Monday, February 20, 2012

Friends of Science in Medicine: Irrelevant and Inconsequential?

[Post moved to other blog.]

Peter Jean, Health Reporter for the Canberra Times, wrote a good piece (clear, informative, balanced) about FoSiM, Sunday 19th Feb, 2012: "Accessing the Alternatives".

In researching a follow-on piece to Peter Jeans', I took 4,500 words of notes - without covering anywhere near the number of topics I wanted to bring together. I wrestled with:
a) how to meaningfully condense such a wide field, and
b) Just what is the story here?
The crux of my dismay and discomfort with FoSiM, Marron and Dwyer is their outrageous attack on a relatively benign and low-impact Healthcare Services ("Complementary and Alternative Medicine" [CAM]), whilst ignoring massive, real and pervasive fundamental problems with mainstream Medical Healthcare.
FoSiM, Marron and Dwyer are asking us to shutdown and prevent from practicing those who account for under 1% of Medical fatalities and errors, whilst comprehensively ignoring the major problems. What is going on here???

Loretta Marron, CEO and the apparent Power behind the Throne, is the medical equivalent of Pauline Hanson: industrious, opinionated, loud, self-promoting - and ultimately mostly irrelevant.

Prof. Dwyer and his other "Executives" are all well-known, reputable medical scientists and academics with an axe to grind. It appears they are upset that they don't control or regulate every aspect of Medicine, mainstream and Alternative. Appearing so very "50's" and "Doctor knows Best".

Plus you'd have to wonder if like "One Nation", people of the calibre of David Oldfield will move in and use FoSiM to further their own careers, pursue their own aims/agendas, damaging organisational credibility and undermining their goals.

Some observations on the FoSiM goals:
  1. Any call for Science in Medicine is fraught for mainstream medical practitioners. If the spotlight is turned on them and they are required to provide Evidence of Competency themselves, even expected to practice "Real" Quality, their life will get much more difficult.
  2. This appears solely to be a turf war. Since the 1950's Doctors have lost their high-standing in the community and automatic respect from the public. Doctors have lost the unquestioning confidence of the public, who decided to look elsewhere for compassionate, engaged care.
  3. This is mostly about money. Doctors don't practice solely for the love of it. GP's are small businesses who collectively try to both defend their income and look for ways to increase it.
    If this aspect isn't acknowledged and discussed openly, the whole debate will become very murky indeed.
  4. There is a real problem under all this: vulnerable people are conned all the time. They want to believe in miracles, snake-oil and panaceas and resist all attempts to be warned or enlightened.
    This isn't a recent phenomena, nor confined to Medicine of any description.
    FoSiM appears to be advocating for a unilateral approach: Ban the Bad Guys (practitioners).
    The 1920's "Prohibition" in the USA and the current "War on Drugs" shows that you can't just legislate problems away. This simplistic approach of FoSiM will not work - there is overwhelming evidence of this, which makes you wonder what sort of 'Scientists' these folks are.
  5. The Internet is a searchlight that illuminates dark corners everywhere.
    FoSiM should be calling for a definitive on-line wikipedia-style 'register', not registration, of all Health Practitioners. It would allow the relatives and friends of people entrapped by shonks of any kind (including AHPRA registered and certified) to uncover warning signs and to warn-off others.
  6. Mainstream Medicine gets a "free pass" from the ACCC with their business model.
    They don't have to refund the cost of "failing to provide the service advertised" as does every other retail business.
    If Doctors wish to enforce Accountability on others, they should be prepared to give up their privileged position and join the rest of us in ordinary business.
  7. What s Loretta Marron's motivation? I cannot understand her complaining and campaigning about other people's problems when she is not a Healthcare Practitioner of any type.
    Only in movies and comic books do people need "Super Heroes" to look after them and defend them from the ranged Forces of Evil. Adults in the real world need Information, Training and Support - not being "stood up for" by some self-appointed 'guardian'.
    There is a word for this in law-enforcement: Vigilante.
  8. Loretta Marron, interview on 4BC and her constant untested accusations of "voodoo and witchcraft", seemingly against all CAM (as MP3). Love her or hate her, you need to hear the lady in her natural element. I found it hugely ironic that she was preening herself over being the first person ever to be recipient of dual "Australian Sceptic of the Year" awards (2007, 2011) - an self-appointed organisation built on judging others and requiring evidence but the antithesis of "open and transparent" themselves. All while she threw nothing but untested, unproven accusations and innuendo around. One standard for her, another for everyone else...

Queensland Public Hospitals Commission of Inquiry, 2005:

While the site for the Davies Queensland Public Hospitals Commission of Inquiry is still on-line, that for its immediate predecessor, Morris' Bundaberg Hospital Commission of Inquiry is not, existing only in The Internet Archive.

Initially I was going to start this piece with this bunch of aphorisms relevant to FoSiM and their performance and bias:
  • "by their actions you will know them"
  • "ends must match the means"
  • "first remove the log from your own eye"
While these are still relevant and appropriate, indicating that FoSiM, Marron and Dwyer are being driven by a hidden agenda, I was derailed by the next thought:
Just how Professional are Mainstream Medical Practitioners? (could they really withstand a serious Inquiry?)
For example Jayant Patel (JMP), "Doctor Death" of Bundaberg.
Reading the ~550 pages of the Davies Inquiry report I was struck by many things:
  • The only reason there was ever an Inquiry is that a single nurse, Toni Hoffman, sacrificed her career by whistle-blowing. Otherwise none of this would have happened, raising the question: "How many incidents like this had happened previously without comment?"
  • Although Patel's "Mortality and Morbidity" statistics implicated him in 30 or more deaths, the legal system requires proof of causality. Hence he was only prosecuted for a small number of cases.
  • Jayant Patel was by far not the only "renegade" practitioner identified by the Inquiry, nor the only person whom the Inquiry made recommendations about.
  • There were multiple other hospital districts found to be delivering unsafe care to patients. This is further evidence of wide-scale, systemic failures in Queensland Health.
  • There were serious systemic problems within Queensland Health, including its treatment of local medical graduates and GP's (as VMO's, Visiting Medical Officers).
  • These origins of these problems is complex and due to Political, Public Service Administration and Medical Profession issues - going back 30-40 years.
  • Margaret Cunneen SC, in "The Patel Case – Implications for the Medical Profession (Medico-Legal Society of NSW, 2010), points out:
    • Queensland has a "Criminal Code of Law" which made the criminal prosecution of JMP possible.
    • Patel, and any doctor acting maliciously, could not be charged with a criminal offence in NSW and most other Australian jurisdictions.
    • Cunneen says little has changed in NSW in over a century:
      She reviewed an 1893 case of a person practicing as a doctor, but not legally qualified. He failed to deliver a baby, causing it severe injuries and death - but the charges were dismissed because the man had no case to answer under the law then, or now.
    • Cunneen, a senior prosecutor, says:
      "because of this expectation that doctors will not do something maliciously against a patient, that they will only make a mistake which may or may not be civil negligence."
    • There have been no calls by the Australian Medical Profession to address these problems of Jurisdiction, consistent Medical Board judgements or malicious injury by doctors.
There is overwhelming evidence that Queensland Health has had pervasive, systemic problems for decades. Is that Politically acceptable or a proper use of Public Monies?

The most critical question is:
What has fundamentally changed so that any of this could not happen again, that these lives lost and unnecessary injury inflicted has not been in vain? [Nothing?]
My rubric for Professionals:
Is there ever a reason for any Professional to repeat, or allow, a known Error, Fault or Failure?
By this test, Aviation professionals and technicians, at least here in Oz, are overwhelming more Professional that every registered Doctor. Part of the proof lies in the Open and Transparent collection and reporting of critical outcome data.

The lack of demonstrated improvement, in fact the universal absence of critical outcome data, for Hospitals, GP's and specialists suggests a fundamental, systemic failure within Australian Mainstream Medical practice.

That's something definitely worthy of FoSiM, Marron and Dwyer's time and attention, and demonstrably of massive benefit to Australia.

"A primer on leading the improvement of systems"
Donald M Berwick. BMJ VOLUME 312 9 MARCH 1996
Institute for Healthcare Improvement,Boston, MA 02215,USA
Donald M Berwick, president and Chief Executive Officer.

Learning points:
  • Not all change is improvement, but all improvement is change.
  • Real improvement comes from changing systems, not changing within systems.
  • To make improvements we must be clear about what we are trying to accomplish, how we will know that a change has led to improvement, and what change we can make that will result in an improvement.
  • The more specific the aim, the more likely the improvement; armies do not take all hills at once.
  • Concentrate on meeting the needs of patients rather than the needs of organisations.
  • Measurement is best used for learning rather than for selection, reward, or punishment.
  • Measurement helps to know whether innovations should be kept, changed, or rejected;
    • to understand causes; and
    • to clarify aims.
  • Effective leaders challenge the status quo both by insisting that the current system cannot remain and by offering clear ideas about superior alternatives.
  • Educating people and providing incentives are familiar but not very effective ways of achieving improvement.
  • Most work systems leave too litle time for reflection on work.
  • You win the Tour de France not by planning for years for the perfect first bicycle ride but by constantly making small improvements.

Not all change is improvement, but all improvement is change.
The relation derives from what I will call the central law of improvement:
every system is perfectly designed to achieve the results it achieves.
The central law reframes performance from a matter of effort to a matter of design.

The central law of improvement implies that better or worse "performance" cannot be obtained from a system of work merely on demand. [Therefore Inquiries and Political directives that mandate change without organisational redesign are doomed to failure. This is confirmed by the outcomes we've seen.]

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