Articles

New CMS Chief Donald Berwick: a Trojan Horse for Quackery?

NB: I posted this on Health Care Renewal a couple of days ago, figuring that Dr. Gorski’s post would suffice for the SBM readership (he and I had discussed the topic while at TAM8 last week). But Managing Editor Gorski has asked me to repost it here, which I’m happy to do. I am especially pleased to demonstrate that I am capable of writing a shorter post than is Dr. Gorski. ;-)

On July 7, President Obama appointed Dr. Donald Berwick as Administrator of the Centers for Medicare and Medicaid Services (CMS). Dr. Berwick, a pediatrician, is well known as the CEO of the non-profit Institute for Healthcare Improvement (IHI), which “exists to close the enormous gap between the health care we have and the health care we should have — a gap so large in the US that the Institute of Medicine (IOM) in 2001 called it a ‘quality chasm’.” Dr. Berwick was one of the authors of that IOM report. His IHI has been a major player in the patient safety movement, most notably with its “100,000 Lives Campaign” and, more recently, its “5 Million Lives Campaign.”

Berwick’s CMS gig is a “recess appointment”: it was made during the Senate’s July 4th recess period, without a formal confirmation hearing—although such a hearing must take place before the end of this Senate term, if he is to remain in the position. A recent story suggested that Obama had made the recess appointment in order to avoid a reprise of “last year’s divisive health care debate.” The president had originally nominated Berwick for the position in April, and Republicans have opposed “Berwick’s views on rationing of care,” claiming that he “would deny needed care based on cost.”

A “Patient-Centered Extremist”

If there is a problem with the appointment, it is likely to be roughly the opposite of what Republicans might suppose: Dr. Berwick is a self-described “Patient-Centered Extremist.” He favors letting patients have the last word in decisions about their care even if that means, for example, choosing to have unnecessary and expensive hi-tech studies. In an article for Health Affairs published about a year ago, he explicitly argued against the “professionally dominant view of quality of health care”:

I think it wrong for the profession of medicine—or any other health care profession, for that matter—to “reserve to itself the authority to judge the quality of its work.” I eschew compromise words like “partnership.” For better or worse, I have come to believe that we—patients, families, clinicians, and the health care system as a whole—would all be far better off if we professionals recalibrated our work such that we behaved with patients and families not as hosts in the care system, but as guests in their lives. I suggest that we should without equivocation make patient-centeredness a primary quality dimension all its own, even when it does not contribute to the technical safety and effectiveness of care.

A new definition. My proposed definition of “patient-centered care” is this: The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.

Does this mean that Dr. Berwick would also eschew professional, i.e., expert, judgment in favor of patients’ wishes? In a word, yes:

Evidence-based medicine sometimes must take a back seat. First, leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat. One e-mail correspondent asked me, “Should patient ‘wants’ override professional judgment about whether an MRI is needed?” My answer is, basically, “Yes.” On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase “a fully informed patient.”

Dr. Berwick is not so naive as this opinion might suggest. He envisions a “mature dialogue” in such a case, and argues that “if, over time, a pattern emerges of scientifically unwise or unsubstantiated choices…then we should seek to improve our messages…” He also admits that there might be an occasional patient whose demands are so unreasonable that “it is time to say, ‘No’.” That exception, he argues, should not dictate the rule.

There are situations in which most civilized people would agree with Dr. Berwick’s view of ‘patient-centeredness’. In both the Health Affairs article and in his recent address to the 2010 graduating class of the Yale School of Medicine, he offered real examples of petty, arbitrary hospital rules causing unnecessary sorrow for patients and their loved ones. It is in such contexts that he makes a convincing case that health professionals ought to behave “as guests in their lives.” In an interview for the New York Times, he argued:

We don’t have a standard of services or processes that are comfortable for patients. We have built a technocratic castle, and when people come into it, they are intimidated.

Nothing to disagree with there. To create that standard, moreover, would not undermine settled medical practice ethics—it would celebrate them, even as it rightly embarrasses the profession for having taken so long to do so.

Enter the Woo

Eschewing the scientific basis for modern medical practice, however, is another matter. In February of 2009, Dr. Berwick gave a ‘keynote’ address at the IOM and Bravewell Collaborative-sponsored Summit on Integrative Medicine and the Health of the Public. He shared the podium with Mehmet Oz, Dean Ornish, Senator Tom Harkin, and other advocates of pseudoscientific health claims. I wrote about the conference at the time, mainly to call attention to its misleading use of the term “integrative medicine“: literature emanating from the Summit characterized it as “preventive” and “patient-centered,” whereas the only characteristic that distinguishes it from modern medicine is its inclusion of various forms of pseudomedicine.

I noticed that Dr. Berwick was on the speaker roster, which I found disappointing: I imagined that he had either gone over to the Dark Side or, perhaps, was sufficiently naive about the topic to have been duped; or, more likely, that he had cynically accepted the offer to further his ambitions. I didn’t bother to listen to his speech until the CMS appointment was announced a few days ago.

It is troubling, to say the least. Dr. Berwick did not argue, as he had in the NYT piece, that “If we doctors feel a person is going to make unwise choices, we have to take on the responsibility of being teachers, educators and informers.” Rather, he praised his fellow speakers, most of whom were spouting nonsense, for their “reach” and “eloquence.” He praised the IOM for its “glorious record…in pursuit of better designs in health care…traditional, allopathic curative care and now migrating into this distinguished and important new arena.” He mentioned homeopathy and acupuncture, not to wonder why they should be promoted as effective, but merely to warn that they will fail—presumably in some economic sense—if they try to compete with each other for reimbursement.

Such language, and Dr. Berwick’s very presence at the Summit, were a far cry from advocating “patient-centeredness.” What they amounted to was a generous endorsement of pseudoscientific practices and of the socio-political movement that promotes them. Even granting some naivete on his part (he called himself “an amateur at this topic”), he must have known this. Such an endorsement, unlike tearing down the “technocratic castle,” has ethical implications at least as profound as those that Dr. Berwick tacitly or explicitly relies upon to support his arguments for patient-centeredness.

“Physicians have no Immunity to Moral or Ethical Constraints”

The relevant medical ethics treatises (reviewed here) are in substantial agreement that it is unethical for physicians to prescribe scientifically implausible methods or to refer patients to other practitioners for the same purpose. They are also in agreement that it is unethical to prescribe a placebo to a patient while claiming that the treatment has specific biologic activity—a point that has been vigorously argued in the UK this year, with regard to homeopathy. These ethical tenets are not mere odes to nerdy, sciency thinking; they are matters of honesty and integrity—fundamental bases for ethical interactions between physicians and patients.

In 1983, philosophers Clark Glymour and Douglas Stalker published an article in the New England Journal of Medicine titled “Engineers, cranks, physicians, magicians.” They framed modern medicine as follows, comparing it to what was then called “holistic medicine” (the article is quoted extensively here):

Medicine in industrialized nations is scientific medicine. The claim tacitly made by American or European physicians, and tacitly relied on by their patients, is that their palliatives and procedures have been shown by science to be effective. Although the physician’s medical practice is not itself science, it is based on science and on training that is supposed to teach physicians to apply scientific knowledge to people in a rational way.

The practice of medicine in the United States and in other industrialized nations is a form of consultant engineering…

That statement is just as accurate now—even more so, in this era of Evidence-Based Medicine—as it was nearly 30 years ago, even if some might find the likening of medicine to engineering displeasing. Nor is it at odds with almost any definition of “patient-centeredness,” other than one that presumes that the patient’s desires trump the physician’s ethics:

A physician engineer can act as consoler; nothing in either logic or social psychology forbids it. But certain combinations are impossible or extraordinarily unlikely. A physician engineer cannot honestly claim powers of magic or occult knowledge. The principles governing scientific reasoning and belief are negative as well as positive, and they imply that occult doctrines are not worthy of belief. Moreover, physician engineers have no immunity to moral or ethical constraints. On the contrary, they are by training and by culture enmeshed in a tradition of rational thought about the obligations and responsibilities of their profession.

Dr. Berwick—if he really believes what his presence and words at the “Integrative Medicine” Summit imply—is playing with ethical fire. (If, as I hope, he doesn’t really believe those things, he’s playing with ethics of another kind). Will we begin to see pseudomedicine “integrated” into Medicare and Medicaid? That is certainly the expectation of those who observed Dr. Berwick’s performance at the Summit, and who appear intent to hold him to his word.

Posted in: Health Fraud, Homeopathy, Medical Ethics, Politics and Regulation, Science and Medicine, Science and the Media

Leave a Comment (19) ↓

19 thoughts on “New CMS Chief Donald Berwick: a Trojan Horse for Quackery?

  1. wales says:

    Wow, Berwick really irritates sbm bloggers. From DG’s strenuous attempt to somehow link Berwick to the “anti-vax’ movement, to KA’s “trojan horse” label. Interesting. Well we know what the sbm agenda is, I expect to see more negative posts on Berwick. Any sbm bloggers have a different take?

  2. wales says:

    I have a great respect for Atul Gawande http://gawande.com/
    and what he has to say in his New Yorker essays about excessive costs in health care. I like the fact that Berwick and Gawande are “on the same page” as Maggie Mahar phrases it.

    http://www.healthbeatblog.com/2010/03/atul-gawande-in-the-april-5-new-yorker-now-what—maybe-we-should-pay-hospitals-for-empty-beds.html

    And have collaborated on articles

    http://www.nytimes.com/2009/08/13/opinion/13gawande.html

    Rather than viewing Berwick as a “Trojan horse” for evil, I see him as a sorely needed breath of fresh air.

  3. weing says:

    Sounds like he is making lots of profit off his non-profit organization. If only practicing medicine were as profitable.

  4. David Gorski says:

    I am especially pleased to demonstrate that I am capable of writing a shorter post than is Dr. Gorski.

    Only on rare occasions… :-)

  5. Dr Benway says:

    “In February of 2009, Dr. Berwick gave a ‘keynote’ address at the IOM and Bravewell Collaborative-sponsored Summit on Integrative Medicine and the Health of the Public. He shared the podium with Mehmet Oz, Dean Ornish, Senator Tom Harkin, and other advocates of pseudoscientific health claims.”

    Always it’s either Oz, Weil, Ornish, Hyman, or Chopra, or some combo.

    I smell a racket.

    If I had more time, I’d start a Muckety on all these guys, the IOM, the heads of naturopathic programs in the US and UK, and their biggest supplement making buddies (e.g., Herbalife).

  6. Dr Benway says:

    wales, I can always count on you to play tone police.

  7. Jann Bellamy says:

    I thought Medicaid and Medicare could barely afford real medicine. Where will they get the money for faux medicine?

  8. Harriet Hall says:

    wales says, “Well we know what the sbm agenda is”
    Yes, we do: science-based medicine.
    Please tell us, what is your agenda, and what is your take on Dr. Berwick?

  9. Mark P says:

    Quite a few politicians are 100% committed to “returning power to the people”.

    Until elected, that is.

    Mr Berwick might find his budgeting and legal requirements might start to interfere in what he thinks he thinks.

    The trick might be, as gruesome as it seems, to make sure he gets any severe medical mistreatment from woo shoved firmly in his face early on. Make him see the risk he runs when the loonies are in charge.

  10. JMB says:

    If Dr Berwick is planning to implement rationing similar to the Oregon State initiative, then I would not have a problem with his approach.

    http://www.indiana.edu/~rcapub/v20n1/p16.html

    (A description of the Oregon state strategy)

    Such a strategy would insure that no dollars were diverted from therapies proven effective, to therapies with no proven benefit. His statement may have been a euphemistic way of saying that alternative medicine will be judged by the same criteria as conventional medicine, right in front of proponents of alternative medicine. However, the healthcare reform bill leaves the door open that there may be different standards applied to alternative medicine than to allopathic (as integrative medicine advocates label conventional science based medicine) medicine.

    http://tiih.org/wp-content/uploads/2010/06/CIM_Stakeholder_Summary.pdf

    (From a forum “Jointly sponsored by the Center for Medical Technology Policy (CMTP) and the Institute for Integrative Health (TIIH)
    Meeting Summary”

    “The CIM community has spent a great deal of time debating the merits of “gold-standard” RCTs as appropriate tools for the evaluation of integrative medicine interventions, but because RCTs are best suited to determine a single intervention’s net benefit under closely controlled circumstances, it is becoming increasingly apparent that they are not well suited to provide the best evidence for integrative options. Therefore, the CIM research community needs to explore other research approaches to provide high quality data for decision-makers about the effectiveness of CIM interventions in actual practice.”

    So conventional medicine will be held to the gold standard of the Randomized Clinical Trial, but integrative medicine won’t.

    That is playing politics with science as a cover. All healthcare strategies should be held to the same science based standards. Any effectiveness measure should be as objective as possible, with a scientifically valid conclusion that the effect is greater than placebo effect. If healthcare reform was sold to the American public as, “We spend more per capita on healthcare than other countries, but we don’t have the highest life expectancy”, then healthcare reform should deliver on that promise of greater life expectancy for less money. Spending on alternative medicine will certainly not deliver on that promise. (It’s true that better diet and exercise could improve our health, but I have seen nothing proving that alternative medicine will have greater success than conventional medicine convincing patients to eat better and exercise.)

    We will see the direction Dr Berwick and Kathleen Sebelius takes us, because they are now empowered to make such decisions.

    http://theintegratorblog.com/site/index.php?option=com_content&task=view&id=653&Itemid=93

  11. Jolo5309 says:

    A friend of mine disclosed to me today that she has an appointment with a naturopath. I asked her a lot of questions and gave her info from here and quackwatch. She finally broke down and emailed me this:

    Because I have yet to go to a doctor that will take me seriously. I’ve been coughing up gunk (sometimes with blood in it) for about 5 years and I was told “you have a cold” and “that’s going around” and “you definately don’t have asthma” and “don’t worry it’s nothing.” Now this thing with my stomach and rapid weight gain and pain in my side. The doctor fixates on weight. I’m sick of no one listening to me.

    She knows that the naturopath won’t do much, she just wants to talk to someone that will ask questions and listen to her. Until medical doctors can start paying attention to the patients, these people will flourish.

  12. Calli Arcale says:

    Medical doctors can listen to these patients. However, they are human, and as such, some of them are jerks. This is not a problem that we are likely to solve in the forseeable future, because there aren’t a whole lot of non-human alternatives to doctors. It sucks to spend five years doctor-shopping. It seriously does. That doesn’t mean your friend can’t find a good doctor. Just that she’s had rotten luck so far. Maybe there’s something wrong with how she’s searching? I don’t know. I’ve had my share of jerk doctors and doctors who do a crappy differential diagnosis, but the majority have been genuinely interested in figuring out what’s causing my complaints. It’s worth looking again.

  13. JMB says:

    I do not know if Dr Berwick participated in this conference, but his company co-sponsored the conference that I referred to in the preceding post.

    http://tiih.org/wp-content/uploads/2010/06/CIM_Stakeholder_Summary.pdf

    One other disturbing part of the discussion is that in spite of some participants calling for the input of biostatisticians, there seemed to be no conclusion supporting the input of biostatisticians. Science is about collaboration of ideas. Developing or incorporating new methods of analyzing data should involve a multidisciplinary approach, and not be so insular. Several of this SBM community on this blog have criticized medicine for being out of date and weak when it comes to data analysis. Medicine ends up with embarrassing novel developments, such as the application of the efficient frontier analysis to a decision analysis of medical data. If medical scientists are free to develop data analysis methods that are not solidly founded in mathematics, or tested by experiment, then they can argue for any strategy they prefer, but it will be pseudoscience.

  14. Dr Benway says:

    However, the healthcare reform bill leaves the door open that there may be different standards applied to alternative medicine than to allopathic (as integrative medicine advocates label conventional science based medicine) medicine.

    I has an angry.

    It’s not “alternative” verses “allopathic.” It’s “pre-modern” verses “modern” or “pre-scientific” verses “scientific.” Or “stupid” verses “sensible.”

  15. @JMB,

    I agree that it would be disturbing if Dr. Berwick’s company had co-sponsored the conference to which you referred, but I don’t see any evidence of that in the Meeting Summary. Did you find it somewhere else? Is it possible that you confused Berwick’s Institute for Healthcare Improvement (IHI) with the Institute for Integrative Health (TIIH) that co-sponsored the conference?

    KA

  16. JMB says:

    @Kimball Atwood

    Thank you for the correction. It was not Dr Berwick’s company that co-sponsored the meeting. My apologies if they took offense over my misquote.

    I should have linked to the IOM Summit Report,

    http://books.nap.edu/openbook.php?record_id=12668&page=77

    Although Dr Berwick was a featured speaker at this IOM Summit (and not a sponsor), I can find no indication of his participation in the discussion of the Science section, where statements were made about research methodologies that are similar to those in the pdf I cited.

    From

    http://books.nap.edu/openbook.php?record_id=12668&page=108

    “Briggs agreed with Green, indicating that RCT methods, developed in order to determine the efficacy of drugs, may not be sufficient to examine other types of interventions.”

    And note that in the paragraph above this quote, there is a discussion about biostatisticians.

    So, I cannot discern whether Dr Berwick is advocating new data analysis methods without adequate input from biostatisticians. Therefore, I cannot say whether he will use different standards for assessment of complimentary integrative medicine and conventional science based medicine.

  17. E says:

    My ruminations about Donald Benwick are that he’s more impressed with patients who are studied and up on things, that those patients should be given priority, and that he hopes all this catches on as a trend.

    The way I see it: Were there to end up being rationing, it would come about by way of some patients themselves – those ones too ill to keep up! I mean, who’d want to go to a doctor if ‘you haven’t done your homework’ and can’t express to the doctor exactly what course of action he/she should take? Right?

  18. E says:

    Dr Benway,

    As for Hyman (Mark Hyman, that is), well, let’s just say he leaves the locals lots to ponder upon. And it’s things he himself comes out with that fuel some of that pondering. Like the following excerpt from his own website:

    “Other experiences, though, weren’t as humorous, and one forced me to leave the area. The daughter of the town banker, whose life I saved when she suffered a sudden heart attack during a pregnancy, had a miscarriage. To save her life again, we had to remove the fetus. It turned out the baby had had a heartbeat, and soon the rumor spread around town that I was performing abortions in my garage.

    “Various segments of the community, including two of the other doctors’ wives, announced a boycott of my practice and formed a committee to run me out of town. My patients supported me, but I’d had enough and I felt compelled to move, this time to Mainland China to develop a clinic whose goal was to integrate Eastern and Western medicine.”

    http://www.ultrawellness.com/about-us/mark-hyman/health-story

    Despite what point-of-view one might take on any particular issue; there’s just something weeeeeeird going on there!!

  19. BillSeitz says:

    I think patients should have the right to seek non-SBM treatment. But they should pay for it themselves (or buy private insurance which covers such treatment). And doctors should always have the right to stop treating a patient who won’t follow their advice.

Comments are closed.