What happened to doctors serving as advocates for their patients?

The Hippocratic Oath. Most medical students in America recite some version of this oath at their medical school graduation. Its text implies a sacred and overriding respect (ethic if you will) for the individual.

Doctors are currently witnessing the profession of medicine moving from the ethic of the individual to the ethic of the collective. The passage of the Affordable Care Act has solidified this treatment ethic and, as a consequence, often creates conflicts between the treating physician and their individual patients.

Nowhere is this shift to the ethic of the collective clearer than our expanding attempt to determine treatment “appropriateness” using a look-up chart of euphemistically-scored clinical scenarios owned and trademarked as “Appropriateness Criteria®” or “AUC®” by our own medical professional organizations. For those unfamiliar, these “criteria” label the care rendered in hypothetical clinical situations as “appropriate”, “uncertain” or “inappropriate.”  While touted as “evidence-based,” these criteria simply are not — they are a consensus opinion of a collection of physicians for clinical scenarios unrelated to any real patient.

What happened to doctors serving as advocates for their patients? Are doctors really turning to these tables to decide which clinical care to render? Or do we really use them to make sure their EMR note reflects aspects that will assure third-party payment for care?

As we wallow in this latest unfortunate mandate being served to doctors, perhaps there is some use in investigating the origins of these ridiculously-complex criteria, for it is telling.

A few clicks of a computer will show the idea of “appropriateness” came from the Europeans via the RAND corporation. The organization quickly spread abroad and is now RAND Health in Santa Monica, California, USA and RAND Europe in Leiden, the Netherlands. Not surprisingly, it is those who stand to gain from the business of medicine, the vast majority of whom are not even doctors. It is also worth noting that this is the same RAND organization that promoted unrealistic estimates of cost-savings to our health system afforded by electronic medical records subsidized and promoted by the government today; the same business interests who make billions upon billions on Wall Street.

Our professional subspecialty societies, often funded by these very same organizations who sit as board members of the RAND Corporation, have turned a blind eye to this conflict of interest. They have adopted the process “in response to the imperative for improving the utilization of cardiovascular procedures in an efficient and contemporary fashion” and few have ever questioned its downside.

In turn, doctors who use these methods collude with our well-meaning professional society colleagues to perpetuate a health care delivery model that prioritizes business interests on behalf of the “collective” above those of the individual patient. Why are we allowing trademarked intellectual properties like “Appropriateness Criteria®” to substitute for clinical judgment about our patient’s individual clinical circumstance?  Could our societal self-appointed gurus ever know anything about the constellation of complicated medical and social circumstances that patients bring before us in the private confines of our office?  Of course not.

Yet here we are.

It seems a day never ends that physicians aren’t being instructed on what else we must do to massage a chart for the good of the collective without a moment’s consideration of what their “criteria” might mean for our patient’s best care.

This is our new ethic, our new reality.

Speak out against this practice and the doctor is instantly labeled “non-evidence-based,” “greedy,” “self-serving,” and “unconcerned” about the “patient collective.” So doctors actively put their heads down and care for their patients as best they can.  Daily, doctors experience the angst of this movement. We don’t want to admit what has happened. Time and again we find ourselves constrained by these guideline- or appropriateness use-directed care that has been authorized by our own “physician collective” as “appropriate” when, by its very nature, is outdated by the time the guidelines are published, static and fail to incorporate newly-vetted therapies, and conflict with our patient’s actual medical needs.  Our field of medicine has become so complicit with this movement that we’ve even allowed our political and justice systems to threaten or impugn those who step outside these or other outdated care guidelines.

When doctors abandon our most basic ethic of caring for the individual for that of the collective, we are served our just desserts. Perhaps writing something like this will open our eyes. Or perhaps, as we’ve been so quick to do, we’ll choose to keep them closed and not admit that this has happened.

Remember this when others say no to the care your patient needs.

Wes Fisher is a cardiologist who blogs at Dr. Wes.


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  • Dr. Drake Ramoray

    I think we are getting tired. Insurance companies, bean counters, and administrators have decided to continue the beatings until morale improves. I just finished my second letter, having supper with my family at the office, to appeal the denial of a pituitary MRI in a patient because they denied it based on the wrong diagnosis code a month ago. I corrected them and pointed out that a different and correct code was used for the MRI. The reply to my letter says the denial stands and they then proceeded to state the very clinical scenario that I am treating as an example of what is required to get the MRI. So second letter this time copied to the insurance commissioner in my state.

    The patient hey a guy in his 20′s who probably has a brain tumor. I’m advocating, but Im getting really tired of it, and so is my family.

    • Suzi Q 38

      Dr. Ramoray,

      My various MRI’s were denied until the doctors gave up and gave me the insurance phone numbers and who they spoke with last.
      I called them personally and told them a thing or two.
      I pulled out the “cancer card,” and they agreed to all MRI’s.
      I recently needed another MRI on my right knee, which was initially denied. The receptionist gave me the phone number again, and I was able to get approval.

      I have PPO insurance, so IMHO, they should not be giving me grief.
      Try having the patient’s family call.

      It is worth a try.

      Good Luck.

      • DoubtfulGuest

        Good for you, Suzi Q 38. I think quite a few people would be willing to take initiative to deal with their insurance company if they knew it could have an impact. I can think of times I should have done this but was too overwhelmed/feeling poorly to think of it. Also I didn’t understand how it works. Doctors, please try asking the patient — it’s a reasonable request and we might just need it brought to our attention.

      • Dr. Drake Ramoray

        An excellent point.

        Fortunately this patient is involved in this case. My state also has an excellent insurance commissioner. I always tell my patients I’m with them but we should work it from both ends.

        I’m suspicious that this company knows that my patient’s insurance is changing (we don’t know this for sure) and that they are trying to drag their feet till the end of the year.

    • querywoman

      Have you heard from your state insurance board yet? Texas always sides with the insurance board, but I have not written them in years.
      Did you try just submitting a brand new request?

  • maryhirzel

    Poke around http://aapsonline.org/, a much maligned and misunderstood physician organization that has been warning of where third party interference was heading for many decades.

    Difficult as it will be, getting out of third party paid practice is the only hope of turning this around.

    Cash paying patient for over 20 years.

    • ninguem

      I’ve always found the AAPS to be a buffet table.

      Lots of stuff I like, a few dishes not for me. I’ll leave it on the buffet table.

      Interesting discussion there once at a meeting with someone who took great pains to explain the difference between the Libertarian Party and the Constitution Party.

    • SarahJ89

      I’m on Medicare. I’m not rich, not by any means. But I would prefer to pay cash to have my PCP left alone to practice as s/he used to and reserve my insurance for more complicated things. Of course, that’s now impossible because all the practices around here are owned body and soul by the local hospital.

  • disqus_qJEMXTKtR1

    Our medical profession has been taken over by big business. We have allowed their “MBAs” to overwhelm our “MDs” becoming their commodity for profit resulting in huge corporate salaries and golden parachutes. Decades ago they saw this potential, and our lack of business understanding, leadership, inflated egos and arrogance has led to this situation.

    What can we do? Organize and find a “voice” informing the public of this threat. It is truly David versus Goliath, and our sling must intellectually be a massive public relations campaign of medical professional writers to fight back. Whether it be a loosely banded group, or large national organization, the public ire must be raised.

    Anybody with me?

    Gene Uzawa Dorio, M.D.

    Santa Clarita, CA

    • SarahJ89

      Honestly? I see some small hope in that patients and doctors are actually able to discuss common issues here. I know I’ve learned a lot about the kinds of pressures doctors are under, some of which I’d figured out, some not. You almost need another union. Your union of record (AMA) has seriously failed you.

      • disqus_qJEMXTKtR1

        Unfortunately, the AMA is not a union and therefore doctors are not able to strike nor negotiate through collective bargaining. If so, that would change some of the present dynamics.

        Gene Uzawa Dorio, M.D.

      • Suzi Q 38

        I agree.

    • Suzi Q 38

      If you want to keep your sanity, I say “go for it.”
      What do you have now?
      Are you just waiting for them to tell you they are only going to pay $20.00 a patient?

  • SarahJ89

    It’s no picnic being a patient in this scenario, either. I much prefer lifestyle changes and in-office diagnostics to pills and incredibly expensive tests but I’m never offered anything but pills and incredibly expensive tests. We got labeled “noncompliant” as you are rated “non-evidence based.”

    • SarahJ89

      I have to add that the incredibly expensive tests are offered (pushed, actually) when and as my insurance covers them. This isn’t the doctor’s doing, he’s got people looking over his shoulder.

    • May Wright

      Carrying the label “non-compliant” as a patient would be as bad as carrying the label “disruptive” as a physician. And unfortunately, both those labels are hard to shake once they’ve been stuck on you.

      • rbthe4th2

        I’ve found doctors sling it around quite frequently when the patient calls them on evidence based medicine. I think my favorite was when 2 docs gave me 2 opposing treatments and I told them, I have to be non compliant to someone. Sure enough, I got called non compliant.

  • Rob Burnside

    In general, I think this is an unfortunate result of our transition to a “service” economy, wherein “process” has become “product.” But it’s a more abstract product than widgets or wingnuts, and therefor more difficult to improve. This is where professional organizations like the AMA could really do some good, by approving or disapproving various service components like the SAE (Society of Automotive Engineers) approves or disapproves motor oils.

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