Sunday, February 26, 2012

Friends of Science in Medicine: Hypocritical call to action

[Post moved to other blog.]

Update: 17-Jul-2012: There is now considerable blowback from the Medical Community towards Dwyer and his "little Friends". The MJA [Medical Journal of Australia, behind a paywall] of 16-Jul had multiple articles on this topic.

From a report on the Editorial and associated articles.

Professor Stephen Myers, SCU [Southern Cross University]:
“the real benefit of an appropriately mentored and approved university education is the exposure of students to the biomedical sciences, epidemiology and population health, differential diagnosis, safe
practice and critical appraisal."
Professor Paul Komesaroff, Monash University, on MacLennan's MJA in editorial in March-2012:
“exceed the boundaries of reasoned debate and risk compromising the values that FSM claims to support”.
Professor Komesaroff:
"while there was now an extensive evidence base in relation to complementary therapies, the concept of evidence-based medicine was highly contested and debated within Western medicine itself." 
"It is not appropriate for doctors or scientists with a particular view of medicine to impose those views on the whole community; rather, they should respect the rights of individuals to choose the approach to health care they feel is suitable for them." 
“It is important that those who seek to be friends of science do not inadvertently become its enemies. We call on the members of FSM to revise their tactics and instead support open, respectful dialogue in the great spirit and tradition of science itself”

In writing an inadvertently long piece on the Irrelevance of Marron and Dwyer's "Friends of Science in Medicine", I had to reflect on what what a convincing "short version" would be. Here's an attempt:
  • Dwyer, as a respected and long-serving medico, has to be aware of the estimated 18-35,000 preventable deaths in Australian Hospitals each and every year. [1995 QAHCS report, disputed.]
  • He must also be aware of the lack of good data on Adverse Events (AE) and Iatrogenic Injuries.
  • Similarly, the extra $2B/year estimated additional cost of treating AE's in hospitals.
  • He should also be aware of Dr Brent James reports (2001) from Intermountain Health, Utah, that only "3.5% (of patient injuries) resulted because of a human error" and from the APSF report on Iatrogenic Injuries (2001)  "The causes of iatrogenic injury appear to be systemic".
  • There is also a 2004 report on the effects and additional preventable deaths from overcrowding in Accident and Emergency. 
All of which could be used to suggest by Dwyer and friends:
Australian Medicine and Hospitals do very well in the face of insurmountable odds and lack of Political will and funding. [A justification used by AMA President Rosanna Capolingua in 2008, below.]
Only it isn't so...
Compare the complete lack of an Evidence Base for Patient Outcomes for Australians and any coherent, credible, co-ordinated plan to address this with the UK's Civil Aviation Authority's current Safety Plan
Secondly, Dr Brent James reported a 20% reduction in costs by reducing Patient Injuries through a "Do it Right, First Time" approach to Quality. This corresponds with the 2002 results from Ehsani, Jackson and Duckett. As Berwick suggests, organisational change is required to address systemic issues. Unless the system is changed, results won't change.
The CAA's Safety Plan [excerpted below] conspicuously shares a feature unknown in Australian Medical literature and seemingly in Hospital improvement plans: The Most Important Problems List.

The CAA has its "Significant Seven" and Dr James his "Bg Six List".
These seem unknown and unreported in Australian Hospitals and Health Department Plans and Operations.

Where this line of reasoning leads to:
After 50 years of large jet aircraft being used in Commercial Aviation, 'we' know exactly what has to be done to economically achieve good, reliable and safe Public Services, so why isn't this approach being advocated and adopted by Medicos and Hospitals?
From Dr. James, we also know that it is cheaper to fix systemic issues through a "Get it Right First Time" Quality approach, so after more than a decade of being known in Australia is this not being done?
How many "Adverse Events" are there in the Australian Hospital system? We don't know.
But the best evidence available is that they are not reducing. [below]
The most conservative estimates, "Sentinel Events", counts around 270 adverse events/year.
The QAHCS report estimated 18,000, the difference being direct, provable causality.
While the Australian Doctors Fund (ADF) would like us to use the American UTCOS report figure of 3.3 times less, of ~5,500 per year.

From Dr. James definitive work, the number of patient injuries is around 30 times the number of Adverse Events reported, reasonably 165,000 per year.

So why isn't Prof. Dwyer advocating and campaigning for the Medical Profession in Australia to adopt known, effective Evidence-Based Systems for itself preventing thousands of deaths, eliminating hundreds of thousands of injuries and reducing needless waste, rather than what appears to be a distracting side-show of "look at all those Bad Guys over there!".

This is the nub of his hypocrisy: Everyone else is doing it wrong, but we are beyond reproach.

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