Sunday, March 25, 2012

Unsolicited advice for the new Queensland Government

Last night in Queensland, the Liberal National Party (it could only happen in QLD), won in a landslide, led by Campbell "Can Do" Newman, son of Federal Politicians and with 13 years distinguished service as an Engineer in the Army.

One of the candidates I graduated with from school, 40 years ago has a very successful legal practice, I'm an underemployed I.T. consultant.

I sent him this unsolicited advice.
Not very original of me I know, but I hope it gives a useful insight to them.

First, from my profession of I.T.

 A piece of ~1,000wds on the cost to Govt. of essential infrastructure (IT) not fulfilling its promise (slanted more to CBR than QLD):
"The Triple Whammy - the true cost of I.T. Waste"

And a way out of the hole (600wds):
"Controlling Waste in Government I.T. - An Immodest Proposal"

Create two bodies like Aviation has, ATSB/CAA. One to investigate, identify root-causes and write detailed recommendations for remediation, and another to implement and enforce those recommendations...
It means making the Audit Office do more than check for fraud/broken regulations and develop real, on-going expertise in essential disciplines, starting with I.T.

And establishing an Independent Authority with real teeth... One of the first actions has to be "start collecting performance and outcome data", like the 15yr old CHAOS report that reports on I.T. project outcomes in the USA.

If people and firms are assessed as incompetent or worse then, like in Aviation, the Govt has the right to de-licence them, only they aren't licenced. But they can be put on a public "not to be employed by Govt." register , which others will know if it is lawful currently or not.

Most importantly the "Authority" has to focus on Change and Improvement, not disciplining and "handing out consequences" (which is part of its remit) or it becomes counter-productive. (900 wds)
"The Accountability Paradox: Personal Consequences and Blame"

It comes down to a basic proposition:
Is it ever acceptable for a Professional to repeat, or allow, a Known Error, Fault or Failure?
I'd argue that a number of professions owe a Fiduciary Duty to their clients/patients and professional failures in this way should result in the most serious penalties.

In Aviation, not repeating mistakes is taken very seriously, but not in I.T. nor seemingly in the medical world.

In any Engineering profession, a professional who fails in this way, causing fatalities or allowing preventable economic failure, not only loses their license to practice, but is open to criminal, not just civil, charges.

Secondly, on Public Health and Hospitals.

Urgent reform is needed within Queensland Health, at many levels, but what's been tried over the last 20 years hasn't worked. A radical approach is needed, and one that is known to work.

This is not my area of Professional expertise and I wouldn't know where to start...

But I know who does and how to do it:
Adopt the Aviation model of Systemic Quality and Deliberate Change Implementation.
A recent article in the Journal of Patient Safety proposes exactly this:
"An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate",

What they don't say is that Systemic Quality (my term) isn't just free, but because it embraces active, intentional learning and improvement, it is better than free:
20% cheaper is well documented.
1. Dr Brent James of Intermountain Healthcare. You can read his 2001 ABC interview "Minimising Harm to Patients in Hospital" and his "its 20% cheaper" data.

2. Dr James' work is reflected in a major report by the US Institute of Medicine:
   "To Err is Human: Building A Safer Health System" (1999).

3. Donald Berwick and the "Institute for Healthcare Improvement".
    Here is a landmark article by Berwick from 1996:

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

I'm sure you've read the 500 page QPHCI report and possibly Margaret Cunneen SC's "The Patel Case – Implications for the Medical Profession" (which as a layperson I found astounding).
The inherent problem with Commissions of Inquiry is that they cannot oversee or enforce the implementations of their recommendations. The responsibility gets handed back to Govt. which delegates the Change and Improvement process to the organisation that has the problems.
This fails a basic sanity test:
If the organisation could've changed itself, it would've.
Continuing systemic problems are not the result of lack of knowledge or insight.
Berwick formulates this problem exactly with:
every system is perfectly designed to achieve the results it achieves.
The Organisational Rules have to be changed to create more than cosmetic change because the incumbents have both an investment in keeping the status quo (its worked for them) and if they could've changed the system within the existing Rules, they would've.

Changing Organisational Rules, and making them stick, can only come from above.
This is exactly why Dr Demings' "Quality Circles" (and his teachings) worked in Japan and failed in their country of origin, the USA. Deming was hired by the heads of Japanese industry and they were able to mandate the changes.

Some things to kick off reform of QLD Health are:

  • assess the degree of compliance with the QPHCI recommendations within 2 weeks.
    • Any good bureaucratic will attempt to stall efforts like these for months or years. Think of the HSU Inquiry by Fair Work Australia as an outstanding example.
  • look to new laws addressing Patel's deliberate action in harming patients.
    • There is also a lesser offence of ' professional incompetence', proven by the statistical outcomes of a doctor. Individual victims cannot be identified, but that there are victims is proven by the stats.

Systemic Quality and "The Iron Triangle" of Quality, Cost and Schedule.

The work on Safety and Quality systems by James T. Reason and Charles H. Perrow redefined the world of Quality, showing up in acceleration Safety in Aviation post-1970.

But what do you call this approach?

I'd like to suggest, "Systemic Quality".

Perrow called them "Normal Accidents" and Reason "Organisational Accidents". Both were talking about System created Accidents. Where multiple events, not individuals, are the cause of unintended poor outcomes. But neither coined a term for this approach to Safety and Quality.
My reasoning for the naming is:
Name the approach after the cause addressed, Systems create the problems, so it's Systemic Quality.
The text below is adapted from a piece on suggesting Medicine become a Modern Profession, like Aviation.

What Dr W. Edwards Deming understood so well is that Quality, Process Improvement and Performance Improvement are linked through the same fundamental:
Deliberate, focussed review of work outcomes with intentional Learning and Adaption are necessary for, and common to, all three.
This is enshrined in Deming's P-D-S-A (Plan-Do-Study-Act) cycle, which he called the Shewhart Cycle.

Systemic Quality through its design and nature improves Safety, Performance/Productivity and Economic Performance/Profitability.
Something that Apple Inc knows and Microsoft, the long-time market leader, does not.

What does a modern Profession look like?
Aviation as a perfect model.

In Project Management, there is the "Iron Triangle", usually explained as "Good, Fast, Cheap: pick any two".

Alternatively, the "Iron Triangle" is described as: "scope, schedule and cost constraints".
This definition, with no explicit mention of emergent or unspecified Dimensions like Safety and Quality, can lead Project Managers astray. Deming showed that Cost and Quality are intimately linked, and focusing only on costs ultimately drives costs up, while driving quality down.

This piece of received wisdom says that Economic Profitability, Job Performance and Product/Process Quality are competing dimensions, to optimise one of them, others have to be sacrificed.

This just isn't so.

It only appears that way if a) you examine a single project (in the short-run) and
 b) your Project Methodology doesn't include the last half of Demings' cycle (Plan - Do - Study - Act to improve system).

Dr Deming's proven theories on Performance and Quality rely on two fundamentals which you might recognise from the Scientific Method:
  • Be inquisitive, examine your own performance, look for insights into your work and outcomes, self-examination is the precursor to insight, and
  • try to constantly improve both your knowledge and practice, to consciously learn both from your failures and successes.
This "conscious, deliberate learning" mindset is a necessary condition for constant improvement in all three aspects of the Iron Triangle: Profitability, Performance and Quality.

It's a long-run, not short-run, effect. It doesn't appear within a single project, but after the execution of many. The most important part of every project is the Analysis/Learning phase after it, the Project Review.

For cottage-industry crafts, where you only practice "as learnt" skills without deliberate improvement or correction, the veracity of the "Pick any two" rule is both obvious and unbreakable.

For modern Professions which practise System Quality, i.e. "Do it Right, First Time", the 'rule' is wrong and misleading.

Back to Aviation, a modern Profession where, in most but not all countries, Systemic Quality is pervasive and firmly embedded in the culture and practice of each discipline and speciality, as well as in the governance of the whole Industry and its component parts.

More importantly, there is free, public data on the performance of the Industry.

Page 11 of the EASA's 2010 Annual Safety Review, has a powerful chart [Fig 2-1] showing how the Industry has progressed/improved and some words that should make the Australian Medical Profession both ashamed and envious:
The data in Figure 2-1 show that the safety of aviation has improved from 1945 onwards. Based on the measure of passenger fatalities per 100 million passenger miles flown, it took some 20 years (1948 to 1968) to achieve the first 10-fold improvement from 5 to 0.5. Another 10-fold improvement was reached in 1997, almost 30 years later, when the rate had dropped below 0.05. For the year 2010 this rate is estimated1 to have stayed at 0.01 fatalities per 100 million miles flown.
The accident rate in this figure appears to have been flat over recent years. This is the result of the scale used to reflect the high rates in the late 1940s.
Another Canadian education site, with an inspiring graph on the improvement in Aviation Safety says:
Up to the early 1970s the number of fatalities increased with some proportionality with the growth of air traffic. By the 1970s, in spite of substantial growth levels of air traffic, fatalities undertook a downward trend. This is jointly the outcome of better aircraft designs, better navigation and control systems as well as comprehensive accident management aiming at identifying the causes and then possible mitigation strategies.
This isn't isolated or peculiarly European: 
The reason for these massive, on-going improvements is the detail and seriousness of incident investigations. Notably, while commercial "Air Carriers" have improved their Safety and Operations by several orders of magnitude while being profitable in a cut-throat industry experiencing a 1,000-fold increase in services delivered, "General Aviation" has improved, but by only approximately 5-fold. The difference isn't in the technology, training available or processes/procedures detailed. It's the Professional "Right First Time, Every Time" approach of Systemic Quality and attention to preventing Organisational Accidents.

The crash in early 2009 into the Hudson River of US Airways 1549, piloted by  Capt. "Sully" Sullenberger, was dramatic, widely reported, and resulted in no fatalities and only a handful of injuries.
In most professions, it would be regarded as a huge success and not studied.

Yet it led to 35 "Recommendations" by the US official investigator, the NTSB (National Transport Safety Board). Think how different this is to most Medical practice: even injuries resulting in permanent disabling of patients, like the 2010 preventable and foreseeable injury to Grace Wang, a repeat of a well known Error, led to news reports, but no obvious investigation and certainly no consequences for anyone involved.

These NTSB "recommendations" will be implemented, will be checked upon by a regulatory body [the FAA] and failure to do so will result in proportional, direct, personal and organisational consequences.

This is completely at odds to the 550+ page report by the 2005 Queensland Public Hospitals Commission of Inquiry, triggered by Jayant Patel and others, where the Recommendations are optional, their (timely) implementation won't be checked, nor will there be consequences for anyone repeating these Known Errors, Faults and Failures.

One of the reasons for this cultural change in Aviation and resulting the on-going improvement of Safety, Quality and Performance in Aviation is the theoretical work of two men:
NASA uses Perrow [PDF] as a basis for its Safety programmes.

Prof. Reason seems to have retired from Academe, but is still listed as an advisor to "The Texas Medical Institute of Technology (TMIT)".

James Reason's work is well known in the medical community: it was used by Dr Brent James and colleagues in the remarkable turnaround and improvement of Intermountain Healthcare, reported in "Minimising Harm to Patients". On the wikipedia page on "The Swiss Cheese Model", a large number of pieces in "Further Reading" are medical.

Where this ends is a 2012 article published in "Journal of Patient Safety", available on the TMIT site, "An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate", where the authors, Medicos and Aviators and authors of 100 medical papers, call for applying what is known to work in Aviation to Medicine.

An idea that seems long overdue, although they don't go as far as suggesting the second, necessary, pillar of the Aviation system, the US FAA or UK's CAA, a regulatory and compliance organisation (also responsible for provision of common services, like Air Traffic Control). These organisations are charged with first implementing and on-going checking of NTSB recommendations, bringing direct, personal consequences to those not complying.

Without "accountability", recommendations and findings have little likelihood of being fully and consistently practised.
Economic and medical risks threaten the national security of America. The spiraling costs of United States' avoidable healthcare harm and waste far exceed those of any other nation. 
This 2-part paper, written by a group of aviators, is a national call to action to adopt readily available and transferable safety innovations we have already paid for that have made the airline industry one of the safest in the world. This first part supports the debate for a National Transportation Safety Board (NTSB) for health care, and the second supports more cross-over adoption by hospitals of methods pioneered in aviation. 
A review of aviation and healthcare leadership best practices and technologies was undertaken through literature review, reporting body research, and interviews of experts in the field of aviation principles applied to medicine. An aviation cross-over inventory and consensus process led to a call for action to address the current crisis of healthcare waste and harm. 
The NTSB, an independent agency established by the United States Congress, was developed to investigate all significant transportation accidents to prevent recurrence. Certain NTSB publications known as "Blue Cover Reports" used by pilots and airlines to drive safety provide a model that could be emulated for hospital accidents. An NTSB-type organization for health care could greatly improve healthcare safety at low cost and great benefit. A "Red Cover Report" for health care could save lives, save money, and bring value to communities. 
A call to action is made in this first paper to debate this opportunity for an NTSB for health care. A second follow-on paper is a call to action of healthcare suppliers, providers, and purchasers to reinvigorate their adoption of aviation best practices as the market transitions from a fragmented provider-volume-centered to an integrated patient-value-centered world.

EBM's and RCT: Doubt, Scientism and unquestioned Ideologies

[Full post moved to other blog.]

update 8-Apr-2012: Quotes from "Evidence-Based Medicine: Neither Good Evidence nor Good Medicine" by Steve Hickey, PhD and Hilary Roberts, PhD.
  • The current approach to medicine is "evidence-based." This sounds obvious but, in practice, it means relying on a few large-scale studies and statistical techniques to choose the treatment for each patient. Practitioners of EBM incorrectly call this process using the "best evidence."
  • Significant Does Not Mean Important...
  • Large trials are powerful methods for detecting small differences.
  • There is a further problem with the dangerous assertion implicit in EBM that large-scale studies are the best evidence for decisions concerning individual patients.
  • As we have mentioned, EBM restricts variety to what it considers the "best evidence."
  • A doctor who arrives at a correct diagnosis and treatment in an efficient manner is called, in cybernetic terms, a good regulator. 
    • According to Roger Conant and Ross Ashby, every good regulator of a system must be a model of that system. Good regulators achieve their goal in the simplest way possible.
    • In order to achieve this, the diagnostic processes must model the systems of the body, which is why doctors undergo years of training in all aspects of medical science.
    • In addition, each patient must be treated as an individual.
    • EBM's group statistics are irrelevant, since large-scale clinical trials do not model an individual patient and his or her condition, they model a population-albeit somewhat crudely.
    • They are thus not good regulators.
    • Once again, a rational patient would reject EBM as a poor method for finding an effective treatment for an illness.
  • Diagnosing medical conditions is challenging, because we are each biochemically individual.
    •  As explained by an originator of this concept, nutritional pioneer Dr. Roger Williams,
    • "Nutrition is for real people. Statistical humans are of little interest."

The Friends of Doctors espouse an uncritical Ideological belief in a simplistic doctrine:
Evidence Based Medicine is the only source of Good Science and hence Good Medicine.
All else is, by definition, irrelevant, invalid and, at worst, quackery.
Which is a variation on Scientism, "the universal applicability of the scientific method and approach".

In 1898 you might've excused a Great Expert from declaring "We know everything and have invented everything" [paraphrased] - but in the 21st Century, for anyone to have the arrogance and hubris to make universal/absolute statements that are not dissimilar is unbelievable.
Doubly so, if like FoSiM, they hold themselves up as Great Experts (Professors with many awards and decades of experience).

I have a very specific objection to the FoSiM position, roughly, EBM/RCT's are OK as far as they go, but are far from being the only thing:
RCT's are a necessary, but not sufficient, way to gather evidence, but can never provide proof. Popper's "falsification" notion says theories can never be proven, only disprove with 1 counter-example. The source of the economics/finance term "Black Swan" - something completely new and unexpected.
Why would a group of eminent persons go out of their way to make themselves look complete fools, espousing an entrenched and immovable position that is obviously flawed?

The only reasonable answer I can come up with is:
They are fighting a Turf War and using EBM/RCT's as an overwhelming strength with which to beat-up their opponents. But if the opponents start to provide RCT's, then they can either play "Change the Rules" or "Move the Goal Posts" to force the opponents to waste time and resources.
The unreasonable explanation is these folks are uncritically and intractably wedded to the Ideology, "EBM and RCT's are everything".

In summary:
Medical Science uses RCT's because it's the best thing they've got, but belief in them "should be held lightly", they are not infallible nor free of serious deficiencies.

Evidence Based Medicine is a good servant and a poor Master. The emphasis must be on Medicine, not 'Evidence', on providing good patient care and outcomes. Chief of which is focussing on Patient Safety, not the glittering bauble of "efficacy". "First, do NO harm"...

Saturday, March 24, 2012

Friends of Doctors: What the figures say...

[Post moved to other blog.]

An analysis of the 11-March-2012 members list of "Friends of Science in Medicine":
  • They can claim 28 'Friends' outside the field or their parent body and who still work.
Calling the group "Friends of Doctors" is far more accurate.

Note: A full count of members of the parent Organisation, "Australian Skeptics" is not possible without a public membership list (4,000 subscribers are claimed to "The Sketpic").

The organisation's own analysis, (494 members, 25-Feb-2012) is:
Of the 494 individuals were a total of 226 (45%) medical doctors (212 Australian, 14 Overseas) and other disciplines (243 Australian, 25 Overseas).
My analysis:
  • 502 unique names,
  • 1 duplicate record, "Prof Jon Emery"
  • 123 with title "Dr"
    • 5 non-health related
  • 334 with title "Prof" (including A/Prof)
    • 4 FoSiM Executive members
    • 34 Emeritus or retired
    • 165 MBBS, MD, BMedSci, FRACP, FRCP, FANZCA, FRACGP, Obstetrics & Gynaecology, Medical Oncology, Psychiatry, Pharmacy/Pharmacology, RN
    • 131 remaining:
    • 15 in non-health areas
  • 41 not "Dr", "Prof" or on the Executive.
    • 7 declare or publicly state membership of the parent Organisation, "Australian Skeptics"
    • 17 are in Medicine/Medical Science or allied disciplines (Pharmacy, Nursing, paramedic)
    • 18 "non medical" vocations [counts not given].
      • health/biology related
      • 8 non-health related
        • Information Technology 
        • MSc(Astronomy) BSc(Finance & Economics) 
        • Science, eLearning Officer
        • legal researcher, solicitor
        • science writer/editor/creative director

Tuesday, March 20, 2012

Censorship in 300 words or less. What's up at Fairfax?

[Post moved to other blog.]

An article in the Fairfax media entitled "Homeopathy | Alternative Medicine | Ian Gawler" drew my attention. I went to the effort of registering and making a comment. It didn't appear, having been "moderated", presumably breaking the Fairfax Rules for Commenting on articles and blogs :-
... any comments that can be reasonably considered offensive, threatening or obscene will not be allowed.
  • Do not post material that may incite violence or hatred.
  • Gratuitous abuse - be it of the author, subjects of the story or other commentators - will not be accepted.
  • Please keep your comments relevant to the discussion at hand.
  • Do not use the comments section for commercial purposes or spam.
Herewith my comment and the original article... [See full post]

Friday, March 16, 2012

The Accountability Paradox: Personal Consequences and Blame

A recent piece in The Journal of Patient Safety, "An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate" by experienced, highly-competent Aviators and Medicos prompted me to ask a question about on the subject of Dr Brent James, Chief Quality Officer of Intermountain Healthcare:
The NTSB only recommends, the FAA makes sure those things (and more) are done.
As a regulatory and compliance organisation, the FAA is able to hand out "direct, personal consequences" - and make them stick. [Natural Justice suggests proportionality as well].

Any Aviation Professional who repeats, or allows, a Known Error, Fault or Failure will be discovered and will suffer the consequences. [Hence would a medical version need two bodies?]
Dr James kindly responded to me and I was gently reminded of James Reason's "Blame Cycle" [below] and Dr James own comments on the 2001 ABC's Health Report, "Minimising Harm to Patients in Hospital":
Norman Swan: So remove the culture of blame, sort out the legal liability problems, without ignoring the fact that there will be the odd rogue doctor or rogue nurse who needs to be sorted out. What we should be seeing here, we haven't really emphasised it up till now, is that most of the problems that occur when injuries occur, are system problems, the hospital, the management, the organisation of the hospital, rather than an individual going wrong?

Brent James: Exactly. We know that the individuals will have problems. How do we create an environment in which it's easier to do it right, and hard to fail? That's the real issue. It's an institutional responsibility not an individual responsibility. The next thing that we need is an organisational structure. In the United States we're calling them Patient Safety Officers, and in the Institute of Medicine Report we asked that all care delivery groups appoint Patient Safety Officer, usually from existing personnel, usually a good clinician.
The Military have a "Rule of Three" for all leadership roles [definitions from the Apple dictionary App]. The three have to be aligned for every role or either the task/function won't be done well, or the individual in the role will be falsely held to account for actions they are unable to control:
  • Responsibility:
    "a thing that one is required to do as part of a job, role, or legal obligation"
  • Accountability
    to be held to account for actions. "(of a person, organization, or institution) required or expected tojustify actions or decisions; responsible"
  • Authority:
    "the right to act in a specified way, delegated from one person or organization to another", including "to give orders, make decisions, and enforce obedience".
These are very specific meaning for the words "responsibility" and "accountability".
In normal, conversational English, the words are mostly used interchangeably.

In this more formal sense, there is a difference drawn between "a task or function delegated to an individual" (responsibility) and "an item for which you may be held to account" (accountability), a fine, but important, distinction.

It is in this second, more formal sense that I wish to use "Accountability" here.

My central concern with the NTSB-for-Medicine proposal is the necessity for the organisation to not be a "toothless tiger", to have the power to cause change, but simultaneously engender a "Safety Culture" where Openness and Transparency are the norm and individuals do not feel threatened by the system.
Audit reports and Commissions of Inquiry into major failures (QLD) say what's wrong, but have no powers to cause change. They are equivalent to the NTSB, but lack the ability of the FAA to implement, to cause or require necessary change and to check that it is done.

Reason's "Blame Cycle", and my own more extreme "Blame Spiral", require Dr Demings' exhortation to "Drive out Fear" be scrupulously and systemically be applied.

How can these two conflicting objectives be achieved? I've no experience in this.
This is The Accountability Paradox:
For real change in the system, any person who repeats, or allows, a Known Error, Fault or Failure, must be held personally liable (including criminally if they caused death or severe injury/disability),
BUT if that is perceived as the Primary Role of the compliance and governance organisation, then it will be ineffective, instead it will engender the "Blame Cycle" as a minimum.
We know that in the USA the NTSB/FAA work together, in the UK the AAIB/CAA, in Australia the NTSB/CASA and, from outside, there are well developed and sustainable "Safety Cultures" operating within them all (vs Blaming Cultures).

So how can our Public Healthcare get there from here and avoid perverse outcomes, like the "Blame Cycle"?

How can Hospital and Healthcare systems in Australia copy the Intermountain Healthcare model and move from chaotic, inconsistent "heroics" to a consistent Safety and Quality Culture, embracing Continuous Improvement whilst driving down waste and system inefficiencies?

How can Australia both create a system where the Public Healthcare system improves both its performance and accountability, so the 2004 "Dr Death" scandal in QLD is never repeated but where all Healthcare workers trust they will not be blamed for speaking truth to power,  to know they can raise important issues and be properly heard, unlike Toni Hoffman in Bundaberg?

I'm sure the Medical Error Action Group would love to post a final message saying "the system has been changed to pick up its own problems, we're not needed anymore."

Some references to Prof. Reasons' "Blame Cycle":
"Diagnosing “vulnerable system syndrome”: an essential prerequisite to efffective risk management" (2001, Qual Health Care 2001;10:ii21-ii25 doi:10.1136/qhc.0100021) and
"Managing the Risks of Organizational Accidents" [1997].

The "Blame Spiral": How a blame culture destroys Projects and what to do about them.

James T. Reason has a very well developed model of the "Blame Cycle", e.g. "Diagnosing “vulnerable system syndrome”: an essential prerequisite to eVective risk management" (2001, Qual Health Care 2001;10:ii21-ii25 doi:10.1136/qhc.0100021) and "Managing the Risks of Organizational Accidents" [1997].

It is based on:
  • The Fundamental Attribution Error: misidentifying the root cause of an event (a person who chose to do it, rather than a multi-factorial Organisational Error).
  • A "Person Model" not "Organisation Model" of errors, and
  • if informed, people will just stop making mistakes.
  • [and there is much more to it than this]
The remedy to the "Blame Cycle" is creating a "Safety Culture" which is where, in Deming's words, "Drive out Fear", is conscientiously and consistently practised.

All of which is correct, but doesn't explain three things:
  • Why after around 25 years of writing, research and implementations by Reason and Perrow and around 75 years since H.W. Henrich's "Industrial Accident Prevention, A Scientific Approach" (1931) are Blame Cultures still the norm, rather than the exception, even in High Safety environments like Healthcare. Aviation and space flight (e.g. NASA) seem to be leaders in the implementation and practice of the "Safety Culture" approach.
  • After more than a century of definitive, proven Management Science theories, why does the Default Management Style, of which the "Blame Culture" is one aspect, still prevail? It isn't just that better techniques/systems aren't known or aren't practiced, but that organisations revert from their good practices. World leaders, like Kodak and General Motors, stop their successful practices and go back to known worst practices and suffer terminal decline. How can this be so in a rational, well-informed world?
  • Individuals in teams and projects start out with good intentions and high hopes, only to end up mired in the tarpits of Blame. How can this happen over and over again? What is the common, systematic element, or where are the payoffs?

Here is my description of "The Blame Spiral", how things work in the Real World with the Default Management Style in I.T. Projects.

Jim McCarthy in "Dynamics of Software Development" (1995, 2006) made many pertinent observations about the software development process (positing 54 'laws'), which I've seen confirmed repeatedly in many settings. Two of which are:
  • The Team is the Software, the Software is the Team. All of the assumptions, biases and limitations of the individuals in the team and the dynamics/relationships of the Team show up in the Software. To have successful Software produced, it is first necessary to have a successful Team.
  • "Don't flip the Bozo Bit". If there is an error or an individual seems to do something stupid ('be a Bozo'), do NOT blame them, ever. It is toxic to the team and because the Team is the Software, it will destroy the project.
The effects of Blame operate at four levels:
  • identifying and fixing the real cause of the error, fault or failure,
  • the blamed individual(s),
  • those who've avoided blame (this time around), and
  • within the Team Context or the "management" view.

ROUND 1. The First Blaming.

The first individual to be assigned blame, rightly or wrongly, will feel bad in some way. Humiliated or guilty perhaps, resentful definitely, more than likely end up "with low self-esteem" (worse if not resilient) and will be guaranteed to be disengaged, disaffected and ambivalent towards the Organisation, their Manager and "management" in general, the Project/Product and possibly all or some of the other team members. Special vitriol and even hatred will be felt, even manifested, towards the person perceived to have "fingered" them, to have identified them as blameworthy.

Externally, the First Blamed may be stoic, even accepting of the situation. Internally, they will have at least withdrawn their commitment and may be actively seeking, if not revenge, then 'satisfaction' through either passive-aggressive acts or active undermining and sabotage, depending on their proficiency and predilection to "playing politics". They will not be contributing their best work and if not ostracised, will be spreading dissatisfaction and ill-will.

The others, non-Blamed Persons, in the team will feel a mixture of Relief (it wasn't me!) and Caution (I need to protect myself). They've learnt the workplace is not a completely Safe Environment and messages must be 'tempered' with a little self-interest.

The Management view is that "the squeaky wheel has been fixed", that a Problem (the Blamed) has been identified and swiftly and effectively dealt with before it had a chance to escalate and create real harm. Perhaps there the proactive Project Manager has publicly berated the First Blamed to "show what happens when you mess up around here". Senior Managers will view the Project Manager as decisive and effective.

Meanwhile, the root cause has not been identified nor corrected.
The initial problem has been papered over, ready to come back to haunt the team and undermine the project in every successive round.

ROUND 2. The Second Blaming.

Because the root cause has not been diagnosed and corrected, another Blameworthy event must arise (a an Error, Fault, Failure, Deadline Overrun or Delivery/Feature Shortfall).
It is unlikely to be seen as caused by the First Blamed, they should've been re-assigned to other duties.
The Second Blamed will go from feeling pleased with themselves to feeling worse than the First Blamed initially felt - they know what is coming and will experience dread at the thought. They experience a greater drop in self-esteem than the First Blamed - self-doubt, self-criticism and disaffection/disengagement will be greater in this individual.

Now the First Blamed has an ally and someone to commiserate with. They will form a mutual admiration society, bitching together about their 'team' mates, their Managers, the Organisation and everyone they've felt wronged by... The chance of escalating to active undermining and sabotage grows.

The rest of the 'team members' will probably feel a little more superior, they've dodged a bullet twice now, but their level of Caution/Concern over becoming Blamed will escalate, at some point to real Fear.  With difficult creative cognitive tasks, Fear immobilises and robs them of their abilities.
In this round, the 'Team' is now dissolved - it's "every man for himself", there is an underground "anti-management" faction, almost everyone is deliberately not doing their best work and every individuals creative potential is seriously compromised.

Truth is the first victim of Blame.

No project member will now be open and honest about problems they are experiencing, so they cannot openly ask for help and guidance, they will deliberately fudge their numbers/estimates and deliberately hide any evidence of problems in their code: to the point of active deception (faking test results, cooked interface responses, lying about work completed).

The Project Manager (PM) will see a very busy group, "just humming along" without any interruptions. On every measure, including notional progress, they will appear to be The Perfect Team comprised solely of World's Best Coders. The PM will be exceedingly happy with the effect his "tough hard-nosed approach" has created and will crow about his prowess to anyone that will listen, especially his superiors. Bonuses will be considered, the Project Group will be held up as the epitome of performance, quality and success and overall everyone but those on the Project will be patting themselves on the back admiring how clever they all are.

That the original problem was never found and fixed is long forgotten.
It has spawned a dozen work-arounds and a legion of smaller problems that nobody can or will identify. Each of these spawning more... The pace of work, frightened atmosphere and rush-to-deadline mean that all deep inspection and significant Quality reviews will be forgotten, avoided, faked or circumvented. Every day more faults are introduced and undetected, quickly rising to the point that the daily committed future work, in the form of time needed for future bug-fixes, exceeds the daily rate of progress.

The Project has entered the "Nett Negative Progress" zone. Every day of "production" pushes the delivery date further off, taking the "Team", the Software and Organisation farther away from its Goal every day... But all the metrics, estimates and reports being "fed up the line", tell a different story, a wonderful fantasy land of glowing results, outstanding progress and wonderful Zero Defect Software.

The Team and hence the Software, has disintegrated and turned Toxic, its only downhill from now on. The individuals are quite rationally protecting themselves as best they can and saying anything but the Truth.

ROUND 3. The Rest of the Blamings.

The project is now an official "Death March". Everybody at the coalface knows it is dead and irretrievable. They are all going through the motions, faking progress or pushing their problems "over the fence" to Integration Testing (an ideal Cover-Your-Ass (CYA) ploy. "It's was perfect when it left here"). Everyone is running scared, looking for ways out or up and cliques are forming for mutual self-protection. On the walls you're likely to see the age-old adage:
 "The Floggings will continue until Morale Improves!"

Meanwhile, management will have its Golden Haired Favourites, "super-programmers" it can wheel into any crisis and whom will beat any and all problems into submission in a trice. But this hacking and fudging only makes the Software worse in whole, pushing back further any possible completion date because old bugs are hidden or moved to unlikely places or new, very subtle bugs are introduced. The Golden Ones are "teflon coated", nothing can ever be laid at their feet, even if fully documented and proven.

Management at some stage has secured extra-funding and employed more people in an effort to "push this important project out the door". [The Standish Group reports that abandoned projects consume on average 200-300% of original budget before being cancelled]. The "Team" has grown significantly and has been broken into multiple groups working on 'sub-projects', usually led by the original members of the team. That "Brooks Law" has been documented for a half-century ("adding more people to a late project makes it later") is ignored. Somehow it doesn't apply to this group or The Project.

All cliques and power-groupings will still be submitting unrealistic schedules and estimates. This is a game called "Schedule Chicken" - whose lies will be uncovered first, or who can't effectively shift Blame onto others, loses. The best players, not coders, are the ones who can fudge their numbers so they never have to admit overshooting their deadlines. When another group is declared the loser ("look, you can't meet your deadline!"), all the other groups then use the extra time to work towards their deadlines. Of course, none of this appears in the projects' reports and metrics.

A wonderful side-effect is that overheads (communications) increase super-linearly. To double the output of any group, you have to triple the number of people in the group. With every hierarchical level added to the Project, the ratio of communications overhead increases. More meetings are needed, more decisions need to be explained, more "Compliance and Good Governance" steps are needed and the proportion of productive time spent programming declines...

Which, when you're in the "Nett Negative Production" zone, is A Good Thing, it actually slows the rate the deadline pushes back every day.

For "creatives", like programmers, stress and exhaustion, the inevitable result of organisational pressure to perform and long work hours, have a triple-whammy effect:
  • The absolute rate of production slows. The number of Lines of Code per person-day falls, often dramatically.
  • "Creatives don't do good, let alone their best, work when 'stressed and tired'". The "degree of difficulty" of problems that individuals can solve when chronically tired and stressed declines, as is well known in many areas where "Human Factors" are seriously studied, like NASA (think Apollo 13 astronauts at the end of the trip) or in various war-fighting specialities. The project might notionally have a band of high-performing Senior Programmers, but they've been "derated" to Ordinary or Junior capability.
  • The Undetected Error Rate (causing Rejects, Rework and Returns) increases super-linearly ('exponentially' is the colloquialism). Every extra hour work per week increases the average fault-rate for every hour worked. Every 5-10 hours additional worked at least doubles the average fault-rate. [At 35 hours, fault rate is '1unit/hr', so 35 units/week/coder. At 40 hrs, 80 units/week/coder. At 45 hrs, 180 faults/week/coder, 50 hrs, 400 units/week/coder...]
The Undetected Error Rate, creates committed future work of fault correction (rework). All rework also  has at least the same error injection rate, often much higher due to "distance" effects. Tired and Stressed coders are less capable in finding and fixing faults, with the added problem of unintentionally making things worse, often with rookie mistakes.

No single fault in any commercial programming environment takes under one-half programmer day to fix (ancillary time to check, document and track faults is routine administration and should not be on the Projects' critical path).

Rephrased, commercial programmers can pick up, analyse, find, fix, document and pass-on at best 2 faults per day. This becomes the (feedback) loop stability criterion for Software Development:
 The faults introduced per coder-day must be less than the Fault Fix Rate per coder-day for the Project to ever deliver.

The Project Manager will be working 120 hour weeks, barking at everyone and threatening "the direst of consequences" for anyone found not to be "pulling their weight". His Senior Managers will be mightily impressed with both his dedication and forceful 'control' of the project, lining him up for Bigger and Better Projects and possibly a path into Senior Management itself.

The ultimate Blamings, Firings, may now start.
The hard-thrusting PM will be wanting to "make an example of them for others" and "to show we are serious about achieving our targets".

Senior Management will be exceedingly impressed with this "standing up to the Unions/Workers" approach.

Those on the coalface will become more disengaged, fearful and disenfranchised. Many will give up trying because "what's the point? I work 80 hour week for terrible pay and can do nothing to please anyone".

Once the purges have started, those that can leave, the best, brightest and most knowledgable, will leave, first. The Project is now getting rid of exactly those people that can save it...

ROUND N. The End Game.

Finally, the Death March is ended, The Great Project is somehow wound up.
Senior Management have had many gut-wrenching meetings and "taken an extremely hard decision" to cancel, postpone or "Reset" (code for start-over, completely afresh) The Project.

Sometimes in Bureaucratic Double-Speak, the Project is declared finished and "A Great Success". The Project Office is shutdown, awards and bonuses given, promotions made and contractors and temps 'let go'. With the software never being deployed or going into full-scale production. A variation is some small functional subset, usually created in the first 6-12 months, will be put into production and this declared to be The Project Deliverable.

The bean-counters will have been consulted to create the best fiscal-reporting effect, especially if the "Great Success" route was taken.

The Project Manager will be feted and covered in praise.
Senior Management, who funded and allowed this rolling disaster, will do a Project Review and decide that "we encountered problems much harder than we anticipated", "there were severe technical issues we were unable to resolve" and "we need tighter processes in future to avoid the same pitfalls", etc...

None of which comes near the reality: Blame is toxic, it will kill every Project it is allowed to enter.

Which has led to this widespread cynical view from the trenches:
The five project phases:
  • Unbridled enthusiasm: Unrealistic promises 
  • Disillusionment
  • Panic
  • Investigation: Dodge blame, Search for scape-goats
  • Punish the innocent, Promote the guilty, Reward the uninvolved

There are two topics left to cover:
  • The promise in the title, "Blame Spirals ... and what to do about them.", and
  • "Blame Spirals" elsewhere.

What to do about Blame Spirals?

Follow Deming exhortation to "Drive out Fear", which if it was easy and simple, would be the norm not the exception. Generally, this behaviour can only flow from the top...
  • If you're on the coalface, you can work to become a Golden Haired Favourite, find a better project to work on, play Office Politics better than everyone else or take an extremely risky option: try to float above it all by demonstrating Open, Honest Communication and refusing to buy into the Blame Game. The downside is you'll set yourself up as a target.
  • If you're the Project Manager, you need to model Open, Honest Communication and actively try to engender Trust within the Team. This isn't simple or easy and generally takes courage and dedication. My best advice: get expert help and assistance, it does exist and unfortunately needs more than a one-day talk or reading a book.
  • If you're somewhere above the Project Manager, if your Projects don't reliably come in on-time and on-budget, especially if your Project teams have high churn, then you've got a problem. Again, get expert help and assistance, especially someone that can offer an on-going Mentoring/Coaching service.

"Blame Spirals" in non-Project contexts.

Projects are different to "Business as Usual" operations:
  • The first challenge is "can we complete this as designed at all, or even close enough"?
  • they are condensed, high-pressure and by definition non-routine, not "fully specified" and mostly ill-defined.
  • All required people/skills may not be available when needed, or at all, and necessary resources/tools may need to be built or created. The scheduling task runs opposite to routine production. Something not discussed at all outside the Industry is the 1000:1 (thousand-fold) performance variability in individuals and "nett negative producers", people who every day do more harm than good.
  • there is no working process to start with, as with "Business As Usual" (BAU). Projects are building the deliverable (product or process), constructing it in layers (dependencies). The effects of underlying problems are magnified due to consequential problems.
  • Deadlines are aspirational because the design and build task is undefined and uncertain, not because 
  • Every project is different and the exact solution path unknown, with challenges waiting to be discovered.  By definition, it's a voyage of discovery, otherwise it's a defined, repeatable "Business As Usual" task. Projects are about dealing with uncertainty, 'discovery', challenges and the unknown.
I.T. Projects suffer all these constraints, along with:
  • the deliverables are intangible, invisible and often unmeasurable/unquantifiable. Outsiders can't turn-up on site and see progress, making the normal large I.T. Project methodology, "Big Bang" (a single-event deliverable of 'everything', versus frequent small/incremental releases) doubly wrong. Problems and delays are only visible at the end when its too late to do anything about them: redefine goals/deadlines or correct course.
Projects are about keeping Promises that usually someone else has made on your behalf.
They aren't just full of Rumsfelds' "Known Unknowns" but are guaranteed to be riddled with "Unknown Unknowns".

What is essential to Project 'success' is the antithesis of the simplistic model:
"Plan, Schedule, Control, Deliver" (guaranteed to fail in the face of even minor challenges).
To navigate the shoals of "Unknown Unknowns" inherent in I.T. Projects, the Project Manager, the Project Sponsor, the team and the Methodology must be:
  • flexible,
  • adaptable,
  • responsive,
  • innovative,
  • truthful and courageous.
Being rigid and inflexible, unable to request assistance or clarifications, or unable to negotiate changes is the kiss of death for any I.T. Project.

So how does the "Blame Spiral" look on a Production Line, office or providing routine services?

Most work environments, including I.T., cannot suffer the extreme breakdown experienced in I.T. Projects because some, or all, the pre-conditions are missing. If you know how to reliably and economically deliver products, services, tasks on-time and to-specificiaion, the consequential dependencies required for the "Blame Spiral" are not possible.

But the Blaming component of the "Default Management Style" still exists. It will express itself in the less extreme "Blame Cycle" of James Reason and/or institutionalised workplace bullying.

BAU tasks are not without variability and uncertainty, but it is constrained and completely new situations are extremely rare - experienced staff can anticipate and correct for "process deviations". An oil refinery needs to be constantly adjusting its process to the feed-stock, the products made and the various maintenance/upgrade activities. The focus is on maximising Plant performance, economics and meeting delivery schedules rather than "just make it work".

There are two obvious Industries where the full "Blame Spiral" can develop, Aviation and Healthcare.
They have aspects in common with I.T. Projects and a few of their own:
  • There are intangible, undefined Outcome Measures: "Safety" and "Quality of Care/Service"
  • "Not twice the same." No two cases or services are identical, hence cookie-cutter solutions will turn deadly for a significant minority of people.
  • "Unknowns", both "Known" and "Unknown" are endemic and coping easily and flexibly with them is central to success.
  • "Success" is ill-defined and a slippery concept.
  • "Efficient and Effective" performance is impossible to recognise in the absence of precise data collection and careful analysis - all of which will be resisted as "a waste of time" is the system is in overload. If data is collected and analysed, the delay means inefficient temporary staff (necessary when overloaded) won't be detected in a timely manner.
  • Problems don't present simply. Correct diagnosis is difficult because there is no simple, consistent mapping of symptoms to diagnosis and treatment can be time-critical. In both Aviation and Healthcare a trivial problem can become deadly very quickly if just one usual constraint is changed. e.g. Aircraft doesn't have room to manoeuvre or patient is highly allergic to the usual drugs.
  • There is no "finish line". If staff are efficient and effective hence create some "discretionary" (vs committed "reactionary") time to improve systems, management will "for efficiency reasons" cut hours/resources until staff are again overloaded (100% committed to "reacting").
  • Rewards are perverse. Inefficient areas, constantly overloaded and in continual crisis are given more management attention and increased, but insufficient, resources - taken from efficient areas. It's a management sin to underbid the yearly budget, it is doubly wrong for a manager to underspend in any year - not only do they lose the money in that year, but in every future year.
  • Heroic performances are lauded and praised, whilst the unglamorous act of incident-free service from good planning and preparation is dismissed as "you had it easy".
James Reasons' "Blame Cycle" is detailed, correct and useful, but misses two important points clearly seen in I.T. Projects:
  • The interaction of Blame with the non-rational, uninformed "Default Management Style", and 
  • the psychological dimension: the predictable reaction of individuals, groups and organisations to Blaming in circumstances that can spiral out of control.
Simplistic Safety and Quality systems, based on formulaic, inflexible action/response "protocols" not only cannot cope with the complex, variable everyday challenges of systems with intangible, undefined Outcomes, but push the organisation down the "Blame Spiral" into Toxic collapse and overwhelm.

Demings' exhortation of "Drive out Fear" is the solution, but must be imposed from the top down. This requires determination and consistency of purpose all through the management chain. Along with the identification and elimination of perverse incentives and outcomes.

Monday, March 12, 2012

Friends of Science in Medicine: What's the Agenda?

[Post moved to other blog.]

The more research I do, the more amazed I am at the Agenda of "Friends of Doctors and Maintaining the Status Quo".
  • "Inconvenient Truths" are simply ignored or edited out by FoSiM. Would you expect less of these folk with their doctrinal attitude and blinkered views?
    • In "Doctors, Nurses Often Use Holistic Medicine for Themselves", it is reported that in the USA around 25% more Healthcare Professionals than the general population (76% vs 63%). Should as the FoSiM stance implies, they all be drummed out of the Profession? Or do they know what they doing and actually look after themselves in the best possible ways?
  • Fundamentals are ignored by FoSiM:
    • "Show us the Data!" FoSiM are violently and implacably opposed to "CAM" (presumably Complementary and Alternative Medicines), roundly criticise and vilify therapies they do not approve of and loudly call for all Alternative Medicine/Therapies to be justify themselves with EBM and RCT, so beloved by FoSiM. Only no data are provided to suggest this is warranted, only opinion and non-peer reviewed articles. Compared to Establishment Medical and Hospital practice and outcomes, are alternative methods etc unsafe enough to be called into question? No data, no case...
    • This is an argument first and foremost about Patient Safety, then Quality of Care and lastly about Effacy of treatment, therapies, medicines. But there is no definitive data for the outcomes of Establishment Medicine, despite them consuming consuming 10-15% of National GDP in mature, western economies to use as a baseline in discussing Efficacy.
    • Science is not Practice. Substantially more than a few studies is needed to convert some Theory or data into reliable, repeatable Real World Practice. We know this, because it is being done intentionally and deliberately by at least one significant Healthcare System in the world, Intermountain Healthcare, Utah.
There is a well-known, perfect model for how to create an Industry-wide Quality and Safety Culture, in one of the most cut-throat profit-driven businesses ever: Aviation.
Adopt what is known to work in Aviation, and has been proven to be Cheaper, Safer and Better on every metric for coming up to 2 decades by Intermountain Healthcare with their "Do it Right, First Time" Quality approach.

Isn't it odd that the self-appointed, self-proclaimed "experts in all things Medical", the FoSiM, haven't suggested this approach nor flagged that our Hospitals and Medical system are far from World's Best Practice.

Instead of seeking to improve their own failed Profession, they are seeking to attack and discredit "The Competition", or at least those that they can identify and target.

Friday, March 9, 2012

First, Do no harm: Patient Safety and the central fallacy of the "Friends of Science in Medicine" position.

[Post moved to other blog.]

"First, Do no harm"... Or so the Hippocratic Oath is presumed to begin.

The Dwyer/Marron "Friends of Science in Medicine" campaign against the teaching, insurance/reimbursement-for and ultimately practice of Alternative Therapies and Medicines of which they, and they alone, do not approve, is based on a central fallacy:
People are much safer being treated by the Medical Establishment not using Alternative Therapies and Medicines, but exactly the reverse is true. 
This debate is "all about Evidence", as in hard-data, but Patient Safety and Quality of Care must be examined first before any debate on Effectiveness can even be started.
The flip-side is the erroneous logic that "Good Science" is somehow causally linked to "Good Patient Care", but FoSiM ignore the Golden Rule of Execution: 
Science and Knowledge don't deliver outcomes, Practice does.
Before the Dwyer/Marron group can argue against any Therapy, Treatment or Medicine, by its own strict rules ("there must always be very strong Evidence"), it must:
Show us the Data! 

Where is their Evidence, the "Good Science" they want from everyone else, to demand any changes?
The worst logical trick and intellectual swindle played by the Dwyer/Marron group is their conflation and confusion of terms:
  • A slew of unrelated practices are strung together in one long line of gibberish, with no distinction between recognised, well-controlled modalities and others, with all presumed to be 'equivalent'.
    If the Dwyer/Marron group cannot, or will not, distinguish between a piece of crud and a gem, what relevance or vracity do their arguments have?
  • In Australia, there is a trivial and essential differentiator between all Medical Therapies, Practices and Medicines:
    • Is there a AHPRA Registration Board? and hence
    • Do Practitioners have a Medicare Provider Number?

    The failure of the Dwyer/Marron group to make this simple and essential distinction invalidates all their arguments, just who are they vociferously and ferociously objecting to?
  • For the Dwyer/Marron group to disagree with Government Policy and Processes is their Democratic right.
    For them to not understand the way these decisions and processes are changed is via Lobbying and the Political process is both ludicrous and naive.
Whilst the Dwyer/Marron group and their FoSiM purport a wish "to foster Good Science in Medicine", their actions and statements belie a rabid bigotry, bias and prejudice.

Even in their Constitutions' statement of Object, they don't define or elaborate on their terms:
  • "Good Science" is a vague, ill-defind term. To quote Shakespeare's Macbeth:
    "it is a tale told by an idiot, full of sound and fury, signifying nothing".
  • There are "scientific methodologies" (hypotheses, test, result) and "(apparently) good or valid studies/experiments" with "strong evidence", but "Good Science" is at best a lay-person's term, not something any Professional in the field would use.
  • Likewise, "Medicine" is a broad church...
    There is no definition ever offered for FoSiM's frequently used acronym, "CAM", presumably "Complementary and Alternative Medicine". This has some mysterious meaning only known to the Inner Sanctum of the Dwyer/Marron group. I expect it falls in the category of "I know it when I see it", a throughly undisciplined, non-rigourous and unscientific methodology - because it is inexact, ill-defined and non-repeatable.
Where does the Richard Dawkins comment that "there is only medicine that works" leave the Dwyer/Marron definition of "CAM"?

Invalid and irrelevant, like the rest of their bluster, assertion, dogma and prejudice parading as "the opinion of experts", because they can provide no test or Evidence to show, as Dawkins says, "what works and what doesn't".

The very real risk they face with their simplistic and naive thinking is that if they ever construct testable definitions, then a good deal of their own Establishment Medicine would be found wanting.

It comes down to this:
The Dwyer/Marron group have no documented process or methodology to define the Alternative Therapies and Medicines of which they, and they alone, do not approve. They have a loose, informal, self-referential definition: "Good Science, it's what we say it is".
They are self-appointed experts and judges, without credentials, special expertise or relevant experience, who are presuming to force their opinions, biases and prejudices upon the rest of us.
Whenever they cry "Show us The Evidence" or "That's not Good Science", all they are displaying is their own ignorance, ineptitude and biases.

Thursday, March 8, 2012

Australian Medicine as a Failed Profession. #1

[Full post moved to other blog.]

Australian Doctors practice medicine as if it was a cottage-industry craft supported by a 'Guild', not as a modern, accountable Profession practised for the Public Good.

Guilds limit new entrants, protect and control 'the secret craft knowledge' and vigorously defend their turf. A monopoly on the practice designed for restraint-of-trade, not the benefit of clients nor the community.
  • We are entering the second decade of the doctor and specialist shortage here.
    • How can there be a shortage? It's not because its not needed nor not possible here.
    • Why aren't doctors picketing every Parliament in the land on behalf of their patients and the wider community? Letting known dangerous conditions for patients and doctors continue is neither Ethical nor Professional behaviour.
  • Five plus years on from "Dr. Death" in Bundaberg, is anything different? Is there any excuse for that?

Friends of Science in Medicine: Irrelevant #2

[Post moved to other blog.]

The Dwyer/Marron Friends of Science in Medicine, finally have a public website where we can learn a little more about them.

Their constitution lists their "Objects" as:
to foster Good Science in Medicine [my capitalisation]
Their home page states:
We are currently campaigning:
"to reverse the current trend which sees government-funded tertiary institutions offering courses in the health care sciences that are not underpinned by sound scientific evidence"
I'm not aware of any usage of "to foster" that translates into attacks and calls for banning properly instituted and checked activities... Buts that's a side-show to the real game.

The Dwyer/Marron group choose to ignore multiple Elephants in the room, hospital deaths, medical adverse events and patient injuries in favour of a campaign that's been termed "a witch hunt", and even if completely successful would achieve so little as to be farcical.

The only fact I can present in support of this is: There are no facts.

Which in itself is a complete failure of Governance and Safety/Quality systems of the Australian Medical system and Profession.

The Irrelevance of Friends of Science in Medicine:
The Dwyer/Marron group make no claims for the numbers of Patient Injuries, nor their severity, attributed to their foes, "Complementary and Alternative Medicine" (CAM).
Are they claiming figures of 1,000,000 injuries and a few thousand fatalities: in the ball-park of known good estimates for Medical and Hospital systems?
If they aren't then:
  • They should say nothing until they go out can get some hard-data on the actual injury and fatality rates.
    • Unfortunately, a single media appearance by Lorreta Marron exposing and shutting down one uncertified backyard operator, while preventing a few injuries, does NOT constitute research or evidence.
    • Friends of Science in Medicine need to apply their own standards to themselves.
      Without strong evidence, what anyone says is completely irrelevant, misleading and potentially harmful.
  • Estimates of use of Alternative Medicine and Therapies in the general population vary between 40-60%. How many visits and treatments does this translate into? NOT anywhere close to the 100M/year visits to GP's? What about the total patient injury rate via CAM?
    • Even the anecdotal evidence doesn't support the view that there are close to the same number of patient injuries as from doctors and hospitals.
    • Get some data before you criticise everyone else.
If even a guesstimate (that's a valid Engineering term and process) put the total Patient Injuries by CAM at 10% of mainstream Medical and Hospital, I'd be very surprised.

And if fatalities were even has high as 1,000th of the known, preventable deaths in Hospitals, I'd be astonished. Do we lose as many as 5 people to certified, registered Alternative Therapy practitioners in a year? You'd have to make some outrageous assumptions to even get there.

So why do these people want to shine a light in an area where the total potential for harm and injury is not even a rounding error in the statistics of the practices they are so virulently supporting?

The irrelevance and hypocrisy of Dwyer/Marron and their The Friends of Science in Medicine is that they know full well the scale and scope of the preventable failures of mainstream Medical and Hospital system, but they then choose to "raise Cain" about areas of relative inconsequence. What's going on?

My message to the Dwyer/Marron group:
Practice what you Preach and Get your own house in order first.