The history behind the MOC®kery

AMA building, Chicago.  Photo Credit: Shutter Runner via Flickr.
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For those affected or scandalized by the way MOC® programs are being foisted on doctors, the following Wikipedia entry may provide an explanatory frame of reference:

A union security agreement is a contractual agreement, usually part of a union collective bargaining agreement, in which an employer and a trade or labor union agree on the extent to which the union may compel employees to join the union, and/or whether the employer will collect dues, fees, and assessments on behalf of the union.

Of course, the American Board of Medical Specialties (ABMS) is not a physician union in the strict sense of the term.  From the vantage point of ABMS executives, the situation is far better.  ABMS bosses can impose enrollment into MOC® without needing to grant doctors membership—and therefore voting rights—in the organization.

COI and empirical fundamentalism

"Francis Bacon, Viscount St Alban" by Unknown - National Portrait Gallery
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Over at the Incidental Economist, Austin Frakt has published a thoughtful commentary on Lisa Rosenbaum’s NEJM series on the obsession over conflict of interest. Frakt is supportive of Rosenbaum’s position but also touches on a dimension to the story which I did not address in my admittedly polemical piece yesterday.

Frakt’s most important statement is actually not in the post itself but in a Tweet linking to it.

Frakt is absolutely right and his statement points to a very fundamental assumption that underlies not only the COI concerns, but the legal practice of medicine in general.  Namely, the assumption is that in science and medicine, we should “let the data speak for itself.”

COI in medicine: the pharisees exposed!

Elihu Vedder (1836–1923). Corrupt Legislation. Public domain via Wikipedia
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Irvine Page’s 1987 medical textbook Hypertension Mechanisms begins with the following acknowledgment:

My special thanks are due to the Ciba-Geigy Company, who not only has contributed generously to the financing of this book, but who–over the years and more than any corporation–has recognized and encouraged the development of research in hypertension

The famed Cleveland Clinic physician-scientist, who died 4 years after the book was published, would not live long enough to have to apologize publicly for this colossal evidence of conflict of interest (COI).  It would take a few more years and a few scandals to set into motion the current phobia against industry influence.  In fact, Page would undoubtedly be stupefied by the rituals we now go through to show that our research and opinions are unblemished by the taint of for-profit corporations.

Against the war on obesity

Peter Paul Rubens (1577-1640).  Minerva protects Pax from Mars.  [Public domain], via Wikimedia Commons.  The National Gallery, London.
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This essay was published in the May 2015 issue of San Francisco Medicine. The entire issue is devoted to obesity and you may find it on-line here.

A war on obesity has been declared. Public health authorities have identified excess body mass as an epidemic threat. With a great sense of urgency, they are mobilizing resources to address this preeminent health concern. To bolster the effort, the American Medical Association has recently decreed obesity as a disease. Local, state, and national political powers are now engaged in its eradication and have enlisted the assistance of a number of celebrities.

But does the war on obesity have clear objectives and a sound strategy? Will the campaign be conducted as a targeted strike with a well-defined exit plan, or will it turn into an open-ended conflict with limited prospects for victory? Will the offensive conform to “just war” principles, or will it be mired in moral confusion? Whatever the answers, I have reasons to object to this war.

Are patient safety organizations losing the war on error?

Photo Credit: Flickr, Superjet International
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The war on medical error was officially launched in 1999, when the Institute of Medicine (IOM) published its landmark report To Err is Human, alleging that up to 98,000 yearly deaths in US hospitals were due to human missteps.

Despite significant ambiguities in the definition of a medical error, numerous militias known as Patient Safety Organizations (PSO) sprung up almost overnight to help combat the terrible enemy.

On the looming shortage of doctors

Unemployed men queued outside a depression soup kitchen opened in Chicago by Al Capone, 1931. Public Domain via Wikipedia
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I keep getting served a Facebook ad from the American Association of Medical Colleges imploring me to ask politicians to fund residency training for medical school graduates.  The link leads to a webpage with neat graphics and a series of well-designed cartoons dramatizing an ominous shortage of 90,000 doctors expected to occur by 2025.

Now, the notion of “doctor shortage” by itself is meaningless.  Doctors—like plumbers—are a scarce resource and therefore always in shortage.  Patients have always had to contend with waiting rooms, whether at the outpatient clinic or in the emergency department.  People have always had to wait to see a specialist, especially a good one, and this will never change.  The supply of doctors must be judged in the context of the needs of patients and the economics of supply and demand.

But here’s the rub.

Population medicine: The other “dismal science”

Golconda by René Magritte.  1953.  The Ménil Collection, Houston.
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On May 18, the website of the Ludwig von Mises Institute ran a slightly edited version of this article. You can find it here.

In its current usage, the phrase “dismal science” is a disparagement leveled against mainstream economics for its failure to provide a coherent account of economic activity.

According to Austrian school critics of the neo-Keynesian synthesis, this failure is in large part due to a foolish determination to bring into economics the mathematical precision of the physical sciences.  To achieve this precision, neo-classical economists disproportionately focus their inquiry on global measures of economic activity: gross national product, aggregate demand, global supplies of money, goods, or labor, and other variables that lend themselves to quantification and numerical modeling.  Lost in mainstream economic analysis is the attention due to the individual economic actor who, by virtue of his or her power of self-determination, is ill-suited for the equation or the graph.

A similar love affair with quantitative methods has rapidly taken over the medical field over the last several decades.

“An interview with Sami Karam”

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I was interviewed by Sami Karam, editor of Populyst, a demographics and economics blog and podcast.  Sami lives in New York and became interested in my “early detection” approach to heart disease prevention.  Here is the link to our conversation.  We covered a lot of ground, contrasting a screening approach to the standard “risk-factor” approach for heart disease prevention.  I think you will find our dialogue informative.

A deadly choice for the medical profession

The (assisted) death of Socrates, by Jacques-Louis David.  Metropolitan Museum of Art, New York
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As part of the debate on physician-assisted suicide, the San Francisco Medical Society kindly invited me to write an article taking the “contra” position.  Below is the text of the article.  You can find the print version along with the article taking the “pro” position here.

“Physician-assisted dying”

When a terminally ill but mentally competent patient wishes to die, should a physician be allowed to bring about such wish?  The California legislature is considering that question, and physicians will soon be asked to weigh in on it.  Until recently, so-called “physician-assisted dying” (PAD) garnered little support among doctors.  Currently, however, enthusiasm in its favor is growing.  What are the reasons given to justify this emerging practice?  Do they truly warrant legal sanction?  And do they justify an about-face from the medical profession’s long-held stance on this matter?

The apostles of “less is more”

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Gnosticism in medicine

Gnosticism describes a religious movement flourishing at the beginning of the current era, as Roman paganism was foundering but before Christianity became firmly established.

The main belief of the Gnostic sects was a doctrine of “Salvation by Knowledge (gnosis),” the idea that a privileged class of human beings can, by special insight, obtain possession of the mysteries of the Universe.

Gnostics held a deprecating view of the material world, and favored instead the spiritual realm.  Gnostic elites would profess a severely ascetic lifestyle as the path to enlightenment, although some have been accused of hypocrisy for shunning the austere discipline they would demand of their followers.

American medicine in the 21st century bears resemblance to the Gnostic movements of old.