Donald Berwick running for governor of Massachusetts

His recent interview at Medscape with Editor-in-Chief Eric J. Topol, MD was not exactly hardball. I ranted extensively about Berwick a few years ago, around the time of his recess appointment as head of CMS, mainly concerning his duplicitous statements about health policy. He is a man of contradictions. I have long struggled to find clarity in his positions. The Medscape interview did not help. It was a great opportunity to press Berwick to resolve his inconsistencies but Topol did not take advantage. Let's take a look at some of the double talk.


Double talk on rationing

Berwick has expressed views favorable to health care rationing. In the health care policy debates of a few years ago he said:

“the decision is not whether or not we will ration care, the decision is whether we will ration with our eyes open.”

But when Topol asked him about his views on rationing:

Dr. Berwick: It was ridiculous. Rationed care? I'm a pediatrician, for Pete's sake. I've gone to the mat over and over again for my patients.

For more on Berwick's rationing flip-flops see this article by Wesley Smith.


Double talk on waste, efficiency and evidence based medicine

From the Medscape interview:

We've built this kind of volume-based, do-more-and-more-stuff healthcare industry, and I've very systematically looked for years at the levels of overuse... We now have the data that 30%-40% of care is just wasted...

We just go back to the question, "What will help the patient?" And if there is something we're doing that doesn't help the patient that means we can stop doing it. It's the intellectual route out.

But then there was this from a few years ago (hardly the intellectual route out):

For example, “leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat,” Berwick says. “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.”

Straight out of Dr. Berwick's mouth. Both sides of his mouth.

If Berwick were still just brainstorming at IHI this might be humorous. But he is seeking public office and wants to help shape policy. I'm a little concerned.


Inscrutably, Berwick seems to vacillate between the incompatible extremes of central control and radical consumerism. Orac, the blogger at Respectful Insolence, has commented on this before:

Finally, unfortunately Dr. Berwick’s philosophy is custom-made to be an enabler of the very woo that I so frequently rail against on this blog. After all, if patient empowerment and “patient-centeredness” trump science- and evidence-based medicine (except in “rare” circumstances that Dr. Berwick declines to define), then there really is no reason not to give the people what they want when they want it, all the time, so to speak. They want woo? Give it to them! They don’t want to vaccinate? No problem...

Sadly, his idealism is not grounded in the real world and, worse, it does not place science- and evidence-based medicine on even close to the same level as it does to turning patients into “consumers” and physicians into people who cater to those consumers no matter what.

If Berwick is so radically patient centered why, when he was head of CMS, were the Republicans so afraid he would favor government intrusion and rationing? It's because he has talked out of both sides of his mouth on this issue so many times, not only in the examples above but in many other speeches and writings including, for example, his well known remarks on the British National Health Service.

Radical consumerism and central control are at opposite ends of a spectrum and we may never know where he really stands. One thing is certain though. Neither is compatible with evidence based medicine.