So there I was, trying to figure out why all these bigshots are telling me not to test my patients, and wondering why (and remembering I was once sued for not ordering a test that was still experimental at the time, and only available 800 miles away at a University that was doing a study on the test at the time).

So what am I talking about? from AMA wire 

Nine physician specialty societies in the new Choosing Wiselyâ„¢External Link campaign have each identified lists of five frequently performed medical tests and procedures that often are unnecessary. …

Yes, these organizations spontaneously responded to pressures from their members to do this…or maybe not:

Intended to promote health care quality and patient safety, the campaign is a partnership between 17 health care organizations, the ABIM Foundation and Consumer Reports.

So the impetus came from bigshots, not from the grassroots. The bigshot organizations (who are funded how?) pressured the actual organizations that represent physician to make out these lists. Most of the lists are well known to docs, but we sometimes order them because we treat patients, not lists.

But why are these lists being released right now, with a lot of propaganda publicity in the press, instead of quiet notices in medical journals?

Answer: To pressure the doctors who don’t agree with the list. And to educate patients that health care costs money by substituting words like “evidence supported” tests or medicines for what is actually medical rationing, “Quality of life decisions”  instead of death panels, and “quality assessment and improvement”  for letting bureaucrats decide what health care you are allowed.

One suspects that in the near future, these “suggestions” will be codified in law, so you not only won’t be paid if you order them, you might end up being fined for not following the “scientific guidelines”.

The first nine listsExternal Link, released last week, aim to promote conversations between physicians and patients to determine whether those common tests and procedures are  supported by evidence as necessary and whether they will expose patients to risks of harm.

See, you aren’t treating patients by ordering tests, you are “harming them”…all of this is about not hurting patients, right?

from page 2 of their site:

Choosing Wisely® is part of a
multi-year effort of the ABIM Foundation, along with its partners, to
help physicians be better stewards of finite health care resources.

ah ha…remember that word: “stewards”…and remember that part about “finite health care resources”…

So who is the “choosing wisely” organization behind the “initiative”? the Foundation of the American Board of Internal medicine (ABIM).
So who is the “American Board of Internal medicine” who is behind the “chosing wisely” campaign? from Wikipedia:

The American Board of Internal Medicine (ABIM) is a non-profit, independent (italics mine) physician evaluation organization committed to continuously improving the profession for the public good by certifying physicians who practice internal medicine and its sub-specialties. It is not a membership society, educational institution or licensing body but an organization that assess the clinical judgment, skills and attitudes essential for the delivery of quality patient care. (italics mine).

So, this is not a “specialty group”, i.e. grass roots group, but a top down group whose main function is to test docs to see if they are smart enough to be called board certified Internal medicine specialists.(The group that actually represents Internal Medicine specialists (i.e. adult medicine) is traditionally (since 1915) the America College of Physicians. That means docs pay good money to join them.)

And who is the ABIM foundation? from Wikipedia:

The ABIM Foundation is a not-for-profit foundation established by the American Board of Internal Medicine (ABIM) in 1999 to advance medical professionalism and physician leadership in quality assessment and improvement. Their mission is to ‘engage in an ongoing dialogue about  medical professionalism by sharing tools and resources with others who are working to build an equitable, affordable and high quality health care system.’ (italics mine).

A lot of physician groups, such as my specialty group, the AAFP, joined probably for the same reason that the AAFP backed the Obamacare intiative (even though most members opposed it): more money for family docs, who will now become your gatekeeper. This means they follow “guidelines” to decide if you get a test or get a referral. From the choosing wisely website:

The AAFP strongly supports the patient-centered medical home (PCMH) model of care. Care provided in this fashion encourages both doctors and patients to ‘choose wisely’ when it comes to diagnostic tests, treatments and procedures. The PCMH model improves quality of care and medical outcomes, and helps reduce costs to the patient and the health care system.

Notice the definition emphasizes “reduce costs”, not treat people with expensive tests and medicines that might allow them to live longer.

How well does this work? Well, actually it can work quite well. I worked for the federal “IHS” that treats American Indians. If you have catastrophic problem, you get free medical care. For testing and specialist referral, well, when and whether you get these depends on how much “contract health” funding is available. This is one reason that most tribes who now can take over their clinics have done so, and why you didn’t read a lot about how government medicine actually would work when the health care debate was going on.

But there is a more worrisome part of all of this: doctors will now be trained to ignore the needs of the patients  in favor of “professionalism”: and they will educate docs in their group think approach to medicine:

In the ABIM Foundation’s video series, “Renewing Professionalism: A
Challenge to the Health Care Community
,”  (italics mine)  a group of nationally known physician leaders, educators, payers, policy opinion leaders and patient advocates offer their diverse perspectives on a range of issues tied to medical professionalism.

Discussing topics such as managing limited health care resources, addressing conflicts of interest, integrating medical professionalism into medical training and improving patient-physician interactions …

What we now see the triumph of bioethics over medicine, where “stewardship” of scarce resources will be the highest rule.

Via secondhandsmokeblog:

From Irving’s “Bioethics: How Did We Get Into This Mess?”:

Like the word “Bioethics” itself, which formally dates only from the early 1970′s, the philosophical underpinnings of bioethics are completely different from those that underlie traditional medical ethics. Traditional medical ethics focuses on the physician’s duty to the individual patient, whose life and welfare are always sacrosanct. The focus of bioethics is fundamentally utilitarian, centered, like other utilitarian disciplines, around maximizing total human happiness.

Such factors as the feelings and preferences of other people —the parents of a child with severe birth defects, the husband whose wife seems permanently comatose, or even the doctor who decides that an elderly Alzheimer’s patient would be better off dead — along with the possible cost of treatment to society, can weigh in against and ultimately outbalance the afflicted person’s needs. Good–bye, Hippocrates; hello, Peter Singer.

Actually, I think bioethics has splintered since Irving wrote the essay.  There were always dissenters from the mainstream utilitarian view.  Now, some of the radicals she describes are actually the old dinosaurs left behind by their even more radical intellectual progeny.

A quick (and funny) summary of all this evolution of Medicine can be found in a video HERE.


Dad was right. I should have gone into dentistry.


Nancy Reyes is a retired physician living in the rural Philippines.

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