DrRich does not like to pick on the New York Times.

No, really. DrRich does not like to pick on the New York Times, because he receives two paychecks each month from the New York Times*. This fact (which has been disclosed on this blog since its inception in 2007) constitutes a clear conflict of interest, at least when it comes to writing blog posts which might criticize or satirize or mock articles that appear in that venerable publication, from which he receives a not insubstantial proportion of his livelihood.

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*DrRich holds two positions at About.com, which is a New York Times Company. He has manged About.com’s Heart Health Center for 11 years, and also serves on About.com’s Medical Review Board.
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Yet, regular readers will know that the New York Times has served as a regular source of material for DrRich here at the CRB, and little of what he has written in response to that material has been supportive of it. Indeed, the opposite is true.

DrRich considers it his duty to respond to the New York Times whenever it publishes an article that advances the covert rationing of American healthcare, which (through no fault of his), it does frequently. The New York Times serves as a chief voice of Progressive America, and the Progressive takeover of the healthcare system has become, since this blog was first begun, the chief driver of covert rationing. So, conflicts of interest to the contrary notwithstanding, DrRich submits to his readers that he has acted responsibly and honorably despite his unfortunate financial conflicts.

But still, he does not like to pick on the New York Times.

It is unfortunate for DrRich, then, that for the second time this week he is compelled to do so. And this time, as it happens, the subject matter has to do with conflicts of interest (a subject about which, as he has just disclosed once again, DrRich knows something).

Today, the Times writes that experts are beginning to worry that the GOD Panels (Government Operatives Deliberating) now working to devise the clinical guidelines under which American doctors will be strictly compelled, under penalty of the law, to decide which patients will get what, when and how, are tainted by members who have had ties to (gasp!) industry.

When the GOD Panels were first set up, not very long ago, it was still considered acceptable for some members to have industry ties as long as they fully disclosed those ties, and recused themselves from voting on matters specifically related to their industry work. Having at least some members with industry ties was deemed essentially unavoidable, because it was thought that deep subject-matter expertise would be desirable on these panels. Since most clinical research in America is paid for by industry, it is difficult to have deep expertise without having had at least some contact with industry.

But as the Times indicates, modern medical ethics has now advanced well past this kind of primitive thinking. Nobody with any industry ties has any business being on a panel with such overwhelming authority over the practice of American medicine.

David J. Rothman, president of the Institute on Medicine as a Profession, tells the Times, “Consciously or not, they may well be making decisions that fit their funders, their payers and not the patient’s best interests. If you want the public to really believe in the guidelines, why not have a committee that is conflict-free?”

And the ubiquitous Dr. Steven Nissen of the Cleveland Clinic (a person DrRich numbers among those individuals who, by their public words and deeds, he speculates may be auditioning for the really important GOD Panels) says, “Recusing, disclosing — the reason it doesn’t work is the process involves give-and-take. Even if you don’t make a formal vote, you can still have a huge influence over what happens in the process.”

And so, while the Times does not come out and say so, it seems as if a purge of the GOD panelists may be already afoot. If not an actual purge, then at least the “conflicted” panel members are being sent a clear message, well before they take any final action. And at the very least, Ms. Sebelius is being given the cover she needs to select the people she really wants for the truly important GOD Panels which are being constructed for Obamacare.

All of this is pretty clear, and DrRich has great confidence that his readers can figure it out for themselves.

What DrRich really hopes to accomplish here is to note for posterity the great paradigm shift that has occurred in just the last two or three years, regarding the appropriate relationship between physicians and industry.

Until very recently, the American public, doctors, industry, and medical ethicists thought about that relationship in a certain way, which DrRich will call Theory A:

Theory A:

-  Medical progress is Good, and benefits mankind.
-  Industry is responsible for a high proportion of medical progress.
-  Industry-driven progress requires the active participation of physicians.
-  Therefore, a well-managed cooperation between industry and physicians is beneficial to mankind, and ought to be encouraged.

If you subscribe to Theory A you believe that, because well-managed physician-industry relationships benefit mankind, these relationships are good. So, fundamentally, it’s the management of these relationships which is at issue. These beneficial relationships produce unavoidable conflicts of interest, which we must manage by strictly limiting their extent, and fully disclosing the ones that are left.

So traditionally, the debate about conflicts of interest have been about where to draw the necessary limits.

What today’s New York Times article points out is that Theory A is no longer operative. The new thinking begins with the proposition that no amount of conflict of interest is acceptable, and ALL physician-industry ties should be prohibited. One of the most prominent advocates of this new thinking is Jerome Kassirer, former editor of the New England Journal of Medicine, who says, “The ideal handling of conflicts of interest is not to have them at all.” For these voices, Theory A simply does not apply. Rather, they subscribe to Theory B:

Theory B:

-    The greed of medical industry creates excessive costs, and produces far more harm to society than good.
-    Physician-industry alliances strengthen industry, and increase the harm.
-    Therefore, crippling these unholy alliances is critical to the interests of society.

Underlying Theory B, of course, is the largely unspoken and unacknowledged, but nonetheless fully-embraced, proposition that medical progress is not Good after all, but is the very thing that is driving up our healthcare costs, and so it must be stifled.

A corollary of Theory B is that not only is the Central Authority the only entity which is strong enough to cripple these unholy alliances between physicians and industry, but it is the duty of the Central Authority to do so.

Proponents of Theory B, noting, not incorrectly, that medical industry is chiefly concerned with profits rather than the public good, conclude (in a manner compatible with Progressive if not classical logic) that therefore industry will always behave in ways that are counter to the interests of society.  While many proponents of Theory B will agree that industry provides at least some benefits, they are convinced that these benefits are far outweighed by the harm they produce to the collective. Therefore, Theory B proposes to stifle, if not cripple, medical industry. And a very useful strategy for achieving this goal is to de-legitimize any practical relationships whatsoever between medical industry and physicians.

Proponents of Theory B rarely say what their real goal is. To come out and say that their goal is to cripple the companies responsible for producing medical progress would not be expedient. So most of them still give lip service to Theory A. One must discern their real motives from their behavior.

Much of that behavior, in practical terms, has to do with controlling the flow of information. Let industry develop whatever it wants (perhaps), but don’t let profit-drunk industry – or its greedy physician spokespersons – instruct doctors and patients on who ought to use industry’s products, or when and how. That kind of information can only be managed by unbiased sources.

This is the very thinking that produces the impetus for GOD Panels in the first place. Only experts who are free of industry ties and who answer only to our beneficent, unbiased, completely objective government can say which products of industry are good and bad, and can manage the flow of information about them. Information coming from anywhere else is to be regarded as being charged with bias and greed, and should be ignored, or even suppressed by whatever means are necessary.

To any reader who believes that our government is or can ever be an unbiased and honest broker, or that government officials (or GOD panelists) can cancel their own human natures when they put on a government name tag, DrRich can only wish upon you the grace of God (the old fashioned one). You’ll be needing it. To the rest of us, it is obvious that the government is desperately biased when it comes to medical progress in general, and in particular when it comes to establishing “guidelines” for the use of expensive drugs and medical devices.

For Theory B to have become the operative paradigm in America, as the New York Times today suggests it has, will assure the Central Authority that it is free to seed its GOD Panels only with members whose bias runs in their direction.

But under Theory B there is no government bias. There is only industry bias. And when we purge the GOD Panels of all industry bias, by definition we will have created perfect objectivity.

And this is why DrRich feels so comfortable continuing to write this blog despite his obvious financial conflict of interest in favor of the Times. For a conflict of interest in the direction of the Progressive agenda is no conflict at all.

A recent article in the New York Times discusses the growing controversy regarding whether nurses who have earned a doctorate degree in nursing practice ought to be addressed, by patients or others, as “doctor.”  The article touches upon several salient aspects of this controversy, but unfortunately does not resolve any of them.

According to the article, most doctors think nurses – even ones with advanced degrees – should not be awarded this honorific. Only physicians ought to be referred to, in any clinical setting, as “doctor.”

The reason, of course, is entirely altruistic. If the nurses are called “doctor,” it will confuse patients; they won’t know what’s going on, or who’s in charge. This kind of reasoning is entirely consistent with physicians’ well-known and unremitting efforts to make sure every patient understands exactly what is going on, at all times. Clearly, nurses calling themselves “doctor” will undermine such noble efforts.

There are other issues to consider. The Times portrays Dr. Roland Goertz, chairman of the board of the American Academy of Family Physicians (and presumably a doctor of medicine, but this is unspecified), as fretting that, should nurses be allowed to wrest control of the title “doctor” from the real doctors, the real doctors would experience a “loss of control of the profession itself.”

Dr. Kathleen Potempa, president of the American Association of Colleges of Nursing (and presumably a doctor of the nursing kind, but also unspecified) counters that nurses are getting doctorates not to take over the healthcare system or screw with doctors’ heads, but merely to boost their education and stay current. There is, she says, a lot for nurses to learn about these days.

But despite such soothing words from one of nursing’s luminaries, the Times notes that doctors remain alarmed. Nurses are really getting their doctorate degrees, physicians happen to know, to boost their credentials to practice independently – making their own diagnoses, initiating their own treatment plans, writing their own prescriptions, &c. Several states already allow them to do so. Louis J. Goodman, chief executive of the Texas Medical Association, is not fooled: “This degree is just another step toward independent practice.”

But the Times article ends with another demurral from Dr. Potempa: “Nurses are very proud of the fact that they’re nurses, and if nurses had wanted to be doctors, they would have gone to medical school.” (As if, DrRich can hear a few of his colleagues muttering, they could have gotten in.)

So, as DrRich says, the New York Times succeeds in rubbing some of the sore spots created by this controversy, but does not resolve anything. In fact, the article merely dances around the real issue, and leaves it entirely untouched.

You are therefore fortunate, Dear Reader, that you have DrRich to explain the whole matter to you. In fact, here are the six things you really need to know about the doctor-nurses controversy:

1) Nurses who decorate themselves with a doctorate degree in nursing practice have every right to refer to themselves as “doctor,” just as any other doctor in any other field has that right. DrRich was reminded of this fact several years ago, when he was severely admonished at a parent-teacher conference by his child’s history teacher for failing to address her as “doctor.” (This was after DrRich had ascertained that this person could probably not name a single event in American history that had occurred prior to 1860. But then, her degree was in “education,” rather than in the subject matter she taught.) And consider this: there are “doctors” wandering our streets whose degrees are in fields of endeavor whose names end in the word “Studies.” If these souls deserve to be called “doctor,” then nurses – who actually know a lot of very useful things – certainly do.

2) It is not the nurses’ fault that the doctors of old, when they finally became tired of being referred to as “barbers” or “chirurgeons,” and wanting a more distinctive name for themselves, commandeered the generic and widely-used title of “doctor.” No doubt they were very impressed with themselves at the time for having gained an education beyond that necessary to create a decent tonsure, but still. It is as if football players had decided to usurp the term “athlete” as referring only to themselves, and then complained when race car drivers began calling themselves the same thing. (The football players would have a point, of course, but on the whole their behavior would be unreasonable, not to mention unseemly.)

3) It seems just a tad disengenuous for physicians to complain because nurses calling themselves doctors might confuse some patients. Doctors themselves have not been particularly assiduous about disabusing their patients of various confusions. Doctors have yet to explain to their patients, for instance, that according to recently adopted precepts of medical ethics, they are obligated to covertly ration their medical care at the bedside. As a result, patients still think their doctors’ primary obligation is to them. This sort of “confusion” seems far worse, to DrRich, than a little confusion about who is a doctor and who is not. (Besides which, evidence suggests that many patients will always labor under the notion that all female health professionals are nurses, and all males are doctors – and so their confusion about who is who is pretty standard stuff.)

4) DrRich knows that you family practitioners out there have bigger things to worry about, but what the heck is the story with Dr. Roland Goertz*, chairman of the board of your professional society? Can it be he’s actually worried that nurses calling themselves doctors will lead to doctors losing control of their profession? What control is that? Gentlemen and ladies, you have elected a chairman who thinks that you family practitioners still have control of your profession! What are you people thinking?

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*DrRich notes that Dr. Goertz is aptly named. The original, according to the Song of Roland, also sacrificed himself fighting a futile rear-guard action against vastly superior forces.

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5) Dr. Potempa, president of the American Association of Colleges of Nursing, seems like a very reasonable person, and perhaps doctors (the physician kind) might be able to work with her. But DrRich has noticed that there are several different professional societies representing nurses, and some are less mild-mannered and less “reasonable” than others. The nursing organization which perhaps most directly represents those kinds of nurses whom doctors are most concerned about (i.e., nurses who become “doctors” and then want to be addressed that way) is the American College of Nursing Practitioners. The ACNP is much less demure than is Dr. Potempa’s organization about its long-term goals, which it has publicly expressed in a Strategic Plan published in 2005. Anyone examining this plan will note right away that it has been published in ALL CAPS, which, by tradition, indicates a shouting, in-your-face, screw-you sort of an attitude. In this manifesto, the ACNP states (among other things) that “INTERDISCIPLINARY NON-HIERARCHICAL TEAM CARE IS THE HIGHEST QUALITY OF CARE” (i.e., we’re not taking any guff, or orders, from you know-it-all doctors, rather we will practice as fully independent agents); and declares that their goals will not be met until nurses are “PRACTICING WITHOUT RESTRICTION IN EVERY SECTOR OF HEALTHCARE DELIVERY” (i.e., there are no limits to our scope of activity). Overall, this document is breathtaking in its breadth, straightforwardness, and attitude. This Strategic Plan, DrRich points out to his physician friends, reveals what the nurse practitioners are really up to.

And it’s just what you thought.

6) There is an overriding fact that renders all of the above entirely moot. It does not actually matter what doctor-nurses call themselves, or even that there is such a thing as doctor-nurses. It does not matter that the ACNP appears to be a predatory organization. It does not matter that Dr. Goertz may suffer from an acute lack of clues, or that Dr. Potempa seems like a nice lady.

None of this matters, Dear Reader, because Obamacare, the law of the land, has promulgated a new definition of Primary Care Practitioner. By law, today, physicians who practice primary care medicine, and doctor-nurses, and nurse practitioners (not to mention various other forms of non-physician medical personnel), are all PCPs. They are all equally qualified under the law.

It is a done deal. Only the details need to be worked out.

It is not convenient to acknowledge this fact. Primary care physicians and their professional organizations would rather not think about the implications. It means that the American Academy of Family Physicians is fundamentally an obsolete organization, as are its officials, such as Dr. Goertz. It means nearly the same for the American College of Physicians. Neither of these organizations is about to admit that. Furthermore, if this fact were to be acknowledged by the academic programs which are training our primary care physicians, they would become obligated to inform their applicants that the 8-10 years of medical training they are signing up for will place them in the same position, legally speaking, as a nurse practitioner (or, if they want to cushion the blow a little, as a doctor-nurse). This is truly an inconvenient truth. So it is being publicly ignored.

And so primary care doctors, and their professional organizations, go on pretending that the big issue facing primary care doctors is what these new-style PCPs will call themselves. And they are happy to fulminate about that issue to reporters from the New York Times. It seems safer than facing the truth.

But the truth is still the truth, and only the primary care doctors who face up to it will stand a chance of bucking the system, and maintaining their professional standards.

DrRich has heard several primary care physicians argue that their training is just so much better than the training of a doctor-nurse that it’s absurd to suppose those lesser professionals can offer equivalent care. This would certainly be true if primary care doctors actually did the things their training prepared them for. But if they continue following the path the system has laid out for them in recent years – avoiding the management of hospitalized, acutely ill patients altogether; seeing the outpatients who constitute their entire practice at a rate of one per 7.5 minutes; spending that 7.5 minutes making chits on Pay for Performance checklists from On High; sending anyone who actually seems a little sick to the emergency room or to a specialist – it is actually difficult to see what the big drop-off will be if doctor-nurses are doing the job.

When DrRich’s 15-year-old automobile displays some horrible new symptom, he wants a well-trained and experienced mechanic to diagnose the problem and fix it the right way. But if he’s only taking it to one of those 10-minute places for an oil change and a filter, it’s fine with him if the technician just learned the job last Tuesday from Stu. Primary care doctors have allowed themselves to be converted into Jiffy Lube. The training advantage they have over doctor-nurses matters less and less.

The Central Authority is assembling panels of experts to determine which medical decisions are to be made under which circumstances for which patients, and all it asks of doctors is to follow their instructions to the letter. Further, the Central Authority has determined that doctor-nurses will be very, very good at following those instructions – better than physicians, almost without a doubt. Indeed, the nurses’ lesser training – enough to allow them to recognize common conditions, and also enough to teach them that medicine is extraordinarily complex and there’s a lot they don’t understand and never will – is aimed at rendering them satisfied to comply with the directives handed down by panels of experts, and to be very thankful they can do so. Their reduced training is a decided advantage to the Central Authority.

To the Central Authority, the role of an ideal “practitioner” will be much better filled by a nurse, whose training is brief, to the point, focuses on following treatment plans, and is not burdened by centuries of professional pride and embarrassing oaths to dead Greek gods.

Primary care doctors who still value their professional pride, oaths, &c. had better light out for the territories while they still can, and quit worrying about the doctor-nurses (who soon enough will have big problems of their own).

Doctors need to face what is happening to their profession, and avoid getting distracted by battles over nomenclature. If they want to maintain their professional integrity, they will need to clearly distinguish themselves from the checklist checkers and the guideline followers, and demonstrate how the individual expertise and the personalized care they offer will be a big advantage to many patients.

If primary care doctors believe they really do add value to patient care over and above whatever nurses can provide, then they had better learn to articulate exactly what that value is. And once having articulated it, they will need to organize themselves to deliver and market that value, at a reasonable price, to the people they expect to pay for it.

And the “people they expect to pay for it” had better be their patients – because the Central Authority and other third party payers have made crystal clear precisely what they want, expect, and will tolerate from a PCP. What that is, of course, is complete compliance with central directives, and an end to the annoying expectations physicians have traditionally expressed for individual decision-making.

And as for those within the Central Authority, DrRich humbly suggests they carefully read the ANCP manifesto, and ask themselves whether the object of their affection, when finally won, is going to prove quite the demure, compliant little partner they’ve been pining for all this time.

In a recent post, DrRich described the Regulatory Speed Trap, and alleged that our leaders (long before the Obama administration came along) have learned to use it to intimidate and control selected citizens and institutions when it is to their advantage to do so.

The Regulatory Speed Trap, readers will recall, involves the sudden and arbitrary “reinterpretation” of various confusing, ambiguous, or impracticable regulations which have been on the books for some time, and for which affected citizens and institutions (out of sheer necessity) have established de facto interpretations so that they can continue to function. By their longstanding acquiescence with these de facto interpretations, the Central Authority has at least tacitly endorsed them, and thus commerce is permitted to continue. Until, that is, the time arrives when it behooves the Central Authority to suddenly reinterpret those tangled regulations, and convert selected law-abiding citizens into criminals. By the selective enforcement of ambiguous laws, of course, the goals of Social Justice can be advanced.

As a public service, as a warning to academic medical centers, and as a heads-up to the Central Authority (which DrRich has found in personal encounters to be very scary, and to which he would very much like to endear himself against any future encounters) he will now describe a very serviceable but potentially forgotten Regulatory Speed Trap which was laid more than 15 years ago, and which is ripe for springing.

During the decade of the 1990s, DrRich was chairman of the Institutional Review Board (IRB) in a major teaching hospital. The IRB is the committee that reviews all proposed human research projects in the institution, and assures that the research meets ethical and legal standards as set forth by the Office of Human Research Protections (OHRP) of the HHS, and that the rights and welfare of the human research subjects are protected. The IRB has the duty and the authority to prevent or shut down any research project which is not meeting expected standards. The IRB, unlike any other committee within a hospital, reports directly to the Feds, in order to limit any local influence that may be brought to bear over its decisions by hospital administration, well-endowed researchers, or any other local big wigs.

If the Feds decide that an institution’s IRB is not assuring compliance with all the rules, regulations, guidelines, &c., in all their particulars, then they can arbitrarily and indefinitely terminate all human research in that institution, until such time that sufficient corrections, and sufficient penance, can be made – a process that is typically measured in years. This kind of research “death penalty” – which can ruin an academic institution – has been dealt out more than once.  The prospect is a dreadful one to any academic medical center.

It was, in fact, in his capacity as IRB chair that DrRich first became reasonably adept at reading and interpreting the kinds of obtuse regulations and guidelines commonly promulgated by our government. The official documents under which an IRB must operate are many, lengthy, and often difficult to interpret with absolute surety. Yet, in order for the IRB to function, these regulations and guidelines must be resolved into concrete meanings, which, under scrutiny, would most likely prove acceptable to the Feds. (A difficult task to be sure, but still, not markedly different from the task faced by anyone who wishes to conduct an activity for which the government has devised regulations.)

In any case, readers will understand why it was with some dismay that, in 1994, DrRich received this letter from the OHRP, announcing a new policy regarding diversity in human research.

Now to be sure, such a new policy was needed, since up to that time medical research evaluating new therapies was overwhelmingly performed on adult white males. However, this distribution of the benefits (and risks) of research was not in place because of prejudice against (or in favor of) women or non-whites. Rather, it was there for good and practical reasons. Ever since the thalidomide fiasco, it was verboten to enroll women who might become pregnant (i.e., any woman of childbearing age) in most kinds of clinical research. And African-Americans were understandably and appropriately distrustful of medical researchers ever since the Tuskegee study, and as a group they assiduously avoided participating in clinical research. So the exclusion of these groups was made, for the most part, either out of the desire to protect certain classes of individuals (such as unborn babies), or out of the desire of certain groups of individuals to protect themselves.

Still, DrRich was very sympathetic to efforts to find ways of safely extending research on new products to excluded groups. Otherwise, how could we learn if new medical products were safe and effective in everybody? So he read the letter from the OHRP with interest.

And he was immediately dismayed. While the government’s new policy of diversity in clinical research was advanced for the best of intentions,  the substance of the policy was impracticable past the point of absurdity.

The new policy on diversity in clinical research, in its essentials, stipulated:

1) All minorities and all genders MUST be included in all clinical research studies.
2) Sufficient numbers of subjects MUST be enrolled to allow valid outcome statistics to be performed for each category of participant.
3) Cost is NOT allowed as an acceptable reason not to enroll the stipulated groups in sufficient numbers.

The letter and its supporting documents defined six racial and ethnic categories that must be included: Hispanic or Latino, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, Black or African American, or White.

The letter and its supporting documents defined the three genders that must be included as: Male, Female, Indeterminate or Transgender.

Because each defined subgroup must be included in each study in sufficient numbers to allow for valid outcome statistics to be computed, the new directive seemed to require each research trial to expand its size by 18-fold (to account for six racial/ethic categories, and three genders). So a study which would normally require the randomization of 1,000 patients to achieve statistical surety would now need to enroll 18,000 patients. Notably, the recruiting effort that would be needed to comply with this new policy would be far more than merely 18 times more difficult. For it is one thing to find an “extra” 17,000 people who are willing to risk their health for the sake of medical science, but quite another to find these altruists in just the right distribution, including, for instance, 1,000 indeterminately-sexed Pacific Islanders.

But no matter. The new policy explicitly stipulated that the expense of such a recruiting effort was not a permissible excuse for failing to enroll the proper distribution of subjects.

After carefully examining the letterhead of this document to make sure it did not come from The Onion, DrRich made some well-placed, but gentle and appropriately circumspect, inquiries in an attempt to determine whether he was reading it correctly. How seriously must one take this astounding new federal policy on diversity in research? He quickly learned he needed to stop asking questions. His sources revealed to him that several of the authorities in question actually considered their new directive to be a bit mild – a little too watered-down.

For instance, limiting the number of racial and ethnic categories to only six had been a major concession to practicality. Some of the interest groups that had been instrumental in constructing this new policy apparently had argued, for instance, that each of the 337 federally-recognized American Indian tribes ought to be called out as distinct groups. And the authors had thoughtfully compressed the number of genders to only three (when clearly there are at least four). So the people responsible for this new policy had already carefully considered the issue of practicality, and had mercifully compromised in order to render this policy as reasonable as the principles of research diversity would allow.

So yes, the Central Authority was deadly serious.

As it happened, at this very time DrRich was lodged in the teeth of another Regulatory Speed Trap (which he has described elsewhere), so he took this new OHRP policy very seriously. He knew that while it could not be complied with in all its detail, it also could not be ignored. So he called a special meeting of the IRB to discuss how to respond to the new policy.

A long meeting was held in which this new policy was introduced to the membership, and the members’ reactions were permitted to move through the necessary stages of mirth, horror, disbelief, resignation, and finally, resolution. When sober discussion was finally possible, the members unanimously agreed that encouraging the enrollment of women and minorities in clinical research was an important and laudable goal. We also agreed that if researchers were made to comply with the letter of this new policy, all clinical research in the U.S. would come to an immediate halt. And for this reason, we concluded, it must be true that the policy actually desired by the OHRP must be different from what appeared to be the letter of this policy.

We therefore composed a formal response to this policy, which we placed into the minutes of the meeting, for posterity, and for the benefit of whichever future government agents might burst through the doors with automatic weapons, in order to conduct unspecified investigations. That response went something like this:

Medical research aimed at reducing mortality and limiting pain and suffering is a great boon to mankind, and as long as it is conducted ethically it should be encouraged in every way. Diversity in research is also an important good, and to the extent it is practicable, individuals from all races and genders should be offered an opportunity to participate in clinical research. In deciding which of these laudable goals takes precedence, we note that while research can continue despite imperfect diversity, it will not continue if perfect diversity is an absolute requirement – in which case, one ends up with no research, and no diversity. Such a result, we hold, cannot possibly be the aim of the OHRP.  It therefore seems apparent to the committee that the intent of the diversity policy recently handed down by the OHRP must necessarily be to optimize diversity to the fullest extent practicable, and not to stifle research altogether in service to impossible diversity goals. We therefore interpret this new policy to indicate that all practical efforts must be made to recruit research subjects from all racial and ethnic groups, and from whichever genders we can find, and we will hold researchers in this institution to that policy.

And that’s just what we did.

Our formal interpretation of the OHRP’s diversity policy, it must be admitted, did not follow what certainly appears to be the letter of the policy. But it does work toward the stated intent of the policy, and it has the not-inconsiderable advantages of: a) being actually feasible to implement, and b) allowing medical research to continue. In general, DrRich has found that regulators are somewhat more inclined to look upon your behavior as being relatively benign, if you are able to demonstrate that you have taken their regulations seriously (no matter how absurd they might be) instead of simply disregarding them. Accordingly, our IRB created a record demonstrating that we explicitly acknowledged the new policy, we made a good-faith effort to interpret it in light of universally-recognized truths, and then we acted in accordance with that reasonable interpretation.

DrRich does not know how all the other IRBs in the U.S. responded to this new diversity policy. However, since no institution has stopped doing research on its account, and since no institution has launched massive programs to seek out the tens of thousands of transgender Alaskan Natives that would be required in order to conduct medical research under such a policy, one can only conclude that all those other IRBs also decided not to follow the new diversity policy to the letter. DrRich does not know how many of them took the trouble to make a formal record of their interpretation of that policy, and of their rationale justifying their subsequent behavior. In any case, by the studied inaction of the Central Authority, those interpretations have been allowed to stand for well over a decade, and medical research has proceeded accordingly.

DrRich left the practice of medicine – and the wonderful world of IRBs – at the turn of the millennium. He has no idea how big a deal the issue of “diversity in research” is these days. But to the best of his knowledge the OHRP policy has never been rescinded. Indeed, DrRich finds it extremely unlikely that, at any time during that interval, it would have been politically feasible for any government agency, under any Administration, to soften this or any existing formal policy on diversity.

Most likely, after 17 years, this Regulatory Speed Trap is still set, and waiting to be sprung.

As it happens, the Central Authority today is desperately looking for ways to stifle medical progress, since medical advances are among the chief drivers of increased medical spending. The 1994 diversity policy, whose clear-cut plain-English language is being so universally ignored by medical researchers in every American institution, would seem to offer a fine opportunity for shutting down some of that research.

This Regulatory Speed Trap is not only set and baited, but is swarming with potential victims. Fair warning.

Note: DrRich has issued this warning more than once before. It has always gone unheeded. He will now try one more time, with this updated and hopefully more compelling version, not because he actually believes it will do any more good than similar warnings did those other times, but because he is a humanitarian and time is growing short. American physicians will continue to ignore this warning at their own peril.

The history of Western civilization, from prehistoric times until relatively recently (so recently, in fact, that one cannot be absolutely certain the pattern has been broken), has been marked by successive waves of invasions by wild barbarians from the north. (This explains why DrRich will never completely trust the Canadians.)

Every few hundred years, one group of primitives or another – Scythians, Goths, Vandals, Huns, Avars, Norsemen, Bulgars, Mongols, and others named and unnamed – would sweep down upon their betters, upon the more civilized, more culturally and intellectually advanced people to the south, and by the expediencies of slaughter, rape and pillage, would take their land, possessions, freedom, and their lives. The advancing barbarian wave would eventually play itself out, and individual members of the untamed horde would simply settle in place, and over a few generations would become civilized themselves – until the next group of barbarians, in turn, would fall upon them.

It was a cycle as natural as the seasons.

What drove these irresistible barbarian movements? Historians still argue about it. Likely these violent migrations were caused by several different things – famine, plague, encroachment by even nastier barbarians from even farther north, and climate change (though this latter conjecture is now politically incorrect, since the official and proper view of the earth’s climate is that it was absolutely stable for millions of years, until Henry Ford and George Bush came along and bent the temperature curve upwards, like a hockey stick).

The reason DrRich brings all this up, of course, is: to warn his medical colleagues about the cardiologists.

Dear reader, the cardiologists are on the move. Their home turf is being encroached upon, their livelihoods gravely threatened, by the biggest, most ruthless, and most irresistible force on earth – the Feds. And in response they are gathering themselves into a great wave, and they are preparing to overrun the territories of less robust, less terrifying, more civilized (possibly more effete) medical specialists, and make themselves a new home.

Some medical specialists aside from the cardiologists are of course also predatory by nature, but for the most part their territorial incursions are predictable, localized and contained – the orthopedic surgeons and the neurosurgeons, for instance, will fight over lumbar disc surgery. Not so for the cardiologists.

DrRich is a cardiologist, and he knows that the Board Certification papers wielded by cardiologists do not read: “Certified in the practice of cardiac medicine,” but rather, “Certified in the practice of cardiovascular medicine.” Cardiologists, in other words, are officially certified not merely in the practice of heart disease, but also in the practice of any and all disorders affecting the blood vessels.

And DrRich urges his unsuspecting medical colleagues to please notice that blood vessels are prominent features of every organ system in the body. Cardiologists therefore recognize no natural limits to their rightful turf; if it is supplied by the vascular system, it is theirs. And if some other kind of specialist has traditionally claimed sovereignty over some particular organ – say, the liver – their continued success lies entirely in the fact that the cardiologists have not yet chosen to assert their rightful authority. (As it happens, hepatologists are relatively safe, as most cardiologists think of the liver as a particularly uninteresting organ, which, after all, just sits there doing nothing. Many cardiologists, in fact, persist in getting the liver and the kidneys mixed up.) Still, should it ever become convenient for cardiologists to invade the hepatologists’ space, these relatively intellectual, relatively sedentary specialists don’t stand a chance.

What all this means is that when the cardiologists are on the move, nobody is safe. And they are on the move.

Hide the women and children!

The cardiology settlements have been restless for years, continually expanding and growing, and spilling out across their borders to encroach on the turf of their nearby neighbors. They long ago began driving the formerly proud and powerful cardiothoracic surgeons into a sad state of underemployment. More recently they have usurped the formerly sovereign territory of diabetes specialists. They are currently laying siege to sleep medicine (pulmonary specialists) and bariatrics (weight loss specialists). All of these incursions can be related, within one or two degrees of freedom, to heart disease. So these are localized disputes.

But in the last year or so, cardiologists have moved from a state of mere restlessness to a state of high alarm. The ruthless Feds (a mysterious tribe arising from a dark, inexplicable cauldron of a place where even the laws of physics, economics, and human nature do not apply) have taken to attacking the cardiologists where they live – in their home turf of stents and implantable defibrillators. By conducting secret and extensive DOJ investigations as to whether cardiologists are plying their trade according to “guidelines” (a form of tribute acknowledging their state of thrall to the Central Authority), and by threatening to jail them or fine them into professional oblivion (to the point where even the ubiquitous threat of malpractice suits has become a relatively trivial concern), the Feds have forced cardiologists to recognize that it is time for them to move on. It is time to seek out new territory.

There is no telling where they will show up next. If any of you non-cardiologists think you are safe, think again.

To illustrate just how unpredictable the Great Cardiology Migration is likely to become, DrRich will review a few of their recent incursions into the territory of some of the least likely of the medical specialists – the neurologists and the neurosurgeons.

The cardiologists’ encroachment into the field of neurological medicine is not only surprising in itself (for who would have thought that such shoot-from-the-hip, action-addicted specialists would find anything interesting about the brain?), but especially surprising is its scope and its persistence. Cardiologists actually began this process several years ago, under the radar, when they took to blaming imbalances of the autonomic nervous system (i.e., dysautonomia) on mitral valve prolapse. In more recent years, and somewhat more openly, they have attempted to take ownership of migraine headaches.

And now, in recent months, cardiologists have laid claim to the brass ring of the neurological diseases – Alzheimer’s Disease. If they can wrest this common and expensive disorder away from the neurologists, a disorder which people will pay almost any amount of money to prevent or treat, they can set themselves up for generations.

The typical pattern of behavior employed by the cardiology invaders is easy enough to spot. First, they call attention to an alleged association between some cardiac condition (a condition they will manufacture if necessary), and a neurological disorder. Then, immediately, they will assert that (or at least begin behaving as if) the association proves a cause-and-effect relationship. Finally, since they have demonstrated that the neuro problem is produced by a cardiac condition, it will become necessary to refer patients who have (or might develop) that dreaded neuro problem to cardiologists, who, lo and behold, will have invented a well-paying procedure which they claim will treat it.

The best known example is mitral valve prolapse (MVP), a congenital condition in which the mitral valve partially flops open when it should be closed, thus allowing blood to flow backwards (i.e., to regurgitate) across the mitral valve as the heart contracts. (For anyone interested, here’s a brief description of the heart’s chambers and valves.) Now, significant MVP can be a serious medical problem which requires mitral valve surgery. Fortunately, however, this kind of serious MVP is relatively uncommon.

But happily for cardiologists, echocardiography (a non-invasive test using sound waves to create an image of the beating heart) has become so advanced that some degree of trivial MVP, it seems, can be found in almost anybody. According to some studies, as many as 25 – 35% of healthy individuals – people without any cardiac problems or any symptoms whatsoever – can be said to have some degree of MVP. In fact, whether you have MVP or not depends largely on what criteria the echocardiographer uses to make the call, and how badly the referring doctor wants you to have the diagnosis.

Over the years it has become customary to diagnose MVP in young, apparently normal people who have the temerity to complain about the highly disruptive symptoms of dysautonomia (such as fatigue, weakness, strange pains, dizziness, constipation, diarrhea, cramps or passing out), without supplying the kinds of objective physical or laboratory findings which, doctors insist, patients are always obligated to provide. Such thoughtless patients are now routinely sent for echocardiography, so that MVP can be diagnosed (since it can be diagnosed just about whenever it is looked for). The patient is then given the diagnosis of “mitral prolapse syndrome,” even though: a) the MVP is usually so trivial as to be nonexistent; b) the studies which claim to show an association between MVP and these sorts of symptoms are generally based on a gross over-diagnosis of MVP; and c) there is no credible theory based on actual physiology to explain how MVP – even real MVP, much less the trivial kind – might cause such symptoms.

But no matter. “Rule out MVP” has become one of the most common reasons for young, healthy people to be referred for echocardiography, and has become a stable source of income for cardiologists.

The story is similar for the association between patent foramen ovale (PFO) and migraine headaches.

In the developing fetus, the foramen ovale is a hole that is present in the atrial septum (the thin structure that separates the right atrium from the left atrium). At birth, a flap of tissue imposes itself over the foramen ovale, causing it to close. In some people, however – people with PFO – the tissue flap is still capable of flopping open. In people with PFO, the foramen ovale can open for a few moments if the pressure in the right atrium becomes transiently greater than the pressure in the left atrium, such as with coughing, or straining during a bowel movement.

In rare instances, strokes in healthy young patients have been attributed to PFO. The supporting theory is that a stroke can occur when a blood clot happens to be coursing through the right atrium at the precise moment when a person with PFO is coughing (for instance), allowing the clot to move into the left atrium, and on to the brain. And because this theory is at least plausible, in a young person who has an unexplained stroke and is then found to have a PFO, it makes at least some sense to close the PFO.

But the presence or absence of a PFO is a little like the presence or absence of MVP. Its diagnosis depends to some extent on how hard the echocardiographer looks for it, and on how much the referring doctor would appreciate the diagnosis. With modern echocardiographic equipment, at least some sign of PFO can be found in as many as 25% of normal individuals.

Being able to make this nifty diagnosis would be of little use to cardiologists if the only clinical problem it may cause is a one-in-a-million chance of stroke. One cannot make a living, or even make a decent car payment, doing echocardiograms in those extremely rare young patients with cryptic strokes. So it didn’t take long for cardiologists to draw a more useful association – this time, between PFOs and migraine headaches.

While all the things that have to happen in order for a PFO to cause a stroke are very unlikely, at least one can assemble a string of very unlikely events that, should they all occur simultaneously, might possibly produce a stroke. This is not the case with migraine. No plausible theory has been advanced to explain how PFO might cause migraines. The only reason PFO is being invoked as a cause for migraine is that when patients with migraine have been carefully studied for the presence of PFO, an increased incidence of PFO was found. (But again, when PFO is carefully sought in any population of patients, it is more likely to be found.) The only likely reason PFO has not been associated with cancer, red hair, type A personality, or difficulty in memorizing the multiplication tables is that cardiologists have not thought of looking for it (yet) in these conditions.

For cardiologists, the poorly-supported allegation that PFO causes migraine is particularly compelling, since not only can they get paid for the echocardiograms to look for PFOs in migraine sufferers, but also there is an invasive (and lucrative) procedure they can do to close PFOs, to “treat” the migraines. Studies to date have not been successful in showing that closing PFOs improves migraine headaches, but that hasn’t kept cardiologists from screening migraine patients for PFO, then offering them PFO closure as a therapeutic option.

Migraine sufferers are particularly vulnerable to this and many other unproven therapies, since they are often disabled by their condition, and in many cases medical science (or medical ignorance) offers them insufficient help. Consequently, anecdotal stories abound regarding unorthodox therapies that cure migraines. (DrRich, himself a migraine sufferer for many decades, has heard them all.) One undeniable truth is that merely performing PFO closures on enough migraine suffers is guaranteed to produce a patient here or there who will report a positive response. And despite the continued negativity of actual clinical trials so far, that’s what happened.

So, by anecdote – but not by controlled trial – closing PFOs can cure migraines.

But now it gets even worse for the neurologists. Any who ignored the cardiologist’s usurpation of dysautonomia, and who may have felt only a little more concern when cardiologists began to lay claim to migraine headaches, had best sit up and take notice. Because now, cardiologists are laying claim to Alzheimer’s Disease.

Recently, researchers presented a study suggesting that ablation procedures for atrial fibrillation are associated with a lower risk of subsequent Alzheimer’s disease. (Here’s some information on atrial fibrillation and its treatment if you are interested.) The study was presented as an abstract only, so we know relatively little about the specifics.

But, really. Atrial fibrillation and Alzheimer’s are both disorders associated with aging, so it is not surprising that they are associated with each other – in the same way that atrial fibrillation is associated with gray hair, cataracts, and bunions. Ablation for atrial fibrillation is a relatively lengthy and difficult procedure, whose results are relatively middling, and which carries a substantial risk of some really nasty complications. So these ablation procedures are generally reserved for carefully selected, reasonably ideal candidates – usually, the relatively young, relatively healthy atrial fibrillation patients, who are less likely to get Alzheimer’s disease over the next few years whether they have ablations or not.

So there is a lot to be cautious about in interpreting a preliminary study like this one.

But such objections are just quibbles. When this study was reported, the headlines in the typically discerning American press blared: “Ablation Procedures For Atrial Fibrillation Prevents Alzheimer’s.” Whatever the details and limitations of this study, cardiologists can now treat Alzheimer’s. Mission accomplished.

Then, just last week, the American Heart Association and the American Stroke Association released a formal scientific statement to the effect that vascular disorders are an important cause of Alzheimer’s disease. So this new statement clearly plants the flag for the AHA’s chief constituency – the cardiologists (who, DrRich reminds his readers, own vascular disorders).

Remarkably, the American Academy of Neurology, apparently failing utterly to grasp its significance, endorsed the statement. As a result, American neurologists have formally taken the knee before their new masters.

You see how this works?

Now, having for the last time, with an unerring sense of fair play, called this problem to the attention of his non-cardiologist medical colleagues, DrRich would like to finish by emphasizing an overarching point.

You can’t fight the Feds. When the Central Authority, at the point of a gun, decides to reach down into the world of the medical specialists, and dictate which medical services are no longer going to be feasible (all for the noblest of purposes, of course), the affected medical specialists have a limited range of possible responses. And fighting the Feds is NOT among these available responses. It would be more effective – and certainly safer – for doctors to fight against the change of the seasons.

So the affected specialists have only two options. They can contract their horizons, take what’s left, and try to make the best of it. Or, they can do what the Visigoths did when the people of the steppes fell upon them. Strike out against other, weaker tribes and take what’s theirs.

DrRich is not passing any judgment on his cardiology brethren here. (Would you have him judge a she-bear protecting her cubs?) He is just describing what’s happening. You who lie in their path can do with the information as you see fit.

In the meantime, DrRich remains supremely confident that his cardiology colleagues can find a nearly unlimited supply of plunder in this brave new world. They are very robust barbarians.

In his last post, DrRich pointed out to his PCP friends that their chosen profession of primary care medicine is dead and buried – with an official obituary and everything – and that it is pointless for PCPs to waste their time worrying about “secret shoppers” and other petty annoyances.

It is time for you PCPs to abandon “primary care” altogether. It is time to move on.

Walking away from primary care should not be a loss, because actually, primary care has long since abandoned you. Whatever “primary care” may have once been, it has now been reduced to strict adherence to “guidelines,” 7.5 minutes per patient “encounter,” placing chits on various “Pay for Performance” checklists, striving to induce high-and-mighty healthcare bureaucrats (who wouldn’t know a sphygmomanometer from a sphincter) to smile benignly at your humble compliance with their dictates, and most recently, competing for business with nurses.

This is not really primary care medicine. It’s not medicine at all. It’s something else. But whatever it is, it’s what has now been designated by law as “primary care,” and anyone the government unleashes to do it (whether doctors, nurses, or high-school graduates with a checklist of questions) now are all officially Primary Care Practitioners.

What generalist physicians (heretofore known as primary care physicians) need to realize is that “primary care” has been dumbed-down to the point where abandoning it is no loss; indeed, it ought to be liberating to walk away from it.

The beauty is that to survive and flourish, you don’t really need to change your medical ideals or even your medical behavior (unless, of course, you have bought in to the strict adherence to guidelines, checklists, &c.) You simply need to practice medicine exactly as you were trained to practice it – taking all the time needed for careful, thoughtful attention to detail; seeking out the meaningful nuances in your patients’ medical conditions; personalizing both diagnostic and therapeutic recommendations not only for your patient’s medical problems, but also for their psychosocial and economic circumstances; relishing the challenge of making the difficult diagnoses, and managing the complex medical disorders that so often break from the designated norm; and treating guidelines as just that, as often-helpful guideposts, rather than mandates; and most important of all, embracing the classic doctor-patient relationship in all its particulars, and having the latitude to become a true advocate for your individual patients within a hostile healthcare system. In short, you can go back to being a real doctor, and not a cipher in some bureaucrat’s database.

There are only two things you need to do to move in this direction.

First, abandon the “primary care” label. Remember, primary care is now the standards-based, checklist-driven, one-size-fits all, “high-quality” system of practice imposed by government bureaucrats, a practice which is now open to both doctors and nurses (and, in the future, most likely to others).  That’s not what you do. So find a new name for yourself.

The choice of nomenclature is yours, of course, but DrRich humbly suggests “Advanced Care Medicine.”

What you do is not primary care; it’s far more advanced than that, and nobody could do it without the sort of extensive training you have. “Advanced Care Medicine” captures that notion. This name also opens the possibility of referrals from the new-style, government-sanctioned “PCPs,” some of whom undoubtedly will come to recognize that at least 20% of their patients will present as clinical puzzles that do not fit very well with any of the standard medical diagnoses with which they are familiar, and another 20% will not respond to the recommended therapy as the guidelines say they must. These patients obviously will need advanced management, management beyond what a modern primary care practitioner is able (or allowed) to offer. Why not refer them to an ACM physician?

Second, you need to establish practices whereby you are paid directly by your patients. You need to do this because it is the only method available for avoiding the bureaucratic nightmare that wrecked your former profession of primary care in the first place. Payment models can be established that will allow most patients – anyone, say, who can afford a cell phone contract or cable TV – to participate.  (Making your services readily available will blunt the obligatory attacks of “elitist!” which will be aimed your way in the attempt to shame you back into the primary care gulag). There really ought to be nothing particularly revolutionary about this kind of practice, since it was the norm throughout most of the history of medicine until 40 years ago. It is likely that many patients who today would never consider paying any doctor out of pocket will eventually change their minds, once it becomes apparent to them the depths to which primary care medicine has fallen in the United States, and that as a result their lives are on the line.

In any case, when you are paid by your patients, you answer to your patients (not some hostile bureaucrat), and the quality of the care you deliver is measured by your patients (and not some other hostile bureaucrat).  There are no externally imposed time-limits to your office visits, no checklists you must complete, no bizarre documentation rules you must follow for reimbursement, no guidelines you must obey even if it makes no sense for your patient. Those things are for the modern, government-approved “PCPs” to concern themselves with, poor souls, and you do not dwell among these unfortunates anymore.

And happy it is that primary care medicine is killed off now, at this time – because time is of the essence. DrRich has already pointed out that an essential feature of our new Progressive healthcare system will be to make it illegal (in the name of fairness) for individuals to spend their own money on their own healthcare. For Advanced Care Medicine (or whatever you may choose to call it) to become a viable path, you’ve got to begin immediately to make it a fait accompli – to establish it as something patients value, and which they fully expect as a personal healthcare option, and furthermore, as an indispensable referral resource for those sad souls – physicians, nurses and others – who retain the label “PCP,” and who will be powerless (if not clueless) when it comes to providing complex medical care to patients who come in with a difficult diagnosis, or more than one diagnosis, or who otherwise display guideline-unfriendliness.

So at the end of the day, the fact that Obamacare has formally brought primary care medicine to a merciful end may turn out to be a positive thing.

And by all means, don’t sweat President Obama’s “secret shoppers,” or any other cutesy ploys which our policy experts may dream up in the future to amuse themselves, and to distract you from the real issue (which is the demise of your profession). When those phony secret shoppers call for a phony appointment, simply tell them you have openings for any patient, at very reasonable rates and at at a time of their choosing, and that they can see a real doctor who will treat them with dignity, care, expertise, and respect. Or on the other hand, you can remind them, they can take their chances with one of those embittered or indifferent, underutilized or under-trained, oppressively over-regulated or complaisantly submissive, new-style PCPs specified under Obamacare.

Even Obama’s secret shoppers would have to think twice about a choice like that.

The recent announcement that President Obama would dispatch “secret shoppers” – agents of the government posing as patients with either private insurance or Medicare/Medicaid, who would call primary care physicians’ offices to document how long it takes to receive appointments – had many PCPs quite upset.

PCPs were upset despite the fact that the administration assured them that the President’s spies were only aiming to help. In particular, the secret shoppers were going to document that America has a PCP shortage, presumably so that government programs of some sort could be devised to fix that shortage. (They would also document, bye the bye, that patients with government insurance have a more difficult time getting appointments with PCPs.) Apparently, however, the outcry from insulted PCPs was so great that the administration quickly decided to scrap the secret shoppers program – for now, at least.

It is obvious that what the administration claimed they wanted to measure is already well known. Yes, there is indeed a PCP shortage. And yes, PCPs (being, on average, intelligent persons) are relatively slow to schedule patients whose insurance is known to result in a financial loss – if they schedule them at all.

Therefore, equally obviously, there must be some other motive for the administration to have devised this secret shopper program.

The real motive, DrRich submits, was to establish with actual data that: a) we have a two-tiered healthcare system, in which patients on government insurance plans sometimes have more difficulty obtaining medical care, and b) doctors (even the universally-beloved PCPs) are greedy and untrustworthy. Such results, with expert handling, would have served to move some American citizens a little closer to accepting a single-payer healthcare system. It would also serve to convince a few people that, seeing as how physicians behave so badly, perhaps it is not really necessary to have a doctor as your PCP.

All in all, the secret shopper program would have been a few hundred thousand dollars well-spent.

Still, DrRich can only shake his head in wonderment that his PCP friends expressed such great dismay over such a small thing as the secret shopper program. It is as if, after the Titanic struck the iceberg, a delegation of passengers was dispatched to berate the Captain because the turn-down service seemed slow that night.

How is it possible for PCPs to be so indignant about such a trivial thing as secret shoppers, when the very means of their livelihood – their chosen career – is at an end? For it is plain to anyone who cares to look that primary care medicine as we know it is dead. It lingered for years in a moribund condition, and its obituary was finally published last year in the Obamacare legislation.

Primary care’s cause of death was a culmination of two fatal disorders. Firstly, the healthcare system itself – well before the Obama administration came along – slowly smothered primary care into oblivion.

Consider the reduced condition to which the healthcare system – especially the government payers – eventually drove the primary care doctor: Their pay is determined arbitrarily by Acts of Congress, like workers in the old Soviet collectives. They are directed to “practice medicine” strictly according to directives (quaintly called “guidelines”), handed down from on high by panels of sanctioned experts, and accordingly PCPs are enjoined from taking into account their professional experience, or their specific knowledge of their individual patients. They are limited to 7.5 minutes per patient “encounter,” and the content of this brief encounter is determined by sundry Pay for Performance checklists, so as to strictly limit any interactions with their patients that do not meet the approved agenda. Their every move must be carefully documented according to incomprehensible rules, on innumerable forms and documents, that confound patient care but that greatly further the convenience of the stone-witted bureaucrats who are employed specifically to second-guess every clinical decision and every action they take. Worst of all PCPs have been charged with being the primary mediators of covert, bedside healthcare rationing, and to this end have been pressed to nullify the classic doctor-patient relationship by the healthcare bureaucracy that determines their professional viability, by the United States Supreme Court*, and by the bankrupt, new-age ethical precepts of their own profession.

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*Pegram et al. vs Herdrich(98-1940), 530 US211 (2000)
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By such insults, even before Obamacare became the law of the land, primary care medicine had been reduced to one of the most frustrating, enervating and demeaning endeavors a physician could imagine.  Many if not most practicing PCPs are looking to either retire early or change careers, and medical students – even the most idealistic ones – are avoiding primary care in droves, especially if their training exposes them to the palpable despair radiated by actual primary care physicians.

But the second fatal disorder has nothing to do with policy or politics. Even if doctors had perfect control of the healthcare system and the political realities, primary care medicine (as we know it) would still be in trouble. This is because of an axiomatic truth revealed by the annals of human progress, to wit: As knowledge increases and technology improves, activities that used to require the services of highly-trained experts become available to non-experts who have much less training. A lot of what PCPs have traditionally done – check-ups of well patients, screening for occult disease, controlling cholesterol, advising on diet, weight loss and exercise, managing routine hypertension and diabetes – really can be reduced to a series of guidelines and checklists, which can be adequately followed by individuals with much less training than these doctors receive.

When any area of expertise evolves to this level, it is inevitable (in a free economy) that lesser-trained individuals will inherit it. This event greatly increases productivity, makes the services in question more readily available to many people at lower cost, and (ideally) frees up the experts to take on more challenging endeavors. While this kind of transition is nearly inevitable, it is often painful and disruptive. The pain and disruption are being experienced by PCPs today.

DrRich agrees with fellow blogger Wade Kartchner that primary care medicine has advanced to the point where it really would make sense to turn over many of the routine, mundane, and reducible-to-checklist tasks that PCPs typically perform to non-physicians. PCPs who are fighting against this inevitability are wasting their time and energy. They are fighting both history and the laws of economics, so in the end it is a losing battle. It is time for PCPs to move on.

It is of course immaterial whether you agree with DrRich on this point. It is immaterial because this is how the Central Authority sees it.

Having painstakingly reduced you PCPs to tools of the state – whose chief job is to follow the guidelines and place chits on the checklists, &c. – it is only natural for the Central Authority to eventually notice that you really don’t need all that training to do the kind of job they have invented for you. Nurses – who can be “trained up” much more rapidly than you, who will work for much less money than you, and who (they think) will be much less recalcitrant about following handed-down directives than you – will fill the gap. And you, doctor, can go pound salt.

So it was really only a formality for the Obamacare legislation to make the death of primary care official. And the new law, accordingly, did so by stating explicitly that PCPs and nurse practitioners are now equivalent, one and the same. They are both PCPs under the eyes of the law. The actual language of the obituary is as follows:

The term ‘primary care practitioner’ means an individual who —

(I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or

(II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in 9 section 1861(aa)(5))

What this means is that today there are two pathways to becoming a PCP. You can spend four years in college, four years in medical school and three years in a clinical residency – or you can go to nursing school and do another year or two of clinical training. Given this established fact, one could hardly fault patients for questioning the common sense (if not the intelligence) of a healthcare worker who, at this point in the history of medicine, would choose the former pathway.

And so the issue is decided. PCPs: by virtue of your specialty you have been formally (and legally) reduced to the status of a nurse-equivalent. Your specialty, as you have known it, is dead.

Among other things, this means that the secret shopper gambit – when it is finally implemented – is just not worth worrying about. It’s only a way to convince a few more Americans that their PCPs are essentially worthless, and that they’d be just as well off having a nurse practitioner do the job. So don’t sweat the secret shoppers. Forget them.

Instead, you need to decide what you’re going to do about the demise of your chosen career.

In his next post, DrRich offers you some friendly advice in this regard.

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This is the first in a series of articles on End-of-Life Care and Covert Rationing.  The second article can be found here.

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It is easy to have missed it, because it went by so quickly.

On January 1, the White House announced a new policy that would have paid doctors for discussing end-of-life planning during their Medicare patients’ annual “wellness visit.” Under this policy, physicians would be paid to encourage their patients to establish an advance directive, which would guide medical care if the patient became incapacitated from illness, and could no longer make medical decisions for him/herself.

But on January 5, the new policy was suddenly revoked. It was revoked, CMS lamely explained, because it had not been implemented using the correct process. But, as anyone would know who watched Congress make Obamacare the law of the land, this could not possibly have been the real reason.

The real reason, of course, has to do with the firestorm this new policy threatened to unleash, just as the House of Representatives was about to be taken over by the cretinous opposition party.

As regular readers will recall, the Obamacare bill originally included similar language on advance directives. Physicians were supposed to urge their patients, repeatedly if necessary, to establish advance directives, and their success in extracting advance directives from their patients was to be one of the “performance measures” by which doctors would be judged to be in good or bad standing with the Central Authority.

But then Sarah Palin said “death panels,” and a furor ensued. The provision on advance directives was quickly removed from the Obamacare legislation, as if Congress was admitting that Ms. Palin had been correct and they had been caught out.* Similarly, the effort last month to reinstate the provision failed to stick for fear of criticism at a bad time.

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*The original advance directive provision in Obamacare, of course, had nothing whatsoever to do with “death panels,” since there are no panels of any sort involved in establishing advance directives. Rather, the entities that some might call death panels, and which DrRich has chosen to call GOD panels (Government Operatives Deliberating) – that is, panels of distinguished experts that will determine, by means of “guidelines,” which patients will get what, when and how – remain fully operative within Obamacare.
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DrRich has nothing against advance directives, and indeed, thinks they are a good idea – in concept, at least. Advance directives allow patients to establish beforehand, usually by a written document, what kinds of medical treatment they would or would not want should they fall victim to a serious, life-threatening illness that leaves them unable to express their wishes. Advance directives are supposed to work by providing guidance to their physicians, who, in their fiduciary capacity, are charged with acting in the patient’s best interest.

A well-constructed advance directive allows patients to choose to spare themselves from demeaning, undignified, painful or otherwise undesirable medical procedures and treatments, should they become incapacitated at a later date. “Well-constructed” implies that the advance directives are clearly and concisely written, that they honor the ethical and legal norms approved by society, and that they provide the physician with clear guidance.

But it is more difficult to write a “well-constructed” advance directive than might at first meet the eye. The major problems are two-fold: Advance directives often express imperfect knowledge, and they are often imperfectly expressed. These limitations mean that in appropriately exercising an advance directive, often the physician cannot follow them to the letter, but must interpret them according to the circumstances at hand.

A healthy and relatively robust individual cannot always know how he or she will feel years into the future, when illness strikes and it is time to exercise an advance directive. Every doctor has seen critically ill patients who, despite having advance directives to the contrary, unhesitatingly choose to be attached to a ventilator when the time comes, for instance, rather than face certain imminent death. So experienced doctors know that advance directives do not always indicate what patients will actually choose to do when the time to make a choice is upon them.

They also know that, while conscious patients have the opportunity to repeal their advance directives, unconscious or incapacitated patients do not.** So, in exercising an advance directive, the conscientious physician interprets that directive in light of many other factors, such as, her personal knowledge of the patient, the opinions of family as to what the patient would want done, and the chances of a long-term recovery if the therapy being considered is used. Then she will negotiate with responsible family members an approach that appears to meet the patient’s presumed desires.

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**Conscious patients can repeal their advance directives in theory. DrRich has witnessed actual doctors, however, arguing vociferously against using a medical therapy that a sick patient now desperately wants, because years ago the patient signed an advance directive expressing aversion to that therapy.
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Therefore the advance directive in many cases is an important part of the decision-making process, but it is not the only part. The appropriate use of an advance directive requires the doctor to behave as a true patient advocate, to selflessly place the desires expressed in the directive in context with everything else that might affect the patient’s true and current wishes, and then make a recommendation that, to the best of his or her ability, honors those wishes.

Unfortunately, doctors can no longer act primarily as their individual patient’s advocate. Indeed, physicians are officially enjoined (by the New Ethics formally adopted by their own professional organizations) to give the needs of society at least equal consideration. And so, as has demonstrably happened with other “guidelines” in medicine, it is inevitable that advance directives will be reduced to a legal edict, which must be followed to the letter if the physician wishes to remain clear of the Department of Justice.

The likelihood that there will be no room for interpretation means that constructing just the right kind of advance directive for yourself – one that will be precisely suitable to any contingency that may occur – has become extremely difficult. If you get the details just a little bit wrong for the circumstances that actually arise, the price you pay may be very heavy. It would be better to have no advance directive at all than to have one that is misleading or ambiguous. Advance directives must be written with extreme care, and only after long, thoughtful consideration.

That is not how the government would have it, however. For many years now, the Feds, under the Patient Self-Determination Act, requires hospitals to inform patients about advance directives at the time of every hospital admission, and to invite them to sign one. To say this is a less than ideal time to implement an advance directive would be something of an understatement. Asking a patient to sign an advance directive at the time of hospital admission, often by including it in the pile of routine and mind-numbing legalistic documents which patients must sign if they want to receive medical care, and often with no more guidance than that provided by the admissions clerk (who might explain, “This tells the doctors you don’t want to be kept alive on a machine like a vegetable,”) tells us something about whether the true motive for advance directives is to protect the patient’s autonomy – or to reduce costs.

Having the discussion in a doctor’s office these days, sadly, might not be much better. The Central Authority knows that squeezing what really ought to be at least a 30-minute discussion into a 10-15 minute office visit already packed with Pay for Performance requirements (while providing the added threat of punishment if the physician fails to extract an advance directive from the patient), will yield, at best, a signature on a boiler-plate document.

But despite the slap-dash method by which such a document may be implemented, it is a document whose language – when the time comes – will be exercised with all the legalistic exactitude of a contract attorney by any doctor who knows what’s good for him.

DrRich thinks that Americans are right in being suspicious of the big push they are seeing to urge advance directives upon them. Invoking “death panels” in this regard is utterly inappropriate, but the end result will suffice. It is good that we have all been given pause.

Still, the concept of advance directives is a good one, and DrRich thinks most Americans might do well to have one. Despite the damage that is being done to them, DrRich thinks advance directives can be salvaged. To this end, DrRich suggests several steps we can all take in executing an advance directive that will actually do what we want it to do:

1) Don’t be pressured into implementing an advance directive by anybody whose career depends on keeping the Central Authority happy. Unfortunately, this likely includes your doctor if you are not paying your doctor yourself.

2) Don’t sign a boiler-plate document. These likely will have been drafted with the interests of the Central Authority in mind, with the help of very smart lawyers, and when these documents are called into use in all probability they will be interpreted for the convenience of the Central Authority.

3) Try to keep your advance directive from showing up in an electronic medical record. Write it yourself, and store it where your loved ones can find it when they need it. Give a copy to your spouse, your children, and perhaps (if you have a direct-pay doctor who works only for you) your physician. This way, since your advance directive will not be immediately available to hospital personnel if you are suddenly incapacitated, no unfortunate and irreversible decisions regarding the aggressiveness of your medical care can be made until your loved ones are notified.

4) Write your advance directive as a general guideline, with as few specifics regarding particular types of medical care as possible. You should assume that any type of treatment you mention in a negative light will be withheld under any and all circumstances, including circumstances you may not be aware of in which you would want that treatment.

5) You are not writing your advance directive for the doctors (it is most tragic that we can no longer trust doctors in this regard!); you are writing it to help your loved ones make the right decisions for you, perhaps despite the doctors. So your goal should be to clarify your general desires for your loved ones. Discuss your advance directive with your loved ones after you have written it, and ideally, before you have written it. Your written words will remind them of your wishes when the time is right.

Lest you think, Dear Reader, that  DrRich is merely being sarcastic  here (and why would anyone think so?), he is not. DrRich himself has an advanced directive that attempts to follow these rules. The document is stored at home with his important papers. Mrs. DrRich knows where to find it, and knows DrRich’s general feelings regarding these matters. With the guidance he has provided, DrRich trusts her and his children to make these important decisions for him. For anyone who is interested, DrRich’s advance directive is reproduced, in its entirety, at the end of this post. (The general language, which has been adapted and revised by DrRich for his own use, was originally suggested to him by a good friend who is a superb internal medicine practitioner.)

So. Advance directives are a very good idea, but unfortunately, have been identified by the Central Authority as a potentially powerful cost-cutting tool. Even before Obamacare, certain HMOs were refusing to reimburse hospitals or doctors that provided medical care that seemed to go against specific language contained in an advance directive. That, of course, was child’s play. Now that the Central Authority has gotten hold of them, advance directives will likely be treated the same way as other guidelines are now treated in medicine, that is, as edicts, and thus as vehicles for the criminal prosecution of medical personnel who deign to “interpret” them.

This means that if you wish to take advantage of the benefits which advance directives can provide, you will have to proceed very, very carefully.

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DrRich’s Advance Directive:

If I am able to communicate my wishes by any means whatsoever, then I wish to make my own decisions regarding my own healthcare. If, despite my ability to communicate, my condition makes it inconvenient to fully inform me of my situation and all my treatment options, then until such time as it becomes sufficiently convenient to do so, I want everything possible to be done to sustain my life and effect a recovery.

In the event of an incapacitating illness in which I cannot communicate, the basic guideline initially should be to do everything possible to sustain my life and effect a recovery.

After a reasonable period of time (in general, I would consider a week to be reasonable) if no progress has been made in the recovery of my mental function, and the likelihood of mental recovery is judged to be small, then withdrawal of life-sustaining care should be strongly considered. To help my wife and/or children with this decision, I would like to have an evaluation by a neurologist to help clarify the prognosis.

If improvement in my mental status has been made, then efforts to sustain my life and affect a recovery should be continued.

If at any point in my care there is a period of at least two weeks in which I am persistently unable to carry out meaningful communications sufficient to make my own wishes known (in the opinion of my family members and the neurologist), and the likelihood of mental recovery is judged to be small, then I would consider the withdrawal of life-sustaining care to be a blessing.

DrRich has known this man for nearly two decades, and from the very beginning he has insisted his real name is Joe Smith. So let’s go with that.

Joe’s recognition by HealthLeaders is very well deserved. Joe is chief medical and science officer of the West Wireless Health Institute in San Diego, a non-profit institution whose mission is to bring wireless technologies to the patient, technologies to diagnose, monitor and treat health conditions in the patient’s own home. Joe is uniquely qualified for this role, having earned a PhD in medical engineering and medical physics, an MD from Harvard (a place DrRich has never even been allowed to see), and having spent years practicing medicine as a (particularly well known) cardiac electrophysiologist. (Electrophysiology, as regular readers will know, is widely recognized as the geekiest of medical specialties.)

For what it’s worth, DrRich considers Joe to be one of the most honest, most ethical physicians he has ever known, one who will always place the welfare of patients ahead of his own treasure and his own career. DrRich has seen him do it.

Significantly, one of Joe’s chief goals at West Wireless is to use advanced biosensors, attached to wireless communication, to lower the cost of healthcare. This can be done in at least two ways. First, by using wireless healthcare to keep patients healthy longer, and thus reduce hospitalizations and other expensive healthcare services; and second, by making at least some of these technologies available as consumer products, used by patients as they see fit for their own benefit, so they become part of the general economy (like toothbrushes and televisions).

DrRich is particularly pleased that Joe’s efforts are being recognized as worthy, since DrRich himself has devoted much of his professional effort to biosensors and wireless healthcare for the past 10 years.  Indeed, at one point he had the pleasure of working together with Joe Smith in this area.

The Top 20 healthcare leaders to which Joe has been named is an eclectic group. It includes John Goodman, another of DrRich’s heroes, as well as a couple of people readers of this blog would recognize as individuals whom DrRich would not consider as “changing healthcare for the better.”

In any case, please go read the HealthLeaders write-up of Joe Smith and his cutting-edge work at West Wireless. Congratulations, Joe!

Rachel Maddow, in a discussion related to the provision of abortion services, once proposed that we (society) should invoke the Amish Bus Driver Rule whenever medical professionals invoke their personal convictions in refusing to provide legal medical services.

The Amish Bus Driver Rule goes like this: If you’re Amish, and therefore have religious convictions against internal combustion engines, then you have disqualified yourself for employment as a bus driver. (Presumably Ms. Maddow would not apply the Amish Bus Driver Rule to everyone, since it would disqualify, for instance, Al Gore from utilizing horseless carriages and other fossil-fueled contrivances.)

The Amish Bus Driver Rule would do far more than merely render it OK for doctors to perform abortions and other ethically controversial (but legal) medical services. The ABDR would obligate physicians to provide such services, whatever their personal moral or religious convictions.

The reason DrRich brings this up is not because he considers Rachel Maddow to be the giver of rules for the left, or for the government, or even for MSNBC. Rather, he brings it up because the Amish Bus Driver Rule is entirely compatible with Progressive medical ethics, and therefore it has a pretty good chance, sooner or later, of becoming the official policy of our new healthcare system.

To spell it out: Once you agree to accept from the government a license to practice medicine, and thus accept a privileged and restricted position within our society, then you are naturally obligated to provide any medical services, approved by the government, that you are called upon to provide. In particular, you are obligated to check your personal  – and most especially, your religious – convictions at the door. If you are unwilling to carry out this obligation, then, like the Amish bus driver, you have disqualified yourself from that privileged position. Go do some other job that does not violate your prissy sensibilities.

This logic is eminently simple. In fact, it can be reduced to an elementary syllogism:

Premise 1: Society awards physicians an exclusive license to provide legitimate medical services.

Premise 2: Society deems certain medical services such as abortion, assisted suicide or euthanasia to be legitimate medical services.

Conclusion: Therefore, all licensed physicians are obligated to provide these services.

Many conservatives will be nearly apoplectic over the idea that doctors who are morally opposed to life-ending medical activities must either agree to perform those activities (once society decides they are legitimate medical services) or leave the profession. But conservatives, proud of their self-described tradition of acting on the basis of hard data and cold logic (unlike those silly liberals who let simple emotions rule them), find themselves in this instance stymied by the very foundation of logic – the syllogism. They are hoisted on their own petard.

Indeed, doctors who object to having to provide life-ending medical services find themselves in quite a fix, and what’s more, it is a fix that has resulted from the actions of their own profession.

When we are faced with a syllogism whose internal logic is unassailable, but whose conclusion we strongly believe to be wrong, then Aristotle (him again!) teaches us to check our premises. But when we do so, in this case we quickly see that while both premises may “feel” wrong to many physicians, in 2010 they are indeed correct. And therefore, so is the conclusion.

Premise 1 asserts that the physicians’ primary obligations are defined by a contract between themselves and society – or (let’s be frank) the state.

Until just a few years ago doctors could have legitimately objected to this assertion, since from the time of the ancient Greeks the physician’s prime obligation was defined by a direct covenant between themselves and the individual patient. And the precepts of medical ethics that governed the behavior of physicians were focused entirely on sanctifying that doctor-patient relationship. Those ethical precepts took precedence over everything else, like ethical precepts are meant to do, and at least in principle superseded all other authority down through the ages.

But alas, modern doctors don’t hold to such things anymore. And in recent years they have made their departure from their ancient ethical principles, and from the traditional doctor-patient relationship, fully explicit and quite formal.  They have done this to such an extent that they can no longer even aspire to the relatively minor sin of hypocrisy.  (Say what you will about hypocrites. At least they espouse firm principles which they can then violate.)

It is clear, of course, that doctors do not work for their patients anymore. Instead, they now work for the government and the government-regulated insurance companies. Still, this new kind of working relationship does not necessarily have to wreck medical ethics or the doctor-patient relationship, were it managed thoughtfully. But rather than figure out how to preserve their professional obligations within a new economic paradigm, the medical profession instead has chosen to issue a revised set of ethical precepts “for a new millennium,” aimed at adjusting what were supposed to have been (and had been, for the prior two millennia) timeless principles, in order to comport with the changing needs of society.  And so, of its own accord, the medical profession has abandoned its foundational ethical precepts, and thereby has abandoned the classic doctor-patient relationship – the very thing which defined the practice of medicine to be a professional endeavor in the first place. The medical profession has redefined itself by a new obligation to the changeable needs of the collective, instead of its old obligation to the expectations of the individual patients who place their lives in their hands.

In short, the profession of medicine has formally and voluntarily converted itself into a primarily contractual enterprise (i.e., as contractors for the government and government proxies), instead of a primarily ethical enterprise between themselves and their patients.

And so, whereas Premise 1 could have been easily cast aside just a few years ago (which is why it still “feels” wrong to a lot of doctors), today it is entirely legitimate.

Premise 2 recognizes certain life-ending activities to be legitimate medical services. Abortion, of course, has been legal in the U.S. for several decades. Since many of his readers will quibble with the assertion that abortion is life-ending, DrRich has decided to make Premise 2 somewhat forward looking, and so he has included the other two life-ending actions which will very likely become legitimate, approved “medical services” in the foreseeable future.

The medical profession not too many decades ago was quite clear on the ethical status of life-ending actions taken by physicians. Such actions in all their forms were proscribed. The Hippocratic Oath forbids taking actions intended to end life, and specifically calls out abortion as one of those  forbidden actions. But the Hippocratic Oath (like the Declaration of Independence and the Constitution) has become merely quaint in our modern, advanced society.

One of the reasons DrRich appreciated the Hippocratic Oath, when it was recited at his medical school graduation way back in a different era, was that it so clearly reflected non-religious standards. Yes, it blustered on about Asclepius and Hygieia and so on, but even the ancient Greeks didn’t really take their gods seriously. The Oath invoked the gods in the same manner in which, some assert, our founders invoked the Creator in the Declaration of Independence. Whether or not they were actually asserting that our foundational principles come directly from a being named God, they were making a very powerful statement. At the very least, they were saying, “We hold these principles to be so fundamental to the essence of man that to violate them would violate our very reason to exist. They are our bedrock, and to challenge them would be fatal to our enterprise. Here we draw our line in the sand, and we will defend this line to our deaths.”

The Hippocratic Oath was kind of like that.

The Hippocratic invocation against physicians ending innocent life was a clear line in the sand, and its purpose was a practical one rather than a religious one. For, in order to legally take an innocent life, we are required to say either that sometimes it is perfectly OK to kill an innocent human being, or that for some reason (because, for instance, at such-and-such a stage of fetal development the potential human is not yet viable) a particular innocent life is not really a human being after all. If it is sometimes perfectly OK to kill an innocent human being, our society is terminally corrupt. On the other hand, if society has the temerity to define “human being” in such a way as to meet its exigencies of the moment (beyond the most conservative possible definition suggested by nature, that is, the point where sperm and the egg combine to form a new life entity), it will necessarily be a fundamentally arbitrary definition. And once society undertakes to define human life arbitrarily, then there is nothing to stop society from changing that arbitrary definition as expediency requires.

Wise Hippocrates (DrRich suspects), foreseeing that mankind was likely to continue with its periodic spurts of genocidal indignation against this or that sub-human subset of our species, and seeing that it would be fatal to the medical profession to allow its special arts to be turned toward aiding such efforts, and realizing that it would be impossible, once physicians engaged in any small but legitimized taking of innocent life, to keep from escalating those activities if the needs of a society under duress demanded it, came to the conclusion that the profession required an absolute proscription here. This proscription was not a religious statement, but a practical and entirely secular one, based on a long and thoughtful observation of human nature, and aimed at keeping the medical profession focused on its real mission (caring for individual patients) rather than becoming an instrument of societal or political imperatives. And for over two thousand years the medical profession followed this line of reasoning.

The Hippocratic Oath has not been read aloud during medical school graduation ceremonies for decades now. The reason it was dropped has nothing to do with the usual claptrap you hear about not wanting to swear to Greek gods anymore. It has to do with the fact that doctors no longer subscribe to the content. It is no coincidence that the oath disappeared from the program in very short order during the 1970s, right after the Rowe v. Wade decision.  In any case, over the past few decades many physicians – possibly a majority – have quite gotten over their queasiness about taking actions that either a) end innocent life, or b) admit that society has the right to define arbitrarily what it means by “human life.” And the ones who still object to such actions are in dire risk of becoming the Amish bus drivers of healthcare.

So Premise 2 clearly expresses the actual default position of the medical profession today. While, for many physicians, it (like Premise 1) “feels” wrong, Premise 2 stands on its own merits.

Thus, like it or not, almost entirely due to the “evolution” of the profession of medicine itself rather than to any externally imposed changes, our syllogism appears entirely correct.

The implications are quite disturbing, and go far beyond the mere prospect of forcing pro-life doctors to either get with the program or get out. For what this syllogism really says is that the state will determine which medical actions are legitimate (or to be more specific, ethical), and that physicians being (through their own voluntary capitulation) mere contractors working at the pleasure of the state, are thus obligated to just shut up and sing. To say it more plainly, what is medically ethical is to be determined by the state, and individual doctors (except for the ones acting as collaborators and spokespersons for the state, whose job will be to make the ethical pronouncements seem medically legitimate), will have nothing to say about it.

When we view the history of mankind, we see that when the sovereign state is the entity which determines what is ethical, there is always hell to pay.

History teaches us that the state is sovereign not because it is inherently the most ethical entity within a social construct, or an ethical entity in any sense at all.  Sovereignty is determined by power, not ethics. Indeed, the most useful definition of “sovereign power” is: that power which has the ultimate ability to impose its will by the application of violence. The state is inherently a political and power-based entity, whose survival depends on manipulating the political landscape and the ability to threaten (or exert) adequate violence whenever required. Such a beast is inherently poor at ethics.

DrRich happens to believe that American society is essentially good, and constitutes the most ethical large and sustained social system that has yet been devised by mankind. Yet when pressed by economics, war, political strife, manifest destiny or a myriad of other stresses, even our government has behaved dismally and frankly unethically, and has done so on numerous occasions throughout its history. One merely needs to consider slavery, the Dred Scott decision, the Mexican-American war, the treatment of native Americans, World War II internment camps, and the Tuskegee study (DrRich ignores more recent history here to avoid stirring up still-fresh controversies) to get a taste of what kinds of government behavior we in our culture are capable of justifying to ourselves when under duress. (To put this in perspective, of course, other highly-developed Western cultures during the past century, where powerful sovereign authorities assumed the right to define ethical actions, performed atrocities that cause ours to pale in comparison. But this mitigation merely reinforces DrRich’s main point.)

As DrRich has been fond of pointing out on this blog, the need to find ways to ration American healthcare covertly has created extreme duress within our healthcare system, and within the government and the insurance companies responsible for administering it. And as a result covert rationing has already produced deeply and widely distributed behaviors that are harmful, inefficient, unfair and yes, frankly unethical, which affect every aspect of American healthcare.  Ceding to the state – desperate to ration healthcare in any manner it can get away with – the right to define what is medically ethical, and assigning to doctors the obligation of simply obeying, sounds to DrRich like a prescription for catastrophe.

And in this way, Progressive medical ethics has brought us to a very dangerous juncture.

Having advanced his theory of Progressivism, and having shown how his theory explains certain behaviors on the part of Progressives that otherwise might be difficult to explain, DrRich now proposes to examine the question of the medical ethics of Progressivism.

This ought to be an important question to doctors, patients, and anyone who thinks they might someday become a patient. For, however else one might want to define “ethics,” for practical purposes a system of ethics fundamentally determines how one ought to act when one must act in the face of competing interests. And the healthcare system being rife with competing interests, ethical guidance is critical as we determine who is to get what, when and how.

Because ethicists generally attempt to devise a solution which balances, to some degree, the various competing interests (which all tend to have at least some merit), the field of ethics has become very complex to the uninitiated. Indeed, the arguments ethicists use to justify their positions are frequently so difficult to follow that professional ethicists all too often have been reduced to a virtual priesthood, dispensing their lofty wisdom from on-high.

But since truly ethical behavior requires more than merely following handed-down marching orders, and indeed, requires a certain amount of clarity as regards ethical precepts, DrRich has always considered the arcane work-product being offered up by most modern ethicists to be, well, unethical.

And this is where Progressivism, for all its faults, provides a breath of fresh air. For the chief ethical precept of Progressivism is an item of exquisite clarity, a bright, shining beacon that cuts through all the fog and fuzziness, and points the way.

To review, Progressivism (in DrRich’s formulation, at least) is the idea that the driving imperative of mankind is to devise the perfect society, that, indeed, the desired “progress” in Progressivism is the steady advancement toward that perfect society. The Progressive program is the natural result of the belief, most famously espoused by Aristotle, that man is inherently a social animal, an animal that naturally forms into complex societies; that individual men and women do not have much intrinsic worth as stand-alone units, but only as components of their larger group.

Furthermore, the Progressive program is to be driven by an intellectual elite, who will determine what does and does not advance the perfect society. This requirement for an elite leadership also derives from Aristotle, who recognized that most individuals within a society are incapable of perceiving the greater good, and if left to their own devices would return mankind to the ranks of the apes.

The Progressive program of steadily advancing toward a perfect society is much more than merely a desirable goal, it is an imperative; it is intrinsic to humanity itself. All other programs (libertarianism, conservatism, religions which emphasize the importance of individual salvation, &c.) are not only counterproductive to man’s true imperative, but are heretical.

And so Progressive ethics, if nothing else, are crystal clear: Anything that advances the Progressive program is ethical; anything that hinders it is unethical.

This general statement of ethics immediately implies two corollaries that more directly define what “right behavior” will look like:

Corollary 1) What is best for the collective is best for the individual. That is, since individual humans only achieve their humanity as a part of the greater whole, it follows that the chief obligation of any individual within a society is to act for the good of the collective.

Corollary 2) Since what is best for the collective is determined by the intellectual elite, it is the obligation of all individuals in a society to follow that elite.

With this summary of Progressive ethics, let us now turn to the question of medical ethics.

Classical medical ethics, from the time of Hippocrates, required the physician to always use his/her special training and special capacity for autonomous action for the benefit of the individual patient, and to place the needs of the individual patient above their personal needs. This requirement is what defined medicine as a classical profession.*

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* While the term “profession” has become diluted to include streetwalkers and football players, classically “the professions” were limited to physicians, lawyers and clergy, precisely because of this definition.
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But classical medical ethics cannot be permitted under a Progressive program. Allowing (much less encouraging) physicians to act autonomously for the good of their individual patients will necessarily conflict with that which is best for the collective. This is true because if the needs of the individual were to prevail, then patients who are lucky, smart or rich, and who have doctors who are particularly clever or aggressive, will get more than their fair share of the healthcare resources, leaving the collective wanting.

Accordingly, after years and years of dogged work, the Progressive agenda has succeeded very recently in changing the formal definition of medical ethics. In early 2002, a “new charter” of medical ethics was published in the Annals of Internal Medicine. This new charter has since been formally endorsed by every major medical professional organization in the world. It charges physicians with the ethical obligation of achieving a fair distribution of healthcare resources. Medical students worldwide are now being taught that their main ethical obligation is to work for distributive justice, their obligation to work for the optimal benefit of their individual patients is a secondary concern, because of Corollary 1.

DrRich has described elsewhere how this new medical ethics places patients in great jeopardy, and wrecks medicine as a true profession. But old farts like DrRich (who prefers to think of himself as a “classic” physician), who still care about such things, will be gone in a few decades and can be safely ignored.

(For those who are interested, DrRich had the opportunity earlier this year to engage representatives of the American College of Physicians – chief authors of the New Ethics – in a public debate over medical ethics in this very space. DrRich was, at the end of the day, brushed off by the ACP, but not before eliciting a response from the Chair of the ACP’s Committee on Ethics, Professionalism, and Human Rights. That response, in essence, was, “What is good for the collective is good for the individual, and any jack-dog knows this. Who the hell are you?” In other words she invoked Corollary 1. You can read all the details about the great Medical Ethics Smack Down in this series of articles.)

One might ask, what was the impetus for physicians to voluntarily change their time-honored ethical precepts?

They were coerced.

Significant coercion was being applied to doctors to place the interests of the third party payers – both insurance companies and the government – ahead of their duty to individual patients. The utter impotence of physicians in fighting off this coercion was the impetus for promulgating the new ethical precept (to society) in the first place. This fact was stated explicitly in a 1998 article by Hall and Berenson in the Annals of Internal Medicine (volume 128, p 395) which stated: “It is untenable for the medical profession to continue asserting an idealistic ethic that is contradicted so openly in clinical practice. . .,” and which called for a “new ethic” which was more consistent with how doctors were being forced to behave. Specifically, the proposed “new ethic” was a duty to the group.

This paper was an important impetus to formally changing professional ethics. When the new ethical standard istelf was finally published in 2002, its very first sentence began, “Physicians today are experiencing frustration as changes in the health care delivery systems in virtually all industrialized countries threaten the very nature and values of medical professionalism.”

In other words, physicians felt powerless to fight off the coercion – so in response they changed medical ethics to make it OK to cave in.

And to say it yet another way, physicians can now act under Corollary 2 with a clear conscience.

Accordingly, it is now become the physician’s ethical obligation – and not merely a legal or regulatory obligation – to follow to the letter the guidelines, processes, and procedures that are handed down to them from various government-established expert panels, when they are caring for their patients. Autonomous actions taken on behalf of individual patients is more than just discouraged, it is, simply, wrong.

Under our new program of medical ethics, then, doctors are absolved of much of the responsibility of clinical decision-making. As many of those decisions as possible – a continually increasing quantity of them as time goes by – will be determined centrally, at which point the doctor is ethically obligated to follow them.

DrRich continues to think this new program is harmful to patients and to the medical profession. He will bring up some specific issues in this regard in future posts.

Throughout the millennia, the characteristic that has distinguished robust barbarians from extinct ones is that, when forces beyond their control begin encroaching on their turf, they simply pick up and encroach on the turf of less aggressive people (generally, of people who are more advanced, both intellectually and culturally, than they are).

And so, when the Feds begin making noises about limiting some of cardiology’s favorite revenue-generating activities, the cardiologists – among the most robust of the medical barbarians – are quick to overrun the turf of other, less bloodthirsty and more civilized, medical specialists.

DrRich in the past has attempted to warn his medical colleagues about the predatory nature of cardiologists. He has told how the cardiologists have driven the formerly proud and powerful cardiothoracic surgeons into a sad state of underemployment, how they have usurped the formerly sovereign territory of diabetes specialists, and how they are currently laying siege to sleep medicine and bariatrics.

And now, continuing his public service to the less robust medical specialists (whose great achievements, like all cardiologists, DrRich admires), he must reluctantly extend his words of warning to his friends, the neuroscientists.

Cardiologists began encroaching on the field of neurology many years ago, but only surreptitiously, when they took to blaming imbalances of the autonomic nervous system (i.e., dysautonomia) on mitral valve prolapse. In more recent years, somewhat more blatantly, they have attempted to take ownership of migraine headaches. And now, just last week, in a full frontal assault, cardiologists laid claim to Alzheimer’s Disease.

Neuroscientists, nobody is safe! Hide your women and children!

The pattern of behavior employed by the invaders is easy enough to spot. First, cardiologists call attention to an alleged association between some cardiac condition (a condition they will manufacture if necessary), and a non-cardiac medical problem. Then, immediately, they will assert that (or at least begin behaving as if) the association proves a cause-and-effect relationship. Finally, since they have “proven” that the non-cardiac medical problem is caused by a cardiac condition, patients who have (or might develop) that non-cardiac medical problem need to be referred to cardiologists, who, lo and behold, have invented a well-paying procedure to treat it, or at least, to study it further.

The best known example is mitral valve prolapse (MVP), a congenital condition in which the mitral valve partially flops open when it should be closed, thus allowing blood to flow backwards (i.e., to regurgitate) across the mitral valve as the heart contracts. (For anyone interested, here’s a brief description of the heart’s chambers and valves.) Now, significant MVP can be a serious medical problem, and it often requires mitral valve surgery. Fortunately, however, significant MVP is a relatively uncommon condition.

The problem is that echocardiography (a non-invasive test using sound waves to create an image of the beating heart) has become so advanced that some degree of trivial MVP, it seems, can be found in almost anybody. According to some studies, as many as 25 – 35% of healthy individuals – people without any cardiac problems or any symptoms whatsoever – can be said to have some degree of MVP. In fact, whether you have MVP or not depends largely on what criteria the echocardiographer uses to make the call, and how badly the doctor wants you to have the diagnosis.

Over the years it has become customary to diagnose MVP in young, apparently normal people who have the temerity to complain about the highly disruptive symptoms of dysautonomia (such as fatigue, weakness, strange pains, dizziness, constipation, diarrhea, cramps or passing out), without supplying the kinds of objective physical or laboratory findings which, doctors insist, patients are always obligated to provide. Such thoughtless patients are now routinely sent for echocardiography, so that MVP can be diagnosed (since it can be diagnosed just about whenever it is looked for). The patient is then given the diagnosis of “mitral prolapse syndrome,” even though: a) the MVP is usually so trivial as to be nonexistent; b) the studies which claim to show an association between MVP and these sorts of symptoms are generally based on a gross over-diagnosis of MVP; and c) there is no credible theory based on actual physiology to explain how MVP – even real MVP, much less the trivial kind – might cause such symptoms.

But no matter. “Rule out MVP” has become one of the most common reasons for young, healthy people to be referred for echocardiography, and has become a staple source of income for cardiologists.

The story is similar for the association between patent foramen ovale (PFO) and migraine headaches. In the developing fetus, the foramen ovale is a hole that is present in the atrial septum (the thin structure that separates the right atrium from the left atrium). At birth, a flap of tissue imposes itself over the foramen ovale, causing it to close. In some people, however – people with PFO – the tissue flap is still capable of flopping open. In people with PFO, the foramen ovale can open transiently if the pressure in the right atrium becomes transiently greater than the pressure in the left atrium, such as with coughing, or straining during a bowel movement.

In rare instances, strokes in healthy young patients have been attributed to PFO. The supporting theory is that a stroke can occur when a blood clot happens to be coursing through the right atrium at the precise moment a person with PFO is coughing (for instance), allowing the clot to move into the left atrium, and on to the brain. And because this theory is at least plausible, in a young person who has an unexplained stroke and is then found to have a PFO, it makes at least some sense to close the PFO.

But the presence or absence of a PFO is a little like the presence or absence of MVP. Its diagnosis depends on how hard the echocardiographer looks for it, and on how much the doctor would appreciate the diagnosis. With modern echocardiographic equipment, at least some sign of PFO can be found in as many as 25% of normal individuals.

Being able to make this nifty diagnosis is of little use to cardiologists if the only clinical problem it may cause is a one-in-a-million chance of stroke. One cannot make a living, or even make a car payment, doing echocardiograms in young patients with cryptic strokes. They’re just too darned rare. So it didn’t take long for cardiologists to draw a more useful association – this time, between PFOs and migraine headaches.

While all the things that have to happen in order for a PFO to cause a stroke are very unlikely, it is at least possible that they could all occur simultaneously in a patient. This is not the case with migraine. No plausible theory has been advanced to explain how PFO might cause migraines. The only reason PFO is being invoked as a cause for migraine is that when patients with migraine have been carefully studied for the presence of PFO, an increased incidence of PFO was found. But (as we have seen) when PFO is carefully sought in any population of patients, it is more likely to be found. The only likely reason PFO has not been associated with cancer, red hair, type A personality, or difficulty in memorizing the multiplication tables is that cardiologists have not thought of looking for it (yet) in these conditions.

For cardiologists, the poorly-supported allegation that PFO causes migraine is particularly compelling, since not only can they get paid to look for PFOs in migraine sufferers, but also there is an invasive (and lucrative) procedure they can do to close PFOs, to “treat” the migraines. Studies to date have not been successful in showing that closing PFOs improves migraine headaches, but that hasn’t kept cardiologists from screening migraine patients for PFO, then offering them PFO closure as a therapeutic option.  This, again, is because an association implies cause and effect, at least when that implication can be helpful to someone.

Migraine sufferers are particularly vulnerable to this and many other unproven therapies, since they are often disabled by their condition, and in many cases medical science (or medical ignorance) offers them insufficient help. Consequently, anecdotal stories abound regarding unorthodox therapies that cure migraines. DrRich, himself a migraine sufferer for many decades, has heard all the stories. (He even has one of his own. If DrRich maintains a schedule of running at least 20 – 25 miles a week, he does not get migraines. If he quits running for a few weeks the headaches come roaring back. He has mentioned this decades-long and reproducible pattern to several neurologists and other specialists over the years. They conclude that DrRich – and this should not be a surprise to many of his readers – is nuts. But if cardiologists had a billable procedure that could make you exercise, you can bet they’d fold DrRich’s experience into their formal clinical guidelines.) In any case, merely performing PFO closures on a few migraine suffers was almost guaranteed to produce a patient here or there who would report a positive response. And despite the continued negativity of actual clinical trials so far, that’s what happened.

So, at least by anecdote if not by controlled trial, closing PFOs can cure migraines.

But now it gets even worse for the neuroscientists. Any neurologists who ignored the cardiologist’s usurpation of dysautonomia, and who may have felt only a little more concern when cardiologists began to lay claim to migraine headaches, had best sit up and take notice. Because now, cardiologists have a way of treating (at least preventing, if not actually curing) Alzheimer’s Disease.

This time it is DrRich’s own particular sub-branch of the cardiology tribe which is the culprit – the electrophysiologists.  In a way, it is a little disappointing for DrRich to see his EP brethren going in for the same, turf-grabbing sophistry used by lesser cardiologists. EPs are known for being more intellectually sophisticated than your typical heart doctor (who, after all, is a glorified plumber). Indeed (as he thinks he may have mentioned in the past), DrRich has a neurosurgeon friend who, when he wants to convey the idea that what he is doing isn’t quite as difficult as it appears, but at the same time what he is doing is, in fact, neurosurgery, will say, “It’s not exactly electrophysiology!” But of course, he may not say this anymore once he finds out what we EPs are up to.

Last week, at the Heart Rhythm Society Scientific Sessions, researchers presented a study suggesting that ablation procedures for atrial fibrillation are associated with a lower risk of Alzheimer’s disease. (Here’s some information on atrial fibrillation and its treatment for anyone who is interested.) The study was presented as an abstract only, so we know relatively little about the specifics.

But, really. Atrial fibrillation and Alzheimer’s are both disorders associated with aging, so it is not surprising that they are associated with each other – in the same way that atrial fibrillation is associated with gray hair, cataracts, and bunions. Ablation for atrial fibrillation is a relatively lengthy and difficult procedure, whose results are relatively middling, and which carries a substantial risk of some really nasty complications. So these ablation procedures are generally reserved for carefully selected, reasonably ideal candidates – usually, the relatively young, relatively healthy atrial fibrillation patients, who are less likely to get Alzheimer’s disease over the next few years whether they have ablations or not.

So there is a lot to be cautious about in interpreting a preliminary study like this one. For a well-presented, comprehensive treatment of why the results of this study should be largely ignored for now, see Dr. John M’s blog. (It sounds like John M is as embarrassed by his fellow EPs in this instance as is DrRich).

But such objections as DrRich and John M may express are just quibbles. The headlines are already blaring: “Ablation Procedures For Atrial Fibrillation Prevents Alzheimer’s.” Whatever the details and limitations of this study, cardiologists can now treat Alzheimer’s. Mission accomplished.

Having duly (and humanely) called this problem to the attention of his neuroscience friends, DrRich would like to finish by emphasizing a larger point.

You can’t fight the Feds. When the sovereign authority, at the point of a gun, decides to reach down into the world of the medical specialists, and dictate which medical services are no longer going to be feasible (all for the noblest of purposes, of course – to maximize quality and efficiency and the collective good), the affected medical specialists have a limited range of possible responses. And fighting the Feds is NOT among these available responses.  Better to fight the change of seasons.

So the affected specialists can contract their horizons, take what’s left, and try to make the best of it. Or, they can do what the Visigoths did when the people of the steppes displaced them. Strike out against other, weaker specialists, and take what’s theirs. If you can’t grow the pie anymore, then take the other guy’s piece.

DrRich is not passing any judgment on his cardiology brethren here. He is just describing what’s happening, as a public service. You neuro-types, he believes, have a right to be told what’s happening. You can do with the information as you see fit.

In the meantime, DrRich remains supremely confident that his cardiology colleagues can find a nearly unlimited supply of plunder in this brave new world. They are very robust barbarians.

Many thanks to a loyal reader, Ivan from Montreal, for calling DrRich’s attention to a recent editorial in the New England Journal of Medicine, arguing for more dollars to go to “public health,” as opposed to “healthcare.” The editorial is by David Hemenway, Ph.D., director of the Harvard Injury Control Research Center of the Harvard University School of Public Health.

By “public health,” Hemenway appears to mean that branch of academics that deals with promoting the overall health of a community through organized societal efforts. Some effective public health efforts have included vaccination programs, improved sanitation, motor vehicle safety, draining the swamps, limiting public smoking, and the chlorination of drinking water. A few of these efforts have even been advanced by actual public health experts, such as those to which Hemenway refers.

Hemenway’s main argument is that society gets more bang for the buck with money spent on these kinds of public health efforts, than on money spent on healthcare for individual Americans, an argument which is almost certainly true.

But his conclusion, that the distribution of healthcare dollars should be adjusted accordingly, is spurious. All four of the specific arguments he gives to bolster his claim that public health is underfunded are insubstantial, and more importantly, the folks who have given us most of the wonderful public health benefits we all enjoy are actually not the public health experts whom Hemenway wants to fund.

First, Hemenway claims public health is under-funded because people are just too stupid to understand the importance of public health. Specifically, they are incapable of valuing and thus implementing actions whose benefits lie in the future (such as those provided by public health). Hemenway is quick to say that it is not peoples’ fault; they are built that way. He even gives a complex neuroanatomical explanation for the innate inability of folks to plan for the future.

So: This must be why Americans have never landed on the moon, and why they refuse to invest in cancer research, or to fund their 401(k) plans. As Ivan from Montreal points out, this must be why the great cathedrals were never built. Hemenway’s point here is so spurious on its face that DrRich must wonder if it reflects that baseline contempt for the mental capacity of the proletariat, which is so fundamental to Progressive thinking.

Secondly, Hemenway points out that the beneficiaries of public health (being the public) are not identifiable as individuals, and so we (the bovine masses) cannot bring ourselves to care about them, as we care about individuals such as, he suggests, Baby Jessica falling down the well. This additional deficiency of the proletariat puts public health at a major disadvantage.

It is indeed true that humans have more capacity to identify with individual stories than with “populations.” But this issue is not unique to the field of public health. Those raising funds for heart disease research, for instance, deciphered this mystery long ago – since statistics only gets you so far, you need to tweak potential donors’ emotions by advancing the story of the 12-year-old heart transplant recipient. If the academics in public health haven’t been able to figure this out – using the Baby Jessica story to advance their latest theories on well safety, for instance – whose fault is that? (If what Hemenway says is true – that the field of public health “relies almost exclusively on government funding,” that’s where the fault is. Being on the public dole greatly dulls one’s perceptiveness and creativity.)

Thirdly, Hemenway says, “in public health, the benefactors, too, are often unknown.”  That is, whereas medicine has its great public heros – Hemenway suggests DeBakey and Barnard – the great heroes of public health do not get their due. There are doubtless many heroes of public health – the inventor of the flush toilet comes immediately to mind – but unfortunately most of them remain anonymous. The flush toilet’s inventor, for instance, based on current archeological evidence, died in the Indus valley 4600 years ago. Indeed, many if not most of the truly impactful public health advances took place outside the ivory towers of the modern academy.

Hemenway struggles mightily to come up with an unsung hero for modern, academically-based public health, and – and undoubtedly wishing not to remind us of certain well-known, early20th century heroes of the academy who espoused eugenics as the most effective means of achieving public health  – offers up one Maurice Hilleman, who saved countless lives with his development of more than 30 vaccines. Now, DrRich completely agrees that Hilleman was one of the most important scientists of the 20th century, and probably was responsible for preventing more premature deaths than any other person in history, and, certainly, that he is an unsung hero. But it is a bit of a stretch for Hemenway to claim him for one of his own. Hilleman did his vaccine development as an employee of E.R. Squibb, and then, of Merck. That is, his research was funded by private industry, whose primary motive was filthy lucre. If Hilleman is a hero of public health (and DrRich agrees that he is), then his career is an argument for unleashing the capacity of the private pharmaceutical industry, rather than an argument for more government funding.

Fourth, Hemenway laments that public health efforts often meet with fierce opposition from well-placed interests. This is true. Limiting smoking in public places, for instance, required a sustained battle against powerful interests for decades. But here, Hemenway tips his hand a bit too much. He cites a study showing that having a firearm in the house is a risk factor for gun death, and offers up this rather obvious result to illustrate the important work which academic public health can offer, and to decry efforts to de-fund that kind of important research. Now, DrRich does not diminish the importance of research whose aim is to improve gun safety. But he does wonder why Hemenway could only come up with an example of productive research which is just a little more helpful than, say, a study revealing that automobile deaths are more frequent in the U.S. than in Romania (where ox-carts remain a chief mode of transportation). If DrRich were grading this editorial request for funding as a formal grant proposal, he would take points off for the effectiveness of the applicant’s (that is, academic public health’s) prior work.

Hemenway’s fundamental sin is conflating “real” public health with whatever the people with degrees in “public health” are doing. “Real” public health consists of flush toilets, water treatment, draining swamps, pest control, well-lit streets, and the like, and tends to have a lot more to do with good civil engineering and fundamental medical research than with “academic” public health.

Some of what the modern experts in public health are doing, DrRich suspects, is quite important and is worthy of funding. But just because the schools of public health split off from medical schools in the 20th century, and established their own academic fiefdom, and commandeered the name “public health” as their exclusive domain, they ought not commandeer the credit (as Hemenway does here) for inventing and building sewage treatment plants, vaccines, or side airbags. Most of the actual “stuff” that makes public health so effective comes from somewhere else. If there’s to be more funding, give it to the people and enterprises that actually invent and develop that stuff.

Call DrRich a cynic, but he suspects that schools of public health really want more money so they can publish academic papers that will justify – or demand – more invasive governmental action to control private behavior, for the good of the collective. For instance, while DrRich does not know anything about Hemenway himself, he notices that a major interest of his Injury Control Research Center is firearm injury. Nothing wrong with that. But he also notices that the Injury Control Research Center gets a big chunk of its funding from the Joyce Foundation, an organization with a strong, self-professed “anti-gun” (and not merely gun safety, or gun control) agenda. One might be forgiven for wondering whether one of the “public health” agendas of the Injury Control Research Center in this regard might be to help justify stiffer anti-gun legislation. Whatever you may think of stricter gun legislation, diverting healthcare dollars to support one side or the other of a fundamentally political issue does not seem like a good precedent to set.

Let the public health experts get their own funding. Dollars that people pay for health insurance – whether through direct premiums to insurance companies or through tax dollars to Medicare, Medicaid, and whatever else is coming down the pike – ought to go for individual healthcare, and not to any interest group that can assemble an argument that whatever it is they are doing benefits the overall health of the collective. After all, anybody – from gym owners to grocers to game manufacturers to medical bloggers – can do that.

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Part 1 of Limiting Individual Prerogatives

Part 2 of Limiting Individual Prerogatives

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The thing about Progressives is that the characteristic which makes them most endearing (and, which makes them most attractive to the unaware), is the very characteristic which makes them the most dangerous.

Fundamentally, Progressives believe in the perfectibility of mankind, or at least, of society. Indeed, they have discovered the very Program which will lead to the perfect society, a society which will maximize the good of the whole. Their vision is so compelling, and their ends so utterly and undeniably right, that it becomes legitimate for them to engage in whatever means are necessary to achieve it. (Indeed, for those who have been paying attention, “By Whatever Means Necessary” appears to have supplanted “Hope and Change” as the catchphrase of our current political leaders.)

The thing that always trips up Progressives (and their more revolutionary cousins, the Communists), is, of course, human nature. In order for their Program to work, it is necessary for each individual to behave in the prescribed fashion. And, at the end of the day, a substantial proportion of the population (any population) will insist on striving for their own individual benefit, rather than (as the Program requires) for the benefit of the collective.

The major competing system of societal organization – capitalism – recognizes this facet of human nature (i.e., the essential imperfectability of mankind, as manifested by the non-suppressibility of self-interest), and attempts to channel it into relatively productive and non-destructive (but still competitive and individually-directed) behaviors that limit the damage, and maximize the public good to a reasonable degree.

In contrast, Progressives attempt to change human nature to fit their inherently superior Program.

The fact that you cannot change human nature to fit the Program is what makes them dangerous. Their initial wide-eyed optimism that us folks will just “get it,” once they explain it to us, invariably evolves to an essential contempt for our limited intellectual capacity. This contempt justifies all manner of prevarications, to fool us into going along. Even in societies where the tyranny of correct-thinking has gone so far as to elicit the cooperation of the people at the point of a gun (rather than through the preferred methods of “education” or misdirection), the achievement of the predicted perfect society is invariably prevented by the recalcitrance of human nature. (The final realization that not even an all-powerful central authority can make people behave in the prescribed way always produces a nearly psychotic frustration that – in virtually every Communist country – has led to atrocities against various subsets of the recalcitrant people.)

DrRich does not believe there will ever be pogroms in the United States.

But this does not mean that the Progressives will always be kind and gentle as they attempt to achieve their goals. As DrRich sees it, in the U.S. the Progressives have clearly evolved to the “contempt for the masses” phase of their Program, a phase which justifies all manner of techniques – just this side of violence – to get us all to cooperate. Currently they are intent on demonizing their opponents as being racist, stupid, uneducated, selfish, overly dependent on outmoded supernatural beings, violent, and (of course) obese. This demonization is quite useful, since there is obviously no need to address any actual ideas put forth by such as these, even if they were capable of the feat of “ideas.”

Healthcare is, at present, the chief battleground in the war between Progressives vs. non-Progressives in the U.S., and the outcome of this battle will likely determine the success or failure of the entire Progressive Program. And the most fundamental (and emblematic) aspect of this battle is over what to do about the “doctor-patient relationship.”

The classic doctor-patient relationship was a celebration of the primacy of individual rights. And, for over 2000 years (at least since the advent of the Hippocratic Oath) guaranteeing the sanctity of that relationship was the basis of all medical ethics.

Until very recently doctors, patients, philosophers and ethicists recognized that, when you are sick, you are no more capable of navigating a complex and hostile healthcare system than are accused felons a complex and hostile legal system, and you are no less in peril if you run afoul of that system. And, just as the felon has a right to a personal advocate, a professional whose job is to protect his individual interests against the conflicting aims of the “system,” so does the patient. That is (quaint conventional wisdom held), when you are sick, you should be entitled to at least the same protections as when you rob a convenience store. And the doctor-patient relationship was supposed to guarantee you that right.

This is why, throughout the ages, the basic precepts of medical ethics were aimed at guaranteeing the sanctity of the doctor-patient relationship. Fundamentally, these ethical precepts required the physician to place the needs of his or her individual patient above all other considerations.

It should be clear to everyone that, under either our “old” healthcare system or the one that Obamacare promises us, this formulation of the doctor-patient relationship cannot be allowed to stand. Neither the insurance executives nor government officials can allow spending decisions – that is, decisions on how to spend their money – to be made by individual patients (and their personal advocates). For this reason, the classic doctor-patient relationship had to go.

And so, in 2002, official medical ethics was formally amended to require physicians (while still giving lip service to their obligation to individual patients) to strive for a “just distribution of healthcare resources.” That is, official medical ethics now makes it ethical for physicians to ration healthcare, covertly, at the bedside – and indeed, makes it unethical for them to fail to do so.

The New Ethics has been enthusiastically supported by medical ethicists worldwide (a field which now seems to be dominated by utilitarians), and worse, has been embraced by all the world’s major medical professional organizations. DrRich has not embraced the New Ethics (on the grounds that it places individual patients at great peril, and destroys the profession of medicine), and neither have many (possibly a majority) of older physicians. But it has been taught in medical schools around the world for over a decade, and in another decade it is likely that the vast majority of practicing physicians will accept as a matter of course that their primary obligation is to control healthcare costs, and only secondarily to try to meet the needs of their individual patients.

The plan, therefore, is for Obamacare to provide physicians with directives from expert panels on which medical services to supply to which patients and when, and for the New Ethics to allow physicians who go along with such directives to live with themselves. The feasibility of this plan depends entirely on physicians acceding to the program.

So, incentives are being put in place to “help” doctors cooperate. Quality measures will be implemented, with “quality” being defined as doctors doing what they’re told, and reimbursement will be tied to one’s quality rating. Possibly more persuasive will be the fact that the Feds can construe the failure to follow handed-down rules, regulations and guidelines, at any time, as a federal crime. (Even doctors who don’t mind being labeled as “substandard quality” – perhaps even considering the label as a badge of honor – will mind going to jail.)

But by whatever means necessary, the happiness of the government is to be the doctor’s first consideration, and not the happiness of their individual patients. The classic doctor-patient relationship is being terminated with extreme prejudice.

To see just how important it is to destroy the doctor-patient relationship, one merely has to observe what is happening to primary care doctors who have the audacity to leave the system, and set up a direct-pay medical practice.

Part of the problem, to be sure, was caused by these doctors themselves. The first few to do so unabashedly catered to rich patients, and to attract the rich, referred to themselves as “concierge” practitioners. This name (and its elitist connotations) have been forcibly affixed to all direct-pay practitioners, even as this style of practice has evolved into a much more democratic form. Today, more and more doctors are starting direct-pay practices (in which patients pay the doctors out of their own pockets) which are easily affordable to anyone who can afford a cell phone or cable TV contract.

While many direct-pay practices offer patients certain benefits they can usually not get from primary care doctors who remain in the approved system (such as phone and e-mail access, same-day appointments, appointments lasting as long as necessary instead of the allotted 7.5 minutes, etc.), the fundamental benefit, to both the patient and the doctor, is that it restores the classic doctor-patient relationship. The physician’s primary obligation is no longer to the 3rd-party overlord, or to the Progressive ideal of social justice, but to the patient.

And while critics (who abound) attack direct-pay practitioners for their elitism, laziness, and greed, their real issue is that direct-pay practitioners are acting as if their primary duty is to their individual patients, and not to the needs of society. This latter fault simply cannot be tolerated.

Having gained nearly complete control over the behavior of primary care practitioners, it is critical for Progressives – in making sure that practice by handed-down “guidelines” is not simply the only legal way to practice, but also the only ethical way to practice – to shut the door to any alternative forms of primary care. Direct-pay practitioners are a menace because they threaten to raise the expectations of both doctors and patients. Perhaps, doctors and patients might tell themselves, there really is a way to maintain individual autonomy within the healthcare system.

The attacks on direct-pay practitioners have followed the usual scheme Progressives follow when they discover a faction they need to suppress. First, they were ridiculed. “For a Retainer, Lavish Care by ‘Boutique Doctors,’” said a headline in the New York Times in 2005. Then, they were demonized, widely attacked for their elitism, laziness, greed, and lack of fundamental medical ethics. In this latter effort, it was not difficult to find fellow physicians – generally, from the medical organizations which promulgated the New Ethics – to lead the attacks. There are countless examples. DrRich will give just two.

Anthony DeMaria, then President of the American College of Cardiology, criticized the practice of direct-pay medicine in an article in the JACC in 2005, saying, “Personally, I do not mind if people acquire yachts or personal trainers if they have enough money, nor would I object if they secured a physician at their beck and call. However, unlike yachts, health care is not discretionary, and everyone should be entitled to the same quality.” As a matter of social justice, direct-pay physicians improve healthcare quality for only some patients, and so have no place in the healthcare system.

In an article in the New England Journal of Medicine, Troyen A. Brennan (M.D., J.D., and M.P.H., so we know we’re in trouble) really gets to the point. Referring to direct-pay practices as “luxury primary care,” he notes that “traditional medical ethics is rather poorly equipped to address issues related to luxury primary care.” That is, while “traditional” medical ethics always places the individual patient first, that kind of thinking is now outmoded. “(M)ost ethicists now agree that the financial structure of health care is an important subject for ethical consideration. Access to health care, in particular, is a salient ethical issue.” Direct-pay practitioners threaten (by their elitism and the limited size of their practices), to limit access to primary care, and thus are in fundamental violation of medical ethics.

The argument here, for those who missed it (advanced by fellow physicians no less), is that, of the two competing ethical precepts now established by New Medical Ethics (i.e., the physician’s obligation to the individual patient vs. the physician’s obligation to society), clear primacy is to be given to the physician’s obligation to society. Physicians must (like it or not) participate in covert bedside healthcare rationing. Physicians who take the only path remaining to them that allows them to make the individual patient their primary obligation are to be castigated as ethically deficient.

When ridicule and demonization fail to suppress their opposition, Progressive dogma indicates it’s time to resort to force. The first pass in this regard, of course, is always to render the opposition illegal. (Actual violence is reserved for criminals who persist in their misbehavior, despite more polite efforts to get them to behave lawfully.)

Making direct-pay medical practice illegal has not been accomplished yet, but clear efforts have been made in this regard. Noting with alarm the rise of direct-pay primary care, numerous Congresspersons have issued statements of concern, suggesting that perhaps Congress should look into the propriety of such activities.

Indeed, the first step by Congress has already been taken. In 2003, as part of the Medicare Prescription Drug, Improvement, and Modernization Act, Congress directed the GAO to study and report on the effect of direct-pay practices on Medicare patients. The GAO did so in 2005, and a fair paraphrase of its report is as follows: “The practice of direct-pay medicine is not currently a threat to Medicare patients, because the direct-pay movement is not large enough yet to have an impact. If it does begin to have an impact on Medicare patients, action will have to be taken.” That is, direct-pay medicine was considered OK in 2005 not because it was inherently an ethical and legal form of medical practice, but simply because there were not enough practitioners at that time to significantly affect Medicare patients. The clear implication is that Congress stands ready to pass laws outlawing – or, at least, severely limiting – direct-pay practices, as soon as those practices begin to “impact” the system.

Certain state governments are not waiting for Congress to ban direct-pay practices. The state of Maryland (and a few others) have taken the creative position that, because many direct-pay practices work on a retainer basis, they meet the definition of a health insurance company. And as a health insurance company, to be considered legal entities, they have to have millions of dollars set aside to pay for unforeseen “claims.” (Interestingly, this same argument was not applied to Maryland lawyers, who also often work on a retainer model.) According to the Baltimore Sun, the state’s stance in this regard has already successfully caused several primary care physicians to abandon their plans to become retainer practitioners.

Less devious (but more draconian) than the state of Maryland is the state of Massachusetts (whose universal healthcare system, we’ve all heard, is a preview of Obamacare circa 2015). A bill is under consideration in the Massachusetts Senate (Bill 2170) which requires doctors, as a condition of their licensure, to accept payment rates as determined by the government. If it passes, it will be the first actual legislation in the U.S. to ban direct-pay medicine, if only by making it completely impracticable. (Thanks to Dr. Wes for pointing out this important development.)

Since medical licensing is controlled by the various states, of course, it would take 50 bills like the one in Massachusetts to really get rid of direct-pay healthcare. But there are other ways for the Feds to accomplish the same thing. Now that the federal government directly controls all student loans, for instance, it would be a simple matter to make those loans contingent on agreeing to become primary care doctors working strictly within the government controlled system, or to offer loan forgiveness for doctors who agree to do so, or to rescind favorable re-payment conditions (retroactively, and decades after the fact, if necessary) for doctors who go to a direct-pay model later in life.

DrRich does not really know how the Progressives will actually place the final nail in the coffin of the doctor-patient relationship. All he knows is that they have – well, more than the desire – the deep and abiding need to kill that relationship, once and for all. Unless we the people decide we ought to stop them, this is going to happen.

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Part 4 of Limiting Individual Prerogatives

A few days ago Mr. Doherty (who is also the ACP’s Senior Vice President of Governmental Affairs and Public Policy), graciously agreed to engage in this discussion, and promised to do so after consulting with the ACP’s Committee on Ethics, Professionalism, and Human Rights.

DrRich had hoped that Mr. Doherty would reply with a post on his ACP blog, which (since it likely has a vastly greater readership than the CRB), would more effectively give this topic some much-needed airing – and in particular, might engage some of the ACP’s membership (specialists in internal medicine) in this important discussion. DrRich was disappointed, then, when the reply came today in the form of a comment, which was tacked on to a long queue of reader’s comments at the end of DrRich’s posting.

DrRich was also very disappointed by the content of the reply which, fundamentally, was: This is a non-issue, and even if it was an issue, it’s now a settled issue. (So go away.)

Because he fears that his readers may not find the ACP’s response (buried as it is), DrRich will post it here in its entirety. But first he will very briefly summarize his complaint against the New Ethics promulgated by the ACP and other Millennialists. The New Ethics takes classical medical ethics (which obligates doctors to always place the welfare of their individual patients first) and adds on to it a new ethical obligation, called Social Justice, which obligates doctors to work toward “the fair distribution of healthcare resources.” This new obligation (which is to society) will inherently conflict, at least some of the time, with the physician’s traditional obligation to the individual patient. So, under the New Ethics, the doctor’s loyalty is now officially divided. DrRich asserts that this divided loyalty (which is now declared to be entirely ethical) leaves the patient in a dangerous position, and breaks the profession of medicine.

In the ACP’s response Mr. Doherty begins: “I asked Dr. Virginia Hood, chair of ACP’s Committee on Ethics, Professionalism, and Human Rights, to respond to Dr. Rich’s post. Her reply is below:”

Much ado?

We are surprised to see the comments about ACP and medical ethics. We urge readers to read the actual text of the ACP Ethics Manual (the College’s Code of Ethics) and the Professionalism Charter, which the College’s Foundation helped develop. Both say that social justice is a consideration in medical ethics, but the physician’s primary responsibility is to his or her patient. Resource allocation decisions are policy decisions and are most appropriately made at the system level, not at the bedside. The Ethics Manual discusses at length the clinician’s primary role as an advocate for individual patients. But it also notes the duty to practice effective health care and use resources responsibly, which are not incompatible with being a patient advocate. As the Manual notes, physicians should not overtest or otherwise overuse services:

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

This is nothing new. Indeed using “effective and efficient health care and health care resources responsibly” for all patients is one way to minimize rationing as the result of an over costly system. The Manual also says that physicians and their professional societies should work toward ensuring access to health care for all and the elimination of discrimination, and deficiencies in availability and quality, in health care services. Likewise, the Charter on Medical Professionalism endorsed by ACP and 120 other medical organizations in the USA and internationally, states that professionalism involves commitments to improving quality of care, improving access to care, eliminating discrimination in health care, and yes, to a just distribution of finite resources. But the Charter explains the commitment to a fair distribution of finite resources as follows:

While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others [ii].

The patient-physician relationship and our medical ethics are the soul of medicine. The blog commentators are correct– it is important that we get it right.

Thank you.

Virginia Hood, MD, FACP
Chair, American College of Physicians Ethics, Professionalism and Human Rights Committee

As much as DrRich may feel he has been condescended to here (as if the ACP has found a fly buzzing around its head and has attempted to swat it away), and recognizing that the ACP has decided not to engage in a give-and-take (which, of course is their prerogative), but rather, has responded with a brush-off statement which they have chosen to bury in the comments section of DrRich’s obscure blog (which is also their prerogative), DrRich will attempt to reply as politely and as analytically as possible. (He does, however, sincerely hope that Mr. Doherty – who really seems like a good person and is an excellent writer – will not be called to the woodshed for obligating an august Ethics Committee Chairperson from this prestigious organization to issue a formal response to an annoying blogger such as himself.)

Dr. Hood’s artful (and dismissive, it seems to DrRich) statement can be fairly summarized thusly: After beginning with the implication that DrRich is making much ado (about nothing), and that she is surprised that anyone would dissent from ACP’s New Ethics, she says that the New Ethics does not entail the problem that DrRich alleges; indeed, there really is nothing new about it. Of course patients come first. (Just study the various documents the ACP has published on this point.) Cost-effective and efficient care is a part of good medicine, and always has been. What we mean by a fair distribution of finite resources is to practice medicine wisely, so as not to waste resources and not to expose patients to the risk of medical services they do not need. The legitimacy of the New Ethics is supported by the fact that it has been formally adopted by 120 medical organizations internationally (which to DrRich means that when you go to a doctor anywhere, this is the code of ethics under which they are now officially practicing).

There is a lot in her statement DrRich could comment on, but he does not want to bore his readers with a lengthy parsing of this finely crafted response. Rather, he will just talk about its main point.

Fundamentally, Dr. Hood is denying that there’s any problem. There’s no conflict between “the fair distribution of healthcare resources” and doing what’s best for individual patients – and furthermore, she’s surprised anyone would think so.

DrRich does not accuse her of sophistry. Perhaps she is just deceived.

The fact that there are huge conflicts between providing individuals with all the healthcare that would likely be useful to them, and the inability of society to pay for such a thing, is the fundamental problem with the public funding of healthcare. We simply can’t afford to buy everybody all the healthcare that would likely benefit them. There’s not enough money in the world to do that.

Consider just a few of the examples DrRich has discussed here over the years. Implantable defibrillators have been shown to significantly improve the survival of a substantial minority of patients who have heart disease, and indeed guidelines issued by cardiologists’ professional organizations indicate that defibrillators ought to be implanted at a rate of about five times their current actual implant rate. But if doctors actually did that, it would cost Medicare an extra $7 – $8 billion each year. Then there’s the fact that if doctors used the statin drug Crestor in the way the very well-designed and compelling JUPITER trial says doctors should use it, we would be spending an extra $10 billion per year on Crestor. In a thousand ways, the “best” healthcare for the individual is very often not cheaper (or better for society) than less-good healthcare, and DrRich is impressed that Dr. Hood is willing to say that it is.

Dr. Hood would likely deal with this problem, and implies so, by devising “guidelines” that doctors would be ethically obligated to follow. Obviously, it is entirely possible to convert “guidelines” from just that (i.e., a set of guidelines which doctors ought to take into strong account when deciding what’s best for their individual patients) into a set of formal rules that must be followed, and which will then be enforced by federal regulators (and their posse of ethicists). Indeed, such “guidelines” might be one of the ways in which society imposes its own goals over those of individual patients. But that is not the same thing as insisting that individual patients (who often do not fit the “average” profile) will necessarily profit if doctors always follow the guidelines as a matter of policy, or of enforced expectations, or of “quality”.

(Further, as DrRich has pointed out, the rapidly developing paradigm in which “guidelines” are becoming inviolate rules has led competing organizations to rush to issue their own sets of competing guidelines, that best comport with their individual agendas. While this phenomenon of “guideline wars” is endlessly amusing, it may not always serve the best interests of doctors or their patients.)

And then there’s the problem that, no matter how you define “waste” or “inefficiency” or “unnecessary care,” there simply cannot be enough of it to account for the runaway healthcare inflation we’re seeing (as DrRich has shown here). A substantial proportion of this fiscally disastrous healthcare inflation must necessarily derive from the delivery of healthcare that is actually useful.

So the crux of Dr. Hood’s reply – that all the ACP is talking about when it mandates that doctors fairly distribute limited resources is that they ought to practice good medicine, and if they did that simple thing no useful therapy would need to be withheld from any individual patient – is absurd on its face.

DrRich would be less disturbed by Dr. Hood’s assertion if he really thought it was simply a misapprehension of the truth. And perhaps it is. After all, her statement reads as if she is truly surprised that anyone would think otherwise.

Perhaps Dr. Hood came to her high station within the ACP’s Ethics Committee very recently, and is unaware of the history of the new Professionalism Charter which advanced this New Ethics, or of the controversy that was raised by many critics at the time of its adoption, or indeed, of some of the language that was in its penultimate version (and that was likely removed to silence some of those critics). Indeed, she cannot be aware if it, since she is “surprised to see” that anyone is bothered by the Charter, and since she believes that questioning it is but “much ado.” But to anyone who knows a little of that history, Dr. Hood’s assertion that controversy over this Charter is a novel experience, or most especially, her assertion that this New Ethics is really “nothing new,” would come as a very great surprise indeed.

First, we should note, if the new Professionalism Charter was really “nothing new,” and was just a restatement of the physician’s traditional obligation to place the patient first, and if fairly distributing society’s resources really was just a matter of practicing good medicine, then there would have been no need for a new Charter of medical ethics in the first place. And certainly the need would not have been pressing. It would have served quite nicely instead to produce some sort of document reminding doctors that unneeded healthcare services expose their patients to unneeded risk, so (based on the traditional ethical precept of patient welfare), to remain ethical they must stop being wasteful. Certainly, this kind of wasteful medicine would not produce a need to redefine medical ethics.

But the new Charter’s very first sentence describes something more dire, more pressing, than can be explained by Dr. Hood’s benign assertions. It says, “Physicians today are experiencing frustration as changes in the health care delivery systems in virtually all industrialized countries threaten the very nature and values of medical professionalism.” So: the whole purpose of this new Charter, its entire impetus, was the frustration of physicians.

Frustration? What frustration is that? Interestingly, the document does not come right out and say it. The closest it comes to spelling it out is to say, “We share the view that medicine’s commitment to the patient is being challenged by external forces of change within our societies.”

But even though the document seems strangely reticent about spelling out which frustration produced the very impetus for its creation, we can rely on the fact that the document must be designed to cure this mysterious frustration (whatever it is), and that the only revolutionary change in the document is an addition to the code of medical ethics requiring physicians to work for “the fair distribution of healthcare resources.” We can only conclude that this new ethical obligation is meant as a cure for that foundational frustration, and that therefore this frustration must be that doctors are finding it impossible to meet their traditional ethical obligation to to place their patients’ needs first.

But, as it happens, we do not really have to resort to this sort of documentary detective work to parse out the purpose of the new Professionalism Charter. That purpose was quite open at the time this document was being developed – and it produced robust controversy that was certainly no secret. One can read about this controversy in many places, but for our purposes now (i.e., in replying to Dr. Hood’s assertion that there’s nothing new here, and that it is a matter of some astonishment that anyone would find the Physicians Charter controversial) it might be best to refer to one of the ACP’s own publications from that time.

An article in the July, 2001 ACP-ASIM Observer, which was entitled, “Charter on medical professionalism addresses issues of finite resources,” goes into some length about the controversy. And it is very plain that the objection many raised to the new Charter was precisely that which DrRich is raising now in his challenge to the ACP: that the New Ethics being espoused in the Professionalism Charter fundamentally and explicitly divides the loyalty of the physician between the patient’s needs and society’s needs. When one listens to the defenders of the new Charter (quoted extensively in the ACP-ASIM Observer article), one finds the unmistakable tones of utilitarianism: We have to change our ethical precepts, the argument goes, because that’s just the way the world works now.

This article also indicates that the draft of the Physicians Charter presented to ACP general membership at their annual meeting in 2001, a few months before the final version was finally published, was perhaps more forthcoming than the final version, regarding what it was really all about. For instance, this nearly-final version of the Charter specifically admonished physicians that they must “be aware that the decisions they make about individual patients have an impact on the resources available to others.” One can only assume that this sort of explicit language was taken out of that final version in response to the critics (who were many, and vocal) to soften the blow.

Indeed, the “softer” language of this strange final version (which has all the hallmarks of a heavily edited document, beginning as it does with a heartfelt cry against the frustrations being experienced by physicians, then neglecting to spell out what those frustrations are, and never explicitly saying which aspect of the document addresses those frustrations), is now possibly soft enough, if not read carefully, to allow defenders of the Professionalism Charter to get away with asserting (as Dr. Hood has done) that the New Ethics is really pretty much the same as the old ethics, and does not change anything. (So move along, move along.)

But the New Ethics changes everything.

DrRich is very sorry about this, and is especially sorry that the ACP’s Ethics Committee, and the other 120 physicians organizations that have adopted this New Ethics, insist they do not see a problem here. DrRich assumes by this response that the ACP has little interest in revisiting its new ethical stance, and further, is undoubtedly busily training today’s medical students that doing what’s best for society is the same as doing what’s best for the individual.

This is a theme, DrRich thinks, he’s heard a lot lately.

Patients who want a true advocate in their life-and-death encounters with the healthcare system, an advocate whose loyalty is not divided between them and a society that, with increasing desperation, wants not to spend its money on them, had better go out and hire their own. Your doctor will now find it officially unethical to serve that office him-or-herself.

And meanwhile, we can now be sure that the physicians organizations which are responsible for protecting the ethical foundation of the profession of medicine are quite satisfied with the job they are doing.