Friday, November 2, 2012
The kind of doctor that helps people
I was chatting with someone who asked what I did for a living, and I told him I am a doctor. "The kind that helps people?" he joked.
I knew what he meant. The MD is the practical fixer, the PhD the omphalocentrist academic. Many believe in this dichotomy, as false as it is. And such a philosophy underlies the opposition to some elements of the PPACA, aka Obamacare.
There's a board of experts, the Independent Payment Advisory Board, which is tasked to (per Wikpedia, which seems mostly accurate): "... develop specific proposals to bring the net growth in Medicare spending back to target levels if the Medicare Actuary determines that net spending is forecast to exceed target levels, beginning in 2015.
According to official records, the proposals made by IPAB should not include any recommendation to ration health care, raise revenues or increase Medicare beneficiary premiums, increase Medicare beneficiary cost sharing (deductibles, coinsurance, or co-payments), or otherwise restrict benefits or modify eligibility criteria ..."
The usual suspects have come out against the board: the AMA (that well known and long term opponent of health care reform, who came out for Obamacare only weakly), Big Pharma, the American Hospital Association. Though I discount most of their concerns out of hand, the AMA does make an interesting point, namely, that working physicians (not eligible per the legislation for board membership) should be included.
But why? The assumption is that only clinicians can know what really helps the individual patient, and bean-counters and economists care only about money.
This is false in so many ways! First, as I have repeated time and again in this space, sometimes doctors don't know, know only some of what they think, or base a whole practice on precious little evidence.
Second, sometimes population health is the best guide to what is most likely to help the patient in front of you. In fact, most of evidence-based medicine is founded on controlled trials among thousands of people. Now, although these are imperfect at best, we do know something. Beta blockers help after heart attacks. In severe depression, SSRIs can improve matters. And so on.
The clinician is powerless without population health, profligate to no purpose without health economics, and stabbing in the dark without policy and health services research.
Is there a unique perspective that a physician can bring to such a board? Perhaps, but I worry that such a doctor would be the AMA's (or the specialties'/the RUC's) Trojan horse to sneak in unsubstantiated overuse. I, for one, accept that a board of experts, tasked with cost-cutting without affecting quality, does not need a token physician.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.
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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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