Saturday, March 10, 2012

Parsimonious

I love persimmons with their luscious flavor and their rich exotic texture, but parsimony has nothing to do with persimmons. For the 99% of Americans who are less familiar with the term parsimonious than they are with the rare persimmon fruit, here are the suggested synonyms to parsimonious, according to the Merriam Webster dictionary: “cheap, chintzy, close, closefisted, mean, mingy, miserly, niggard, niggardly, stingy, penny-pinching, penurious, pinching, pinchpenny, spare, sparing, stinting, tight, tightfisted, uncharitable, ungenerous”.

In the sixth edition of its Ethics Manual, the American College of Physicians (ACP) is stating the following: “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” [emphasis added]. If you don’t use the term parsimonious in casual conversation, feel free to substitute any of the Merriam Webster synonyms, so you can enjoy the full flavor of this recommendation. We should note that the President of the ACP, Dr. Virginia Hood, while acknowledging that “it has some connotations where people think frugality or being parsimonious is the same as being mean or inadequate”, she does not “think that is the real meaning of that word". According to Dr. Hood “Parsimonious is a good word in the sense that it means that you use only what's necessary". Unfortunately she stopped short of defining “necessary”.

But the term parsimonious can be understood in a different way too. From the Latin “lex parsimoniae”, parsimonious, when scientifically understood could be a reference to Occam’s razor principle “requiring that the simplest of competing theories be preferred to the more complex or that explanations of unknown phenomena be sought first in terms of known quantities”. So perhaps the ACP is advising doctors to refrain from seeking zebras each time they hear galloping hooves, which may be fine medical advice up to the point where it requires respectful consideration for “resources”, which is just a polite term for money. When money is inserted into the scientific equation, we are drawn back to the penny-pinching definition, and since nobody wants to go on record advocating cheap care, we are back to parsimonious and the comfortable ambiguity cover it provides.

As noted in a recent New York Times article, despite this ambiguity, and perhaps precisely because of it, parsimonious care is quickly becoming a very popular term in the industry. In a NEJM article on costs of health care, Peter J. Neumann dares to ask the question and proceeds to answer it too: “Is “parsimonious” the right word? Perhaps there are better ones, but “frugal,” “prudent,” “thrifty,” “cost-conscious,” and others would also raise objections. … Calling it parsimonious is a reasonable start.” Yes, we can’t really call it what it is because it would raise objections. Similarly, we can’t call something a “tax” because it would raise objections, so we call it “penalty” instead, and this too is a reasonable start.

So what does parsimonious care look like? There are no exact descriptions, presumably because they too would raise “objections”, but there are philosophical principles involved. Dr. Zeke Emanuel, for example, is thrilled with the ACP daring to be “a professional society unafraid of advocating the principle of cost-effectiveness”. Cost-effectiveness, which has been in wide use before parsimonious came into vogue, is best examined at the edges where costs differ widely and effectiveness is held constant, or vice versa. It is prudent to stay away from instances where both costs and effectiveness vary widely in direct proportion to each other, because close scrutiny may raise objections. Perhaps this is where parsimonious care kicks in, invoking the renowned 80-20 business rule. If you get injured in an accident and we can restore you to 80% functionality for 20% of the cost, should we really spend the remainder 80% of the money for a measly 20% in diminishing returns to society? 

We may be able to gain additional insight by understanding what parsimonious care is not. A much debated recent study published in Health Affairs concludes that for office-based physicians, electronic access to imaging and lab results does not reduce the frequency of test orders, and advises that “[i]nsurers and health care providers should also be wary of claims that computerization alone will lead to a more parsimonious practice style”. Disregarding the policy implications and the validity of these conclusions, along with the vigorous rebuttals, and sticking with our largely semantic analysis, we may conclude that a reduction in ordering of expensive tests is a characteristic of parsimonious care. Examining the data in this study, which has not been questioned by those taking issue with the conclusions, one should be immediately struck by the fact that doctors in private solo practice are about four times less likely to order expensive imaging tests than physicians employed by hospitals, and significantly less likely to do so than doctors practicing in large group settings.

Since this particular study took the liberty of making some pretty wild assumptions, and since the rebuttals engaged in similarly wild predictions, perhaps it would be beneficial to disregard the multitude of controversial trees and observe the forest in plain view, which reveals that parsimonious care is more likely to be delivered in small private practice. The obligatory implications to policy makers would be to quit the mindless herding of doctors into unparsimonious hospital employment and consolidation, and to conduct some studies of readily available data on the parsimony, or cheapness, of care in various practice settings. The definition of parsimonious care, at least for ambulatory practice, as that which is offered in small private practice settings, and the promotion of the same, is guaranteed to not raise any objections from the public. The alternative would be to continue using terminology nobody understands to make policy nobody understands, while engaging in esoteric conversations for the illuminati who possess the encryption keys to public discourse.

Addendum: For the sake of completeness, here is the brand new response from the authors of the Health Affairs study on imaging, to the ONC rebuttal. (3/12/2012)

3 comments:

  1. This is very nicely put. Of course, I'm a doctor in small private practice so it does suit me. But my observation, having worked in settings large and small, institutional and individual, is that my practice style is most "cost-appropriate" and, well, *effective* in the personalized small practice setting.

    Thank you!

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  2. Thanks, Dr. Abramson. You may want to peruse the response published today by the study authors (see link in addendum to the post above).

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  3. Thanks for taking the time to discuss that, I feel strongly about this and so really like getting to know more on this kind of field. Do you mind updating your blog post with additional insight? It should be really useful for all of us.
    Mental health

    ReplyDelete