Farmer Emanuel has 10,000 head of cattle in his beef herd. He prides himself in staying up to date on all the latest methods, so he knows that adding a certain antibiotic to their feed will reduce the incidence of intestinal infections, and will increase his annual overall yield, measured in pounds of beef, by 7%. Unfortunately, he also knows that roughly one in 200 of his cattle will experience a likely fatal allergic reaction to the antibiotic. It is possible to do a blood test to determine which specific members of the herd are allergic, but the test itself is quite expensive, and the logistics of separating the allergic cattle at feeding time and providing them with their own antibiotic-free feed would be expensive enough to entirely wipe out his savings.

Obviously, the cost-effective solution is for Farmer Emanuel to give antibiotic-treated feed to all his cattle, accepting the losses of a few head as the necessary price for an impressive overall gain in productivity. He would be an ineffective and incompetent rancher indeed if he were to pass up this opportunity to achieve cost-effectiveness.

For the last two posts (here and here) DrRich has had some fun in deconstructing the Sixth edition of the American College of Physicians’ Ethics Manual, and especially in demonstrating how the ACP leadership has managed to wrap its collective tongue around the axle defending its unfortunate choice of the word “parsimonious” to describe the ideal mind-set of the modern physician. In the present post, DrRich will discuss a somewhat more serious aspect of the document, namely, what this re-statement of medical ethics really means, and why it was produced.

The Sixth Edition of the ACP Ethics Manual elevates the term “cost-effectiveness” to an ethical mandate; and furthermore, it locks this often ambiguous term down into its apparently final form, and in so doing formally launches the era of herd medicine.

Until now, efforts at covert healthcare rationing have been aimed mainly at coercing individual physicians to surreptitiously withhold certain medical services at the bedside. Mainly, doctors were to accomplish this withholding of care simply by failing to inform patients of all their medical options, or perhaps more commonly, by painting certain medical options in an unfavorable light (so that, while they were, in fact, offered, they were offered in such a way that the patient would almost certainly turn them down).

What the Central Authority has learned, over the past 15 years, is that this style of covert rationing simply doesn’t work. It still leaves medical decisions up to individual doctors and individual patients, who have apparently continued to act against the best interests of the collective despite all the coercion that has been brought to bear. The end result has been unremittingly bad – healthcare costs have continued to rise at multiples of both the GDP and the general level of inflation. It has become obvious to the Central Authority that, in order to set the matter right, all healthcare decisions will have to be made centrally, from the top down.

Accordingly, during the first decade of the New Millennium we saw a steadily rising emphasis on “guidelines.” Guidelines are not intrinsically a bad thing, and indeed, when properly used can be greatly beneficial to both doctors and patients. But in a relatively gradual process, guidelines came to be spoken of as more than merely guidelines – that is, as more than helpful considerations which doctors ought to take into serious account when deciding what’s best for an individual patient. Instead, guidelines have become directives for definite action.

In 2010, the Obamacare legislation took the concept of “guidelines” a giant step forward, and essentially rendered it a crime for doctors to “violate” guidelines, which are now to be handed down by federally-appointed panels of experts. As if to emphasize this new paradigm, the Department of Justice a year ago began a secretive investigation of an unknown number of electrophysiologists, for alleged violations of guidelines for using implantable defibrillators. We do not know if any criminal charges will be brought (and because the particular aspect of those guidelines which doctors have allegedly violated were based on rather flimsy evidence, perhaps not), but during the past year American electrophysiologists have certainly been intimidated into reducing the number of implantable defibrillators they offer to their patients. (And so, whether any charges come out of this “investigation” or not, mission accomplished!)

Dear Reader, how do you suppose some of these electrophysiologists must feel, after failing to offer implantable defibrillators to their patients who they believe have clear-cut indications for the device, knowing that by failing to offer this treatment their patients may very well (and very predictably) suffer sudden death? At least a few doctors, DrRich warrants, are probably feeling very guilty about it.

And here is the real import of the updated Ethics Manual. It aims to assuage the guilty conscience of physicians who follow handed-down guidelines to the letter, even against their better medical judgment, instead of tailoring the application of those guidelines to the benefit of their individual patients (which, DrRich feels compelled to remind his readers, was the original but now archaic intention of “guidelines.”) Doctors who had been feeling badly because they were preserving their own skin at the cost of their patients’ can now take heart. They are not behaving selfishly at all, the New Ethics assures them. They are in fact acting for the greater good of the collective – and therefore they are obeying a higher principle of ethics than those outmoded principles mentioned in the Hippocratic Oath.

While herd medicine was made the law of the land by Obamacare, until now it was still technically unethical. The ACP’s new Ethics Manual repairs that uncomfortable discrepancy, using, of course, what has become the traditional methodology. (That is, when it becomes  difficult or impossible to adhere to ethical precepts, change them.)

For those who missed it, the relevant passage of the new Ethics Manual states that physicians have an ethical obligation to “practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to diagnose a condition and treat a patient respects the need to use resources wisely. . .”

Dr. Ezekiel Emanuel offers the midrash on this passage, in his editorial which accompanied the publication of the new Ethics Manual. Emanuel rhapsodizes that it is “truly remarkable” that an “authoritative medical body [is] using such words as ‘efficient’ and ‘parsimonious’ – and without ‘qualifications’ – to describe the ideal physician’s practices.” Dr. Emanuel notes further that to fulfill this new ethical obligation toward efficiency and parsimony, the Ethics Manual specifies that doctors should act based on “the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches.”

And that, readers, is the key, for it specifies how doctors, in pursuit of the new ethics, are to act. They are to follow the “best evidence,” in particular, the best evidence on “cost-effectiveness.”

In the past, when doctors were exhorted to practice cost-effectively, the term was used as a general admonition to not be wasteful. But here, in this formal ethics document (as in the Obamacare legislation), it has now become a term of art. “Cost-effective” now has a specific meaning. It is cost-effectiveness as determined by “best evidence,” and since any body of clinical evidence will inevitably have conflicts, and since doctors cannot be expected (or permitted) to determine for themselves which evidence is best in every clinical situation, Dr. Emanuel is talking about the “best evidence” which will be determined by one of his panels of experts.

Therefore, the ACP’s new Ethics Manual stipulates that it is now an ethical obligation for doctors to follow expert-produced guidelines to the letter.

But in the real world, there is no single “best” determination of cost-effectiveness. This is because any determination of cost-effectiveness depends entirely on who is making the assessment. For instance, when DrRich was deciding whether to buy a smoke alarm to protect himself and his family from dying in a fiery inferno, he judged it to be cost-effective to do so. For a mere $20, DrRich was able to protect himself and his family from death or injury, in the unlikely event that a fire should occur in his home. A bargain to be sure, and at least by DrRich’s lights it was highly cost-effective (if only for the peace of mind it brought him).

But if the purchase of fire alarms was covered under Obamacare (and why should it not be, since fire-related injury is certainly a medical problem, which produces a burden for our healthcare system), then the cost effectiveness calculation would look very different. For while fire alarms indeed save lives, they do so at an exorbitant cost – likely more than a million dollars per life-year saved. Clearly, from the perspective of the collective, the purchase of fire alarms ought to be made illegal, and owning one a crime.

And the only reason it’s not a crime is that such Fire Protection Appliances have not (yet) been designated as being subject to the rulings of the US Preventive Services Task Force.

It is axiomatic, therefore, that the assessment of the cost-effectiveness of any product or service will depend on which party of interest is doing the assessment. And often, what might very well be considered cost-effective by an individual might just as well be considered criminally cost-ineffective by the collective.

And so we have the situation, under both Obamacare and now under the new code of medical ethics, in which doctors are obligated to practice medicine cost-effectively, and the kind of cost-effectiveness being referred to is decidedly NOT the kind that applies to individuals. It’s the kind that applies to the collective.

Those assembling the GOD panels (Government Operatives Deliberating) – the panels which will determine the most cost-effective way to practice medicine, and which will distribute rules down to American physicians for deciding who gets what, when and how – tell us that what’s good for the herd is certainly what’s good for the individual. Indeed, this is the precise message of Dr. Hood, president of the ACP.

For the majority of Farmer Emanuel’s beef cattle, this may very well be the case. But for the unfortunate beeves who will turn out to have a fatal allergy to the antibiotic, and who could have been saved with a little extra effort aimed at optimizing the results for every individual, well, not so much. (Progressives like Keynes have been known to justify such results by noting that whatever we do has limited significance for individuals, since, in the end we individuals – like the beef cattle – are all dead anyway.)

Until last week American physicians were ethically obligated to optimize their medical care for every individual, as difficult and dangerous as it has become for doctors to do so in recent years.  No doubt some of them will be relieved to know that their ethical obligations now have been formally changed, to comport with the requirements of their masters, and the facts on the ground.

So open wide and say Moo.

The American College of Physicians published the Sixth Edition of its Physicians Ethics Manual yesterday. Regular readers may find it surprising to hear DrRich say that there is little objectionable in it, and actually much to admire – that is, when it is considered as it is written, as a stand-alone document.

But of course, when it comes to statements of medical ethics in the New Millennium, one cannot rely on the face value of the written word. For the purpose of the modern medical ethicist is to supply a plausible justification for the covert rationing of healthcare. That is, they need to make it ethically justifiable (if not ethically mandatory) for doctors to ration their patients’ healthcare at the bedside. Because statements of medical ethics cannot just come out and say that, ethicists must compose these statements quite artfully, so that when somebody (like DrRich) calls them on it, they can indignantly deny any such thing.

Therefore, DrRich submits, an accurate interpretation of the ACP’s New Ethics Manual requires an exegesis – that is, it requires that we go beneath the actual words, that we explore the derivation of this text, in order to discover its true underlying meaning. Fortunately, this process will be pretty straightforward, and will not require us to have a working knowledge of Latin, Greek or Hebrew. Plain English will do, as long as we keep the true aim of the modern medical ethicist in mind.

Accordingly, we need to begin this exercise by reminding ourselves of what that true aim is. This was probably stated most clearly in a quote DrRich has used before, by Dr. Berwick and his co-author Dr. Troyen Brennan (another ACP ethics maven) in their 1995 book, “New Rules.” To wit: “Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care. . .is to constrain decentralized individualized decision making.”

That is, the primary aim of the new medical ethics is to get doctors to stop focusing on the specific, unique needs of their individual patients, and instead to focus on what is best for society – which means acceding to centralized, collectivized decision making (the opposite of the decentralized, individualized decision making which the ethicists are pledged to constrain). For doctors to do so, of course, will utterly violate the primary ethical precept which the profession has followed for more than two millennia, and so, obviously, if only for the sake of appearance, will require some revision of those ethical precepts to accommodate the new reality.

And that is the program of the modern medical ethicist.

They have been at this for a long time (at least since the early 1990s), and the Sixth Edition of the ACP Ethics Manual – despite its largely benign language and even occasional retrograde pledges to the needs of the individual patient – advances the true aims of the medical ethicists to a new level. DrRich will provide three lines of evidence to support this contention.

First,

in its section on “Professionalism,” the new Ethics Manual defers specifically to a foundational document written by the ACP and published in 2002 entitled, “Medical Professionalism in the New Millennium: A Physician Charter.” That Charter, which DrRich has critiqued in detail, established a new ethical precept which physicians must now follow – and to which they must give equal weight to their ancient duty to the best interests of their patient. That new precept is to social justice – to a just distribution of healthcare resources.

To understand the real import of this new ethical precept – which is introduced in the Charter in a determinedly bland manner – we must do a brief exegesis of the Charter itself. Notably, the first sentence of the Charter, which attempts to explain just why such a new charter on medical professionalism is needed in the first place, 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.”

While this sentence obviously expresses the utter frustration doctors were feeling at being coerced – at the time mainly by health insurers – to withhold expensive but potentially useful healthcare services from their patients, the document itself never spells this out. Indeed, after this passionate opening sentence, no reference to any particular frustration is made again. Rather the document immediately retreats into a bland prose, and one looks in vain for the authors to spell out the cause of the dire frustration that demands a restatement of medical professionalism.

But even though the document seems strangely reticent to say what 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 further, that the only substantial change in the document was an addition to the code of medical ethics, adding the requirement that physicians work for social justice. Making social justice an ethical mandate for individual physicians, one can only surmise, might help relieve some of the guilt (and some of the frustration) physicians feel when they are forced to engage in bedside rationing against their patients.

The blandness of the Charter is intentional, and was added at the last minute to “soften” the blow. In an ACP policy conference held in the summer of 2001, a much more inflammatory draft of this new Charter was presented to the membership for discussion. That penultimate version made the actual intent of the document far more explicit. It said that when making decisions regarding individual patients, doctors must “be aware that the decisions they make about individual patients have an impact on the resources available to others.”  In other words, it explicitly instructed bedside rationing. To the dismay of the ethicists who had presented the draft, several ACP members at that conference reacted quite negatively to it. (Who knew that doctors still gave so much weight to ancient, outdated ethical precepts?) Because of the uproar, the language of the document was softened before its official publication. While its import remained entirely unchanged, the document was “blanded-up.” In particular, the sentence explicitly spelling out just what the authors meant by “social justice” was removed. In making their final revision, however, the authors of the Charter managed to overlook the passionate tone of that (suddenly incongruent) opening sentence, and thus left an everlasting clue as to what the document was really intended to do.

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

By explicitly endorsing the 2002 Charter on medical professionalism, the Sixth Edition of the ACP Ethics Manual thereby endorses healthcare rationing at the bedside – but it does so quietly, at arm’s length, so as not to stir up unwanted passions.

Second,

the publication of the new Ethics Manual is accompanied by an editorial written by Ezekiel Emanuel, MD, a celebrated medical ethicist, the brother of Rahm, and a special advisor on health policy to the White House. It is widely believed that Dr. Emanuel will have a lot to say about which medical experts are going to be appointed to Obamacare’s GOD panels (Government Operatives Deliberating) – the panels that will establish the formal “guidelines” to determine which patients will get what, when and how, “guidelines” which doctors will have to follow in every particular, or be subject to fines, loss of profession, and imprisonment.

It is therefore instructive that Dr. Emanuel is effusive in his praise of this new ACP Ethics Manual. He is especially delighted that the authors have placed a statement into a special “call-out” box, so nobody can miss it, demanding that physicians, as an ethical duty owed to society, must practice efficient, parsimonious, and cost-effective healthcare.

Emanuel notes that “These positions on efficiency, parsimony, and cost-effectiveness constitute an important shift, if not in ethics then in emphasis.” Dr. Emanuel need not dissemble. It’s a shift in ethics all right – just look at the title of the document.

In other words, dear reader, we have Dr. Emanuel, one of the Supreme Beings who will be directing the GOD panels, declaring that, thanks to the new ACP Ethics Manual, doctors have now fully accepted the proposition that it is a matter of medical ethics for “cost-effectiveness” – as determined by panels of hand-picked experts – to decide whether their patient will receive a potentially beneficial medical service.

(Judging from Dr. Emanuel’s reaction to their work product, if any of the authors of this new Ethics Manual had hoped their participation might serve as their audition for one of the GOD panels, it appears their strategy might work out just fine.)

Third,

the Ethics Manual contains the injunction that doctors practice medicine “parsimoniously.”  While Dr. Emanuel is enamored by and delighted with this word, DrRich finds it at least a little disturbing.

One might speculate that by this word the ACP’s medical ethicists mean to say that doctors ought to arrive at a care plan by applying the “theory of parsimony,” best known as Occam’s Razor. If so, they are urging doctors to error.

The theory of parsimony says that when a series of observations has more than one plausible explanation, the simplest of the available explanations should be considered the “best.” This method usually works quite well when one is devising a theory to explain some phenomenon whose explanation is not a matter of dire urgency. So, for instance, any cave man from the Paleolithic Age who was fond of Occam’s Razor would have concluded, from available observational data, that the sun revolves around the earth. This conclusion was wrong, but little harm was done by it. And when it became important for us to get the movements of the heavenly bodies right (for instance, when we decided to send men to the moon), we first took care to collect additional observational data (just to make sure), and thereby we discovered just in time (a mere few hundred years before launch) that, for a million years or so, our original conclusion had been mistaken.

But Occam’s Razor is less well suited for making medical decisions, that is, in cases where current clinical evidence is consistent with more than one explanation. Here, it is likely that with some effort a discoverable, definitive, correct answer could be achieved, and it is at least possible that always choosing the “simplest” possible explanation would lead the doctor to take action (or more likely, to withhold medical services) that would cause the patient to suffer harm. Sometimes the theory of parsimony can be applied to good effect in the practice of medicine; other times it will be a disaster. Deciding when to use it is a matter of medical judgment and medical experience, best decided locally by a specific doctor on behalf of a specific patient.

The theory of parsimony clearly should not be applied as a matter of course to all medical questions, perhaps not even in most medical questions. So it would seem a shame for the ACP’s Ethics Manual to decree (“without qualifiers,” as Dr. Emanuel approvingly notes) that as a matter of medical ethics, doctors must always do so.

But perhaps the authors were not referring to the “theory of parsimony” at all. Perhaps they were just using “parsimonious” as a synonym for “efficient.” If this is the case, their error was more along the lines of a Freudian slip. For “efficient” and “parsimonious” are simply not good synonyms. Better synonyms for parsimonious would include:

• excessively unwilling to spend,
• ungenerous,
• penurious,
• penny-pinching,
• miserly,
• sparing,
• grasping,
• tight,
• close,
• niggardly,
• illiberal,
• mean,
• avaricious,
• covetous, or
• tight-assed.

Efficient is to parsimonious as fondness is to lust, or as a gentle spring rain is to a deadly deluge. They may be in the same genus, but are of entirely different species.

Since the real synonyms for parsimonious are all quite descriptive of bedside healthcare rationing, DrRich submits that this carefully chosen and strongly praised word is every bit as appropriate to the occasion as Dr. Emanuel indicates. This is EXACTLY how our Central Authority wants doctors to practice medicine – parsimoniously.

In conclusion,

the wording of the new ACP Ethics Manual itself may be, with a few notable exceptions, inoffensive. But when we take the time to explore the derivation of this text, when we consider it in light of the overarching program of modern medical ethicists, and in light of the interpretations now being assigned to it by agents of the Central Authority, it is not difficult to discover its true meaning and its true significance. This document helps establish an ethical mandate for doctors to follow centralized clinical directives to the letter, and doctors who fail to comply will be guilty not only of some legalistic violation of “guidelines,” but also of behaving unethically. And almost anyone will tell you that unethical doctors are the lowest form of life; for them no punishment is too harsh, and the tiniest mercy is too kind.

This, of course, is just what we should have expected.

DrRich has written a lot on this blog about the intentional destruction of the classic doctor-patient relationship. That relationship, of course, was a fiduciary one, under which the patient was encouraged and expected to place full trust in the doctor’s sacred duty to put the patient’s own best interests above all other considerations.

Obviously, such a thing is incompatible with a healthcare system in which doctors are expected to covertly ration healthcare at the bedside. Indeed, it was the ethical tension between what the classic doctor-patient relationship required and the new duties of physicians in the real world, that led professional medical organizations to formally re-define medical ethics in 2002.

And today, of course, under these New Age medical ethics, doctors are no longer expected to place the needs of their individual patient first. Rather, they are required to make the needs of the collective – that is, social justice – their chief consideration.

When the needs of the individual and the needs of the collective coincide, of course, so much the better. But when they do not – and they frequently do not – the needs of the collective take precedence. And “the needs of the collective” are now being determined by panels of experts created under Obamacare, which are busily devising the “guidelines” for treatment that physicians must follow to the letter, or risk their careers, life savings, and freedom from incarceration.

Lest you think DrRich is making this up, allow him to remind his readers of this excerpt, from the ominously-titled book, “New Rules,” co-authored by none other than Donald Berwick MD, who has run CMS for the past 18 months:

“Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care. . .is to constrain decentralized individualized decision making.”

Having thus terminated the classic doctor-patient relationship with extreme prejudice, the same political and medical leaders who conducted this assassination immediately realized they had to fill the void – for how can you have no such thing as the doctor-patient relationship? The solution to this problem, of course, was easy. Just as you can create a New Age medical ethics to fit modern exigencies, you can create a new doctor-patient relationship that will do the same thing.

So, what medical students are being taught today about the doctor-patient relationship has nothing to do with fiduciary responsibilities or ethical obligations. Rather, the New Age doctor-patient relationship is all about the interpersonal relationship between doctor and patient. Doctors are admonished: Be compassionate, be empathetic, be nice. And there’s nothing wrong with crying in front of your patients.

Not being an asshole, of course, has always been a useful trait for physicians. Doctors who can relate to their patients, displaying and actually feeling a certain amount of compassion and empathy, have always been more effective at communicating with their patients – and thus have been more effective physicians – than those who are arrogant, self-centered, aloof, or just plain mean*.

____
*DrRich has already pointed out the following irony: many of the doctors who washed out of clinical medicine, possibly because they were too arrogant, self-centered, rigid, and/or aloof to be effective physicians, are now populating the expert panels which are writing the guidelines which will dictate the behavior of doctors who might otherwise be actually useful.
____

The benefits of being a nice person are not exclusive to the medical profession. The same rules hold for anyone who makes his/her living by engaging in personal interactions with fellow humans. And so, until recent years, the medical profession categorized this fact (that doctors ought to have decent interpersonal skills) within the realm of common sense, common decency, and common knowledge – and the idea of the doctor-patient relationship meant something else entirely.

Every medical school now has formal training on the doctor-patient relationship, under which young physicians are taught to be compassionate, empathetic, and nice. To the extent that such traits can be taught – and DrRich has his doubts – there’s nothing inherently wrong with emphasizing interpersonal skills. There are, however, two problems that come to mind when emphasizing interpersonal skills becomes a substitute for emphasizing the real and true obligations of a professional.

First, teaching young doctors that a good doctor-patient relationship simply means being nice will result in newer generations of physicians having no concept of any fiduciary obligation to their individual patients. They will address the needs of the collective first, as a matter of course. (But as they withhold information on available treatments about which their patients are not to be informed, we can count on them to be extremely nice about it.)

Second, there is a growing school of thought, amongst those who are responsible for teaching this New Age doctor-patient relationship, that not only should doctors avoid stoicism at the bedside, but they also ought to openly display their emotions, so as to further reinforce their compassion, empathy, niceness, &c. By graphically displaying the deep empathy the physician has for his (or more likely, her) patients, he or she can really bond with them, and thus establish a really strong doctor-patient relationship.

And what better way to openly display one’s emotions than to cry?

Just as a general proposition, DrRich is against crying in front of patients. Certainly, there may be rare occasions when emotions rise up unexpectedly at the bedside – when a patient relates a particularly affecting personal story for instance. But in general, DrRich is convinced that doctors should not make a habit of expressing their emotions too frequently or too luxuriously to their patients.

Empathy and compassion are fine, but what sick patients really need is a doctor who can maintain some sense of composure even when things are the bleakest, some sense that, as bad as things are, this situation is not beyond the doctor’s experience. Even if the outcome is destined to be very bad, the patient deserves a doctor who acts like he or she has been there before, and who they can trust to remain at their side and help guide them through the ordeal that remains.

But DrRich is concerned that the faculty of our medical schools, who are busily training America’s Obamacare Doctors of Tomorrow, have reached the following epiphany: A particularly wonderful way to repair the failing doctor-patient relationship would be to indoctrinate young future physicians (most of whom these days, once again, are said to be women – not that there’s anything wrong with that) that crying at the bedside – indeed, openly displaying their every emotion at the bedside – is a marvelously therapeutic act. Such an open display of the doctor’s emotions conveys a powerful message to the patient, namely, “I care.”

Perhaps. But DrRich thinks crying at the bedside actually conveys two powerful messages to patients:

First Message: I empathize with you. I feel your pain.

Second Message: Your medical condition is so unbelievably dire that not even I can face it with any amount of composure. You, my friend, are well and truly screwed. I cannot imagine the agony you’re in for, without falling apart myself.  May God help you.

It is the conveyance of this latter message that, in the opinion of DrRich, ought to make most doctors on most occasions relatively circumspect about crying in front of their patients.

It is also this latter message that offers to make crying doctors a convenient tool for covert rationing.

When the doctor is reduced to tears (thus graphically demonstrating to the patient that the game’s about up; that there’s pretty much nothing, really, that’s going to change this bleak outcome; and how very sad it all is) – well! Talk about reducing your patient’s expectations!

A chief tenet of covert rationing is that patients who can be made to expect little will be satisfied with little. In most cases this is accomplished by simply coercing doctors to withhold from their patients all of their medical options. But if they can be encouraged to cry when delivering bad news, doctors can destroy patients’ expectations in a much more definitive fashion.

Furthermore, the traditional role of the doctor when a patient’s outlook is poor is to take charge of a very bad situation, and with great empathy, patience and fortitude attempt to guide the patient through that situation with as much skill and courage as possible, even if the final destination looks very bleak. If the doctor instead becomes just one more of the people who gather about the bedside crying about it, then the patient immediately perceives themselves to be abandoned and alone, placed into a position irremediably desolate, with no sense of direction, and no sense of control over their own destiny. Patients fighting illness from such a position do more than merely lose their expectations; they will also die much sooner and in greater despair than necessary.

So obviously, our modern healthcare system under Obamacare will see immediate advantages to encouraging emotional outbursts on the part of doctors. In the name of advancing empathetic physicians and fixing a broken doctor-patient relationship, we could, more easily and more often, get those folks who are in the infamous last six months of life to simply stop striving for a medical miracle – or even for non-miraculous but expensive therapies that actually exist, and that (alas!) might actually extend their survival – and thus effect the sick patient’s demise more quickly and more economically.

Certainly, now that medical schools are teaching forms of alternative medicine that in former years would have made real doctors blush, for courses on the doctor-patient relationship to encourage young doctors to let their emotions free is a good and natural fit.

Young doctors should not be taken in by such ploys. They should empathize with their patients, but remain strong, and lead their patients gently and resolutely through their medical ordeals. They should try to avoid allowing a free display of their emotions to break their patient’s spirit. Their job, instead, is to use their expertise to fortify their patient’s spirit, even in the worst of times. And above all they should not allow themselves to become the trained tools of an ultimately cynical healthcare system, that uses every ploy at its disposal to covertly ration medical care.

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.

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.

In an article appearing last week in the American Heart Journal, investigators concluded that if American doctors would prescribe for their patients with heart failure each of the six therapies which are most strongly recommended in current heart failure guidelines, 68,000 lives per year could be saved.

The following (for the interest of the reader, and for the convenience of any attorneys who may follow DrRich’s offerings), is an ordered list of these six proven, life-saving heart failure therapies, along with the number of American lives that could be saved each year if only American doctors would stop grossly under-utilizing them in violation of published guidelines:

• aldosterone antagonist therapy – 21,407 lives
• beta blockers – 12,922 lives
• implantable defibrillators (ICDs) – 12,179 lives
• cardiac resynchronization therapy (CRT) – 8317 lives
• hydralazine plus isosorbide – 6655 lives
• ACE inhibitors or angiotensin receptor blockers (ARBs) – 6516 lives

The authors, of course, are careful to point out that their analysis is based on statistical methods, and thus must be counted as merely estimates of the magnitude of the benefit that would actually occur should American doctors suddenly begin managing their heart failure patients appropriately. (Their presentation of these estimates to five significant figures implies a level of precision far in excess of what can be justified, and therefore must be an oversight not only by the authors, but also by the reviewers and the editors. But still, one gets the idea. A lot of preventable deaths are being left on the table.)

Several studies have reported, over and over again, that fewer than half of American patients with heart failure are receiving all the treatments available to them that have been shown to reduce symptoms and/or prolong life. Indeed, DrRich, on his patient-oriented heart disease website at About.com, has long urged patients with heart failure to familiarize themselves with all the recommended therapies for their condition, so that when they are with their doctors at least somebody in the room will bring it up.

(Such advice, DrRich reminds his readers – all of whom are likely to be patients one day – ought to be considered generalizable for all American patients with all medical conditions, in an era when doctors are being coerced to ration healthcare at the bedside by omitting mention of sundry available medical services.)

But DrRich’s purpose here is not to address those unfortunate heart failure patients whose lives are being jeopardized by their physicians’ acts of omission. but rather, is to strategize with his colleagues who treat heart failure patients as to how they should respond to this embarrassing revelation that by failing to follow published guidelines, they are killing so very many patients.

After all, only a few months ago, when another research study showed that 23% of ICDs were being implanted outside of published guidelines (even though the large majority of those “inappropriate” implants turned out to be actually indicated, but were performed within a 40-day waiting period that the guidelines specified), not only was this violation played up on the evening news and splashed across newspaper headlines, but also the Department of Justice immediately launched an investigation to determine whether it could bring criminal charges against implanting physicians. That is, failing to follow recommended guidelines to the letter is now not merely suboptimal medical practice, but also criminal behavior.

And how much worse than implanting indicated ICDs a few days earlier than the government would prefer, is behavior that causes the unnecessary deaths of 68,000 people a year? It seems to DrRich to be quite a bit worse.

So should American doctors who treat patients with heart failure be feeding their Swiss bank accounts, changing their identities, and stocking their lean-tos in the Montana backcountry?

DrRich brings good tidings – there is no need for you to overreact. The Feds cannot possibly prosecute all deviations from all clinical guidelines. Not only would that be unfeasible, it would also be counterproductive. And deviations from the heart failure guidelines are just the kind of deviations from which the Feds are inclined to look the other way.

We must remember that the primary directive of the American healthcare system, whether it is run by insurance companies or the government, is to ration healthcare covertly. Covert rationing means withholding whatever medical services you can, from whatever patients you can, whenever you think you can get away with it. If one remembers this simple rule, one can accurately predict the response of the health insurance companies or the government to any particular guideline violation.

So: When doctors implant expensive ICDs outside of the guidelines, even when the deviation is to place an indicated ICD a few days earlier than specified, it is a potentially criminal offense. Those ICDs cost a lot of money, and worse, prevent inexpensive sudden deaths, so it is clear that steps need to be taken to prevent their usage. Enforcing the guidelines to the letter therefore is imperative.

On the other hand, when deviations of guidelines result in NOT spending money (say, on drugs, ICDs, and CRT devices), those deviations will  be viewed quite differently. And when those same guideline deviations result in the premature deaths of tens of thousands of patients with chronic and expensive medical conditions (and who, had they survived for another five or 10 years, would have consumed lots and lots of extra healthcare dollars and, in most cases, Social Security payments), the last thing you would want to do is to engage in guideline-enforcement activities.

If you doubt DrRich on this point, ask yourself whether you’ve been treated to news stories over the past 10 days on how American doctors are killing 68,000 people each year by failing to follow guidelines. That story, it seems to DrRich, would be much sexier than the one that made a splash in January about ICDs being implanted too early. Yet we’ve heard next to nothing about it. These are not the kinds of guidelines violations we need to put a stop to. These guidelines violations do not fit the narrative.

Also, consider the editorial that accompanied the article in the American Heart Journal last week. It constitutes a strong apologist argument for violating the heart failure guidelines. It points out, rightly, that perhaps there were good reasons that some patients with heart failure do not receive all six of the recommended therapies, and that not all guidelines are applicable to all patients. It also points out that the number 68,000 was estimated by compounding several assumptions together, which would place large error bars around that estimate. So perhaps the guidelines deviations were not as lethal as the authors estimated. But most striking of all, the editorialist argues that it would just be too expensive to follow the guidelines for all patients with heart failure.  If ICDs were used in all patients for whom the guidelines say they should be used, for instance, this alone “would divert most of the money anticipated for all heart-failure care next year to these devices.”

The editorial is correct, and it is honest. It, at least, openly acknowledges that doctors are obligated to ration healthcare, based on costs, at the bedside, and that following these guidelines would violate the imperative to ration. Current guidelines on heart failure would cost a lot of money up front, and would result in the prolonged survival of a lot of very expensive Americans. And therefore, doctors will not be held accountable for failing to follow them.

American doctors can continue deviating from the heart failure guidelines, secure in the knowledge that their activity (or inactivity) will not capture unwanted attention from the Feds. These are not the guidelines our leaders are talking about when they assure the population that they are going to make sure that doctors are doing all the things the experts specify they should be doing.

These are those other kinds of guidelines.

If you are an American patient with any kind of medical problem whatsoever, DrRich begs you to become an expert in your medical condition. The patients with heart failure who are doing so, and who are prepared to challenge their doctors on their treatment, are among the minority who are receiving all the therapies proven to prolong their survival.

In the epic debate that has played out recently between Shadowfax and DrRich over the transcendent implications of the IPAB (Independent Payment Advisory Board), Shadowfax accused DrRich of being one of those unsophisticates who refer to the IPAB  as a “death panel.”

Nothing could be further from the truth. DrRich does not use – has never used – the term “death panel” to refer to any of the multitude of expert commissions created by Obamacare, whose charge will be to dispassionately examine the scientific evidence in order to determine which patients will get what, when and how. These bodies, in fact, will be explicitly aiming to optimize the medical outcomes of the entire population (titrated to the amount of money we’re allowed to spend on healthcare), and not actively prescribing death for anyone.

Judging from the histories of governments which have adopted a collectivist philosophy, if death panels should appear on the scene they will not be aimed at determining which patients may live or die. That job, of course, will fall to the doctors at the bedside, who will offer or withhold medical services according to the dictates (i.e., “guidelines”) handed down by those sundry expert commissions. Rather, any death panels which eventually materialize will more likely be aimed at keeping those doctors themselves (and any other functionaries whose job is to do the bidding of the bureaucracy) in thrall.

So why has the term “death panel” caught on to such an extent that conservatives so often use it as shorthand to express what they see as the “sense” of Obamacare, and Progressives so often use it to accuse rational and mild-mannered critics of Obamacare (such as DrRich) of belonging to the Neanderthal persuasion?

While most would blame Sarah Palin for coming up with this unhelpful phraseology, it is DrRich’s view that President Obama himself must carry at least an equal part of the blame. If Progressives have not created death panels, they at least created the environment in which those words, when Ms. Palin first uttered them, immediately caught fire.

As readers will recall, Ms. Palin first used the fateful words, “death panels” as the Obamacare legislation was being slowly and painfully shoved through a surprisingly reluctant Democrat Congress. And as a result she caused many of our more complacent legislators to abruptly bestir themselves into a higher state of arousal, if not outright agitation. Palin’s accusation caught more than a few of them utterly unawares, and embarrassingly flatfooted.

They felt, no doubt, like they were in that dream where you unaccountably find yourself naked in a crowd. But this time, rather than reaching to hide their sadly exposed nether parts, they reached instead for their pristine copies of the monstrous Obamacare legislation which had been laid before them, and which they famously (and understandably and logically) never read. One could almost pity them, desperately rifling through the 2700 virgin pages, muttering to themselves, “Death panels? This damned thing has death panels?”

But in fact, their initial instincts were correct as regarded the advisability of actually reading the legislation. There was in truth no reason for them to waste their time. DrRich has subsequently read large swatches of the thing, and he can assure one and all that it was not designed for reading, comprehensibility, or (for that matter) imparting any actual information of any sort.

And besides, Obamacare contained no death panels, so had they read the bill they would not have discovered any. (In their state of sudden and stark panic, however, our newly-aroused legislators quickly moved to strike the section the bill that provided for end-of-life counseling, which, of course, had nothing to do with death panels.)

The very notion of death panels seems to have many supporters of Obamacare nonplussed. How can someone as inarticulate and obviously illiterate as Sarah Palin get away with accusing our highly-educated healthcare reformers of setting up such a thing as death panels?  And even more perplexingly why did so many Americans believe her – even, apparently, hundreds of thousands of Americans who had been enlightened enough to vote for President Obama less than a year earlier?

DrRich thinks it is this: When Sarah Palin said, “death panels,” she was dropping one last, tiny crystal into a supersaturated solution. Her words took what had been an amorphous and even chaotic sense of unease about healthcare reform, and immediately crystallized it into an organized latticework of directed rage and fear. So the real question is not how Sarah Palin came to be savvy enough to know just the right words. (Progressives know that even a distinguished panel of monkeys, given enough time and enough typewriters, will eventually produce King Lear.) Rather, the real question is: What put the rabble in such a supersaturated state to begin with? Why did the absurd-on-its-face idea of “death panels” so resonate with them? What made those words galvanize their shapeless disquiet into a solid mass of resistance?

DrRich is very sorry to have to tell his friends of the Progressive persuasion the sad truth. For it was President Obama himself who created this circumstance. Sarah Palin may have first named the death panels, but before she ever thought of the phrase the President had already described them in detail.

During his first year in office, President Obama offered several homilies relating just what a “death panel” would look like. He described their function, how they would operate, and who they would target. Perhaps the most instructive example is the one he gave on ABC television during his June 24, 2009 National Town Hall meeting.

DrRich refers, of course, to the famous question put to him by the granddaughter of a 100-year-old woman who had received a pacemaker. The questioner pointed out that her grandmother had badly needed this pacemaker, but had been turned down by a doctor because of her age. A second doctor, noting the patient’s alertness, zest for life, and generally youthful “spirit,” went ahead and inserted the pacemaker despite her advanced age. Her symptoms resolved, and Grandma was still doing quite well 5 years later. The question for the President was: Under Obamacare, will an elderly person’s general state of health, and her “spirit,” be taken into account when making medical decisions – or will these decisions be made according to age only?

President Obama’s answer was clear. It is really not feasible, he indicated, to take “spirit” into account. We are going to make medical decisions based on objective evidence, and not subjective impressions. If the evidence shows that some form of treatment “is not necessarily going to improve care, then at least we can let the doctors know that – you know what? – maybe this isn’t going to help; maybe you’re better off not having the surgery, but taking the pain pill.”

DrRich will give President Obama the benefit of the doubt regarding his suggestion that a 100-year-old women who needs a pacemaker might be better off with a pain pill. Mr. Obama is not actually a doctor, and cannot be expected to understand that using a “pain pill” to treat an elderly woman who is lightheaded, dizzy, weak and possibly syncopal because of a slow heart rate might justifiably be considered a form of euthanasia rather than comfort care. DrRich does not believe the President was intentionally suggesting the old woman’s death should be actively hastened by means of a pain pill. Indeed, given that repeated falls from lightheadedness would likely have led to a hip fracture, a pain pill might eventually have been just the thing for granny had the pacemaker been withheld.

Still, President Obama’s clear and unflinching answer in this case tells us several important things. 1) Under Obamacare, there will be at least one panel, or commission, or body of some sort, that is going to examine the medical evidence on how effective a certain treatment is likely to be in a certain population of patients. 2) This, let’s call it a “panel,” will “let the doctors know” whether that treatment ought to be used in those patients. (“Letting the doctor know” is a euphemism for “guidelines,” which itself is a euphemism for legally-binding and ruthlessly enforced directives.) 3) “Subjective” measures ought not to influence these treatment recommendations. Non-objective parameters – such as the doctor’s medical experience, intuition, or personal knowledge of the patient; or the patient’s “spirit,” or will to live, or likelihood of tolerating and complying with with the proposed proposed treatment; or even extenuating circumstances that might increase or decrease the success of the proposed treatment – simply cannot be evaluated or controlled by expert panels, and thus must be discounted. 4) But since our government is a compassionate and caring one, and wishes to reduce unnecessary suffering, palliative care will be made available in the form of pain control, even while withholding potentially curative care.

What the American public accurately heard the President say was that we will have an omnipotent “panel,” acting at a distance and without any specific knowledge of particular cases, that will tell a doctor whether he/she can offer a particular therapy to a particular patient – or whether, instead, to offer a “pain pill.”  His description of this process, repeated with variations over the next several months in several venues, obviously made quite an impact on the people.  Of course, Mr. Obama is widely known to be a gifted communicator.

In any case, all that remained was for Sarah Palin to give the President’s panel a catchy name. And when she did, the American people knew exactly what she was talking about. They knew, because President Obama himself had been spelling it all out for them in plenty of detail for six months.

Indeed, it seems to DrRich that, if not for President Obama’s having so carefully laid the groundwork,  Palin’s accusations of “death panels” would have fallen flat. It would have been regarded by most people as the absurdity that Progressives insist that it is, rather than the epiphany it turned out to be.

Progressives who strenuously object to its usage in reference to the expert commissions created by Obamcare can blame Sarah (or, for that matter, DrRich) if they want to – but by all rights they should actually be taking up the matter with their dear leader, who is the chief source of the misapprehension, if misapprehension there be.

In his last post, DrRich analyzed whether the young Wisconsin doctors who stood out on street corners proudly offering fake “sick excuses” to protesting teachers were engaging in an act of civil disobedience. DrRich respectfully kept an open mind on this question, but after careful deliberation concluded that it is very unlikely that their actions constituted classic civil disobedience as espoused by Thoreau or Gandhi.

Instead, these doctors were, in a professional capacity, lying. They did not lie in any truly malicious way, however. They lied because they have been trained to believe in a higher cause than mere professional ethics, namely, the cause of social justice. They lied in full confidence that telling lies to advance such a noble cause is a natural duty of the medical profession. They never expected to be criticized for it (except perhaps by Rush Limbaugh and sundry teabaggers and the like), and they almost certainly will be stunned into indignant incoherence if they end up actually receiving the full punishments their actions allow.

But what really interests DrRich is the near-perfect silence we have seen from the mainstream news media regarding this sad episode. While it’s easy to find stories about the phony sick excuses all over Fox News and conservative websites, major outlets like the New York Times, Washington Post, CNN, CBS and NBC – sources one might expect to express at least some sympathy for these doctors and their work to advance a just cause – have reported next to nothing about it. When a left-leaning mainstream outlet does report on the episode (for instance, this article appearing in the Atlantic), rather than expressing any support for the Wisconsin doctors, they express at least mild dismay. It seems plain to DrRich that the mainstream media wish the whole thing hadn’t happened, and that perhaps their silence might help it go away as soon as possible.

So here we’ve got a small cadre of youthful and idealistic physicians, behaving in a manner entirely consistent with what they’ve just learned during their medical training, and not only are they facing formal investigations and potential punishment, but also the very people and organizations whom they were surely counting on for support have retreated into an embarrassed silence, or worse, criticism.

What gives?

What gives, DrRich thinks, is the great discomfort being experienced by left-leaning people and organizations by such a blatant, public display of the New Medical Ethics and its ultimate implications. That is, while they don’t actually object to the fact that the doctors were committing professional fraud for the advancement of what passes for social justice, they wish they hadn’t done it out in the open.  Calling attention to the fact that doctors will lie so readily might cause folks to want to take a closer look.

And since lying doctors are part of the plan, such scrutiny might turn out to be inconvenient. You see, Dear Reader, whether the payer is a private insurance company or the Feds, a principle mechanism of healthcare cost-cutting is to coerce the doctors to ration healthcare at the bedside. As a result, many more times per day than one would care to think, doctors are being placed into the unfortunate position of deciding, not whether to lie, but to whom to lie. Do they lie to the insurance companies and Medicare (in order to give one of their patients a needed medical service which, according to insurance company rules or government “guidelines,” they may not have)? Or instead, do they lie to the patient (usually committing a lie of omission, in which they fail to tell patients about some needed and available but forbidden medical service)?

The answer is – both. DrRich, as usual, backs up his outlandish generalizations with data:

Item 1: In a survey conducted by the American Medical Association’s Institute for Ethics, published in the April 12, 2000, issue of the Journal of the American Medical Association, 39% of American doctors admitted that they sometimes or very often manipulated reports to their patients’ health plans so their patients might gain coverage for needed medical care. These manipulations included exaggerating the severity of the patients’ condition, changing the billing diagnosis, or reporting symptoms the patient did not have. And 72% admitted using one of these tactics at least once in the past year. More than a quarter said that gaming the system was necessary in order to provide high quality care to their patients, and 15% asserted that it was ethical.

This survey elicited a deluge of criticism against the cheating doctors. Ethicists called for doctors to stop applying “insular” ethical norms and to begin using the norms that professional ethicists have long established against lying to health plans (which are busily engaged in covert rationing). Similarly, the AMA and the American College of Physicians have published strongly worded statements opposing the manipulation of reimbursement rules. And the federal government has made such “misstatements” to health plans a federal crime, punishable by huge fines, jail terms, and loss of license.

That doctors continue to do this anyway, DrRich has heard some physicians express, reflects that many physicians consider lying to a health plan to be a sin on par with the sin of lying to the SS when they knock on the door to ask if you are hiding a family of Jews in the attic.

Item 2: Another survey, published in the July/August, 2003, issue of Health Affairs, reported that nearly 33% of American doctors admit that they routinely withhold from their patients pertinent information about optimal medical treatments, because they suspect the patients’ health plans won’t cover those treatments. In response to this survey, the American Association of Health Plans, the group representing the very organizations that were pulling out all the stops to make sure that doctors do exactly what this study confirms they are doing, expressed shock at these results, and told the AMA News at the time that AAHP officials “actually find it difficult to believe that that’s going on.” (They found it difficult, no doubt, because they observed just how rapidly spending was still accelerating.) Meanwhile, the authors of the study could only conclude (with seeming surprise) that doctors are “rationing by omission” on their own volition.

These two surveys reveal some of the confusion and frustration being felt by doctors as a result of coercion to withhold medical services, and the guidance they’re getting from their professional organizations as to what to do about those rules. How are they to square those rules and that guidance with their time-honored obligation to always do what’s best for their patients?

So what’s a doctor to do when a patient needs a treatment but they know the health plan won’t pay for it? There are only three choices:

1) Tell the health plan whatever you must in order to get the needed treatment for the patient.
2) Don’t tell the patient about the treatment since they can’t have it anyway.
3) Tell the patient about the treatment they need, and then tell them they can’t have it.

The most truthful thing would be to choose Door Number 3. After all, a patient has a right to know what medical treatment he needs, whether or not he’s allowed to have it. Informing a patient that his insurance won’t pay for the needed treatment gives him useful information. It lets him know that his health plan is not adequate to his needs and gives him an opportunity to respond appropriately to that information. For instance, a patient might appeal to the health plan directly, seek intervention by his local Congressperson, or ask his employer (who is the health plan’s true customer), to intervene on his behalf. He can even raise the funds to pay for the therapy himself (and if he is not a Medicare patient perhaps it will be legal for him to purchase it).

What patients actually do when doctors choose Door Number 3, however, is to beg, demand, threaten, implore, and plead for the doctor to do something to fix things, since after all, it is the doctor who started the problem in the first place by insisting that this forbidden therapy is the only one that will do. So, the moment doctors choose Door 3, they are placed under incredible pressure to go back and choose again – Door Number 1, their patients are communicating to them, is actually the correct choice. This, plus wanting to avoid all the anguish and drama that follows telling the truth, leads doctors who are inclined to lie to health plans (and thus risk angering the entities that determine their ability to make a living, not to mention committing a federal crime), to choose Door Number 1 in the first place. If doctors are not inclined to risk their livelihoods and freedom by deceiving health plans, they will probably simply default to Door Number 2 – rationing by omission.

The above two items reflect the proportion of doctors willing to admit in a survey which group they routinely lie to – health plans or patients. Most of the other doctors, one suspects, would just rather not say.

Item 3: In 2000, the AMA filed an amicus brief with the Illinois Supreme Court on behalf of a Dr. Portes, asserting that doctors have no duty to inform their patients when health plans have given them financial incentives to withhold medical care. Apparently a patient of Dr. Portes died of a heart attack shortly after the doctor allegedly refused to refer him to a cardiologist. As it turned out, the patient’s health plan apparently had agreed to pay the doctor’s medical group 60% of any funds not used on referrals to specialists. A lower court in Illinois had found that Portes had a duty to disclose this financial relationship to patients, since it might clearly impact their interpretation of his medical recommendations, and Portes appealed. In this appeal, the AMA sided with the doctor.

The AMA said in its amicus brief that the obligation imposed on doctors by the lower court amounted to an “insurmountable burden,” since it was hard for doctors to keep track of all the sundry ways that health plans might induce them to behave in this way or that way, and besides, the need to disclose would impinge on the doctor’s valuable time with the patient and therefore disrupt the doctor-patient relationship. Interestingly, the AMA’s own Council on Ethical and Judicial Affairs (CEJA) had previously written that, “physicians must assure disclosure of any financial inducements that may tend to limit the diagnostic and therapeutic alternatives that are offered to patients….” In explaining why its amicus brief differed from the opinion of its own Ethics Council, the AMA explained that its CEJA standard was just an ethical one and not a legal one.

So what we have here is: a) A health plan induces doctors to withhold medical care; b) a doctor acts on that inducement; c) as a result, predictable harm comes to a patient; d) after which, the doctor and the AMA declare that he shouldn’t have to inform patients of all relevant information because; e) to do so would harm the doctor-patient relationship.

This is all just too precious for words.

One can easily see how very confusing it has become for doctors to decide just when they must lie, and whom they must lie to.

Obviously, doctors are now in a position where, just to get by, it behooves them to lie repeatedly to either patients, or to insurers, or both. Their ethical obligation to always be straight with the patient has been turned on its head by the new ethical obligation to do what’s right for the collective.  In more cases than doctors – or the insurance companies and government health plans which (between them) “own” the doctors lock, stock and barrel – would like to admit, lying has become a way of life for many in the medical profession. It is not something they’re proud of (well, at least the older ones aren’t proud of it). It’s just something that is necessary for survival. Most doctors, to their credit, hate this. It’s one of the reasons so many doctors are so frustrated with their lot.

In any case, this is not a truth to which anyone would like to call the public’s attention. So for those callow youths in Wisconsin to don their white coats and go out to the street corners, in front of the cameras, to commit lie, after lie, after lie, and to do so with such obvious pride, and such obvious confidence that what they were doing was not only right but was expected of them as members of the medical profession – that indeed, they could do no less – was to call unwanted attention to what has become an unfortunate truth about our healthcare system and what it has done to our doctors.

No wonder the mainstream media largely ignored this embarrassing episode. Fortunately, the public (despite the best efforts of Fox News) still has not realized how generalized the problem is. The sooner Fox stops fulminating about it and moves on to whatever the next left-wing travesty turns out to be, the better. And perhaps no permanent harm will yet be done to the public’s perception of the truthiness of the medical profession.

Two years ago, for instance, DrRich was “invited” to testify as a witness before a federal grand jury in a matter involving one of his consulting clients. While under oath, DrRich was caused to understand that the Feds (at least certain members of the DOJ) are well aware of this blog, and of the general tenor of its content. The impression left by this experience makes DrRich doubt whether many of his fans come from that particular precinct.

Further, the CRB has been the victim of two targeted denial-of-service attacks just in the last several months. Perhaps this is a common experience for healthcare bloggers, but then again, perhaps not. Finally, there’s the fact that last May (some readers may recall) a nasty hacking exploit completely trashed the CRB at the server level, resulting in the loss of the first three years of DrRich’s endeavors here (which, some have said, is the greatest tragedy to befall posterity since the burning of the Library at Alexandria).

And so, Dear Reader, while DrRich is certainly happy to be hosting Grand Rounds for the fourth time, and is particularly delighted with the quality of postings which he has the honor of featuring this week, it occurs to him that hosting an event with such high (and well-deserved) visibility might draw certain “extra attention” here.  So perhaps you had better read this quickly.

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We begin with HealthAGEnda, the John A. Hartford Foundation blog, which is posting a remarkable series of articles by Amy Berman, a senior program officer at that foundation, who has recently been diagnosed with an incurable form of breast cancer. Ms. Berman discusses very openly and frankly both the good and the bad aspects of the American healthcare system she is encountering  as she deals with this likely fatal illness. In this post, the second in a series, Ms. Berman talks about her ordeal in confirming what she already strongly suspected was a very bad diagnosis, and describes the comfort she experienced, while “meeting the enemy,” from compassionate but frank healthcare professionals. She had a much less favorable experience, which she describes in her first post, demonstrating just how devastating it can be for a patient to encounter a one-size-fits all physician. The impact such an encounter has on a patient who needs real medical help is especially relevant in an era in which doctors are being urged (coerced) into following just such an approach. Ms. Berman is an extremely brave and gracious woman, and the important insights she is providing in her efforts to chronicle her illness ought to be read by every health professional.

Henry Stern of Insureblog discusses the documented, systematic mistreatment of the elderly under the British National Health Service. Stern points out that while similar mistreatment of the elderly also happens in the American healthcare system, here it is sometimes not systematic, but rather is most often due to sloppiness or inadvertent error, and further, when it happens remedial actions (such as lawsuits) are often available. In contrast (evidence suggests), treating the elderly badly in the NHS seems to have become virtual policy. DrRich, of course, longtime president and sole member of Future Old Farts of America (FOFA), is confident that nothing of the sort will ever happen here in the U.S. where the government always has our best interests in mind, and he is sure that when government officials refer to the NHS as an ideal to which we should all aspire, they are probably not talking about this part of it.

Writing on a related topic, Julie Rosen of Bedside Manner tells about steps doctors and families can take to resolve disagreements on how aggressive one ought to be when deciding on the use of certain treatments for elderly and mentally incapacitated patients. DrRich finds Ms. Rosen’s recommendations appropriate, since all of them take place at the local level, with full participation of the patient’s loved ones, and do not (explicitly, at least) involve the heavy hand of any Central Authority.

And still speaking of the role of authority in deciding on aggressive treatments, The ACP Internist posts a news report about a court-ordered spinal operation on a 16-year old who was injured during a wrestling competition. Neither the young man nor his parents wanted the operation, which they feared might cause paralysis.  (Apparently, they were actually paying attention during the “informed consent” process.) Further, as the mother apparently demonstrated in a video shown on local TV, her son had a “full range of motion” prior to surgery. Nonetheless, the young man was removed to protective custody, and the court-ordered surgery was performed (apparently successfully, thank goodness, or else this might have turned into a controversial decision). One hopes the judge, in making his determination that the family was not acting reasonably, was not swayed by their expressed partiality to herbal medicine and homeopathy. Wacko as such practices may be, they do not appear particularly relevant in this case, given the family’s seemingly cogent argument that the risk/benefit calculation, as it had been presented to them by medical professionals, simply did not meet their threshold for such aggressive treatment. Apparently, it met the state’s.

The ACP Hospitalist offers a post from a doctor at Grady Hospital entitled: “10 ways to know that the nurses hate you.” These 10 clues as to nurses’ disapprobation are both amusing and true. However, after observing for over 30 years the kinds of behaviors to which nurses are forced to resort when they see that things are greatly amiss, but at the same time they are powerless to directly intervene, DrRich thinks this post more accurately ought to be entitled, “10 ways to know that the nurses think you are killing your patients.” The nurses may or may not actually hate the doctor for it, but they wish he/she would stop – and here are 10 ways in which they may often express that wish.

While some states are big troublemakers (and you know who you are), others are moving to implement provisions of Obamacare just as the Central Authority has decreed. Louise from Colorado Health Insurance Insider tells us that Colorado Senate Bill 168 was introduced last week to create the nonprofit healthcare cooperative which is required by all states under Obamacare. (Shouldn’t somebody tell the Colorado state senators that writing long tracts like this in ALL CAPS is considered impolite, as it is the documentary equivalent of shouting?) Louise notes that the healthcare cooperatives mandated by Obamacare may help to reduce the number of uninsured, but adds that Obamacare “will do little to address a range of other problems, including rising healthcare costs, the unaffordability of healthcare even for people who have health insurance, over-utilization of care, and the problems created when we link health insurance to employment.” While these are all legitimate points, regular readers will know how little DrRich himself goes in for such grousing.

Obamacare, after all, does so much! As a case in point, David Harlow at HealthBlawg writes about Accountable Care Organizations, a new entity which figures prominently under Obamacare, and which will be a chief vehicle for controlling the cost and quality of healthcare (i.e., for controlling physicians’ behavior). A lot of scary things have been written about ACOs (including, truth to tell, things written here at the CRB), but Harlow points out that ACOs might not turn out to be such a bad idea after all. For evidence, he points to some of the successes realized by AQCs (Alternative Quality Contracts) in Massachusetts, under admittedly favorable practice environments, and notes that some of these successes might be translated directly to ACOs. DrRich hopes he is right. But it is a little worrisome that nobody, including Harlow (as he himself allows), really knows what ACOs will end up looking like. Their structure is, as we speak, being fought over by numerous federal agencies (like a carcass being fought over by a pack of dogs), and among these agencies (DrRich shudders to contemplate) is the Department of Justice. But Mr. Harlow knows far more about this stuff than DrRich, so let’s all hope for the best. Short of defanging Obamacare, that’s about all one can do.

Amy Tenderich of Diabetes Mine submits a guest post from Valentine’s Day, written by Wendy Strgar, entitled “Healthy Sex, Healthy Love.” Ms. Strgar, who is known in some circles (circles of which DrRich himself is innocent) as a “loveologist,” and who markets the sexual-aid products to prove it, actually makes a pretty convincing argument that sexual activity can be an important part of reducing one’s risk for all sorts of medical problems. So: Are you one of those folks who has thought about having more sex, but you’re just not sure the pay-off is worth all the trouble? Read this post.

Dr. Pullen at DrPullen.com posts about the problem of anti-personnel mines, which continue killing and maiming innocent people all over the world, and for decades after hostilities cease. He rightly thinks the US ought to do more to resolve this problem, and in particular, he decries apparently serious suggestions some have made that we ought to deploy mines on our southern border to prevent illegal crossings. DrRich agrees with Dr. Pullen, but does not believe that mining the U.S. border will ever become a serious consideration (unless it is to prevent American citizens from sneaking southward to receive black market healthcare).

Doug Perednia at The Road to Hellth is writing a fascinating series on the wonders of Pay for Performance. In this, his second offering, Perednia provides some pretty overwhelming evidence, including evidence from studies which proponents use to justify P4P, that P4P demonstrably does nothing useful. Actually, DrRich should qualify that statement: It does nothing useful in terms of improving clinical outcomes. What it does do (as Perednia demonstrates) is to forcibly distract physicians from listening to their patients, to fully consume all the time allotted for a patient visit, and to actively discourage other forms of doctor-patient interactions which might lead to additional healthcare expenditures. So despite a now-well-documented lack of any improvement in patient outcomes, P4P is in fact achieving its actual designed ends, and thus must be counted a great success.

Dr. Joe Smith, who writes the Dr. Unplugged blog (a Medscape blog which requires free registration), travels the globe seeking out emerging technologies related to wireless healthcare. In his latest article Smith laments the fact that, so far, the healthcare consumer has completely missed out on the ongoing wireless revolution, a revolution that has greatly empowered consumers in virtually every other economic sphere. He concludes that despite this slow penetration, wireless technology inevitably will also transform the lives of healthcare consumers. DrRich agrees that this outcome is indeed inevitable, but thinks it may take a while. Resistance to the empowerment of individual healthcare consumers is deeply entrenched, massively well-funded, extraordinarily powerful, amazingly ruthless, and very widely distributed (from the beltway to the bedside). Such resistance is akin to the all-pervasive power of the Church 500 years ago, a power that was eventually broken, but that required the technology (printing press), the killer app (Bibles printed in the vernacular), the catalyst (Martin Luther’s 95 theses), the poorly-expressed but ultimately deep-seated desire of the populace for the knowledge being offered, and the fortitude to persevere through 300 years of reformational bloodshed. So, yes, history ultimately will win out with regard to wireless healthcare, but one fears it may take more than just the healthcare equivalent of the iPod or Facebook to see it happen.

The anonymous author of The Notwithstanding Blog is a Canadian medical student with a background in economics. In the short time this blog has been around, he (or she) has done some very cogent writing applying economic insights to medicine. The featured post describes why medical ethicists (despite their constant yammering about honoring the autonomy of the individual) almost always decide specific ethical questions the other way, that is, against individual autonomy. DrRich, in his ham-fisted style of analysis, always tends to blame this phenomenon on the fact that Progressives in recent decades have largely taken over the Ethicists’ house, just as they have taken over in most academic fields, and that Progressives as part of their DNA must always come down on the side of the collective. But Dr. Notwithstanding offers what is likely a better explanation, based on economics (the science of human behavior) instead of on political ideology. As you’ll see, in addition to being an original thinker Dr. N is an engaging writer. You should give this blog a try.

In stark contrast to Notwithstanding’s anonymous blog is Carolyn Roy-Bornstein‘s eponymous one. Here she describes one of the absurdities doctors see every day with the modern-day electronic medical records which are being adopted all over the place, with great fanfare (and with public subsidies), to streamline healthcare, reduce redundancy, eliminate waste, and assure quality care. Namely, while these new electronic records may greatly simplify the lives of the federal regulators and the forensic accountants who keep track of which doctors are being naughty and which are being nice, they often gum up the works for the people on the ground who are actually trying to take care of sick people. EMRs can do this in many ways, and Dr. R-B nicely describes one of them: She laments the reams of redundant, boilerplate, tree-killing verbiage these records spit out, each and every day, for each and every patient, a characteristic which makes the formerly simple task of figuring out how the patient’s doing today a constant challenge, a perpetual exercise in patience and persistence. and a powerful attractor for medical errors. She ends by speculating whether it might make things easier to have somebody sing these records to her. A nice thought, but DrRich thinks it would not help. What you’d get is an early Phillip Glass composition, in which the same nonsense phrases are repeated over, and over, and over, and over. . .

The Happy Hospitalist discovers that latex examination gloves (powdered, one-size-fits-all, Spic and Span brand), are available at 10 for one dollar at the local dollar store. His discovery suggests a couple of things. As Happy points out, hospitals which are expected to survive on Medicaid payments now have someplace to shop. And, if you want to bring down the cost of healthcare products and services, simply make them available for direct purchase by consumers.

Carolyn Thomas of Heart Sisters writes of journalist Melissa Mia Hall who died in her Texas home in January after avoiding medical help for her severe and persistent chest pain (regarding which she wrote a running commentary to friends – and ultimately to posterity – via e-mail). Ms. Thomas concludes that had Ms. Hall had health insurance (which she did not), she likely would have done more than just document the progression of her fatal heart attack. DrRich has no personal knowledge of Ms. Hall, and so cannot contradict this conclusion, nor does he wish to. However, a recent survey by the American Heart Association showed that in 2009, only 50% of women (regardless of insurance status) said they would call 911 if they thought they might be having a heart attack. DrRich, who has long lamented the feminization of men in our society, now utters his dismay at the converse – the masculinization of women. Ladies, if you have symptoms suggestive of a heart attack, don’t try to tough it out. Call 911.

Steven Wilkins of The Mind Gap tells how sessions of culturally-sensitive “storytelling” can break down certain cognitive barriers for some patients, and more fully engage them in their medical treatment. Wisely, Wilkins is not suggesting that beleaguered PCPs develop a stable of appropriate yarns they can spin for their recalcitrant patients during the 7.5 minutes the Central Authority has allotted for each “patient encounter.” Rather, he has several helpful suggestions for incorporating such storytelling into existing systems, which would leave the doctors alone to do what they’re paid for – making little electronic chits on Pay for Performance checklists.

Vineet Arora at FutureDocs talks about the universally-recognized phenomenon of the over-ordering of radiological diagnostic tests, which is detrimental both to patients’ health and to the healthcare budget. She discusses the many reasons too many of these tests are ordered. It boils down to the fact that the healthcare system provides physicians with extraordinarily strong incentives, at many levels, NOT to rely on their clinical judgment, but instead, in order to optimize their odds of professional survival, to just go ahead and get the test. Unfortunately the solutions Dr. Arora suggests to this difficult problem do not hinge on restoring the doctor’s clinical judgment as a legitimate decision-making tool. (This is no fault of hers; to restore respect for the doctor’s clinical judgment would require a wholesale change in how the healthcare system now operates.)  Instead, she suggests counterbalancing the strong coercions doctors feel to order too many of these tests, with new, and equally strong, coercions not to. Laboratory rats faced with similar, unresolvable imperatives to respond to two opposite stimuli, of course, quickly die of the stress.

Dinah from Shrink Rap notes that the FDA is about to take an action that may effectively render electroconvulsive therapy (ECT) a thing of the past. Specifically, the FDA is likely to reclassify ECT machines (which have been in clinical use since long before the FDA controlled such things) as Class II medical devices. If so, then for these devices to remain on the market, the two companies that manufacture them would have to conduct expensive new clinical trials to document safety and efficacy within 30 months. Observers judge that these companies would not have the resources to do so. ECT is a highly controversial procedure, and there are vocal groups which are trying to ban it – but for some patients with severe depression, Dinah points out, ECT has been a very effective and potentially life-saving last resort therapy. These unfortunate patients, apparently, can now join all the others whose response to various treatments resides in the tail of the standard distribution curve, and for whom the tailored, individualized therapy they require will no longer be an option.  So they will just have to make do with the guideline-driven treatments that suit the average patient just fine. Nonetheless DrRich predicts this change can be implemented with minimal outcry, since severe depressives, being often imbued with great inanition, likely won’t complain very vociferously about it.

Speaking of shrinks, Philip Hickey of the Behaviorism and Mental Health Blog writes about his observations regarding how and why “mental illness” has become such a growth industry. He says, “’Mental illness’ is a spurious explanatory concept whose purpose is to medicalize for profit the ordinary problems of human existence which our ancestors tackled and resolved without drugs for thousands of years.” While DrRich might not buy his entire thesis, there is much more truth in what Hickey says than one would like to think.  Among other things, when healthcare becomes a right, then the more struggles of the normal human experience we decide to turn into a medical diagnosis, the more it becomes society’s obligation to alleviate those normal struggles. There is a natural endpoint to this process of over-medicalization, of course, but it is not pleasant to contemplate.

Dr. Wes speculates on what is really different about the new pacemaker leads which recently have been declared officially MRI-safe by the FDA. Wes suggests that much of the extraordinarily expensive and time-consuming effort that was made in obtaining the “MRI-safe” label had more to do with the incredible regulatory maze that had to be navigated, than with any actual engineering changes. DrRich, who a few years ago was peripherally involved as a consultant in a similar effort (with a different company), declares Dr.Wes’ speculation to be likely pretty accurate. But fear not, for Medicare will be reimbursing the manufacturer for its regulatory ordeal for many years to come.

The venerable DB of DB’s Medical Rants offers a timely rant about how those who create the clinical guidelines which dictate the practice of modern medicine often do so inadvisedly, and sometimes with their own (possibly cryptic) agenda in mind, and as a result of such guidelines, patients may die. DrRich himself has covered this same topic lately. DB’s commentary hits the mark.

Paul S. Auerbach of the Medicine for the Outdoors Blog provides this post on cholera vaccines. It turns out that cholera vaccination is a little less than straightforward, and given the relatively small amount of vaccine available worldwide, would not be suitable for wide-scale use. So as far as cholera prevention goes, pray for sanitation.

Rich Elmore and Paul Tuten at HealthcareTechnologyNews write the wonderful news that the Direct Project has launched. The Direct Project, they tell us, is an implementation of a secure, health-related e-mail standard designed to “allow health practitioners to securely exchange health data, medical records digitized to be easily shared between doctor’s offices, hospitals, benefit providers, government agencies and other health organizations, all across America.” This sounds like a pretty good idea, except perhaps for the “government agencies” part, since, for many of us, these are the very folks we’d least want looking at our most private personal information. As for the patients themselves, it is not clear whether they also will have ready access to all this extremely secure information about their own health, or whether instead they will have to wait until the information finally shows up on Wikileaks.

February 24 – DrRich has been petitioned by the authors to issue a correction for this last item. In order to do complete justice to them, DrRich reproduces their suggested correction in its entirety:

“The Direct Project encrypts the information being transmitted.  No one other than the intended received can get the information.  There is nothing stored using the Direct Project technologies – it serves only as a transport mechanism to enable, for example, a provider to securely send information to a consulting physician.  The goal is to replace the pervasive fax machine with something more secure, more modern and able to be used by healthcare stakeholders with the most basic technology (internet access and a PC) up to the most sophisticated user of an electronic health record.”

DrRich thanks the authors for correcting any misapprehensions he may have inadvertently introduced.  To be clear, when the Feds get your personal health information, and when you have difficulty obtaining it yourself, that will not be the fault of Direct Project, whose purpose is merely to assure that the data gets sent only to the person/agency which is targeted to receive it, and no one else.  DrRich leaves it as an exercise for his readers to determine whether his original commentary may still offer any value.

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Thanks for speed-reading Medical Grand Rounds this week.

Next week Grand Rounds will be hosted by The Examining Room of Dr. Charles.

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This is the third in a series of articles on End-of-Life Care and Covert Rationing.  The first two articles can be found here and here.
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In his previous post, DrRich attempted to satirize the lame attempts of certain payers to “inform” certain of their “covered lives” that, among all the wonderful options available to them under their truly comprehensive health plans, the medical service of physician-assisted suicide would be compassionately offered and cheerfully paid for. DrRich even offered, thoughtfully as usual, some free though invaluable advice to payers on how they ought to go about marketing assisted suicide as a cost-saving strategy, and to do so in a far more sensitive and less ham-fisted way than they have managed so far.

If the mark of good satire is that at least some readers will have difficulty discerning whether the satirist is serious or not, then DrRich is feeling genuinely Jonathan Swiftian today.  For some of his readers (one of whom e-mailed, “I can’t believe what I just read. This is sick.”) have taken his modest proposal for selling assisted suicide at face value.  This is not the first time DrRich has made unfortunate impressions upon readers through his (possibly inept) use of irony. Sadly, it almost certainly will not be the last.

But assisted suicide being such an important and ethically charged topic, DrRich feels obligated to clear things up once and for all. So what follows is DrRich’s honest assessment of the advisability of physician-assisted suicide, in which he will attempt to forgo entirely any satire or irony (though he admits to having great difficulty in controlling his sarcasm).

DrRich believes that physician-assisted suicide is a very, very bad idea.  He has two major reasons for this belief.  On a purely practical realm, embracing and systematizing physician-assisted suicide under any healthcare system that is actively engaged in rationing (whether overtly or covertly) will almost surely lead to some terrible abuses of the practice. In this regard you can either use your imagination, or read the history of Europe in the first half of the 20th century.

His second objection to physician-assisted suicide is based on a consideration of ethics. DrRich admits to being on shaky ground here because: a) he is not formally trained in ethics, and b) it appears for all the world that those who are formally trained in ethics have universally concluded that physician-assisted suicide is perfectly OK in every way.

Debating with modern medical ethicists, at least if you are merely a layperson, is mostly a losing proposition.  This is not because ethicists are intellectually (or even ethically) superior, but rather because they are adept in couching their arguments in arcane twists of logic and webs of jargon that make their arguments difficult if not impossible for the uninitiated to follow.  This technique, of course, places novices like DrRich in the position of having little choice but to accept the ethical bottom line without really understanding how the bottom line was reached. It reduces medical ethicists to a priesthood, and medical ethics to received knowledge.

But DrRich maintains that advancing unintelligible ethical arguments is, well, unethical.

So DrRich will now present his understanding of the chain of logic by which modern ethicists justify physician-assisted suicide – and its close cousin, euthanasia.  (If any of you actual ethicists out there object to this analysis, and can explain where DrRich is wrong in clear language, DrRich will be all ears. Absent the clear language, though, you can pound salt.)

Modern ethicists argue as follows:

Point 1: Our society has already decided that the autonomy of the individual patient is the overriding ethical consideration in making end-of-life decisions. We formalized this determination when we decided – by overwhelming consensus – that an individual has a right to refuse medical treatment even if that treatment is very likely to save their life. Therefore, individual autonomy is the universally agreed-upon controlling ethical precept.

And in adopting this controlling precept, we have already firmly decided that passive euthanasia – allowing nature to take its course by withholding treatment at the request of the patient – is ethical.

Point 2: There is no ethical distinction between passive euthanasia and active euthanasia. That is, whether we let death occur by withholding effective medical care, or by actually doing something to help death along a bit, we’re taking an action that hastens death either way. Ethically, both of these actions are equivalent. So, once we decide that individual autonomy is the overriding concern, we must also allow for active euthanasia when a patient wishes it.

Point 3: Once active euthanasia is deemed ethical, there can be no further ethical objection to the lesser act of physician-assisted suicide.  If it is ethical for a doctor him/herself to bring on the death of a patient who requests it, there can be no objection to doctors preparing the suicide machine and handing the patient the switch.

The striking thing here (to DrRich, at least) is that in establishing the ethical case for physician-assisted suicide, we necessarily also establish – as a veritable pre-condition – the ethical case for physician-provided euthanasia. Whether the patient says, “Help me to take my own life,” or “Take my life for me,” modern medical ethics supports the physician who replies, “Roll up your sleeve.”

For those who don’t see a problem with this, DrRich refers you to the Dutch system, where, in full accordance with modern medical ethics, the rules permit both physician-assisted suicide and active euthanasia for patients who request it. Reports on the results of the Dutch system (reports which both sides have used to bolster their respective opinions on either the glories or the travesties of such a system) do point out one striking finding – hundreds of times each year, acts of *involuntary* euthanasia are occurring. That is, patients are being killed under the Dutch healthcare system at the hands of their doctors, without their explicit permission. All these patients, it is claimed, are being euthanized for entirely humane reasons.

What do our friends the medical ethicists have to say about such involuntary euthanasia? Well, it turns out that it’s OK with many if not most of them. Ethicists don’t like to tell us that their chain of logic doesn’t end with Point 3.  But once we make the principle of individual autonomy the overriding consideration in determining end-of-life ethical issues, the same chain of logic takes us directly to Point 4.

Point 4: Since honoring the ethical precept of individual autonomy makes voluntary euthanasia available for patients with intractable suffering, it would be unethical to withhold the same benefit from suffering patients who are too incapacitated to give their permission. Their incapacity should not restrict them from a good that is available to others, for to do so would be discriminatory and inhumane. To cure this problem, the boon of active euthanasia can and must be performed, even without the patient’s explicit permission, in incapacitated patients whom “reasonable people” would agree are suffering too much. Therefore, involuntary active euthanasia is also ethical.

This conclusion, of course, leaves us in a place where others (i.e., “reasonable people,” like doctors or other agents of the Central Authority) can decide for an individual what constitutes intractable suffering, and further, can decide when such an individual is simply too incompetent to know that euthanasia is the best thing for them. Some of you, of course (hello, ethicists!) think this is just a fine idea. Most apologists for the Dutch system apparently do.

But DrRich maintains that under our system of covert healthcare rationing, where doctors are under extreme pressure to do the bidding of the third party payers (private insurers and the government) who determine their professional viability, and where the payers are under extreme pressure to reduce cost, and have already displayed in numerous ways their willingness to permit suffering and death among their subscribers in order to do so, then opening the door for physician-assisted suicide (let alone physician-administered euthanasia, whether the patient requests it or not), would inevitably lead to some nasty abuses, and would ultimately serve to undermine our civil society. DrRich is too politically correct to use the “other” N-word, but he will take this opportunity to remind his readers that such a thing has already happened, in what recently had been perhaps the world’s most cultured and educated society, within the memory of millions of living people.

DrRich believes that the principle of individual autonomy is vitally important, and indeed it is the foundation of American culture. However, no single ethical principle, no matter how important, can be allowed to overrule all other ethical principles in all other circumstances.  By nature, ethical precepts are often in conflict, creating what is called an ethical dilemma. And (DrRich humbly submits) it is supposed to be the job of ethicists to help us work through those ethical dilemmas, to find the right balance between competing principles, and not simply declare that no dilemma actually exists, because Ethical Precept A is the only one we need to pay attention to.

Individual autonomy is critically important to American culture – and the fact that we must fight to preserve individual autonomy in the face of covert healthcare rationing is indeed the underlying message of this blog – but in no other aspect of our culture do we let it absolutely rule. The autonomy of individuals needs to be checked, and we indeed limit it. This is the fundamental reason that governments are necessary in the first place.

The reason we have laws (supposedly) is to make sure that the behavior of individuals acting in their own interest, especially those who have accrued power (for instance, by accumulating great wealth, by acquiring large weapons, or by becoming heads of state), does not abrogate the natural rights of other individuals. Indeed, most of the political fights we have – between Democrats and Republicans or progressives and conservatives – are to determine where to place those limits, on individuals and on the collective, to best encourage a robust society that honors individual autonomy but that also encourages reasonably equal opportunities for individual fulfillment (i.e., “happiness.”) The main purpose of our public discourse, then, is to find the right balance between the rights and needs of individuals and the rights and needs of society as a whole.

So for ethicists to say, “Individual autonomy is all there is to it, and we have no choice but to follow that principle to wherever it may lead us,” is not only completely irresponsible and dangerous, it also flies in the face of our culture’s history and our everyday experience.  The cost to society not only should but must be taken into account as we consider institutionalizing physician-assisted suicide (let alone voluntary or involuntary euthanasia).  In DrRich’s opinion, ethicists who argue that we need not consider the cost to society in making end-of-life policy have declared themselves unworthy of the title and they ought to be completely ignored.

The cost to our society of institutionalizing and systematizing physician-assisted suicide, especially while we are still covertly rationing healthcare, would be severe and potentially lethal. Within the next decade or two, if things do not change, we likely will be facing cost pressures emanating from our healthcare system that will gravely threaten the survival of our culture. With an existential threat such as this, can we really refrain from slowly transforming the request for assisted suicide from an option to a duty? Can the Central Authority really stay its hand when it has the capability of directing its agents at the bedside to perform euthanasia on unfortunate (and unproductive) citizens who are too “incapacitated” to understand it’s the only thing to do?

DrRich, who opened this post with a promise to avoid irony, apologizes. For when all is said and done, it is deeply ironic that by steadfastly clinging to the ethical precept of individual autonomy at the end of life, within in a paradigm of covert healthcare rationing, we will very likely end up by completely devaluing the inherent worth of individuals.

At least until we solve the fiscal problems within our healthcare system, we simply should not embrace assisted suicide – no matter what we may think of the ethics of the act itself – and we should fight efforts to make it acceptable. The cost to our society would be far too high.

If people want to commit suicide and if medical ethicists insist that assisted suicide is OK, then let the ethicists do the assisting. DrRich has relatively little to say against ethicist-assisted suicide. But, at least as long as covert rationing is the chief operating principle of the American healthcare system, for the love of God keep the doctors out of it.

While DrRich is a conservative American, and has made plain the difficulties he has with the Progressive program in general and with Progressive healthcare reform in particular, at times he is forced to admit that, on occasion, the Progressive way of looking at the world has certain merits. And as DrRich contemplates a question that has been bothering him lately, a question that no doubt plagues many American physicians who (unlike DrRich) are still toiling away in the trenches, he finds that this is one such occasion.

That question is: Just who are the people writing all those clinical guidelines – the  “guidelines” physicians are now expected to follow in every particular in every case, on pain of massive fines, loss of career, and/or incarceration?

DrRich is quick to say that the act of creating clinical guidelines is not inherently evil, and indeed, back in the day when guidelines were merely guidelines (instead of edicts or directives that must be obeyed to the last letter), creating clinical guidelines was a rather noble thing to do.

But today, we have physicians clamoring to become GOD panelists (Government Operatives Deliberating). These aristocrats of medicine will render the rules by which their more inferior fellow physicians, the ones who have actual contact with patients, will live or die. Clearly positions of such authority will be very desirable, and so, as one might predict, they are being vigorously pursued. And we are seeing candidates audition for these panels with efforts ranging from amateurish to ruthless. It puts one in mind of the early-season contestants on “American Idol.”

We see them vociferously extolling, in every public venue they can find, the idea of “fly by wire” medicine, whereby every decision physicians make will be determined not at the bedside but by the best and the brightest experts, acting at a distance. The experts will distribute rules of action based on only the best scientific evidence (“best” being determined by those selfsame experts). The directives they hand down will be models of actionable simplicity,spelled out so unambiguously that even doctors born, raised, and trained in the Midwest or the South will be able to follow them.  (And if the doctors refuse to cooperate sufficiently, non-physician medical professionals will be able to do the job.) We see them writing scientific papers that spin the evidence in such a way as to generate conclusions which will be soothing to the Central Authority. We see them editing medical journals in order to make certain that the correct conclusions are published, and the incorrect ones are not. We see them taking control of professional organizations, and using their positions to promulgate changes in medical ethics that advance the Borg-ification of medicine, and to formally endorse Obamacare on behalf of American physicians who, for the most part, were against doing so.

These people have gained great prominence within our healthcare system, and practicing physicians will be dealing with them and the consequences of their actions for many years to come. While the natural impulse of us typical American doctors may be to simply marvel at the wonder of it all, shake our heads resignedly, and go about our increasingly distressing business, it may behoove us to take a closer look at these individuals, to attempt to understand them a little better. After all, their activities in the near future promise to greatly impact our lives, our fortunes, and our sacred honor.

So – who are they, anyway?

This, dear reader, is where the Progressive mode of thought comes in handy. DrRich refers, of course, to the Progressive doctrine of Diversity.

Diversity, for those who pretend not to know, is perhaps the chief mechanism by which Progressives attempt to control the behavior of the population.

Recall that the Progressive program is to create the perfect society. The Progressive elite know just how to do this, of course, but individuals within every population throughout human history have insisted upon acting in their own self-interest, which is counterproductive to the collective goal. In past efforts to perfect human societies, such individual recalcitrance has been dealt with by means of concentration camps and pogroms and the like. “Diversity,” we all should admit, is a much kinder and gentler approach to curing the problem of individualism.

Specifically, the doctrine of Diversity defines the range of permissible behaviors and thoughts for a given group of people within a society. The numerous celebrations of Diversity we see all around us invariably turn out to be strategies to reinforce those allowable ranges of thought and behavior. In this way, members of a particular group who begin behaving and thinking outside the allowable range can be quickly identified and dealt with, either through correction (which brings them back into the group), or through vilification (which marginalizes them). It is easy to become confused about this, since classically “diversity” means something other than “conformity.”  (As a general rule, if you want to know what Progressives are really up to, listen to what they say and then look to see if their deeds are actually working toward the opposite thing.  DrRich thinks that much of the time you will find that they are.)

In any case, while in general DrRich does not approve of Diversity as it is being practiced today, he finds that the concept might be useful in attempting to answer the question at hand.

Specifically, DrRich refers to his theory that physicians (like any humans) tend to end up in careers that best suit their underlying personalities and proclivities, and so physicians in a given specialty will tend to think and behave like other physicians within that specialty, and unlike physicians in other specialties. If this theory has any merit (and let us call it the Diversity Theory of Physicians), it will allow us to make some generalizations about the characteristics of individuals who have chosen specific kinds of medical careers. DrRich stresses that he is aiming to make generalizations only, and while those generalizations might help enlighten us to a modest degree regarding, say, what sort of physician will end up on the GOD panels, they can tell us nothing about particular individuals.

With that annoying disclaimer out of the way, let us examine some ways in which the DTP reveals Truth. An obvious example is the specialty of psychiatry, which tends to attract doctors who are, perhaps subliminally, concerned that they are just a little crazy themselves. As it happens, it often turns out they are correct. In DrRich’s experience, and in the experience of just about anyone who has encountered more than a handful of shrinks, these fine physicians, on average, display an astonishing degree of off-the-wall psychopathology. (Not that there’s anything wrong with that.)

Emergency room doctors have short attention spans and are afraid of commitment.

Endocrinologists get their jollies by sitting alone in cramped offices, parsing tremendous volumes of laboratory data from blood tests, which they claim reflect moment-to-moment variations in hormone levels, and from this arcane evidence are able to parse out (so they say) subtle glandular difficulties. If endocrinologists were not physicians they would be accountants; the more aggressive endocrinologists (who are identifiable by the dirty glance they give you if you happen to interrupt their lonely cogitations) might be forensic accountants. (How anybody could specialize in any organ that just sits there, perhaps secreting various invisible substances, but otherwise not doing anything whatsoever,  DrRich will never understand.)

Orthopedic surgeons are former jocks, or wish they were, and the ones who end up replacing hips in old ladies instead of patrolling the sidelines at college football games are often very frustrated individuals.

Party animals who manage to gain entrance to medical school often end up as anesthesiologists.

Cardiologists like to envision themselves (and would like others to envision them) as living on the edge. After all, they put catheters into damaged coronary arteries in patients on the brink of heart attacks, and, through their skillful manipulations, open those arteries and save lives. They are the extreme sportsmen of medicine, so they believe. But really, their jobs are ones of relative security, predictability and instant gratification. What they do in the cath lab actually is pretty rote, and it provides them with immediate, concrete results. They can even show the “before” and “after” pictures to the person they just saved, who will then heap praise and shed tears of gratitude upon them. But any time fixing a particular artery looks a little too risky, they call a cardiac surgeon right away. This pattern of behavior suggests to DrRich that their aggressive personnas and glory-seeking activities are actually masking an underlying insecurity.

It would not be fair of DrRich to psychoanalyze all these other specialists – who have done nothing to provoke him – without also doing the same for electrophysiologists. All electrophysiologists started out as cardiologists, of course, so they have that going for them. But to really understand electrophysiologists, one must invoke the principle of sublimation. To sublimate is to channel an underlying negative tendency to some activity that partially gratifies that tendency, but that is considered worthwhile by society. So, for instance, people with a tendency toward pyromania may become volunteer firefighters. People with sadistic tendencies may become prison guards. Foot fetishists can become shoe salesmen. Compulsive liars can become novelists.

Who, then, become electrophysiologists?

Back in the 1980s and 1990s, when DrRich was practicing, what electrophysiologists mainly did was to try to prevent sudden death in patients who had a high risk of dying suddenly from cardiac arrhythmias. And in order to find the optimal therapy for these patients, it was necessary to induce, intentionally and repeatedly, cardiac arrests under controlled conditions. This was done in an effort to find an antiarrhythmic drug that would prevent the induction of cardiac arrest. This behavior we euphemistically called “serial drug testing.”  Fortunately, this procedure is no longer necessary, since the implantable defibrillator has been perfected and is now widely available for high-risk patients (if you can get it paid for).

While it has been widely remarked that those early-day electrophysiologists were a very strange group indeed, most of us who did this serial drug testing ended up successfully absorbed into normal society, and today (as far as DrRich can tell) we are for the most part generally pretty harmless. But DrRich sometimes finds himself wondering what might have become of some of us (some in particular more than others) if we had not had this remarkable opportunity to sublimate what one might speculate to be some rather unpleasant tendencies. And what is to become of that young person today who has whatever those unfortunate tendencies might be, and who, 30 years ago, might have found release as an electrophysiologist? One must not think too deeply about this.

Let us now turn our attention to those would-be GOD panelists, and see if we can decipher what kind of people these might be. Admitting that what follows – and, for that matter, what has just been said – amounts only to an educated guess, DrRich submits that the GOD panelists are people you already know well, if you have worked within the American healthcare system.

These are the kids you knew in college who studied all the time and got straight A’s in all the hardest courses, buttered up their teachers, then aced their MCATs. For them the hardest part about applying to medical school was in deciding which of the many schools that accepted them they should attend. Likely, they chose one of the Ivy League ones. Their first two years of medical school – the didactic years – were much like their college experiences. They studied hard, aced all the exams, and were generally acknowledged by both faculty and peers to be at the very top of their class.

Then they reached their clinical years, and things changed. They still knew more information than anyone else, and in fact their information base continued to expand. They read all the journals, and could always quote new research findings chapter and verse. They could conjugate the Krebs cycle on demand (or whatever it is you do with the Krebs cycle), and could recite precisely which enzyme that new drug inhibited, and could say why doing so made it OK to eat pizza again.

But what they could not do was be a good doctor. They had no instinct for it; no ability to get the patients to tell them the important information; no ability to read a patient’s facial expression, or phraseology, or body language, those signs that reveal the real truth. They had no ability to discern useful information from the flood of partial and contradictory clinical evidence that is always pouring in from several sources. When time was of the essence, they had no capacity to figure out what was going on or what they should do about it. They could not adjust to changing clinical situations on the fly. In an emergency they were paralyzed, trying to match the quickly evolving situation in front of them with the static words on the printed page. And often they were klutzes.

They were perfectly cut out to learn medicine, but lousy at actually doing it. What was worse, some of their colleagues who were mediocre in the book-learning department suddenly blossomed into highly competent clinicians on the wards, and quickly became recognized as rising stars by attending physicians, while they themselves were repeatedly chastised, or ignored.

And it just wasn’t right. It just wasn’t fair. They had worked harder than everyone else, had twice the brains as those others, and had learned the material three times as well. But the way God set it up, they just weren’t good doctors.

Many of these unfortunate souls quickly left clinical medicine, and branched off into research, academics, or administration. Most of them did quite well for themselves, because they really are very smart. But they never really got over their frustration and anger over their unjust  failures on the clinical wards, a place where their obvious inferiors lorded it over them. They have now spent years engaging in cognitive dissonance, convincing themselves that their apparent failure was an illusion, merely a sign of having been subjected to the anti-intellectual, shoot-from-the-hip, do-it-quickly-and-make-more-money environment that is American healthcare. After all, how could they be sub-optimal physicians when they are clearly far more intelligent and knowledgeable than the supposed “stars?” If the healthcare system had been arranged differently, in such a way as to make the cowboys behave the right way, they would have proven themselves to be the best clinicians in the land.  It is a bitter, bitter pill.

These are the guys, DrRich thinks, who are chomping at the bit for the opportunity to sit on the GOD panels. They would dearly love the chance to utilize their superior intellectual firepower, to distill the clinical research data, to digest it painstakingly and thoroughly (not haphazardly and on the fly like those others), to put down on paper the RIGHT way of practicing clinical medicine -  and to have the authority to do it in such a way (backed up by the full force of the Central Authority) that those lesser doctors will HAVE to do it their way, at long last.

The point of all this psychoanalytic guesswork is to suggest that the GOD panelists, even the GOD panelists who are physicians, will have no sympathy for the idea that the practice of medicine should be individualized to any degree whatsoever. The idea of individualizing medical care, rather than practicing by formula from a book, is what caused these people the most uncomfortable moments in their professional lives. Far from being sympathetic to the idea, they will probably be more hostile to it than the non-physicians on the GOD panels. When somebody on the panel suggests that, perhaps, we should give the doctor a little more leeway on this particular issue, these physicians will speak up and say, “Listen. I’ve been there and you haven’t. These doctors don’t need any more rope, unless it’s to bind them even tighter.” They were themselves shown no quarter, in the tough arena of clinical medicine where outcomes (and not process or book knowledge) is the only mark of success, and they will offer none in their turn.

DrRich cannot prove any of this, of course. He is just theorizing, based on his own personal observations and prejudices, having observed many of these whiz-kids in his 25 years of teaching medical trainees, and watching where they wound up. He could, of course, be wrong.

In any case, for allowing him to carry on in this manner DrRich owes one more expression of gratitude to his Progressive friends, whose doctrine of Diversity supplies the necessary substrate, and the ethical “cover,” for mercilessly stereotyping selected groups of what otherwise might turn out to be individuals.

In Durango, Florida the week before Christmas, the FBI arrested fugitives Roger Gamlin, 62, and his wife Peggy, 54, at Mercy Regional Medical Center after a doctor determined their real identities through Roger’s pacemaker.

Wanted by the feds for 2 1/2 years on suspicion of embezzling millions of dollars from their south Florida title company, Roger and Peggy had been living quiet and unassuming lives as Ron and Nancy Jenner in Durango.

Then Peggy brought Roger to Mercy Medical Center after he developed a nose bleed that would not stop. The hospital (in accordance with the sage advice of its attorneys) is not saying exactly what happened next. But we know that Roger’s true identity was determined through his pacemaker, and the FBI quickly showed up to arrest him and his wife. Roger and Peggy waived their rights to an identification and detention hearing, were placed into custody, and will be transported to south Florida to face embezzlement charges.

The reason this story made the newswires, of course, is because the fugitives were identified through a pacemaker. Pacemakers can be electronically scanned to reveal information about the patient’s cardiac condition. Every implanted pacemaker also stores information that identifies the patient. That’s apparently what did Roger and Peggy in.

The “angle” that has made this a news story is the pacemaker angle. And yes, it’s true that when you receive a pacemaker or an implantable defibrillator, it’s like receiving a subcutaneous electronic identity chip, like the one you have in your dog. Anyone with the right scanner can find out who you are. So if you plan to become a fugitive from the law, it is best not to have one of these. (Alternately, get your pacemaker AFTER you change your identity, so that it matches with your alias.)

But really, you don’t need to have an implanted medical device in order for a hospital to learn your true identity. A medical facility could find out who you are any time they wanted, by surreptitiously obtaining DNA samples, for instance, or – for extremely rapid identification – dusting your drinking cup for fingerprints and doing a computer match. DrRich doubts whether such things are occurring today. His point is that it could happen whenever somebody wanted it to happen, whether you have a pacemaker or not.

To DrRich, the interesting part of the storyline only peripherally involves the pacemaker. The real story is this:

• A patient goes to a hospital for medical help.
• A medical procedure is done which generates certain data for the medical record.
• The data in the medical record is immediately cross-referenced with data from a federal database that lists persons of interest.
• The FBI shows up at the bedside in less time than it takes to raise a nurse with a bedpan.

Now, that’s actually a pretty interesting story.

(And people wonder why the Central Authority is so hot to have electronic medical records.)

But even that is not the most interesting angle. What DrRich wants to know – the angle he would explore if he were writing this up for the Sunday Times – is: What was the doctor thinking?

You’re an ER doc. A guy comes in with a bad nosebleed. You stabilize the bleeding, but the guy looks pretty pasty and you’re worried about his heart, so you interrogate his pacemaker. (Here’s the first red flag. For an ER doc, interrogating a pacemaker – not a routine procedure in most emergency rooms, and one which yields only sparse information about the status of a patient’s heart – is generally pretty far down the list of things to do. Could it be that Roger is acting suspiciously, and you want to find out whether he is who he says he is? If so, you are no longer acting as a doctor, but as an agent of the government.) In any case, whether intentionally or not, you learn that the patient has checked in under an alias.

So now what do you do?

There are some things you need to consider as you decide what to do. First, you have established a doctor-patient relationship with Roger, which binds you to confidentiality – unless you believe Roger is an imminent threat to himself or others. But simply using an alias does not constitute an imminent threat to anyone. Besides, using an alias is not necessarily illegal. Samuel Clements used one, and so do most people who work in Hollywood. And how many times has Barack Obama changed the name he answers to?

Second, you yourself might get into trouble if you look into the matter. For instance, if Roger were an illegal alien and you took it upon yourself to escalate the matter of false identity, you could get into serious trouble. After all, the U.S. Attorney General has determined that an Arizona law is unconstitutional which would permit police officers to investigate the actual identities of suspected illegals who are detained for other offenses. And you are not even a police officer, and Roger is not being detained for an offense, but has come in to seek medical assistance. Furthermore you are well aware that if a suspected illegal alien shows up in your ER, you are supposed to treat him/her without asking any questions about identity or legal status.

But you determine that Roger does not look Hispanic (or Arabic) – a determination that by any reasonable definition would constitute racial profiling – and so is not likely to be a member of a protected group.

DrRich thinks you are thinking like this: “This man is obviously using an alias – so what is my obligation here? In the old days my obligation would be to honor the confidentiality of my patient, who, for possibly very legitimate reasons, has altered his identity. But it’s not the old days. Now, I’m obligated to do what’s best for the collective, and only secondarily what’s best for this patient. I suspect the collective would like to know about this guy, to check him out. It’s a little risky – what if he turns out to be an illegal from, say, Argentina? A lot of people from Argentina look European. But that risk seems small, and if he is some kind of fugitive from the law I would be doing a great service to my overlords.”

So you rat him out.

We indeed have come a long way. Not only have our doctors apparently lost their scruples, but we also appear to have already arrived at a place where medical records can relatively seamlessly interface with other federal databases. Once medical records become fully electronic, patients needing medical aid will have a lot to consider. Are you an embezzler on the lam? Are you behind in paying your income taxes? Are you a parking ticket scofflaw? Do you have erectile dysfunction, or venereal disease? (These latter conditions cannot get you arrested – as of yet – but we know that all databases controlled by the government, no matter how “confidential,” also interface seamlessly with WikiLeaks, and so the publication of lists of patients with embarrassing medical conditions always remains a possibility.)

Once again, DrRich marvels at the fact that, soon, the only safe way to get your healthcare will be through the black market.

But events force DrRich to throw caution to the wind, and issue a warning, and a plea, to those among the broad community of physicians for whom he has the most respect – the PCPs. The event to which DrRich refers, of course, is the recent, tragic gunning-down of a physician at Johns Hopkins University Hospital by a disgruntled patient (or rather, by the clearly disgruntled son of a possibly disgruntled patient).

This is DrRich’s warning: the recent shooting at Johns Hopkins may indicate that the long-predicted (predicted by DrRich, at least) bloodbath of American PCPs may now be at hand. And this is his plea (and here is where even the usually audacious DrRich must admit to a slight bit of trepidation): PCPs, for your own good, for the survival of primary care medicine, and therefore for the success of Obamacare, you must now prepare to defend yourselves.

Yes, dear readers, it is time for American PCPs to begin packing heat.

DrRich well understands that many of his readers at this moment doubtless think he has, at long last, lost it; that his finely-honed (and amply-demonstrated) abilities in logical discourse have finally taken their leave, that he has, sadly, gone ’round the bend. DrRich forgives you for this reaction.

After all, the doctor who was shot (whose identity has not been disclosed, but who is apparently expected to recover fully), works at Johns Hopkins, one of the premier medical institutions in the world. And therefore, while its leaders undoubtedly give the requisite lip service to the importance of primary care medicine, Johns Hopkins likely does not have very many actual PCPs frequenting its premises. So (DrRich’s clever readers correctly surmise), it seems very unlikely that the shooting victim was a PCP; and for him to find a lesson for PCPs in this unfortunate incident is obviously too ridiculous for words.

DrRich does not take such criticism personally. He realizes that those of you who doubt him in this case are not being mean-spirited, but merely misinformed. DrRich accepts the fact that most of you do not scour the relevant scientific literature with as much care as he does. And so, he does not expect you to be aware of the recent work of one David Fishbain, Professor of Psychiatry and Behavioral Sciences at the University of Miami, who published a study in NewScientist Magazine which indicates that up to 1 in 20 patients would like to kill their primary care physicians.

Professor Fishbain learned this interesting tidbit in a survey he conducted among 800 patients undergoing physical rehabilitation or suffering significant pain.

Those PCPs who are reading this startling news, and who, by virtue of the fact that they are still working as PCPs, have have most likely honed their skills of denial to a high art form, are doubtless consoling themselves at this very moment with this observation: “Sure they want to kill me. But as they’re disabled, their chances of success seem low.”

So chew on this. In a control group of patients who were not suffering from pain or disability, Fishbain reported that “only” 1 in 50 admitted to having murderous tendencies toward their PCPs.

Any way you cut it, the math is not pretty: the typical PCP with a patient load of 3,000 souls can assume that at least 60 of these individuals (up to 150, if he/she treats a lot of patients with pain or disability) would not only like to see them dead, but would be pleased to be the instrument of their demise. Worse, even these statistics are surely unreasonably cheerful, as they rely on the likelihood that everyone who wants to see their doctor lying lifeless in a pool of blood are comfortable admitting this fact to medical researchers doing written surveys.

In any case, whatever the specialty might be of the physician who was shot at Johns Hopkins, it is the PCPs who are at the highest risk. And now that the shooting has actually begun, DrRich does not think PCPs should take much comfort in the possiblity that the first casualty may not have been one of them.

Why are patients murderously angry with their PCPs? Let us count the ways.

DrRich has expended much space and effort on this blog describing how PCPs have been maneuvered into covertly rationing healthcare at the bedside. Patients who go to their guideline-compliant, non-fraudulent PCPs these days will find themselves limited to 7.5 to 12.5 minutes of actual face time, most of which their doctor will spend sitting at a keyboard, staring at an LCD screen, desperately attempting to make the appropriate clicks on the most favorable little boxes next to a government-sanctioned Pay For Performance checklist. There will be little or no time for whatever pressing issues may be on the patient’s own (non-government-approved) agenda.

The patient, who has waited weeks for this opportunity, will be asked to wait weeks more for another appointment to discuss those other things – or will be directed to an emergency room.

But the greatest sin of all is that, to assuage their guilt and to make such behaviors seem less than reprehensible, physicians have allowed their professional organizations to formally adopt a new code of medical ethics, one which charges physicians with the task of achieving a just distribution of healthcare resources – namely, with covert healthcare rationing at the bedside. This new ethical obligation officially drives a stake into the heart of the classic doctor-patient relationship, and is an abject admission that the practice of medicine no longer constitutes a real profession.

Patients may not know the niceties of this New Age medical ethics – they may not be able to articulate the reasons they feel abandoned in their hour of need – but they certainly perceive its effects on their lives. Their anger is not unjustified.

The fallout for the medical profession from all these developments has landed disproportionately on the PCP. For most patients, their PCP is the face of the medical profession, and it is in the PCP’s office where they most often experience the changes.

PCP’s, of course, are no happier with this new reality than are their patients. The loss of their professional integrity and their ability to act as autonomous advocates for their patients has (far more than the steady ratcheting down of their pay) made primary care medicine an exquisitely unattractive proposition, both to current practitioners and to potential future PCPs.

Unfortunately, any notion that this damage to primary care medicine can be readily reversed is sadly mistaken. It would be a great mistake, for instance, to place the blame for all this on Obamacare. While Obamacare will indeed utterly rely on PCPs to do the dirty work of covert rationing, the basis for such reliance was established long ago by the medical profession itself, which voluntarily adopted their New Age ethics several years before anyone had ever heard of Barack Obama or his healthcare reforms.

So it should be no wonder that patients are pissed. And since that which is pissing them off is not going away anytime soon, and indeed is about to become greatly accelerated, PCPs must be alert to the likelihood that the lethal ideations entertained by a small but not insignificant proportion of American patients may soon find an outlet beyond mere daydreaming. The Johns Hopkins shooting ought to be a wake-up call to all doctors – but especially to the American PCP.

And so, as a public service, DrRich reluctantly suggests that perhaps it is time for PCPs to prepare to defend themselves in one of the few ways they have left to do so.

PCPs may have lost everything else, but to this point, at least, they still have the second amendment to rely on.

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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

Now that the great campaign to transform the American healthcare system has passed a critical milestone – the passage of President Obama’s healthcare reform legislation – many Americans find themselves confused about what it all means. What just happened here? What will happen to our healthcare insurance? How much will it cost, and who will pay for it? Why does the whole process seem so darned difficult and confusing?

The confusion is quite natural, since, in fact, nobody really understands what the new legislation says. It is common knowledge that only one or two of our legislators actually read the whole 2700 pages, and those who did only read it so they could make trouble for the President at his Bipartisan Healthcare Roundtable this past spring. (You know who you are, Paul Ryan.)

Remember when Nancy Pelosi said, “We have to pass the bill so we can all find out what’s in it,” and all the Republicans jumped all over her for making such a stupid remark? Well, DrRich is here to tell you that Nancy was displaying uncommon wisdom. Because DrRich now has read large parts of the legislation himself, and can say with confidence that the bill is not merely lengthy, convoluted, and difficult to understand. Rather, its meaning is fundamentally indeterminate.

The indeterminacy of the bill’s language was, of course, intentional. It was done so that, for instance, some legislators could be assured that the bill disallowed Federally funded abortions, and other legislators could be assured that the bill encouraged Federally funded abortions, while the actual language of the bill could be construed to bolster either assertion. Therefore, Speaker Pelosi’s silly-sounding statement was not only correct, but also was probably the most insightful commentary on the bill we’ve heard from any public official.

The bill is now being torn into bits by multitudes of officious bureaucrats, and translated into millions of pages of rules, regulations and guidelines, and then key aspects of those new rules, regulations, &c. will be fought over in courts of law. Once all that is finished, we can all find out what was in it. Just like Nancy said.

In the meantime, whatever the details of our new healthcare system turn out to be, there is a certain clear narrative to our ongoing healthcare saga that, once you understand it, will go a long way toward enlightening you about what’s really going on.

And so, as a public service, DrRich will now explain all this to you in a very simple way, so that – whatever jive you’re hearing from politicians or journalists – you will always get it. For, once you understand a few key concepts, this thing is really pretty easy to follow.

The Fundamental Problem

The fundamental problem with American healthcare is this: None of the pools of money we have created (or ever could create) to pay for our healthcare – whether those pools of money reside with the insurance companies or the government or both – can possibly buy all the healthcare that might benefit all Americans. This means we have to ration healthcare (i.e., intentionally withhold at least some beneficial healthcare from at least some of the people who would benefit from it). But because we’re Americans and Americans don’t ration, we (and in particular, our political leaders) are unable to address this need to ration openly and forthrightly. Therefore, the unavoidable rationing is being conducted covertly.

Until now, most of the covert rationing has been overseen by the health insurance industry. This, indeed, from the very beginning was the primary purpose of modern health insurance companies, as determined by Congress itself when it legislated the formation of HMOs. (See the ruling of the U.S. Supreme Court in Pegram et al. v. Herdrich (98-1949), 530 US 211, 2000.) So, when the health insurers engage in cherrypicking patients, denying medically necessary services, coercing doctors to ration at the bedside, retrospectively canceling the policies of patients after they get sick, and doing everything short of dispatching teams of Ninjas in the dark of night to slaughter some of their more expensive subscribers in their sleep, they are not really being evil. They are only carrying out the job that had been assigned to them by our society. Covert rationing is a dirty, thankless job, but somebody’s got to do it.

The major sin of the health insurers is that, despite their Herculean efforts to harness covert rationing to control costs – and despite the wondrous incentive of greater profits if they do so – they have utterly failed in their assignment. Healthcare costs continue to rise at 3 – 4 times the rise in the cost of living, and within the next couple of decades promises to bring our republic to its fiscal knees (even without all the other stuff that’s making our deficit explode).

This is the healthcare crisis, and it’s real. We simply cannot actually spend $40 trillion on Medicare patients over the next three or four decades (as we’ve explicitly promised the baby boomers). The only real question is whether we will avoid spending all that money thanks to societal disruption and revolution, or by some more civilized means. (The fiscal implosion of our society would of course finally fix our healthcare crisis. Healthcare, far from being an essential and indispensable human need, actually is a luxury, a recent artifact of our advanced, stable, and affluent culture. Runaway healthcare costs, by bringing down our societal stability, will eventually provide its own cure.) Our current “healthcare reform process,” such as it is, is our stab at a more civilized means of addressing our looming impossible fiscal obligations.

What Is Healthcare Reform Actually Going to Reform?

What we are witnessing today is merely a rather messy changing of the guard. The primary responsibility for covert healthcare rationing is going to shift from the health insurers to the government.

The health insurance industry has run out its string. They have had 15+ years of virtually unfettered opportunity to get healthcare costs under control, and they have utterly failed. Over those 15 years, their attitude has evolved from arrogance to concern to abject fear. They finally and starkly realize that they have no clue as to how to control costs. As DrRich has pointed out for three years, the insurance industry has not been looking to block healthcare reform, but rather, was partnering with the reformers in the hope of finding for themselves a graceful exit strategy. They hope to gain one last windfall in profits and stock prices (from mandates and insurance subsidies for the tens of millions of currently uninsured Americans), and once that happens, they hope to settle into the business of administering, and processing transactions for, government controlled healthcare. That is, the insurers hope to become public utilities, since that’s way better than collapsing into oblivion.

So the overriding aim of healthcare reform, with the complete support of the insurance industry, is to conduct an orderly transfer of the pools of money with which we pay for our healthcare – along with the responsibility of managing “risk” and controlling the cost of care (i.e., covert rationing) – away from private insurers and to the government.

Understanding the Players

Government control of healthcare, of course, is precisely what the Republicans accuse the Democrats of wanting, and what the Democrats angrily deny they want.

Understanding the Republicans. Republicans as a group cling to the quaint notion that competition among insurers is all that is needed to reduce healthcare costs; that given the right market incentives, the insurance industry – in its wisdom – will bring healthcare inflation under control. They utterly fail to hear what the insurance companies themselves have said (by their actions): “No mas!”

The Republicans’ arguments ring hollow. It is useless to protest that the Democrat plans will lead to rationing, when not only do we already have rationing, but covert rationing in fact has been the official cost-cutting “plan” assigned to HMOs for decades now. It is useless to protest that 85% of Americans like their current health insurance, when the fiscal reality is that health insurance will change drastically for all Americans over the next decade or so, whether we change it by design or not. It does not matter that a lot of Americans like the health insurance they have now. Keeping it over the long term is not an option.

To a very large extent (DrRich is sorry to say, what with his conservative leanings and all), with such arguments the Republicans have made themselves nearly irrelevant in the current discussion.

Understanding the Democrats. The Democrats were handed the opportunity of a generation. They had a major advantage that Democrats of the Clinton era did not have: the health insurance industry is finished, and the industry knows it. The insurance industry was not going to let this effort fail.

The chief difficulty remaining for the Democrats is that (for their own survival) they must pretend they are not engineering a government takeover of healthcare, when in fact they are. As we have seen, there is not really much choice here. They must take over healthcare even if they don’t want to (though many of them do), because the health insurance industry is finished. The pretense is necessary, however, because the notion of government-controlled healthcare is not something the people – or even many Democrats – want, or are willing to tolerate.

Like the odious job of rationing healthcare (which they have now inherited in entirety), the Democrats must attempt to keep the complete government takeover of the healthcare system as covert as possible.

Which brings us to the biggest problem of all for the Democrats. They now have to take control of covert healthcare rationing. Covert rationing will be much more difficult for a government-run system than it has been for insurance companies. A government healthcare system will not have the opportunity to incorporate the most effective rationing techniques that have been available to the insurance industry – cherrypicking patients, for instance, or canceling the policies of people who get sick. Nor will the government be able to get away with summarily denying patients needed medical services – a standard tactic of HMOs. This is especially true now that chief Republican intellectuals have called everyone’s attention to the possibility of death panels. The unwashed masses, having been duly alerted to the government’s intentions of withholding life-saving healthcare, will now be on the lookout for “unreasonable” denials of care. Any move by the government to refuse to pay for a particular medical service will have to be supported by extremely convincing clinical data (which itself will be very expensive to collect), and even then Americans may not quietly accept such denials. The “death panel watchdogs” will be alert for every move the government makes, and will be quick to howl an alarm.

So the Democrats have won a huge and historic victory. But they are just beginning to figure out what a tiger they have by the tail.

The Bottom Line

As long as we pretend we don’t have to ration our healthcare, any reforms we invent – whether we do it as Republicans or Democrats – will merely add to the confusion, inefficiency, waste, inequity, and ineffectiveness of our healthcare system. How anyone can think that a process so fundamentally grounded in obfuscation and deception as the one we’ve just witnessed will result in anything good is quite beyond DrRich’s comprehension.

Real reform would require us to:

A) Minimize the necessity of imposed rationing by having patients themselves make as many of the spending decisions as possible, using their own money. (Subsidies could be provided to people who don’t have enough of their own money to pay for routine healthcare.)

B) Provide everyone with a high-deductable, catastrophic insurance product to cover non-routine medical expenses. This is where the necessary rationing would take place, but the rationing would be open, transparent, and determined through a public process.

C) Create a private market for “extra” health insurance for those who choose to supplement the universal catastrophic plan with their own funds.

But of course, any plan that relies on both personal responsibility and open rationing is a non-starter. Which is why we are going to get what we are going to get.