The P Word

By Michael Weitekamp, MD

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available. Ann Intern Med. 2012;156:73-104. http://www.annals.orgwww.annals.org

 The excerpt above is from the recently released 6th edition of the American College of Physicians Ethics Manual. Apparently the “p-word” — parsimonious — bothers some of our physician brethren.

Even though the ACP ethics manual has used that term for more than a decade, I guess all the recent talk about “death panels,” “pulling the plug on grandma,” declining reimbursements, physician bankruptcy, and the audacity of the Affordable Care Act to extend insurance benefits to tens of millions of heretofore uninsured citizens has some docs on edge.

Okay, I get it. While the definition of “parsimonious” includes some less-harsh connotations, like “sparing” and “restrained,” it also includes “frugal to the point of stinginess” — and who wants to be accused of being stingy?

Let’s see if we can come up with a better word. Physicians cannot be let off the hook when it comes to stewardship of limited societal resources. Our collective decisions drove the vast majority of the $2.6 trillion spent on health care services this past year in America. If we don’t figure out how to be more <insert better word here> in our day-to-day care of patients, someone else will figure it out for us. Just imagine: more drastic cuts to reimbursement, capital-starved health care infrastructure, and a gutting of the budgets for medical education, public health, NIH and NSF — you get the picture.

The bedrock of medical ethics has not changed. Beneficence, non-malfeasance, patient autonomy, and justice are hardly controversial. Yet health care costs are bankrupting individuals, corporations, municipalities, and the federal government — all serious harbingers of malfeasance if not addressed. Justice and autonomy are already tarnished by geographic, racial, and socioeconomic disparities. National insolvency will do nothing to improve that unfortunate truth. If physicians want to remain in a position to exercise beneficence, steer clear of malfeasance, and preserve justice and autonomy, they need to embrace <insert better word here> and do it fast.

My vote for a better word is another “p-word:” prudent. To be prudent with respect to health care spending is to be wise, judicious, shrewd — much less inflammatory than “stingy,” wouldn’t you agree? To be prudent is also to be provident — to make provision for the future.

Most physicians I know — both in academic medicine and in private practice — understand that there is much we can do to rationalize health care, before it is necessary to ration health care. If health and wellness are the goals, too many of the services society pays for make little or no contribution to that end; some are downright counterproductive.  Misaligned incentives, volume-driven reimbursement, medical illiteracy, accountability for poor personal choices, direct-to-consumer advertising, pre-paid healthcare masquerading as insurance, a dysfunctional tort system, and administrative sclerosis are only a few of the areas ripe for rationalization.

Physician voices must contribute to the solutions. Each of us knows ways we could take better care of individual patients and populations at far less than what we are spending now. Each of us knows that we could do a much better job of educating the next generation of healthcare professionals, ourselves, and our patients about the value of services provided.

While I would never call you stingy if you are “parsimonious,” it is perfectly okay if you would rather consider yourself prudent and providential. Either way, our current and future patients will be the better for it.

Michael Weitekamp, MD, MHA, FACP is a Professor of Medicine at Penn State College 0f Medicine and a Robert G. Petersdorf Scholar at the Association of American Medical Colleges. He can be reached at mweitekamp@aamc.org.

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