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*.

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*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.
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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.

DrRich considers it his responsibility to point out to his readers certain truths related to modern American healthcare which may not be obvious to everyone, and which the fine people in the mainstream press choose not to mention.

Be honest. If it weren’t for DrRich, would you be aware that the only reason Obamacare became the law of the land is that the private insurance companies needed it in order to have any hope of long term survival?  Would you understand that the Progressive healthcare system to which we are now legally committed inherently requires all of the following things (while loudly proclaiming the opposite): ending the classic doctor-patient relationship; preventing individuals from spending their own money on their own healthcare; killing off the practice of primary care medicine; to the furthest extent possible, limiting preventive medicine; and stifling medical innovation?

One thinks not.

And so, DrRich hopes you will pay attention as he reveals yet another poorly-appreciated truth about our new healthcare system. Namely, it has become the case that maintaining your own wellness is not merely something which would be desirable, something you ought to do, or at least something you ought to want to do. It is now your duty.

You owe it to society to maintain your wellness, to take every step at your disposal to keep yourself from needing to consume healthcare resources. You owe it because healthcare is now a collective responsibility. And if your chosen actions (or inactions) cause you to become unwell, and if your unwellness causes you to consume healthcare resources which otherwise might have been available to individuals who (unlike yourself) became ill through no fault of their own, and if such faultless individuals subsequently suffered or died as a consequence of your failure to honor your duty, well then – that would make you no different from any other common criminal whose selfish actions produce harm to their innocent victims.

Maintaining your wellness is not a nice-to-have; it is your non-negotiable obligation.

You have been told that your wellness is very important to the caring people who will run our new healthcare system. And indeed, it is. So you will, by law, be “entitled” to annual, detailed “wellness checks,” provided by a dedicated team of healthcare workers, who will assess (and record) your efforts to maintain your own wellness, and then will give you all the instruction you need to alter whatever suboptimal behaviors you are displaying. The results of these annual wellness checks will be entered into a federally-approved universal electronic medical record, so that any healthcare provider, anywhere, at any time, will have a complete record of the trajectory of your state of wellness over the years – and of the degree of your compliance with the instructions you have received for maintaining that wellness.

Of course, if you elect to forgo the annual wellness checks to which you are entitled, that information (i.e. that you cared so little for your wellness that you couldn’t be bothered to do anything about it) will also be maintained in the universal electronic records.

Then, when you become ill 10 or 20 years from now, your records can be consulted to decide to what extent your illness can be considered self-induced. For, when resources are scarce, the only moral thing to do is to distribute them according to who is the most deserving.

Most readers are now thinking that DrRich is paranoid. Guilty as charged. However, DrRich’s paranoia, regarding the kinds of behaviors of which our Central Authority is capable, is based on hard experience. Indeed, it is evidence-based.

Still, DrRich is enough of a realist to understand that it is unreasonable to ask his readers to just trust him here. Instead, let’s examine patterns of behavior, regarding supposedly self-induced disease, which our society is already displaying. The best example, one which DrRich has written about extensively, is obesity.

We are witnessing a sustained and ongoing campaign to demonize the obese. Consider: While we are universally urged to stifle any impulsive speech or sentiments which, by any stretch of the daintiest of sensibilities, might make any member of any group (however you choose to define a group) the least bit uncomfortable, it is perfectly OK to castigate the obese, loudly and often. We can say about the obese anything we like.  Screw their feelings. It is perfectly fine to insist that it is the obese – gluttonous, lazy, self-indulgent, slothful fat people – who are driving our healthcare spending off a cliff. It is acceptable to publish ridiculously flawed papers in respected scientific journals proving that global warming is caused by the obese (thus pinning upon them the responsibility for upcoming catastrophes of unimagined proportions), and demonstrating that obesity is a contagious disease (which will justify any actions we may choose to take to concentrate the obese into special camps).

A person’s choice to allow themselves to get fat already justifies more than mere words of castigation. Under the British Health Service (the model to which Dr. Berwick and other of our current healthcare heroes openly aspire), the obese (along with smokers, another group of selfish sub-humans who use an unfair share of healthcare) are now being removed from the waiting lists for medical services.* By virtue of their obesity (and the lack of social responsibility their obesity indicates), fat people have forfeited their equal access to healthcare.

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*Removing the fat from the waiting lists has at least two beneficial effects. It punishes them, of course, for their selfish refusal to maintain their own wellness. But it also reduces the long waiting lists that exist in Britain for medical services, closer to the target waiting times which the government has been promising its citizens for decades.
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Demonizing the obese has many advantages. Chief among these is that the obese are easy to spot. In contrast to the Jews of Nazi Germany, one does not have to sew a Star of David to their jackets to know which individuals are wrecking the culture. By just walking down the street (not that fat people do all that much walking, lazy SOBs) they reveal themselves, by their unsightly corpulence, to be one of those people who are ruining the healthcare system for the rest of us. And we svelter, more worthy citizens can look upon them with the scorn they deserve.

Especially now that we have so many programs and policies aimed at preventing obesity – putting apple slices in Happy Meals, publishing calorie counts in restaurants, being lectured at by First Ladies and skinny movie stars, &c., – anyone who still chooses to remain obese despite all this abundant assistance must be especially contemptible.

Perhaps most useful of all, in the long run, is the fact that real, honest-to-goodness, health-threatening obesity almost always has a strong genetic component. When we learn to demonize the obese, we are learning that wellness is a duty even if your genes (or some other force that is largely beyond your control) mitigates against it.

The obese, therefore, are the perfect target. Thanks to them, we are teaching ourselves that it is right and proper to disdain individuals who are leading less than exemplary lives.

Once we have learned this lesson well, it should be relatively easy for us to apply the same kind of disdain to others who who fail to honor their duty to maintain their own wellness. Most of these scurrilous individuals will not be so obvious to spot as fat people.  But at the end of the day, they will reveal themselves in the ultimate manner – they eventually will fall sick. And by their diseases we shall know them.

For the past several years, our healthcare experts have been busy declaring more and more illnesses to be “preventable.” And if an illness is preventable, and an individual fails to prevent it – well, what more do you need? That person has obviously failed to perform their sacred duty to society, and has forfeited any claim to the healthcare we more deserving people can expect.

The list of illnesses which are officially preventable now includes coronary artery disease, heart failure, kidney failure, diabetes, stroke and many kinds of cancer. And just a week or two ago, Alzheimer’s disease was added to the list.

It is possible that in a decade or so, if you acquire an illness from this growing list of “preventable” medical disorders – especially if your annual wellness checks reveal that you have gained weight since college, or you habitually fail to exercise at least 90 minutes per day, or that you imbibe less than one or greater than two alcoholic beverages per day – you may be triaged to Tier B healthcare. Tier A will be reserved for people who obviously care more than you do about wellness, and about their duty to society. Just as obesity does today, the state of your health will demonstrate your true commitment to the perfect society to which we all aspire.

For, when it is your duty to maintain wellness, your illness reveals a grave dereliction.

DrRich, in his last post, attempted to show why a direct-pay medical practice is the only remaining pathway by which PCPs may preserve the classic doctor-patient relationship, and for patients to assure themselves that they are working with a doctor who at least has the prerogative to actually place their individual interests first, above all those other powerful, ruthless, contrary interests, which are striving to control the behaviors of their doctors.

He attempted to show this by making an argument founded in the principles of medical ethics.

As it happens, one of today’s best-known medical ethicists, at about the same time, was telling doctors just the opposite. Arthur Caplan, at the University of Pennsylvania Center for Bioethics, published this advice for doctors at Medscape.com. Here is the meat of Dr. Caplan’s admonition:

“No matter how you look at it, if you allow providers to buy out, you are going to leave other patients with lower-quality care, and you are going to burden the remaining primary care practitioners (who don’t take the concierge route) with more work.”

DrRich has two comments.

First, this argument against direct-pay practices is based solely on the goal of social justice.

DrRich has not been shy about expressing his disdain for the views of your typical, modern medical ethicist. Most of these individuals today embrace the utilitarian camp of medical ethics, wherein formerly revered niceties based on ethical precepts (like the classic doctor-patient relationship) must take a back seat to the goals of social justice. And where social justice is concerned the ends justify the means.

Achieving “social justice,” of course, always and inherently requires a powerful Central Authority which has the muscle to make sure that all of the benefits of life are distributed in a just and fair way. What is just and fair, of course, is to be determined by groups of sanctioned experts, a sort of expert class with guns. These will determine who gets what, when and how.

So once again a member of the group of sanctioned experts, who will determine how things are to be, comes right out and tells us: a doctor who embraces the kind of medical practice where a doctor’s only responsibility is to the needs of his/her patient is behaving unethically.

Second, DrRich calls your attention to the most interesting and revealing phrase uttered by Dr. Caplan: “If you allow practitioners to buy out. . .”

What Dr. Caplan is saying is that doctors must not be allowed to establish direct pay practices. It must not be left to them. We must prevent them from doing so. That is, it must be made illegal.

He is laying out a formal ethical argument for doing what DrRich has been warning his readers, over and over again, the Progressives are bound and determined to do: to make it illegal to sell medical services directly to individuals, and for individuals to purchase medical services with their own money. You can only get your healthcare when, how and from whom the Central Authority says.

The message won’t get much more explicit than this, dear readers. DrRich begs you to take heed before it is too late.

DrRich’s recent posts on the death of primary care medicine elicited several responses from readers, not all of them positive.

Most of the complaints DrRich harvested from these posts had to do with his suggestion that the physicians formerly known as PCPs ought to drop out of the dysfunctional healthcare system altogether (the system that has, purposefully and with malice aforethought, wrecked their chosen careers), then strike out instead on their own, and establish private practices in which they are paid directly by their patients.

This suggestion creates, among many in our society (and apparently, among many of DrRich’s readers), a viscerally negative reaction. Many people believe that DrRich is exhorting doctors to embrace their inner greed, and abandon the great lot of patients in order to satisfy their own selfish desires and foolish professional pride.

A reasonably typical comment came from one Tracy, who avers, “Only the rich will be treated. I don’t think we want to do that do we?”

Now, if DrRich were a Progressive, he would take advantage of the fact that Tracy (who thoughtfully provided his website address) is a health insurance agent, and would dispense with him using a scathing ad hominem attack, something like: Look who’s talking about somebody selling a vital healthcare product at such a high price that people can’t afford it!

But DrRich is not a Progressive. So he will ignore the delicious irony in Tracy’s complaint, and address the substance of his comment. To restate Tracy’s objection (and, in fact, all of the objections that have been made to physicians dropping out of the system and establishing direct-pay practices): For doctors to demand that patients pay them directly is elitist and unethical; only the rich will be able to afford this kind of care; a two-tiered healthcare system will develop, and public health will suffer.

DrRich will answer this objection in two ways. First, he will make a philosophical argument as to why direct-pay practices are the right thing to do. Then he will give a real-world example that demonstrates how a direct-pay practice is, in fact, good for patients and for society.

The fundamental argument that supports the rightness of direct-pay practices has been made numerous times on this blog. In summary: In the attempt to control healthcare costs, the Feds and the insurance companies have, in uncountable ways, entirely coerced physicians (using and exercising the threats of loss of income, massive fines, and jail) to place the needs of the payers ahead of the needs of their individual patients. In so doing, they have systematically destroyed the doctor-patient relationship, in the process killing medical professionalism, and reducing patients to objects, to cost centers, and abandoning the sick to their own devices as they attempt to navigate an increasingly hostile healthcare system.

This process is now firmly established. It has been legislated by Congress, embodied in volumes and volumes of rules, regulations and “guidelines” (strictly and ruthlessly enforced), upheld by the courts, and finally (and most tellingly) sanctioned as being entirely “ethical” by the physicians’ own professional organizations.

It has become impossible for doctors – especially the PCPs, who have been most directly affected – to fight this reality. If they want to escape, their only options are to become a medical specialist (since outpatient primary care is the main lever on which the Feds are pushing), a deep-sea fisherman – or a direct-pay practitioner.

So primary care doctors must either resign themselves to a system that ruthlessly pushes them toward an unethical, demeaning, public-health-destroying style of practice, or (one way or another) get out.

The only means that will allow them the freedom to practice primary care medicine in a way that is compatible with true medical ethics – which allows them to place the needs of their individual patient above all other considerations – is the direct-pay model. And this means that the only way for a patient to have a primary doctor who treats them the way patients are supposed to be treated is to find a direct-pay doctor.

To argue that direct-pay practices – or any innovation that would somehow restore both the doctor’s professional integrity and the patient’s rightful advocate – is unethical is completely upside down. It is one of the few viable pathways toward restoring the foundational (but currently obsolete and officially repudiated) medical ethic of always placing the patient first.

To argue that direct-pay practices threaten public health completely ignores reality. In fact, this is one of the few viable pathways toward restoring protections that the public is supposed to have when facing a healthcare system that is utterly bent on avoiding spending money on them.

To argue that direct-pay practitioners are creating a two-tiered healthcare system is ridiculous on its face in a society that gives mere lip service (though, to be sure, plenty of it) to the problem of 47 million uninsured.

To argue that direct-pay medicine will create a subpopulation of elites (because it provides a mechanism by which some individual patients can escape the deadly obstacles that have been intentionally laid before them), is as absurd as arguing that George Washington was wrong to free his slaves upon his death (or even that New York State was wrong to abolish slavery at about the same time), because it created a subpopulation of “elite” (i.e., free) African Americans; that until all slaves were freed, no slaves should have been freed. But freeing at least some slaves – and forthrightly stating why it needed to be done (see: Declaration of Independence) – was not only ethical, but also showed what was possible, and over time created an expectation that eventually could no longer be ignored, and that, at huge cost, was finally fulfilled.

It is important to note that any innovation that can potentially spare patients from some of the harm the healthcare system has in store for them will necessarily be applicable to only some patients at first. That’s how disruptive processes work. They begin as niche products or services, attractive only to a few high-end users; too expensive or too marginal for the vast majority; ignored, ridiculed or castigated by current providers. But if at their core they’re offering something fundamentally useful, they will slowly demonstrate their worth – and eventually all the potential users will see the light, and demand for the product will become explosive. When that happens, the means are found to make the new product affordable and available to meet the demand – often by making significant adjustments to the original concept, that nonetheless preserve the core benefits. And when that happens, the traditional providers (who never saw it coming) are suddenly out of business.

It may not be that direct-pay medicine plays the personal computer to the traditional healthcare system’s mainframe. But it is inarguable that what it offers to patients – at its core – is every bit as vital and every bit as indispensable. And if a critical mass of the public can be made to understand what is really being offered here, there will be no holding it back.

Unfortunately we have a limited window of opportunity. The vociferousness of the complaints against direct-pay practices indicates just how threatening these are to the Progressive program. Unless this practice model gains a sufficient toehold, and quickly, it will be made illegal. Because Americans cannot be permitted to spend their own money on their own healthcare.

DrRich will finish by pointing his readers to a real-world model of a direct-pay practice which, he believes, graphically demonstrates the potential benefits of such a model.

Epiphany Health is a direct-pay primary care practice recently begun by Dr. Steven Shell and Dr. Lee Gross in southwest Florida. These doctors took pains to make their services affordable to many of the uninsured (and underinsured). For about what you would pay for a cell phone contract or for cable TV, they will be your doctors.

Doctors, that is, in the original sense – a professional who knows you well, a personal advocate for your health, who is dedicated to placing your interests above all the other competing interests within the healthcare system. Because they are paid by you, it is you they must satisfy in order to have a viable career.

As Dr. Shell told Sun Newspapers, “Our simple, preventative healthcare plan has several advantages that include true price transparency (cost of services ahead of time), high quality care, affordable fees, no copays, no deductibles, no pre-existing condition exclusions and a plan not tied to an employer.”

In addition to price transparency, Epiphany offers major price discounts to their patients. They have negotiated these discounts with pharmacies, physical therapists, imaging centers and laboratories. These discounts are often in the range of 75 – 80% of the cost to non-members.

Now, if this kind of practice is unethical, elitist, or damaging to the public welfare, DrRich just does not see it. In fact, as much a benefit as this kind of practice might be to doctors, it is far more beneficial to the patients lucky enough to have such an option available to them.

You who aren’t so lucky should look at what Epiphany is offering – and demand it for yourselves. If you do, you will have it. There are thousands and thousands of disaffected doctors who would love to practice medicine like this, but they have been cowed to inactivity by the naysayers (and Progressives) with their cries of, “Elitist! Immoral! Unprofessional!”

If these doctors heard from their patients, all the negatives would be forgotten, and they too would have their own epiphany.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

____
*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 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.

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.

From the ominously-titled book, “New Rules,” by Donald Berwick MD and Troyen Brennan MD:

“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.”

Unfortunately, Dr. Berwick’s straightforward formulation of the appropriate role of the individual physician in our reformed healthcare system is not isolated to thinkers of the Progressive persuasion. The notion that most clinical decisions can be usefully made by a centralized authority is attractive even to some conservatives.

For example, a few years ago the noted economist Arnold Kling strongly defended the idea. “My own view is that a remote third party probably can use statistical evidence to make good recommendations for a course of treatment.”

Now, Kling is no far-left radical, pushing for centralized control of healthcare (and everything else). Indeed, he is now with the Cato Institute, and before that he taught economics at George Mason University. So he has earned his conservative and/or libertarian chops.

And to be fair, he is not really calling here for “remote third parties” to have final authority on what’s best for individual patients. Rather, he thinks patients should make that decision for themselves, weighing the recommendations of data-driven guidelines promulgated by remote experts, against the ego-toss’d recommendations from their all-too-fallible doctors, or, as Kling sarcastically refers to them, their “heroic personal saviors.” (Such sarcasm, regular readers will know, is as abhorrent to DrRich as it probably is to you.) Kling is saying: trust patients, armed with good evidence-based recommendations handed down from experts, to make the right decisions for themselves.

In concept even DrRich supports this latter notion. Indeed, a chief theme of this blog has been that doctors have been coerced into such a compromised position by the government and the insurance carriers that wise patients will no longer simply trust their doctors’ advice explicitly. As things now stand, patients who place full reliance on their doctors, assuming that they’ll get all the information they need to make good medical decisions, are putting themselves in peril. Smart patients will seek out all the information they can about their own medical conditions, so they can confirm that their doctors are indeed presenting them with all their reasonable options, and so they can more intelligently evaluate those options. And certainly, expert-endorsed guidelines would be an important part of that research.

But Kling’s remedy – that patients rely on the treatment recommendations made by expert panels as a remedy to the conflicted advice being doled out by their own doctors – is seriously flawed.

The first flaw, of course, is the idea that remote third parties, wielding evidence-based data, can make good treatment recommendations for individual patients. Evidence-based guidelines, almost by definition, are designed to improve the average outcome across a population of individuals, and are specifically designed not to optimize outcomes for each individual within that population.

Second, Kling apparently assumes that the remote third parties who are producing evidence-based treatment recommendations will be acting in a completely objective and unbiased manner. But this can never be the case. A major theme of the Covert Rationing Blog this past year has been to demonstrate that a) clinical science is probably the least exact of the sciences; b) the design and interpretation of clinical studies is inevitably attended by significant bias; and c) therefore, no matter who is producing them – whether it is medical professionals or GOD panelists (Government Operatives Deliberating) – these guidelines will always be produced with a particular agenda in mind. To assume that such agendas will be primarily – or even remotely – related to optimizing the outcomes of individual patients will often be a serious error.

Third, the idea that patients, even very intelligent patients armed with “perfect information,” can by themselves reliably sort through the morass of conflicting evidence and conflicting opinions that invariably inform any set of clinical recommendations (whether made by vaunted teams of completely objective experts from on-high, or by one’s inherently flawed, conflicted and ego-driven personal physician) is simply false. This would be the case even if the healthcare system were perfectly aligned to help patients. Which, of course, it is not. (It is aligned to affect the covert rationing of healthcare.)

Finally, while the advice patients get from their doctors is indeed biased, more and more it is biased (thanks to heavy-handed coercion) in favor of those same central authorities that are commissioning the expert panels.

As a result, patients – especially when they are sick and least able to fend for themselves – are generally incapable of negotiating the gratuitous complexities and hidden hazards laid out before them by a hostile healthcare system, a system which silently prays they will, in frustration, just go buy themselves some alternative medicine remedy, then crawl under a bush and die while contemplating their qi. Indeed, patients are as incapable of successfully navigating such a system as are accused felons of navigating a complex and hostile legal system that’s bent on sending them away for 15-20 years.

It is for this very reason that accused felons are assigned an advocate, an individual who is ethically and legally obligated to take their part, to help them navigate all the legal hazards, to do everything possible to see they are treated fairly, and that they are given every reasonable chance to prove their innocence. Lawyers, as much as we physicians might like to castigate them, are absolutely critical to a civil society.

And this is the reason why patients (according to traditional, though now quaint, medical ethics) are also supposed to have a personal advocate, an individual who is obligated to take their part, to help them navigate all the medical hazards, to do everything possible to see that they are treated fairly and that all available medical options are made open to them, and that they are given every reasonable chance of a good clinical outcome. Patients, in other words, need doctors who are devoted to the classic precepts of their profession. Such doctors, as much as Kling and others might like to diminish their importance, are also absolutely critical to a civil society.

But, as we have seen, and as has been publicly celebrated by Dr. Berwick and others, severing the classic doctor-patient relationship has been Job One under our system of covert rationing – whether that rationing is managed by insurance companies or by the government. Doctors simply cannot be allowed any longer to place their patients first. They’ve got to place the needs of their true masters first. They’ve got to keep the government and the insurers happy or they’re out of a job. They are no longer permitted to tailor clinical choices to best fit their individual patients, but they are simply to apply treatment directives as they are handed down by (from now on, government-appointed) panels of experts.

And this brings us back to Kling. DrRich of course agrees with his notion that patients ought to be armed with the high-quality information they need to determine their own medical destiny. DrRich can even agree that relying solely on the information provided by today’s doctor is generally not advisable. But DrRich cannot agree with the reason it’s not advisable. Doctors aren’t so much inherently flawed by ego and other intrinsic character flaws (at least, no more than any other group of humans), as they are operating under duress, under imposed constraints, and under external coercions that systematically and purposefully prevent them from discharging their professional obligations.

Nor can DrRich agree with Kling’s proposed solution. No centralized set of recommendations, evidence-based or not, can fix this problem for patients – especially when the expert bodies that make those recommendations are controlled by the same entities that have, with malice aforethought, killed the medical profession for the express purpose of stripping patients of their advocates, and therefore, of their medical options.

DrRich has trouble seeing a solution to this problem that is not radical. He does not see how doctors can resume their rightful place as their patients’ advocates and remain in what has become of the traditional healthcare system. Perhaps enough doctors to make a difference will leave the traditional healthcare system, shedding themselves of the third parties who now control their behavior, and re-establishing their practices (and revitalizing their profession) with a new commitment to the doctor-patient relationship. If not, then perhaps some brand new profession will establish itself (call it “personal healthcare advocates”) to fill the great void that threatens the safety of every American patient.

So yes, let individual patients weigh all the evidence and choose the healthcare option that suits them best. But unless they have a personal advocate to help them navigate the morass of biased choices – whether that advocate is their PCP like it’s supposed to be, or some new variety of professional advocate – those options will be limited to whatever healthcare is deemed best by the central planners.

A fine economist such as Dr. Kling should realize that a remote third party can no more make good recommendations for individual patients trying to survive in the rough and tumble of the healthcare system, than can a remote third party make good recommendations for individual businesses trying to compete in the rough and tumble of the marketplace. It is one thing for Progressives to hold to such a notion. It is far more disturbing to see respected conservative thinkers doing so.

Regular readers will know that DrRich is not enamored with Obamacare. Further, they will recall that DrRich’s chief objection to Obamacare is that it codifies into law the final destruction of the classic doctor-patient relationship.

Under Obamacare, the physician is not only released from her fiduciary obligation to her individual patient (i.e., the obligation to place the interests of the patient above all other considerations), but is strictly forbidden from acting in accordance with it. Indeed, elaborate mechanisms are established to assure that physicians will follow the directives which are to be handed down from omnipotent and immutable government panels, directives which will be explicitly aimed at optimizing collective rather than individual outcomes. And whereas physicians have long been discouraged from making healthcare decisions based on individual considerations and needs, Obamacare makes doing so a felony.

Combine that fact with inevitable future provisions that will prevent doctors from opting out of the system, and patients from spending their own money on their own healthcare, and you’ve got a prescription for a healthcare system (and a society) that are somewhat less friendly to individual needs, and somewhat more tyrannical, than supporters of Obamacare have promised us.

So, as a matter of principle, DrRich is sympathetic toward the newly-elected (and newly-reformed) Republicans who promise they will introduce and vote on a bill to repeal Obamacare.

But let’s be realistic. Even the most zealous Republicans understand that any repeal bill that passes in the House will stall in the Senate, and if it does not, the President will veto it. Indeed, it is this comforting assurance, DrRich thinks, that will induce many Progressively-oriented Republicans to go along with a repeal vote in the first place. By voting to repeal Obamacare, frightened and disoriented Republicans can mollify the Tea Party, without risking an actual abolition of the new reforms. Because if Obamacare were somehow repealed – well, where would the Republicans be then?

The health insurance industry, however, is taking no chances.

DrRich will remind his readers that Obamacare never would have become law in the first place if not for the solid and unrelenting support of the health insurance industry. The industry’s support for Mr. Obama’s effort was unfaltering. And during the long and perilous process that finally brought Obamacare to the President’s desk, whenever the cause faltered and appeared to be lost, representatives of the insurance industry would rise up and take whatever strong and difficult action was needed to get it back on track.

DrRich will further remind his readers that the insurance industry did not support Obamacare out of any principle, or compassion, or any sense of what was moral or right. They did it as a matter of life and death – theirs. For the health insurance industry had run out its string, shot its wad, blown up its business plan, and had nowhere else to turn. It was Obamacare – and its soothing “promise” to allow the industry to survive in diminished form, as a government-controlled utility – that offered insurers their only visible path away from oblivion.

The insurance industry is not about to go back. Furthermore, unlike Nancy Pelosi, Harry Reid and even President Obama, the insurance industry is not satisfied to let the political realities of the day block the Republicans’ efforts at repeal. For all they know, nervous Democrats in the Senate who want to be re-elected in 2012 will allow the repeal bill to go to the President’s desk. Worse, unused to seeing Presidents willing to sacrifice themselves on the alter of principle, the health insurers, in their existential panic, must wonder whether even Obama might finally change his mind and decide that he wants to be re-elected badly enough to sign a repeal bill. These possibilities seem pretty far-fetched to DrRich, of course, but to DrRich the prospect of repeal does not spell Armageddon.

During the long and painful process that saw Obamacare become law, the health insurers clearly demonstrated just how far they were willing to go to keep that process alive. DrRich is certain they will be happy to go at least that far to block repeal.

So it came as no surprise when, just last week, the insurers sent Republicans their first, gentle reminders that they will not countenance any such thing. At the Reuter’s Health Summit in New York, David Cordani, the CEO of Cigna, warned Republicans, “I don’t think it’s in our society’s best interest to expend energy in repealing the law. Our country expended over a year of sweat equity around the formation of it.” And Mark Bertolini, president of Aetna, said that any attempt to repeal Obamacare, or even an attempt to hold up funding for it, would be “problematic.” “We can’t go back,” said Bertolini,  “We need to keep moving, and we need to improve upon what we have.”

These seemingly mild-mannered statements should send a chill up the spines of Congressional Republicans. Any repeal of Obamacare necessarily and utterly relies on the acquiescence of the insurers, on their desire (or at least willingness) to continue with their current business model (possibly with some tinkering around the edges). Republicans, bless their innocent hearts, assume that’s what the insurers want.

But the truth is that the insurers know that their current business model is completely defunct, and far beyond any salvation. They see Obamacare as their only visible lifeline, and any serious threat to Obamacare as a threat to their survival.

The health insurers simply will not countenance a repeal of Obamacare. They will do whatever is necessary to demonstrate this fact to the Republicans. Their initial foray is suitably gentle. But once the repeal effort gets revved up, watch out. The insurers have already graphically demonstrated just how ungentle they can be.

If the Republicans really want to get rid of Obamacare, they’re going to have to propose an alternate solution that, among other things, provides the health insurance industry with a new and viable business model, one that seems at least as good to them as the rather paltry one Obamacare has promised. (If the Republicans want such an alternate solution, they have only to ask DrRich.)

DrRich does not think the Republicans have any idea of what may be coming their way, and from the very industry, no less, they consider to be their chief ally in the healthcare wars.

They should pay more attention.

In his last post (and in several past discussions) DrRich asserted that the Hippocratic Oath has been declared formally and officially obsolete by the medical profession itself, and that as a result of this action, the medical profession has voluntarily placed the professional viability of all physicians entirely into the hands of the government. Hence, DrRich has postulated, the Amish Bus Driver Rule is thereby activated, which permits (and probably compels) the government to use the leverage of medical licensure to control and direct the behavior of physicians – even their ethical behavior.

Lest anyone think DrRich is exaggerating about this, let us listen to the words of some of the physician-intellectuals who now hold positions of official responsibility, within the Central Authority itself, for determining the behavior of American doctors. DrRich asks his readers to notice both the content and the tone of these words, as both are important.

First, listen carefully to Donald Berwick, MD, recent recess-appointee to the position of head of CMS, in a passage from his ominously-titled book “New Rules,” (co-written with our old friend Troyen Brennan, MD):

“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…Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority…Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.”

(Thanks to Dr. Gaulte of the excellent blog, Retired Doc’s Thoughts, for pointing us to this valuable passage.)

Dr. Berwick’s views on the need to constrain individualized decision-making in the practice of medicine is echoed by none other than Ezekiel Emanuel, MD, PhD. Dr. Emanuel is a bioethicist at the National Institutes of Health, and a fellow at The Hastings Center (a bioethics research institution). He is the brother of former White House Chief of Staff Rahm Emanuel (himself an expert in political ethics). Dr. Emanuel was brought in to the Obama administration as a high-ranking adviser on healthcare reform, and is widely expected to have a strong hand in determining who will sit on the GOD panels and how those panels will operate.

Regular readers will recall that Dr. Emanuel is also the co-author of that infamous paper recently accepted for publication in the Annals of Internal Medicine (and whose editors, thereby, formally auditioned for seats on those GOD panels) which called upon American physicians to abandon their ancient tradition of primarily serving their patients, and instead embrace their true destiny, which is assimilating into the Borg.

DrRich has found two instances in Dr. Emanuel’s writings in which he specifically commented on the obsolescence of the Hippocratic Oath.

In the May 16, 2007 issue of the Journal of the American Medical Association, in an article entitled, “What Cannot Be Said on Television About Health Care,” Emanuel expresses the following complaint about American physicians: “Reasoning based on cost has been strenuously resisted; it violated the Hippocratic Oath, was associated with rationing, and derided as putting a price on life, akin to the economist who knew the price of everything but the value of nothing.”

In the June 18, 2008 issue of the same journal, in an article on healthcare “overutilization,” he discussed seven factors that drive the overuse of medical services. He identifies one of these factors as a “culture of unwarranted thoroughness” on the part of American doctors, which serves to drive up cost. “This culture is further reinforced by a unique understanding of professional obligations, specifically, the Hippocratic Oath’s admonition to ‘use my power to help the sick to the best of my ability and judgment’ as an imperative to do everything for the patient regardless of cost or effect on others.”

Thus, Emanuel finds that it is a stubborn adherence to outdated medical ethics, which causes doctors to strictly place their individual patient’s interests above society’s interests, that accounts for a substantial proportion of unnecessary healthcare costs.

These passages from the very physicians who are directly driving healthcare policy through the auspices not of professional medical organizations, but through the auspices of the Central Authority itself, are striking in two ways.

First, their directness is striking. Doctors no longer work for the good of their patients; they work for the good of the collective. And heretofore they are obligated to follow the rules which are promulgated centrally, rules backed by the righteous force of the Central Authority, rules whose primary function is to make sure that decisions on medical care will be directed centrally, rather than at the doctor-patient level.

Second, the indignation these passages reflect is striking. The obligation of physicians to follow central directives is not an item of negotiation or persuasion – it is a DONE DEAL. Physicians’ own elected leadership of their own professional organizations – all of them – have formally signed on to the New Ethics, ethics which obligate doctors to practice medicine in a way that follows the dictates of remote panels guarding the interests of the collective  (rather in a way that jealously guards the needs of individual patients). And while this abandonment of an ethical precept that had been in force for over two millennia was promulgated with little fanfare, and while most practicing physicians seem not to realize that it has even happened (though we can be sure that all medical students everywhere are being steeped in it), it is a DONE DEAL.

And doctors who persist in practicing the “old way,” are not only acting in a manner that is “no longer tenable or possible,” but they are also violating the very ethical precepts which their own profession has now voluntarily adopted. They are behaving unethically. They are being evil.

No wonder our physician leaders are indignant. No wonder they have little choice but to divine the necessary “rules with authority” to force these recalcitrant physicians to do their self-admitted duty to the collective. By persisting with their old fashioned ideas in the face of that which medical ethics now prescribes, doctors are forcing the Central Authority to take strong action. Fortunately, since (we all know) our government is a benign entity, it will begin gently, with tough central rules and regulations (backed by authority) to “constrain decentralized individualized decision making.” The Central Authority will only invoke the Amish Bus Driver Rule (or worse) if these kinder, gentler steps fail.

As for the doctors who do not like this new reality, DrRich has a harsh message. You brought this on yourselves, by allowing your professional organizations to propose, write, and adopt these “New Medical Ethics.” For all the statements of Berwick, and Emanuel, and other health policy experts, castigating you for your inadherence to these new ethics, are predicated on the fact that you have a formally-adopted obligation to follow them.

It does no good to protest that you yourself were unaware that your profession has taken this formal action. Just as President Obama is your President whether you voted for him or not, the New Ethics is your formal rule whether you agreed with it (or were aware of it) or not.

And if you do not like the idea that the details of your behavior as a practicing physician are going to be handed down from on-high, and that you are not to be permitted any longer to primarily advocate for your patient, against the competing interests of the slavering Central Authority, you have nobody to blame except yourself.

And what this tells us is that if you are going to change things, you cannot hope to seek relief from legislators, or from your medical leadership (which has already assimilated with the Borg). Your only hope is to begin by reclaiming your profession yourselves, and re-asserting your primary obligation to your patient. There are several ways to undertake such a course, all of which will require standing up to the government and to your own leadership, and all of which will be difficult and dangerous at this late stage.  But it is the only path that remains open to you for your professional salvation.

Just keep this undeniable fact in mind: Obamacare, or any other form of centralized control over the practice of medicine, can only be achieved with the active acquiescence of physicians themselves. If physicians decide they simply will not allow themselves to be coerced to unethical medical actions, and insist on reestablishing the doctor-patient covenant as the guiding precept of their profession, the entire house of cards will fall. Physicians are far from powerless, if they would only dare to act.

We will still need healthcare reform, to be sure, but physicians have the power to insist that it can only be a kind of healthcare reform which fully honors and guarantees that covenant.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Hippocratic Oath was kind of like that.

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

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

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

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

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

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

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

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

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

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

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

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.

In a remarkable article that somehow* was accepted for publication in the Annals of Internal Medicine, the White House offered some friendly advice to American PCPs who may be wondering how Obamacare will affect them. That advice, to summarize, is: “We are the Borg. Prepare to be assimilated.”
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* DrRich is forced to wonder whether yet another group of medical editors is auditioning for the death panels.
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The article was written by Ezekiel Emanuel from the White House’s Office of Management and Budget, and Nancy-Ann M. De Parle, who is Mr. Obama’s Czar of Healthcare Reform. (A third author was from the McKinsey Group.) After reminding physicians of their moral obligation to the collective, the White House authors rhapsodized about all of the wonderful changes inherent in Obamacare that will help physicians to realize this obligation.

There’s actually no need to read the entire article, assuming you heard any of the 400 speeches President Obama delivered in his unsuccessful attempt to convince the public that his healthcare reforms ought to displace the holy writ as The Good News. The meat of the article, if you’re a physician, appears at the end:

These reforms will unleash forces that favor integration across the continuum of care. Some organizing function will need to be developed to track quality measures, account for and manage shared financial incentives, and oversee care coordination….These coordinating functions, to the extent that they currently exist, traditionally have been managed by hospitals or health plans….As physicians organize themselves into increasing larger groups — patient-centered medical home practices and accountable care organizations — they are, out of necessity, investing in information technology tools that are becoming both cheaper and more capable and investing in the acquisition or development of management skills that could provide these organizing functions efficiently for physicians groups….For physicians, this means a profession that is more rewarding, more productive, and better able to realize its moral ideal.

DrRich translates this message thusly: “Physicians! You have been neglecting your moral obligation to the collective, in favor of your archaic devotion to the individual patient. Under Obamacare you will need to join organizations which are devoted to the collective goals of Obamacare, and which therefore will guarantee the proper moral ideals. You must function not as individual decisionmakers, but as integrated cogs in a vast healthcare continuum, which will stretch from the centralized bastion of gleaming moral authority (from which we pen this message) all the way down to the humble tip of your stethoscope. You will be rewarded for your cooperation, or suffer for your resistance (resistance, of course, being futile).  So rejoice for the health of the collective, and for your own well-being, and prepare to be assimilated.”

Ostensibly this message is for all American physicians, but it was submitted to the Annals of Internal Medicine for a reason. The Annals is the journal of record for doctors who practice internal medicine, and who comprise the largest group of PCPs. The White House in this article is speaking directly to American PCPs.

This is because PCPs pose the greatest short-term threat to Obamacare.

Most medical specialists have already been “assimilated.” Because they require lots of expensive stuff to practice their specialties – things like gamma cameras, operating suites, catheterization laboratories, hordes of highly trained medical technicians, &c. – it is very difficult for most specialists to function as independent operators. If you want medical specialists to follow the rules, all you have to do is make following the rules a requirement for keeping their access to all the technology and the complex infrastructure they need to practice their specialties.

Only PCPs can fairly readily make themselves independent from the collective.  And more and more PCPs are choosing to do so.

The White House does not like this.  The Annals article, DrRich thinks, is the administration’s first official attempt to curtail the PCPs’ fledgling independence movement. The threat is veiled – the article instead appeals to the PCPs purported moral obligation to the collective, and emphasizes the rewards that will follow when PCPs allow themselves to be assimilated into the Borg.

So this first attempt, for the most part, is merely creepy. The next step will not be as benign.

DrRich urges his PCP friends to take heed. If you have any thought of striking out on your own, and starting a direct pay practice – thus reasserting your profession’s real moral obligation, which is to your patients – you had better act now, before it becomes a federal crime to do so.