Ezekiel Emanuel Attacks Medical Conscience :  Advocates like Emanuel and Stahl would eviscerate medical conscience and impose upon all doctors a tyranny of the majority, whereby any and all interventions generally accepted by the medical community–meaning people like him with the power to decide–must be provided, regardless of a doctor’s moral or religious objections. As I have written elsewhere, this kind of thinking effectively reduces doctors from learned professionals into so many technocratically-skilled order takers. When that process forces doctors to kill–as in abortion and euthanasia–the license to practice medicine requires acquiescing to tyranny.

What does Ezekiel Emanuel really believe about rationing? Age yes, maybe quality of life: Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia.

The Less-Is-More Crusade — Are We Overmedicalizing or Oversimplifying? Unfortunately, the bias introduced by the less-is-more mind-set may be unfamiliar to the public. Everyone knows that pharmaceutical companies are profit-driven and interprets company-sponsored trials accordingly. But when a journal that decries overmedicalization publishes an article highlighting a treatment’s harms, or a physician focused on mitigating overuse is quoted in support of withholding interventions, people reading the press coverage probably won’t weigh the relevant bias.

Smarter Medicine emits negative signals with respect to hope and help. However, positive age beliefs protect against dementia even among elders with high-risk gene. Chossing wisely is a “nocebo-medicine” that is very likeli to increase morbidity, mortality and associated costs in societies.

Choosing Wisely-Where Is the Choice?  Southwest J Pulm Crit Care. 2013;6(6):272-4, Robbins Richard and Allen Thomas: Choosing Wisely ist ein autoritärer Mechanismus gegen die freie Wahl.  “In our view the present Choosing Wisely campaign has fundamental flaws-not because it is medically wrong but because it attempts to replace choice and good judgment with a rigid set of rules that undoubtedly will have many exceptions. Based on what we have seen so far, we suspect that Choosing Wisely is much more about saving money than improving patient care. We also predict it will be used by the unknowing or unscrupulous to further interfere with the doctor-patient relationship. When the recommendations of an authoritarian body take the form of commandments and preempt clinical decision making, then it seems the wise choice of a wary clinician is to tacitly comply – in other words there is no choice.”

How Choosing Wisely produces contrarian effects: Baseline characteristics of patients were similar for the pre- and post-intervention periods. There was a total of 781 patient visits for low back pain in June to September 2014 and 672 in June to September 2016. The XR imaging rate for low back pain increased from 12% (95% CI 9.9-14.5) to 16.2% (95% CI 13.6-19.2) following the intervention (p=0.023). Conclusion: We previously demonstrated a trend towards increased awareness and knowledge of the CWC EM recommendations following a knowledge translation initiative. Baseline XR imaging rates for low back pain were lower than what has been reported. We observed that our intervention was associated with an increased frequency of imaging for low back pain. This may be due to a contrarian effect. We feel this calls into question the role of knowledge translation initiatives where physician practice already closely adheres to pre-established recommendations.

Wikipedia: The Choosing Wisely campaign makes no provision to scientifically research its own efficacy, but academic centers are making plans to independently report on the impact of the campaign.[40] The campaign has been cited as being part of a broader movement including many comparable campaigns.[41] The German Network for Evidence Based Medicine considered adapting concepts from the program into the German healthcare system.[42] In April 2014, Choosing Wisely Canada launched.[43] Choosing Wisely Canada is organized by the Canadian Medical Association and the University of Toronto, and is chaired by Dr. Wendy Levinson. The services targeted by the Choosing Wisely lists have broad variance in how much impact they can have on patients’ care and costs.[44]

Choosing wisely or beyond the guidelines : There is also serious criticism on the ‘Choosing Wisely’ campaign and program. One conservative monthly magazine made the following qualification: ‘The definitive tone of denial repudiates the Hippocratic oath and replaces it with the spirit of The Hunger Games’ [5]. The main objection is the perception that ‘Choosing Wisely’ is the first collective effort on the part of professional medical societies to decide how to practise medicine on the basis of cost first and foremost. Besides, low-risk patients are hard to identify on the basis of risk stratification alone, and the basic principles of ‘Choosing Wisely’ may interact with the primary objectives (cost-containment) of health care providers. Furthermore, each recommendation is preceded by the words ‘Don’t’ and this strongly brings the 10 commandments (in this case 5) to mind, which may not be directly associated with modern medicine.

The philosophical error that plagues American health care: Even stranger, the hubbub ignores two facts. First, health care is already rationed: those who cannot afford treatments forgo them. Second, private insurers have long studied evidence to decide which treatments to cover. Those decisions, however, are inconsistent. A study sponsored by the National Pharmaceutical Council showed wide variation in how insurers evaluate evidence. Americans may detest the idea of limiting care. The idea that no one has done it before is an illusion.

Moving from appropriateness to affordability: “Figuring out how to do this well is likely to be the next major hurdle for medical educators to contend with. Trainees will need a framework to identify patients at risk and to be able to either answer questions that arise or refer patients to someone who can answer. Because each patient’s needs may be unique, clinicians may need to work in concert with case managers, financial counselors, social workers, and other members of the interprofessional team to optimize plans for individual patients.” The authors are all directors at Costs of Care, a nonprofit organization that has received grant support from the ABIM Foundation for programs related to teaching value. Drs. Shah, Moriates, and Arora receive royalties from McGraw-Hill for the textbook Understanding Value-Based Healthcare. Comment VEMS: Instead of spending money for the patient, we now spend it for financial counselors, case managers, social workers and others. If you pay authors, they will write everything that fits into the mandate.

“Few Clinicians are Choosing Wisely”  Another significant barrier to discouraging low-value care is a general dearth of comparative-effectiveness research and data. “Many of the interventions cited in the Choosing Wisely campaign were deemed low value precisely because they have not been tested in trials,” write David Howard of Emory University and Dr. Cary Gross of the Yale University School of Medicine in a commentary piece accompanying the findings in JAMA Internal Medicine.

“Although it is not feasible to conduct a trial of every service mentioned in the Choosing Wisely recommendations, the lack of high-quality evidence will hamper efforts to reduce low-value care,” they write.

Tagesanzeiger vom 25.05.2016. Felix Straumann, Unter dem Titel «Smarter Medicine» haben Ärzte soeben eine Negativliste von unnötigen Behandlungen veröffentlicht. Diese gelten allerdings schon lange als überholt.

Smarter Medicine im Kreuzfeuer: