Harlan Krumholz’s manifesto and the creed of medical collectivism

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In the broadest sense, medical collectivism is the belief that medicine cannot be left to voluntary and unrestricted transactions between individual patients and individual healers but must be improved, directly or indirectly, by the hand of government. Medical collectivism has a long history that begins with the licensing of practitioners by the state, increases with the regulation of drugs, and flourishes with the advent of government financing of medical care.  Medicine today is dominated by the collectivist ideology and Harlan Krumholz is one of its most prominent champions.

This past summer, Dr. Krumholz published in Circulation a manifesto entitled “Outcomes Research: Generating Evidence for Best Practice and Policy.” In this series of articles he educates the reader on his field of study and its demonstrated scientific promise to help shape “high-quality health systems.”  An examination of the first sentences of the introductory paper exemplifies the language, method, and creed of twenty-first century medical collectivism.

It thus begins:

In an era of fundamental concerns about the way that health care is provided to individuals and populations, there is a need for a scientific discipline to bridge the capabilities of the medical profession and the best interests of patients and society.

Care for the common good is medical collectivism’s proclaimed motif, even if the “fundamental concerns” remain undefined.  But squinting through the nebulous phraseology, we can see the necessary scheme of the collectivist agenda take shape: against biblical precept, Krumholz exhorts the medical profession to serve two masters at once.  Individuals and populations, patients and society are conveniently conflated as a matter of fact.

But beyond ignoring the obvious tension between the individual and the group, hoodwinking physicians into practicing “population medicine” is of course the essential means to confuse practitioners into thoughtlessly carrying out sweeping interventions whose primary benefit is the profit of third parties.  Only clever sophistry can claim to reconcile the needs of patients with the profit margin of insurance companies, the bottom line of hospital administrators, the end-of-the-month income of practitioners, the annual reports of employers, the promises of legislators, the zeal of government regulators, the self-importance of academics, the confused intentions of voters, and the pocketbooks of taxpayers.  The term “society” simply conceals the myriad of interest groups that partake in the boondoggle we call the health care system.

Krumholz continues:

Assumptions about what is achieved by our system should be tested by evidence of what actually results from our efforts.

The image of the impartial scientist testing the output that “our system” generates against the input of “our efforts” is a knowingly naïve depiction.  There is no objective or agreed-upon benefit that the health care system aims to maximize and that outcomes research aims to quantify.  The avoided question is: who defines the goals and standards of “what is achieved by our system?”

The “scientific discipline” of outcomes research is a set of statistical techniques applied to ever larger databases of predefined patient characteristics measuring predefined outcomes of interest.  It is not the “system” making assumptions but the investigator and his sponsor whose values, agenda, and biases must be questioned if we are no to be blinded by the “evidence.”

A treatment is proved futile or ineffective only by the specific and necessarily narrow definition of effectiveness selected by the investigator which may mean nothing to the patient.  How else to explain, for example, the wide appeal of “alternative medicine” which time and again fails to pass the orthodox test of effectiveness?

Conversely when a screening test or preventive drug is deemed worthy of broad dissemination, the totality of possible costs (physical, financial, and psychological) to the individual subject can never be measured and are necessarily ignored, even when the vast majority of recipients invariably never benefit from the much touted intervention. And what of treatments whose measured benefits come at a measured risk?  Who decides where to draw the line?  The recent VIOXX debacle that publicly pitted industry, academia, and the FDA against each other should be a plain enough illustration of the many absurdities of the collectivist approach.

Outcomes have relative values that may vary widely according to patient preference.  Preference scales cannot be meaningfully quantified and this necessarily limits the application of statistics to medicine.  The collectivists ignore this to maintain the illusion of objectivity imparted by the use of mathematical models.

Insights from the experience of patients should provide accountability for the investment in health care.

George Orwell once wrote that the “mixture of vagueness and sheer incompetence is the most marked characteristic of modern English prose, and especially of any kind of political writing.”  Whether Dr. Krumholz is unable to express himself or does not care to do so matters little, for political discourse does not to appeal to the mind but to feelings. Stringing together “insight,” “patients,” “accountability,” and “investment” conveys righteousness.  That should be meaningful enough even if it is incomprehensible.

The real effect of the statement, though, is to show how mystifying the stuff of patient encounters must be to the apostles of medical collectivism; how remote it is from the comfort zone of spreadsheets, entry points, and confidence intervals with which they organize their understanding of benefit.

Pledges of equity and fairness should be accompanied by proof that care is provided according to need and not race/ethnicity, sex, or socioeconomic status.

Finally, the stance of political correctness is firmly taken to assert the existence of shared values and seal the argument of a collective health care mission.  What plegde is Dr. Krumholz referring to and what measure of equity must be provided in the “proof?”  Who is to determine the “need” and to select the special groups worthy of “fair” treatment?

These four opening statements establish the preamble of Harlan Krumholz’s manifesto and provide the needed justification to propose interventions and policies on “safety, effectiveness, equity, efficiency, timeliness, and patientcenteredness as key properties of high-quality health systems.”

The boundless reach of such interventions is not wishful thinking.  Professor Krumholz himself leads numerous “guideline” writing committees for the American Heart Association and American College of Cardiology that are increasingly turning collegial advice into practice mandates.  Most subspecialty colleges and societies issue similar directives.  Recently such committees have more overtly published recommendations on “performance measures” that form the basis of “pay-for-performance” schemes to withhold payment for institutions deemed substandard.  Indeed, Dr. Krumholz is directly hired by the Center for Medicare and Medicaid Services to assist in the development of such “quality initiatives” whose real aims shouldn’t be lost on even the most naïve.

Of course, Harlan Krumholz and like-minded outcomes researchers are not the cause but the product of a collectivist culture widely embraced by the academic-industrial complex.  Universities, specialty boards, medical colleges, and academic journals have long ago neglected the individual for the population, the unique for the average, the case report for the clinical trial, and the truth-seeking nuance for the misleading generalization.

Prior to the massive intrusion of government in health care, which has turned medicine into a political activity that imposes immense restrictions on practice and immense profit opportunities for those skilled at exploiting them, the physician’s fiduciary duty to the patient was kept in relative check by the patient’s freedom to choose alternative treatments from competing practitioners.  Today the standards of knowledge, care and quality are increasingly defined by the right-minded who have powerful statistical tools and data sets at their disposal and at the disposal of those willing and able to hire them.  With these, they will continue to confuse individual physicians into a mode of behavior that would be most disturbing to patients were they fully aware of it and cognizant of its consequences.

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2 thoughts on “Harlan Krumholz’s manifesto and the creed of medical collectivism

  1. This is a theme I have been trying to get my mind around for the past three years in my blog “retired Doc’s thoughts”. I think when people begin to talk about fairness, it is time to run for the door. The article you quote reminds me of a series of articles In JAMA about ten years ago by David Eddy.Dr. Eddy was at least fairly clear about what he wanted to do and from what philosophical position he came.