Sunday, January 15, 2012

Does Revised American College of Physicians Ethics Manual Need Revision?

I regard myself as a spirited patient advocate. (What doctor doesn’t?) When facing a patient, I try to focus entirely on the patient’s interest. My advice is hopefully not tainted by the patient’s insurance status or external influences. A patient without medical insurance should receive the same medical advice as a corporate CEO, although the former may reject the medical advice for financial reasons.

As Whistleblower readers know, I am a conservative practitioner of the art and science of gastroenterology. I first developed this medical world view as an intern and resident, and remained a parsimonious practitioner even after completing a gastroenterology fellowship at an institution where patients were routinely subjected to a tsunami of testing.

I don’t pull the colonoscopy trigger easily or order many imaging studies. I prefer to prescribe a tincture of time instead of a test. Most patients appreciate this measured approach, although some prefer the tsunami.

I don’t practice conservatively because it is cost-effective. I do so because I think it’s best for patients. I think it is inarguable that our patients are over imaged, over treated and over tested. I am convinced that there is more than enough wasted money in the health care system to rescue it. Reminiscent of Eisenhower’s warning of a military industrial complex, we are now trying to chip away at a medical industrial complex that is an expanding hydra that takes no prisoners. This is not to suggest that I support Obamacare as a remedy,.  I don't. For a fuller airing of my Obamacare opposition, I invite you to wander through the Health Care Reform Quality category on this blog. But, our health care system surely needs better health. It has inadequate access for millions of patients, conflicts of interests, misaligned incentives and quality lapses that must be addressed. I think that Obamacare aims to restrain excesses and remedy deficiencies by settling for mediocrity. I’d rather strive for excellence.

Physicians are strongly advised to practice cost-effective medicine, a practice that is often resisted by patients who interpret this as an effort to save money at their expense. Of course, the term cost-effective communicates that the mission is to save dollars and not save lives. Perhaps, the medical linguists who have concocted phrases including pay-for-performance and medical provider and pharmacy benefit manager can create a more appealing label. Here are some suggestions.

  • No Frills Medicine
  • Cheapo Medicine
  • Medicine on Five Dollars a Day
Seriously, even the hackneyed evidenced base medicine (EBM) phrase would be a step forward. However, EBM is limited since so many clinical issues that doctors face must be addressed without any available medical evidence to guide us. Perhaps, readers have a suggestion of a better phrase than cost-effective

Recently, the American College of Physicians issued revised guidelines in its newly published ethics manual that instructs physicians that our responsibility extends beyond the patient before us. Here’s an excerpt.

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.

This is an ethical game changer. According to the updated ethics manual, physicians should consider preserving health care resources for the population at large, which may conflict with our patient’s interest. Now, we are told that we are ethically obligated not only to advocate for our own patient, but also for hundreds of millions of other patients. If this becomes standard operating procedure, how will it impact the doctor-patient relationship? Will patients, who are increasingly skeptical of the medical profession, trust us? Will they suspect that we are restraining their care to serve the greater good?

I think that the merits of cost-effective medicine can be persuasively made to individual patients without having to consider society’s needs. Of course, preserving medical resources and health care reform are legitimate issues. But, do they belong in the exam room?

How would patients respond to the following question?

When seeing your doctor in the office, do you expect that he is focused on

(a) your medical interests exclusively?

(b) your medical interests exclusively on Mondays and Wednesdays?

(c) your medical interests exclusively if you are a concierge medical patient?

(d) your medical interests and society’s need to save money?

Physicians are trained advocates. Remind me, who are we advocating for?

As always, your comments are most welcome.


The Medical Contrarian said...

No servant can serve two masters. We can try. It tends to end badly particularly when we are not particularly transparent about things.

Mark Faasse, MD said...

There's often no inherent conflict between value-centered and patient-centered care when the potential harms of intervention are honestly and carefully considered. Fortunately, we aren't yet in a position of being forced to choose between the delivery of high-value and higher-value care. Plenty of care provided in the US healthcare system is of inarguably low value and represents "low-hanging fruit." The question is: will we as a profession rise to the challenge and set aside our short-sighted pursuit of every last dollar?

- Brody, "Medicine's Ethical Responsibility for Health Care Reform – The Top Five List"; NEJM 2010; 362:283-285
- Porter, "What is Value in Health Care?"; NEJM 2010; 363:2477-2481
- Smith and Hillner, "Bending the Cost Curve in Cancer Care"; NEJM 2011; 364:2060-2065

Michael Kirsch, M.D. said...

Comments appreciated. "Will we as a profession rise to the challenge..." Let's hope, Mark, that there will be a profession in the years to come.

James Gaulte said...

It is an ethical game changer as was the publication of the ACP's New Professionalism.I wrote about that issue and your blog comments.
I appreciated your analysis.

Anonymous said...

What do you think of the statement: Physicians and Surgeons are the Guardians of our Health Care Resources.

Add this