Wednesday, January 28, 2015


Between the Wall and Bayonets
I derived that analogy from the old saying, “between a rock and a hard place.” In this case the Wall is not an unmoving stillness but like the front lines of the warriors of the past with shields advancing against a sea of arrows towards the bayonets. The bayonets are also mounted in the arms of the warriors hurtling in space on the backs of their steed collapsing the distance between.

Ah, in between those two movable targets sits the lonely physician. No, I want to make it clear this is not a boo hoo story of the poor physician. It is not and yet something tells me, it might be…read on.
“Choosing Wisely” as most of you might have heard is the latest version of a collective mindset that sits in the ivory tower and tries to control the mind and movement of the rational-decision-making-reason-based management advocates called doctors. What exactly is this “Choosing Wisely?” (

Ok folks gather around the camp fire and we can let our demons fly.

“Choosing Wisely” is purportedly an “Evidence Based Medicine” guideline format to spell out what supposedly works and what does not in the management of the patient. “The Choosing Wisely campaign was created by the ABIM Foundation to challenge medical specialty organizations to create a list of tests or procedures that can be used to "spark discussion" between patients and physicians regarding the utility of the tests.,, Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.” That is what the ABIM Foundation pundits say. But upon further review as most have done, it appears to have other motives behind it. “Why 'Choosing Wisely' Won't Protect You in a Lawsuit.” William Sullivan, DO, JD points out that Section 5001(c) of the Deficit Reduction Act, the stated purpose of the list was to reduce healthcare expenditures under the Social Security Act.” And furthermore he states that “There are more than 2500 guidelines related to diseases and thousands more guidelines related to treatment of diseases, according to a review of the National Guideline Clearinghouse. Clinical practice guidelines may be used by either party in a medical malpractice lawsuit… It is therefore important to use clinical practice guidelines as outlines of general care that may change based on current medical research, and not as stringent datasets that necessarily define the standard of care.”

Herein we have another dilemma the lawyers can therefore successfully call these guidelines if you choose to follow as not the standards of care. Then we are left with, who will the jury believe, the articulate artist in the pinstripe suit or the fearful-chin-buried-in-the-neck doctor?

Here is another caveat that we as doctors may not realize, if the Insurance Company refuses to reimburse for services rendered outside of those that are considered “Chosen Wisely” and some harm was alleged, the lawyer can use the denial of payment as a testimony against good practice of medicine and sway the jury right or wrong against the physician. See how the wall moves towards the bayonets?

Moderate quality evidence is not something that doctors should consider hanging their hats on. Back pain is one of those that afflict a large majority of patients (about 19 million) and the American College of Physicians deems it unnecessary for physicians to do imaging in such cases. Yet 130,000 of patients have cancer and 1900 have spinal vertebral infections. If no X-Rays, CT scan or MRI are ordered, there is a missed diagnosis worth a few million to the plaintiff’s attorney. But here is the trap, articles abound suggesting that doctors order too many CT scans and expose their patients to radiation. There is no give in the opposing bayonets either.

To absolve themselves from any and all litigations related to these guidelines the ABIM foundation, the creators of the “Choosing Wisely” program have disclaimers: “The disclaimers contained in Choosing Wisely guidelines, such as "use of this report is at your own risk" and "the ABIM Foundation ... [is] not liable for any loss, injury, or other damage related to your use of this report…"

On the flip side of doing a test that was suggested as a moderate quality evidence that results in a some harm will automatically enhance the lawyers to seek out the experts from behind the ivory tower walls to shriek and yell as to the need for such a test on the patient thus burying the physician in a sea of troubles from whence he might not be able to practice medicine with reasoning. With one eye on the risk to patient and the other equally focused on “Choosing Wisely” guidelines. So, damned if you do and damned if you don’t! The implied volatility of support from “Choosing Wisely” is a double edged sword of Damocles. It hangs, terrifyingly, until it drops!

And now to the dried fruit approach of bashing the statistical proofs, which are abused in medicine, and draining the water out of them: the statistical methodologies used in scientific articles for majority of the “high impact” journals are unreliable and unverifiable, and bring little solace to the weary physician administering medical care (Ionnadis). When “Choosing Wisely” is based on the shaky foundations of some form of bias, hidden under the shifting sands of “Evidence Based Medicine,” then the rendered care to the vulnerable patient -based on any set of those guidelines is fraught with failure and impeachment.

There is a movement towards statutory guidelines that when followed will protect the physician from litigation. But then not following such guidelines based on physicians intuit and judgment will be subject to penalties and what of the best possible care for the patient?

The squeeze is on! Eat your Wheaties!

“Their understanding
Begins to swell and the approaching tide
Will shortly fill the reasonable shores
That now lie foul and muddy.”

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