Friday, January 8, 2016


In Whose Interest is all this anyway?

Cleverly we design our future. Softening the lights to reduce the shadows. The soft haze beckons us and we follow suit dutifully in line.

Sometimes a question arises. but most times the question is drowned out by fear. The question is “In whose interest is any of this, anyway?”

The trumpets have heralded that all things arriving in the form of gratis are from a benevolent master. And the benevolent master with a tearful eye informs that all things meted out are for the “Public Good.” Indeed the writers write, the bobble-heads on television agree with thrills up their legs and all is a calm sea of bright azure blue.

Is it?

Let us take the mundane but hotly contested yet relentless issue of the EMRs for physicians. The digital interface is designed and promoted as the coming of age in medicine for the “public good.” Touted that the EMRs would lead to portability of patient data and therefore less chance of medical errors. But that is not what happened. The error rate in some cases increased. However there was a bonanza for cyber-charlatans in stealing multi-million patient information. The insurers using it to determine who was being reimbursed and how much, created alternate realities of abuse and through it all the face time, eye-to-eye contact between patients and physicians decreased dramatically. The questions from the physician to the patients were directed at the computer screen in an attempt to reduce the time impact in order to fulfill their goal of filling the boxes and crossing the “t”s and dotting the “i”s to the agencies. The alienation between the patient and physician increased. And as a consequence the “Satisfaction Scores” for physicians took a dive. The dominoes of interests however continued to erect themselves. Software and hardware companies like EPIC and CERNER made billions in the process through government subsidies and contracts. Meanwhile the payments to the doctors dwindled substantially. The declining incomes combined with the will to keep their offices open sent many a doctor to the banks for loans, others to leave the field of medicine and still others into depression.

In whose Interest was the EMRs?

Another commonly used belief that is the care of the patient should be based on the population medicine statistics; a new paradigm. let us dissect that one a bit. Imagine if you will that we take a sample of data from a cohort of patients in a urban hospital or two or three and then based on the statistics conjure up a reality that treatment ‘x’ worked in that sample in, lets say 2/3rd of the patients, would that be appropriate for the entire population? If from that tiny experiment of say a 1000 (the world population is 7,100,000,000) we extrapolate that treatment ‘x’ is the best treatment. That is why most studies are not reproducible! Is that wise? and if it does not work then is it “so be it,” because the data says so and we did the best (based on some guidelines) there is. Allowing the physician who is treating the patient with the right to determine the correct therapy that may be ‘y’ or ‘z’ would be the best for the patient, but that is not the case with this new population medicine format. The insurer having agreed on a contractual and budgetary basis that the cost per patient with ‘x’ is cheaper than alternative therapy with ‘y’ or ‘z’ will opt for wherever the costs are lower. In their context the shareholders ultimately benefit with rising stock prices from the higher EPS as well as the CEOs. The critical thinking of the physician is circumvented by the bulldozing baskets of insufficient data. And patient care is mediocre at best.

In whose Interest is the population medicine mode of therapy?  

ABIM Philadelphia Condominium (Doorman included)

It appears that a third party always seems to insert itself and avows itself as the defender of the public good. Case in point is the American Board of Internal Medicine or ABIM, which is a privately held foundation that saw its coffers filled up from net asset value of $13 million to $132 million in short order. It appears that the ABIM in promising that certification of physicians initially was the way to test the knowledge-base of the doctors. But then came the 10-year recertification to prove that the knowledge was still fresh. The physicians complied, as insurers (who pay) and hospitals (who employ) had bought into the zeitgeist. But that was not enough for the ABIM who doubled down and helped them conjure up the Maintenance of Certification (MOC) as a money making annual endeavor.(even though their argument about recertification and MOC had been debunked over and over in the scientific press) This endeavor helped ABIM increase their own salaries and help buy expensive Philadelphia condominium for retreats replete with Mercedes Benzes to drive them around. Ah the vagaries of such banal thought. Interestingly the examinations and the maintenance “modules” designed by the ABIM were merely a mechanism of esoteric questions that had virtually no value in daily patient care by a physician. It was all about money! Or so it seems.

In whose interest is the Maintenance of Certification?

Lets not forget the multitudes of policies, regulations enacted by the Federal and State agencies that control the “public good.” There are many acronyms that the reader is welcome to look into: ACOs, AMP, P4P, AHQR, PCORI, HIPAA, OSHA, IOM, HICPAC, DHQP all these and more in one way or another impact the functionality of the patient’s care. Is it any wonder that 29% of 1st year residents are depressed with thoughts of suicide and 58% of practicing physicians are depressed with 93% of the doctors not advocating their children to go into medicine? Pamela Wible, MD states that the physicians are abused not depressed. I agree. The suicide rate from such regulatory abuse is killing the field of medicine through depression and overall ill health. filling paperwork now consumes around 40% of a physician’s time. A mistake in not crossing a “t” or dotting an “i” is being construed as fraud by the digital sleuths. The relentless drumbeat of “public good” goes on.

In whose interests are all these agencies?

And then again, there are others that have a stake in this algorithm of human interaction. Read: The Black Cloud of Medical Board Investigations . These politically appointed figures to the Board (physicians, attorneys and public members) by the governors of the state have the power to do "public good." Their power remains subservient to the power of the State governmental oversight and as such they, to a large extent, remain pawns in the chess game. In that "public good" is a lot of pride and prejudice as is decreed in the soul of man. A well publicized case, no matter the cause must be found guilty for political expediency while a well-connected one can be suppressed with a reprimand. Their decisions are final no matter the innocence or guilt while professional lives are buried in the heap. No matter the issue, the attempt is to win a consent of guilt and that proves that the system is working at peak capacity. The poor soul caught in the widening gyre of hurled allegations never sees it coming and proof after proof against the allegations mean nothing. The goose is cooked and the chefs are fattened. To be sure there are a few bad apples (as in any aspect of society) and they should be removed from patient care, but with careful reasoning and judgment and not solely by prosecutorial discretion. From a well-designed and well-meaning system of oversight over physician indiscretion, the system has evolved into a numbers game of how many are thrown to the wolves. If less per 1000 then the oversight is not good. If more, then the state is an exemplar. The evil that men do lives after them; the good is oft interred with their bones. - Shakespeare

In whose interest?

This kind of pain of logic might take you from point A to B but only as Einstein said, “Imagination will take you everywhere.” It appears that the reason has ceased to be the power of wisdom, logic and numbers rule the day. And as Charlotte Bronte expressed, “Better to be without logic than without feelings.” Do the pundits “feel?” in this “for the public good?” Or are they so entrenched in their little silos of punditry that only the artificial hue of fluorescence reaches their retinas?

What makes them tick? Money? Wealth? Greed? Job Security? Power? Influence?

No comments:

Post a Comment