendum : Minor alterations in syntax and spelling and grammar done on 9.24.14.The original, unfinished version was published on 9/19/14 by mistake .

Is the "triple aim of health care" analogous to the dual mandate of the Federal Reserve

Well, it can be argued that they are both unachievable and the execution of their aims and goals will require wise men such as the "Men of system" discussed by Adam Smith.

In 1977,  Congress, having accepted at least part of the theory of Keynesian economics, amended The Federal Reserve Act, with the passage of the Humphrey-Hawkins Act, stating the monetary policy objectives of the Federal Reserve as:

"The Board of Governors of the Federal Reserve System and the Federal Open Market Committee shall maintain long run growth of the monetary and credit aggregates commensurate with the economy's long run potential to increase production, so as to promote effectively the goals of maximum employment, stable prices and moderate long-term interest rates."

In other words, the Federal Reserve System is tasked by law to control inflation and maximize employment in spite of the fact, given the tools to which the system has access, that the two mandates might be incompatible.

Dr Don Berwick speaks of medicine's "triple aim"  ( as envisioned by the Institute for Health Care Improvement)  : Population health,the patient's experience and the per capita cost.The collective medicinal "we" should strive  to improve population health,the individual patient's experience and reduce the per capita cost.

I am reminded of a series of  articles in JAMA in 1994 by Dr. David Eddy ( "Rationing resources while improving quality" ) in which he promised to provide a means to improve quality of medical care and reduce costs. This was to be done by utilizing a utilitarian cost calculus.The idea was to do what was best for the group,the health care collective statistically, even though he admitted that in such a system there would be winners and losers but the utility to the former would out way the dis utility to the minority. Of course in this scheme quality had to be defined or redefined as  what is better for the aggregate. At least Eddy was candid about there being losers,in Berwick's utopian visions in the picture he paints there seem only to be winners.The population will do better, the individual patient's experience will improve and "we" will spend less money per patient. Everyone will do better and it will even cost less.What could possibly be wrong with that?

I believe that IHI's policy recommendations are basically Eddy's prescription adorned with a layer or two of management-speak verbiage dumped on the top to obfuscate what is really happening. When you claim to improve population health care or outcome and simultaneously  decrease per capital costs, you essentially are doing a cost effectiveness analysis based on a statistical benefit to some group ( e.g. those covered lives in an ACO or HMO) regardless of what determent might befall some other  individuals in the group making the third aim of improving the  patient's experience little more than a fraudulent claim. This is population medicine dressed up in polite euphemisms designed to flimflam the members of the health care collective.

Both Dr. Robert Berenson and Dr. Harold Sox,former president of the American College of Physicians, are  perhaps more candid about about their visions for medical care in the country.

Berenson writing in 1998 in the Annals of Internal Medicine said.

"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 makes it clear that the individual's interest should be trumped by the group's interest.


Dr Harold Sox, former president of the American College of Physicians, in his commentary regarding "population medicine"  made it clear that in shifting funds from managing one disease to another would involve for at least a few generations a situation in which some patients might not receive  treatment so that others might enjoy some type of preventive measures.

Quoting Sox's  November 12, 2013 JAMA commentary:

 "Planning to optimize population health will mean determining the frequency,causes and consequences of he common medical conditions in a population and devising strategies for dealing with them over a lifetime. "...
resources must be allocated across program to prevent,detect and treat disease and its risk factors. "...One reasonable principle to move resources from groups of patients less likely to benefit to groups more likely to benefit...

With the application of this utilitarian calculus there will be winners and losers which Sox seems to admit implicitly the following paragraph.

"It will take several generations to realize the benefit of investments in disease prevention.In the short run, these investments may draw resources away from the tests and treatment of some sick people.In the long run, diseased prevention and better low-cost technology could reduce the outlay for treatment."

If Berwick's, triple aim is something other than  the utilitarian approach of Eddy,Berenson and Sox I wish someone would explain. It is the old wine in newly labeled bottles, this time labeled "enhanced patient experience" and the platitudinous "patient centered care" when really it is the greatest good for the greatest number as judged by cost effectiveness calculation and the real winners are the third party payers and their fellow travelers.


addendum: 12.8/2014.Some editorial changes made to clarify some points and correct spelling.

Is there convincing evidence that some high school football players develop traumatic brain injury without sustaining a concussion?

Traumatic brain injury (TBI) is classified as mild,moderate and severe based on mental status change and duration of loss of consciousness (LOC). Mild TBI  involves LOC less than 30 minutes and corresponds to  a Glascow Coma Scale rating of 13-15. For example, a football player who appears stunned and confused with only brief of no loss of consciousness would have a Glascow score of 14.

A major element of TBI is diffuse axonal injury thought to be caused by rotational and linear acceleration of the brain. Conventional MR imaging and CT images do not detect that type of changes. However, diffusion tensor imaging (DTI) can detect changes in fiber tracts reflecting changes in diffusion of water into nerve tissues.A DTI based measurement ,fractional anisotropy (FA) ,reflects water movement along the axons.In normal tissue FA is high ( approaches 1)

DTI abnormalities have been demonstrated in concussive cases of  mild TBI and the degree of abnormality correlates with the severity of post trauma symptoms.(see here). Typically FA increases acutely in TBI and later on values are decreased (see here ), although there is some inconsistency about the direction of change in this measurement  in the literature and there are case reports in which acutely FA decreases.

Football players  college,high school and professional, who have sustained concussions,have been shown to have abnormal DTIs.

There are  several publications  (1. Davenport et al,2.Talavage,3.Barzarian  4.McAllister )describing research involving college and high school football players that have shown similar DTI changes in athletes who did not have clinical concussions,These imaging changes seem related to multiple sub-concussive head blows.Some studies-but not all- have also shown that these DTI findings correlate with decrements in memory test results over the course of one season.Generally these DTI abnormalities correlate with measurements of acceleration forces of the skull detected by in- helmet accelerometers.

 1)EM Davenport and her colleagues from Wake Forest studied the cumulative effects of head impacts in a single high school football season in players without a recognized concussion.(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).

The authors' summary:

"We show that a single season of football can produce MRI measurable brain changes that have been previously associated with mTBI (mild TBI) .Finally, we demonstrate that these impact related changes in the brain have a strong association with postseason change in cognitive function." The cognitive function was noted in a verbal memory composite score which correlated with the magnitude of the MR findings.

 2) TM Talavage and coworkers studied 11 high school players with functional MRs (fMR),measures of head impact events and neurocognitive function testing. "Functionally detected cognitive impairments in high school football players without clinically diagnosed concussion." J of Neurotrauma. 31:327-338,Feb 2014)

 Unlike most of imaging studies of TBI this group found abnormalities in the frontal lobe with functional MR.DTI was not done.

 Quoting from the authors summary:

"Additionally, we observed players in a previously undiscovered third category, who exhibited no clinically-observed symptoms associated with concussion, but who demonstrated measurable neurocognitive (primarily visual working memory) and neurophysiological (altered activation in the dorsolateral prefrontal cortex [DLPFC])."

3 JJ Bazarian  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 DTI was done preseason, immediately post season and six months after the end of the season.

 DTI abnormalities in white matter 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. .. There was a positive  correlation between number of head impacts and DTI findings. The DTI changes were not correlated with changes in cognitive testing or tests of balance.

4)  TW McAllister's study involved 80 college football and hockey players ( "Effect of head impact of diffusivity measures in a cohort of collegiate contact sports athletes", Neurol. 10:1212/01Dec 11 2013.)
Quoting the authors:
"The magnitude of  [TDI] change in corpus callosum MD (mean diffusivity) was associated with poorer performance on a measure of verbal learning and memory."  Again these findings occurred in players with no recognized concussions.

The risk of concussion is greater in certain positions such as quarterback and wide receivers. Lineman , on the other hand have fewer concussions but most experience multiple head impacts during each game and each full contact practice session.See here for a detailed study on impact forces on various player positions.


Maugans and coworkers studied athletes younger than typical varsity high school players.These players were 12 to 15 years of age and DTI scans done fairly soon after the concussion did not show abnormalities in diffusion indicators including fractional anisotropy.

Dementia Pugilistica as a clinical condition in professional boxers was described as a clinical entity in a JAMA article in 1928.In 1973 the pathological findings were published. In 2005,Omalu et al published the results of an autopsy on an National Football League  player, Pittsburgh Steeler center,Mike Webster, on whom Dr. Omalu had performed an autopsy 3 yearns earlier.This was the first report of Chronic Traumatic Encephalopathy in a football player.

Zhang et al provided some data regarding brain changes in boxers who were symptoms free and who had a normal neurological exam. 47 professional boxers ( age 30 +/-4.5 years ) underwent conventional MRIs and DTIs.In 42 the conventional MRI was normal while 7 demonstrated some focal non specific white matter changes. The 42 demonstrated abnormal DTIs, with decreased fractional anisotropy in regions of the corpus callosum and internal capsule.Boxers have been the canaries in a coal mine.Their experience has made it clear that repeated blows to head can cause permanent progressive brain damage that is not immediately apparent but develops over a  variably long period of time.The question is to what extent does this apply to football in which the players wear helmets.For years it was believed that helmets were adequately protective but now that view is increasingly less plausible.

By 2013 the NFL agreed to settle a class action law suit brought about by former NFL players and their families  but the judge did not agree to the amount offered..Now the NFL has seemingly admitted that as many as one third of players will develop some sort of cognitive impairment and that they will have funds available to cover the agreement.

The distinction between a concussive and a sub-concussive head blow is on the margin indeterminate.  A player may experience a blow to the head and feel slightly dizzy or dazed and not report those symptoms to the coach or trainer. There may be social or peer pressures on players to not report symptoms as they would be benched and not allowed to play until they complete whatever concussion protocol is in place.So the distinction between a group of players with a concussion and a group with no history of reported concussion is  not one based on clear cut objective criteria,often relying on the voluntary reporting of subjective symptoms.So it should not be surprising that cognitive tests and brain imaging studies show similar findings in football players with and without a concussion history.

So in reply to the title question, yes I believe there is convincing evidence, But there has not yet been established a clear linage between the changes in cognitive tests and brain imaging studies  seen after a season of high school or college football  and the development of  chronic traumatic encephalopathy .



 

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.

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

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."
and
"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.

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.

Population medicine approach meets Public Choice theory and practice

What happens with the population medicine approach (PMA) when one considers how thing really work according to the insights of public choice theory (PCT). Spoiler alert-you get much more cronyism,favoritism,and focused benefits and diffused costs with certain special interest groups profiting greatly.

Considering what went on with the writing of ACA what groups would be likely to profit from a governmental run PMA? Big Pharma,big health care insurance , big hospital system,big prescription drug management companies,and lots of consultants who will claim to be able to explain it all.

Recall some of the details of the profitable,magical revolving doors that were prominent  in the creation and the subsequent development   of The Affordable Care act.

 Leading the list has to be Nancy DeParle.See here for Dr Roy Poses's comments on her travels in and out of business and in and out of prominent roles in government.

Senator Max Baucus's chief counsel,Liz Fowler, was singled out by the good senator for her important work in crafting the ACA. See here for my earlier comments about the ins and outs of her moving from health related business to  Baucus' influential  committee and back again.

More recently is the interesting matter of the new deputy administrator of CMS,Andrew Slavitt,who assumed that post fresh from his executive position at Optum/QSSI, a subsidiary of the country's largest medical insurer, United Health Group. Optum was hired by HHS to set up the internet hub for Obamacare.The ethics "rule" that a person leaving a private organization to a governmental agency cannot interact in an official capacity with that firm for one year was waived in the case of Slavitt . See here for details.

 Should anyone be surprised that a deputy administrator of CMS would become chairman of ABIMF Board of trustees.

Glenn M. Hackbarth ,JD was a deputy administrator of Healthcare finance administration (the precursor organization to Center for Medicare Services  and  until recently was the chair of the board of trustees of the American Board of Internal Medicine Foundation (ABIMF).

Should anyone be surprised that Sam Ho, an executive Vice President of United Health Care, served on an Institute of Medicine Committee that was charged to devise recommendations to the administration regarding what elements should be included in the mandatory health insurance proposed under Obamacare?

Answer to both- of course not.

After all who should know better what coverages should be included in a program that forces everyone to buy health care insurance than the CEO of an insurance company who will make out like crazy when the bill is enacted?

After all why would  one  of  the hierarchy of the largest third party payer ( ie Medicaid and Medicare) not wish to associate with a foundation that strives to conserve the nation's health resources?

No, these are not instances of strange bedfellows but rather folks synchronizing and harmonizing  their mutual interests? All these folks are just dedicated to providing quality health care to everyone while wisely making choices that will preserve our finite medical resources.

Should anyone be surprised that a former vice president of a large medical insurer (WellPoint)  was the key author of the Obamacare bill as it came out of Senator Baucus's committee? Of course not. who would be better qualified for that task than Elizabeth Fowler who was also chosen by the administration to oversee the administration of the statute after it was passed?


So what does all of this have to do with PMA and PCT? The history of the cahoots and cronyism of ACA provides the answer.

Dr. Gruber-were you wrong then or are you wrong now?

The "were you wrong then.." question is a classic attorney question thrown at an expert witness who has been caught in a contradiction. It seems that would be an appropriate one for Dr. Jonathan Gruber, a MIT economist who is often cited as an architect of Obamacare.Actually he was the architect of the Massachusetts health care law on which Obamacare is said to have been crafted but apparently did play some role in giving advice re: ACA.

In remarks recorded and played repeatedly on the web Gruber make it clear that he believed that only states could issue the subsidies.His comments indicated that states who did not sign on to Obamacare would be doing a great disservice to the its poor citizens as that was, he said, the only way they could get subsidies.
When a Federal court rules that his view was correct he changed his view and claimed that of course the Federal Government could give the subsidies.

See here for an article from Reason which quotes his before and after comments (Before the Halbig decision).

As to how Gruber would answer the hypothetical lawyer question, he has said that he simply made a mistake when he made the earlier remark. You know sort of a "speak- o"similar to the "typo" in Obamacare legislative language  which he claims must have occurred because everyone knew what they "really meant" and that the D.C. court used in its decision.The above quoted Reason article references a second time that Gruber made the  same speak-o.

Speak-o s may have been the cause of his various pronouncements  over time as to if Obamacare would increase or decrease health care costs.

  Being a health care economist, like a public health czar or clinical guideline writer, means you don't not have to ever say you are sorry.

A physician does not need to be society's steward to "Choose wisely"regarding medical advice

Eliminating dangerous and unnecessary medical tests and treatments is the ostensible aim of the "Choosing Wisely" ( CW) initiative that is being promoted by the American Board of Internal Medicine Foundation (ABIMF).

I submit that is is not only unnecessary to evoke the principle of physicians as stewards of society's medical resources to accomplish that goal but it is a dangerous concept and promotes the idea that the individual exists to further the welfare of the collective or " society" Even the most cursory study of world history in the 20th century should disabuse one of the notion that such an approach works out well.

If a physician strives to do what is right for the patients,not to harm the patient and respects the patient's autonomy no other ethical principle is necessary to achieve what the choosing wisely campaign purports to accomplish. Following century's  old  medical ethics it all that is required. A physician so directed would not knowingly order tests or treatments that are harmful to the patient or useless and thereby waste the patient's money, whether or not all or most  of the reimbursement is from an insurance company or the government.The physician by choosing wisely is not saving some mythical society's resources but is spending less of a particular entity's money.

It is not necessary to compare  spending patterns per capita in various countries to cajole physicians to reduce or eliminate  tests or treatments that are useless and or harmful. It is not necessary to change the culture of medicine which has been the announced aim of some spokesmen for ABIMS and ACP to get doctors to do what is right in their best judgment  for their patients.

When my family or I go to a physician I want her to recommended a test or treatment based on her judgement as to whether that would be in the bests interest of her patient and not based on some imaginary role as a steward of some mythical collectively owned resource.

 The folks at ABIMF have been very explicit about linking their version of social justice with the Choosing Wisely initiative.See here.  I submit that physicians have attempted to do what in their judgment is right for their patients without evoking the notion of social justice and that includes not harming the patient by ordering harmful procedures and treatment.Social justice as the term is generally used involves redistribution from the better off to the most disadvantaged. ABIMF's version of social justice is based on utilitarianism keyed to QALY ( quality adjusted life years) per dollar spent and seems to be obsessed with spending less money generally on health care.Think about that for a moment. In what other profession is there a well funded campaign to spend less on what members of the profession have devoted much of their lives learning how to do? Cui Bono.

Being a physician is not the easiest job in the world.It continues  to be true that life is short,the art long, opportunity fleeting, experience treacherous and judgment difficult. My physician has enough to do without assuming the pretense of being a steward of anything-her fiduciary duty to her patient is more than adequate.

Addendum: 12/12/14 Minor grammar changes made.

The population medicine approach does not respect the separateness of the individual,traditional or Rawlsian social justice nor evidence based medicine

 The population medicine approach does not respect  the separateness and sanctity of the individual and individual liberty. It is antithetical to not only traditional medical ethics but also to the ethics of classic liberalism. Further, it violates a major element in the concept of evidence based medicine, patient autonomy. It is not compatible with the social justice concepts as formulated by John Rawls and does not conform with the generally accepted meaning of social justice as redistribution from the less to the more needy.

The population medicine approach is basically utilitarianism which champions policies and actions that are supposed to bring about the greatest good for the greatest number. I say "supposed" because even the founder of utilitarianism recognized that logically and practically determining the aggregate utility or happiness did not make sense.Jermey Betham realized that adding John's happiness and Mary's happiness and subtracting Fred sadness was nonsense.

Quoting Bentham  "Tis vain to talk of adding quantities which after the addition will continue distinct as they were before, one man's happiness will never be another man's happiness;a gain to one man is no gain to another;you might as well pretend to add twenty apples to twenty pears, which after you had done that could not be forty of any one thing  but twenty of each just as there was before. ( ref. pg 136, A system of Liberty, by George H. Smith.) . Bentham admitted his "hedonic calculus" was based on a fiction  but he felt it was a necessary framework to get things done or legislation passed or policies accepted.

His approach echoes the thinking of the man who approached a psychiatrist and told him that he was very worried about his brother. Why are  you worried? Doctor, he thinks he is a chicken. Well, that is very serious you need to get him hospitalized.No, the man replied, we can't do that, we need the eggs.

 Bentham also needed the eggs.

 Everyone make decisions in everyday lives.It may not involve a formal or explicit cost-benefit analysis but it often involves a trade off. Utilitarianism goes beyond  making a trade-off within a person's life to the making of trade- offs between persons' lives and without their consent throwing the discreteness of individual under the bus. The population medicine approach does just that.

Consider the following quote from Dr. Harold Sox writing in the November 13,2013 issue of the Journal of the American Medical Association:Here he is  writing about allocation of funds occurring in the population medicine approach across patients and programs in which funds would be shifted to program in which the value was higher, as judged by QALY per dollar spent.

"It will take several generations to realize the full benefit of investments in disease prevention.In the short run,these investments draw resources away from tests and treatments from some sick people.In the long run, disease prevention and better low cost technology could reduce the outlay for treatment. In the interim, skillful clinical decision making can made the most of limited resources"
and
"Using the same metric of value and the same decision making principles for patients and for populations would be an important step toward a system that fairly allocates resources between the healthy many and the sick few."

The proponents of population medicine cavalierly admit there will be winners and losers. Dr. David Eddy in a series of articles In JAMA in 1995  said exactly that when he discussed the system that he proposed  as achieving better quality at lower cost. It was simply utilitarianism with cost effectiveness being a key metric in the allocations that would be made.Population Medicine is simply utilitarianism using quality adjusted life years (QALY) per dollar spent as the new metric of happiness or utility.

Sir J.A. Muir Gray writing in the Lancet (Vol 382,July 20,2013 ) in a commentary entitled "The Art of Medicine.The shift to personalized and population medicine" said in part:

'In the 21th century clinicians have a responsibility to the population they serves,to the patients they never see, as well as to the patients who have consulted or have been referred.,individual clinicians, while still focused on the needs of the individual in front of them when in the consultation, also make decisions about the allocation and  use  of resources to maximize value for all the people  the population they serve.This could be a decision that will reduce the amount of care that some would receive and increase the amount of resources for another group of patients,or perhaps put resources into education so that generalists can better manage the patient that specialists do not need to see."

Winners and losers but  more than that- Dr. Muir Grey would have the physicians also use their "charismatic and sapiential authority to promote health and prevent disease and encourages sustainable care , getting the best balance of benefit to harm, while minimizing the amount of carbon generated."

This is  a tall order- to balance care for your patient and everyone else and strive to save the environment.Medical schools will have to get even longer and harder to churn out docs with that skill set.Actually the rank and file docs will not have the allocation problem,the Platonic Guardians of Population Medicine will make the big decisions and the regular physicians will just adhere to guidelines.

The proponents of population medicine seem to think they have solved what Bentham thought impossible summing individual utilities by  using the QALY tool, quality adjusted life years which seem more scientific and objective that the "utils" of the early Benthamites.

 The ACP and ABIM Foundation are popularizing the new medical ethics. It appears that this new medical ethical system is an important prerequisite for population medicine  Here is how a former President of ACP, Dr. Harold Sox, ( ref. JAMA Nov.13.2013,vol310,no 8) explains it.

"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 2002,a 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." 

Dr. Sox speaks about "if resources become limited". By definition resources are limited. there has never been a limitless amount of medical care available.Apparently fiduciary duty to the  patient was acceptable as long as resources were not limited but by definition resources are limited.There has never been an unlimited amount of medical resources.

In this passage Dr. Sox ties together the Charter, the Choosing Wisely Campaign and the population medicine approach. Although Dr. Sox omitted mention, the Charter inserted a third ethical principle to the physician's ethical responsibility.It added to beneficence and non malfeasance, the furtherance of social justice which they stipulated was the fair and equitable allocation of medical resources which they later clarified  to mean that physicians should follow medical  guidelines based on cost effectiveness. But social justice as expounded by Rawls and as generally understood by many speople means redistribution to the advantage of the most disadvantaged and that is not what population medicine offers. Shifting of resources to one group from another based on comparative QALY calculations may or may not necessary benefit the most disadvantaged in society. The choosing wisely campaign began with a suggestion to which few physicians would object: eliminate tests and treatments that are harmful or wasteful. But it was not necessary to invent a new ethical principle for physicians to accomplish that goal. The ethical precepts of beneficence and non malfeasance covered that.One need not resort to claiming  that such act were required because physicians were the stewards of society's limited medical resource. It was sufficient to require that under the rubric acting a fiduciary agent of the patient.Further, the Choosing Wisely movement is morphing into something that some (see here) would want to be much more transformative.

Population Medicine approach is not compatible with the basic elements of evidence based medicine.Dr. David Sackett said:"Evidence based medicine is not “cookbook” medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook approaches to individual patient care."

In the scenario described above by Dr. Sox in which funds might be diverted from someone's treatment to benefit some anonymous future person we hear no mention of consent of the patient.  Is it assumed that everyone will selflessly agree to sacrifice for the good of the collective.?Social and political schemes based on that principle worked out rather poorly in the 20th century.

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at: http://www.asha.org/members/ebp/#sthash.4MOV9yTv.dpuf

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at: http://www.asha.org/members/ebp/#sthash.4MOV9yTv.dpuHere is Dr. David Sacket's definition of Evidence Based Medicine (EBM) :"EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal preferences and unique concerns, expectations, and values. The best research evidence is usually found in clinically relevant research that has been conducted using sound methodology". (Sackett D, 2002)What seems lacking in Dr. Sox commentary about population medicine is mention of the patient personal preferences and concerns and values. There is nothing said about how the patient might feel in the scenario Sox describes in which funds that could have been used to treat  some one's illness are diverted to some preventive program in which the result may take generations to be achieved. In a system in which its proponents admit there will be winners and looses we are not told to what extent if any will the values and wishes of the loser be considered .Drs Eddy and Muir Grey seem to assume that patients  will be just fine when funds are directed away from their or their children's or spouses  care to some other use judged to be more valuable or cost effective. Programs which depend on changing human nature have not worked out well.Look at the dismal history of collective planning in the 20th century.

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at: http://www.asha.org/members/ebp/#sthash.4MOV9yTv.dpuf

I submit that population medicine approach and the usual notion of social justice and in particular John Rawls's definition of social justice are not compatible. In fact much of Rawl's magum opus ,A Theory of Justice,was  written at least in part to refute utilitarianism  which is  a principle on which population medicine depends. Rawls said the utilitarianism did not respect the separateness of the individual and argues strongly against treating people as means some social end,In the case of population medicine , this would be optimizing the QALY or QALY per dollar spent.

To mix the concept of social justice and population medicine as done by spokesmen for the ACP and ABIMF is  a masterful muddle of mixing incompatible concepts and stirring it up with platitudes,gratuitous assertions and non sequiturs.


So, other than  that the population medicine approach contradicts traditional medical ethics,does not further social justice as it is commonly understood, flouts a key element of evidence based medicine,and requires individuals to sacrifice  themselves to some alleged greater good, it seems like a  pretty good idea.



Addendum: Minor editorial changes made 12/14/14.

Does the concept of "value based payments" make any sense at all?

Greg Scandlen at the Health Policy Blog comments on the term "value based" quoting from a worth- reading article by David Carr writing on the site Information Week. Here is link to Scandlen 's thoughts.

Scandlen deftly takes apart a widely quoted article by Michael Porter that appeared in the NEJM in 2010 .

The concepts  of professor 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.

A number of the concepts that Porter has made popular ,after a little thought, seem more to be catchy platitudes than useful,reality based insights.For example the notion of improving performance and accountability by "having a shared goal that unites the interests and activities of all stakeholder.s"Is there any real sense in which the patient has a shared goal with the third party payer?

quoting Scandlen:

" ..I would argue that the whole idea that “value to the patient” can be defined objectively is misguided. Even with precisely the same cost and the same medical outcome, the “value” of a service will be different for every patient. Dick Cheney seems to be very happy with his heart transplant and thrilled to extend his life by several more years. Someone else might think that the ordeal of the surgery and medical attention isn’t worth it. Or they might think that their life is pretty crappy and not worth extending."

In other words, value is subjective and in the eyes of the beholder which should be the patient and  not the cost effectiveness practitioners who can "determine" the value with numbers and regressions, even though at the end of the analysis someone has to make a value judgment call.

I have ranted about this near naked emperor before.  See here.

 The " value based payments" meme seems more and more to be  just another phony-baloney justification for third party payers to limit expenditures for medical care and dress it up with platitudes.

Is the underlying problem with the VA hospitals scandals greed?

Perhaps self-interest in a better word to describe what is going here.

There is a wide spread and naive notion that for-profit institutions,  aka business, are driven by greed and that dishonesty and bad motives dominate their existence and that non-profit organizations are the opposite in every regard; But folks who populate non-profit organizations are cut from the same cloth as the rest of humanity and for them as for everyone incentives matter.

This commentary by Glen Reynolds gets it right.

I quote from  his  comments from USA Today:

"In other words, they cooked the books. And what's more, they did it to ensure bigger "performance bonuses." The performance may have been fake, but the bonuses were real. (One whistle-blower compared the operation to a "crime syndicate.")
And that captures an important point. People sometimes think that government or "nonprofit" operations will be run more honestly than for-profit businesses because the businesses operate on the basis of "greed." But, in fact, greed is a human characteristic that is present in any organization made up of humans. It's all about incentives." ....And, ironically, a for-profit medical system might actually offer employees less room for greed than a government system. That's because VA patients were stuck with the VA. If wait times were long, they just had to wait, or do without care. In a free-market system, a provider whose wait times were too long would lose business, and even if the employees faked up the wait-time numbers, that loss of business would show up on the bottom line. That would lead top managers to act, or lose their jobs."

If you look at the history of the VA system you will see greed and corruption boiling over the top at the very beginning..The historian  Burt Folsom gives a brief review of the origin of the VA system and the corruption and mismanagement that characterized its early days under the administration of President  Warren Harding.

The point is that people act in their self interest ( when their actions rub up against our moral priors we call it greed) and that markets impose the discipline of profit and loss that are lacking in  monopolies such as the socialized medicine of the VA system and often -but not always- direct that greed to the benefit of others.

As Milton Friedman said the question is: under what system will
greed lead to the  least harm,his answer was capitalism.Here is his priceless reply to Phil Donahue .

Wanted: Men of System to manage the Population Medicine Approach and maximize society's health

 Let's begin with explaining Men of System and Population Medicine Approach (PMA)

 Adam Smith , in his first book, The Theory of Moral Sentiments spoke of the "man of system"

"The man of system, on the contrary, is apt to be very wise in his own conceit; and is often so enamoured with the supposed beauty of his own ideal plan of government, that he cannot suffer the smallest deviation from any part of it. He goes on to establish it completely and in all its parts, without any regard either to the great interests, or to the strong prejudices which may oppose it. He seems to imagine that he can arrange the different members of a great society with as much ease as the hand arranges the different pieces upon a chess-board. He does not consider that the pieces upon the chess-board have no other principle of motion besides that which the hand impresses upon them; but that, in the great chess-board of human society, every single piece has a principle of motion of its own, altogether different from that which the legislature might chuse [sic] to impress upon it. "

  Dr. Harold C. Sox, , former President of the American College of Physicians (ACP) and former editor of the Journal of that organization, The Annals of Internal Medicine  explains and seemingly recommends the PMA in a commentary in JAMA (November 33,2013) entitled 'Resolving the Tension Between Population Health and Individual  Health Care ".

In this formulation  it is claimed that  one treats the population much as a physician would treat an individual patient.One uses the same "value metric" and the same few decision making principles. For example one would screen a given patient only if that would maximize that person's welfare and similarly in considering applying  a screening procedure to a group would involve screening only those who would gain QALYs. Cox admits we don't really have all that information yet but "the challenge would be to develop models of the principal high stakes decisions of clinical medicine, perhaps starting by identifying these decisions and developing the evidence to inform them"We would need to determine the frequency,causes and consequences of the common medical conditions in a population and devise strategies for dealing with them over the life span.  The public health system and the health care system  and community leaders need to plan together.

Then resources could be allocated between disease-specific programs so that they would be moved from groups of patients less likely to benefit to groups more likely to benefit.

Sox  then seems to admit there may be some growing pains with this approach but in the long run there will be benefit,. That is my paraphrasing now a quote :

"It will take several generations to realize the full benefit of investments in disease prevention. In the short run, these investments may draw resources away from tests and treatment for some sick people. In the long run,disease prevention and better low cost technology could reduce the outlay for treatment. In the interim, skillful clinical decision making can make the most of limited resources. 


To make the population medicine approach operational it would be necessary for physicians to consider themselves practitioners of population medicine and support a system that "fairly allocates resources between the healthy many and sick few:" The Charter for Professionalism paves the way for that by admonishing physicians that they are the stewards of medical resources and that cost effectiveness is the new polar star.As long as physicians considered themselves to be fiduciary agents of their individual patients the scheme would not work. The publication of "Medical Professionalism in the New Millennium:A Physician charter" in 2002 was an important step in the movement to further the dogma of medical collectivism..

To achieve this medical  utopia the Men of System of whom Adam Smith wrote will be required ; some one will be needed to move the different  members of society around the chess board of utilitarian health care with its fair and cost effective allocation of health care resources. And while only a few physicians can be the Platonic Guardians ,some of whom will likely expend their energies on IPAB, the rank and file docs can work for the common good by adhering to guidelines. 


addendum: Minor grammar and spelling corrections made 7/31/14
addendum: typo regarding date of publication of  "Medical Professionalism.." 3/23/17

Swedish study provides More data but not much definitive useful information regarding levels of exercise and atrial fibrillation risk

A recent article in BMJ has stirred  more comments regards the possibility that there is a "j shaped" curve in regard to the relationship between level of exercise and development of atrial fibrillation (AF).

There have been number of publications addressing this issue and to my eye there is good evidence that there is an increased incidence of AF in long time endurance athletes. The magnitude of this increased risk and what this correlates with is less clear-duration of exercise,intensity, height?, genetic profile, confounding factors, etc etc.

The BMJ article is from Sweden by Nikola Drca and is a long term followup of over 44000 men who completed exercise questionnaires and provided  in part retrospective estimates  of hours per week exercised at ages 15,30, and 50.These questionnaires were then linked with data indicating whether they had developed AF.The AF numbers are relatively hard data the historical data much less so.

Of those men who said they exercised more than 5 hours per week at age 30 there was a relative risk (RR) of 1.19 (CI 1.05-1.36) this increased risk in the greater  than 5 hour per week exercise category was only found for age 30, not at age 15 nor age 50 and the RR was higher for the  high exercise at age 30 group  who then stopped exercising  (RR 1.49).

Several points come to mind

When the number in the study group is very large, very small differences in the measured outcomes become statistically significant.  Relative risks less than 2-3 are generally not considered very convincing evidence that there may be causation.My favorite quote in this regard is from Michale Thur , epidemiologist at the American Cancer Society:,

 With epidemiology you can tell a little thing from a big thing.What's very hard to do is to tell a little thing from nothing at all.

and a RR of 1.19 is pretty little 

In trying to assess significance of RRs  from observational epidemiology studies. it is sometimes useful to consider what is the prior evidence and look at biological plausibility (which old time internists like to think of sometimes as pathophysiology or disease mechanisms.)

There are a number of studies that suggest long term endurance athletes have a increased risk of AF but  that is not what the data here suggest at all.The 30 year old heavy exercisers had  increased risk while the 50 year old exercisers did not and there was even  greater risk  in those 30 year old heavy exercisers  who quit. That does not seem like a dose response relationship, i.e more exercise more AF.

What would be the pathophysiology evoked to explain heavy exercise at 30 but not at 50 being related to increased risk of AF.

So what would be the take home advice? Don't begin heavy exercise until age 50 ? But if you are 30 and exercising a lot , don't quit.. None of that makes sense if we believe the is a j shaped curve regarding duration of exercise  and risk of AF or if there is a positive relationship between  duration of exercise and AF.I n spite of headlines emphasizing the 30 year old heavy exercisers risk I think overall the study is more reassuring to long time endurance athletes than it is concerning.The RR for the 30 year old group could easily be just statistical noise and the lack of increased risk for the others a more reliable finding.

 For a more detailed and less biased discussion of this general topic I suggest the excellent blog written by Dr. Larry Creswell.

Disclosure of conflict of interest: I have been doing long distance running for almost 40 years .(Fortunately I did not begin distance running until after age 30,so there should be no problem). So, my mind set  is to be critical of studies that purport to show a problem with too much running.

Former president of American College of Physicians explains the population medicine approach and we should be afraid,very afraid

Dr. Harold C. Sox has played a leadership role in the American College of Physicians  for many years, serving as President of the ACP and long time editor of the Annals of Internal Medicine.

 In the opening paragraph of a commentary in JAMA entitled "Resolving the Tension between Population health can individual health care" (JAMA November 13, 2013,Volume 310, number 18) he states:

"Perhaps the de facto organizing principle of US health care approaching each patient strictly as in individual is obsolete.The population heath approach is an alternative. It aims to improve and maintain health across a defined population."

Later repeating a major theme of the publication,"Medical Professionalism in the new millennium,a physician charter" , Dr Sox says:

"..the physician has an ethical imperative to balance the needs of the individual patient with the needs of  society."

 Dr. Sox  then explains in broad terms how to practice population medicine.

"Planning to optimize population health will mean determining the frequency,causes and consequences of he common medical conditions in a population and devising strategies for dealing with them over a lifetime. "...
resources must be allocated across program to prevent,detect and treat disease and its risk factors. "...One reasonable principle to move resources from groups of patients less likely to benefit to groups more likely to benefit."

With the application of this utilitarian calculus there will be winners and losers which Sox seems to admit implicitly the following paragraph.

"It will take several generations to realize the benefit of investments in disease prevention.In the short run, these investments may draw resources away from the tests and treatment of some sick people.In the long run, diseased prevention and better low-cost technology could reduce the outlay for treatment."

So, in the short run the population medicine approach might deprive some sick patients of treatments but in the long run "the outlay for treatment " could be reduced. Withholding treatment  for those who are sick now for some  purported,future , hypothetical benefit to anonymous  people is completely antithetical to basic medical ethics and has no place in a nation with any remnant of individual freedom remaining.


Dr. Sox after already seemingly condoning  sacrifice of the individual's welfare to some nebulous greater social good then closes the commentary with the following platitude which seems to contradict his earlier statements;
"Much of medical practice has changed but not the basis of patient -centered care."

The term "patient centered care" is a trendy, feel-good cliche without well defined operational meaning but I cannot believe that any generally accepted understanding of that phrase could possibly include not treating the sick to gain some allegedly future benefit to some some subset  of well people.

As someone who did his medical training in the same time frame as Dr. Sox in which the notion of the  physician as the fiduciary of the patient  was sacrosanct   I find his comments wrong on so many levels that I cannot find the words to express it but to the extent that views such as those expressed in his commentary are more widely accepted there is reason to be afraid,very afraid.

Dr Michel Accad critiqued this creed of medical collectivism in his blog writing in part:

"...beyond ignoring the obvious tension between the individual and the group, hoodwinking physicians into practicing "population medicine" is of course the essential means to confuse practitioners into thoughtlessly carrying  out sweeping interventions whose primary benefit is the profit of third parties."


addendum: Several spelling errors and typos corrected on 8/6/2014

Is the bait and switch of the new medical professionalism more apparent now?

The concept "social justice" was the bait. The folks at ABIM, ABIMF, ACP and RWJ declared without even a token effort at historical justification that part of professionalism for physicians was social justice. That 2002 publication entitled " Medical Professionalism in the New Millennium.A physician charter "  did not specify exactly how physicians might work for social justice in their role as physicians.Neither did they offer an operational meaning for social justice which is par for course for folks who promote a collectivist agenda, the ambiguity having significant rhetorical  value.Progressive and liberals love the notion of social justice and would readily give their approval to this new and improved medical professionalism. Conservatives and libertarians not so much but  some went alone to get along to avoid accusations of political incorrectness.

Now the switch. Physicians could/should work for social justice by being stewards of  society's scarce medical resources and that could be done by following guidelines and in that way a fair and equitable distribution of resources could be brought about.

Never mind that the most widely acceptable definition of social justice is redistribution of resources from those who can afford it to those more disadvantaged. This in not what is being promulgated. The ABIM (F) and ACP and RWJF are advocating for parsimonious care in their Choosing Wisely campaign which to the degree it is successful  will decrease care for everyone, at least everyone who depends on their insurance ( private or public) for medical care.  Who gains ? The third party payers and the medical progressive elite and fellow travelers who write the guidelines.

Dr, Scott W Atlas writes here about the two tiered health care that Obamacare will intensify, an interesting irony since folks who continue to defend Obamacare insist that one of the success of it is to further social justice. This is a strange social justice in which the poor and middle class  may  get less care while the connected and wealthy will do much better and in which the young and well subsidize the older and sicker folks even though many of the older are financially better off if only because they may have remnants of lifetimes of earnings.

 addendum: minor spelling and grammar corrections made on 8/8/14   

Has the third party medical payers' dream come true,physicians as medical resource stewards practicing parsimonious care working for the common good

No longer do the third party payers (TPP) have to deal with the physicians and patients working against their bottom line. Physicians,  patients and the TPP will work together in harmony in the land of rainbows,unicorns and the big rock candy mountain.All the stakeholders can get together and work on ways to eliminate waste,low value care and conserve the third party payer's society's scarce resources.Actually TPP have not been dealing with physicians for some time now, they interact with providers of health care.

 The following dream of the TPPs might just be coming true:

Careful analysis of aggregate data  in which patients will gladly participate   will allow cost effective guidelines to be written and executed as all players will realize the wisdom in maximizing the health and well being of the population.The utilitarian ethic of the greatest good for the group will be recognized as the only sensible alternative to the selfish pursuit of individual gain which previously motivated both the selfish patient,concerned as she was with her own health and the health of her family  and the avaricious physician,driven as he was by the flawed and destructive fee for service  system. Value not quantity will be served .

Third party payers should be eternally grateful to the progressive thinking leadership of such organizations as the American Board of Internal Medicine and its foundation,the ABIMF (which was generously funded by the thousands of socially minded internists who sat for repeated examinations) and the thought leaders at The American College of Physicians (ACP) who managed to convince many that providing less care is better for everyone not the least of which are the third party payers and the medical progressive elite who alone will have the wisdom and expertise to determine what is best for everyone.

Can the Choosing Wisely campaign be explained by 1)the follow the money principle and 2)the Baptist and Bootlegger story.

Of course , the dream perhaps had not been completely realized yet. There are still obstacles to overcome;

1) the self interest of the patient and the patient's family. Most people do not think when they develop chest pain " I'm going to the Emergency Room to see how the Doctor can balance my immediate needs with those of society. In other words, one aspect of that darned incentive problem.It is hard to stamp out that pesky tendency of folks to try and act in their own interests and in the interest of those they care deeply about.

2 )that pesky Mal-practice issue . So far the argument that Mr..Jones did badly but it was OK because we followed the latest cost effectiveness guideline has not risen to the level of a major legal defense

3) Reminiscent of the WWII. Japanese soldiers who held out for years on isolated islands not aware they had lost, there are still some physicians who,perhaps educated in an earlier era with a different and less enlightened  ethical upbringing , still believe and as if they are the fiduciaries of their patient.Perhaps time will take care of those dead-enders  but until then the TPP utopia will not be completely  realized in spite of the well funded campaign to convince physicians of their duty to conserve medical resources by following guidelines.