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Friday, February 12, 2010

Politics and medicine

It appears that if one includes ethics in the title and apply the appropriate spin, you can almost anything published in the New England Journal of Medicine.

 Medicine's Ethical Responsibility for Health Care Reform — The Top Five List by Harold Brody, PhD, MD
The author takes the moral high ground in the introduction by stating
It is appropriate to question the ethics of organized medicine's public stance. Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the "special interests" affected by health care reform, justify demanding protection from revenue losses?

Not an unreasonable argument, although I am not sure this will sway many physicians on a daily basis. I can tell you it would not carry much weight at my institution. I do not see us firing our lobbyist and giving them the instructions not to protest Medicare's pending 20% pay cut.

Then the article goes from making an elegant but ineffectual plea to outright loss of reality testing:
In my view, organized medicine must reverse its current approach to the political negotiations over health care reform. I would propose that each specialty society commit itself immediately to appointing a blue-ribbon study panel to report, as soon as possible, that specialty's "Top Five" list. The panels should include members with special expertise in clinical epidemiology, biostatistics, health policy, and evidence-based appraisal. The Top Five list would consist of five diagnostic tests ortreatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit. Examples of items that could easily end up on such lists include arthroscopic surgery for knee osteoarthritis and many common uses of computed tomographic scans, which not only add to costs but also expose patients to the risks of radiation.4,5
Having once agreed on the Top Five list, each specialty society should come up with an implementation plan for educating its members as quickly as possible to discourage the use of the listed tests or treatments for specified categories of patients. Umbrella organizations such as the AMA might push hard on specialty societies and pressure the laggards to step up.
Are they serious?  I will be the first to agree that expensive and dubious interventions litter our health care landscape. These particular dubious but lucrative interventions are also ones that likely float many of the major health care entities. Furthermore, in my opinion those individuals and departments which have most effectively exploited these most lucrative intervention now also essentially control major health care entities. No one gains power and influence at either for profit or non-profit by eliminating highly lucrative interventions to save the public money.

 Does the author actually believe that moving these discussions from Congress to these "blue ribbon" panels will move  them out of a political realm? Huge capital investments have been made based upon the business cases of these lucrative diagnostic or therapeutic interventions. Who will be appointed to the panel that will be willing and/or able to undermine the financial model of the very specialty societies which appoint them? They will gain their positions through political wrangling and those perceived to represent the specific interests of a given specialty society are most likely to be appointed. Decisions to be made will be made through a political process with a similar outcome.

As medicine becomes more dependent upon politically sensitive sources of funds, decisions regarding allocation of resources within medicine will move more and more into the political realm. As sums at stake get larger and larger, the political fights will get uglier and uglier. No amount of Utopian yearning will change this.


  1. Having read other articles by Howard Brody and his book, Hooked, I am fairly confident that he is under no illusions about entrenched power and perceptions and that his Top 5 proposal is purely rhetorical.

    btw, Thank you for informing me about your blog.

  2. Are you suggesting that this piece was written basically tongue in cheek or just an attempt to embarrass those who are entrenched?

  3. Here's the TOP FIVE for pathology!!

    1) 88305
    2) 88305
    3) 88305
    4) 88305
    5) 88305