Tuesday, August 21, 2012

The Professional Mandate Pt2: Continuous Improvement, No Regession

Previously, I've defined the central aspect of the Professional Mandate as:
Its "unprofessional" to repeat, or allow, Known Faults, Failures and Errors.
Which is the Deming/Shewart Quality Improvement Cycle: PDCA (Plan-Do-Review-Improve System, also Plan-Do-Change-Act).

All Quality, Safety and Performance Improvement programs share must contain these 4 elements and have a central element in common:
Conscious, deliberate learning and adaption.
Improvement is not accidental: If you don't design it in, why would you expect it to show up?

There is another, personal, factor underlying Quality and Professional Improvement:
Caring comes first.
Which is not quite a restatement of "Professionals owe a Fiduciary Duty to their Clients". Caring is an unforced, voluntary internal state, Duty is an an imposed external obligation. Good Professionals not only have to perform well, they want to.

More specifically, Professionals must both Care about the Client Outcomes they produce and how well they do job they do. Good Professionals aim, every day for every task, to produce their best performance and provide Perfect Client Outcomes.

Perfect Client Outcomes are NOT "Perfectionism" nor unrealistic and unachievable. It's not about a Perfect Performance, execution without flaw, impossible by definition for Real People ("To Err is Human") but about the Client Outcome:

  • Perfect for the Client may be getting any help whatsoever.
  • Perfect for the Client may be getting "Good Enough" service in a timely manner.
  • Perfect for the Client may be resolving an issue within a time-frame.
  • Some some Clients, Perfect is As Cheap as Possible or Really Close and Accessible,
  • whilst the PT Barnum rules also applies: You can please some of the People some of the time, but not all of the People, all of the time.
    • For some Clients, no outcome will ever be deemed by them to be Perfect.
The execution of a Professional Service may contain Errors, in fact you'd expect (small) Errors every time, but the System and Process creating the Client Outcome need to be tailored to noticing them before they can affect the Outcome and in preventing consequential effects.

It's OK to make an error, so long as its corrected before it has an impact or creates damage. Trying too hard to Be Perfect degrades the Performance and Execution - we are not machines... This is the "secret sauce" known by Elite Sports Coaches:
Perfect is the enemy of Great, Perfectionism doesn't lead to Best.
Expanding notions introduced in Part 1:

  • Professionals must refuse directions and work demands that result in unsafe Practice, endangering clients or the public.
  • Doing The Right Thing must never penalised.
  • There are two sides to improvement: 
    • What not to do,
    • What to do.

Extending the rubric to include "and practice What Works (ie. proven)".

But there are two sides to this:

  • Adopting new Practices when proven superior,
  • Extinguishing old Practices when shown inferior.
There are research papers that conclude that for some "high standard" Professions:
  • It takes 15 years for proven new Practices to be adopted by even 50% of Practitioners, and
  • and 40+ years for old, inferior or disproven Practices to be phased out. Universally? not sure.
This work dovetails with the 1961 book, Science Since Babylon by Derek De Solla Price where he estimates the doubling period of Human Knowledge as shown by Journals and publications at 15 years and ties it in to the working lifetime of Scientists to arrive at his famous observation:
80-90% of all Scientists who have ever lived are alive today
The same 3 doubling periods of the average worklife also explains the time to give up old, inferior practices.

more to follow.

Monday, August 20, 2012

Professions/Professionals: Conflicts of Interest

Consistent Altruism is a rare human commodity, probably impossible over a life-time, yet that's the standard implied by: Learned Professions owe a Fiduciary Trust to their clients.
That's All Clients, All the time.

It's simply stated and tested: Are Client Interests always placed before the Practitioner and Organisations? Yet its impossible without sustained, conscious, deliberate and co-ordinated effort by the whole Profession.

As a client or user of Professions, that's a reasonable standard for them to be held to.
As a Practitioner, Professional Organisation or Profession, it's a profound and never-ending challenge.

The overwhelming human behaviour is self-interest: often expressing as greed or avarice, but also in other "temptations", including sex, power and influence.
People may start with good intents, even living up to their ideals for a long time, but as Hollywood amply demonstrates, the road to hell is paved with good intentions.

Most people exhibit Altruism some of the time and often only towards related groups. How can that be leveraged to impeccable Professional Standards? It's not just a hard problem, but a diabolical one.

It's impossible for ordinary people to keep others interests before your own for an entire career, in the face of all direct temptations and, more importantly, preventing gradual, imperceptible declines especially in the face of "but everyone is doing it".

This is exactly what got the USA from a well regulated banking system in 1999 following the repeal of the 1933 Glass–Steagall Act, to a record financial collapse in well under 10 years.

All Professions have to address this central issue: How to monitor and deal with Conflicts of Interests.

The Iron-Cald Law of Quality applies: You cannot check your own work.

Which means ever Profession that needs to meet a Fiduciary Duty has to design, implement, staff and fund third party checking, investigation and monitoring systems (i.e. Governance and Audit), create Licensing, Compliance and Regulatory Bodies with real teeth and constantly train and check its Practitioners and Professional Organisations against those standards of Knowledge, Performance and Practice.

I'd argue that this Governance and Compliance function is more important for "Fiduciary Duty" Professions than Competency Testing and Licensing:
Without an absolute trust of Clients for the Profession's Services, it is fatally compromised and incapable of delivering good, let alone Adequate or Best Practice Services. If the Public won't come to you and don't trust you, it undermines your Mission/Purpose, devalues the Profession and pushes the Public to find substitutes.
In "mid standard" Professions two factors operate that limit the excesses increasingly found in Professions such as Banking, Finance, Financial Advice and Financial Audit which led to the record collapses of 2007/2008 requiring Public Bailouts:
  • By definition, only "high standard" Professions owe a Fiduciary Duty to their clients, the rest only owe "normal commercial and contractual responsibilities.
    • Consumer Protection bodies and legislation (ACCC and TPA/ACC in Australia) offer common law remedies (protections) to consumers against unscrupulous practitioners and organisations.
    • The Consumer Protection bodies actively monitor the business world (practitioners and organisations) for illegal or 'sharp' behaviour.
    • Cartels and price-fixing is illegal and is aggressively pursued by the ACCC.
  • There is seldom, in "mid standard" Professions, a Natural Monopoly of Practitioners, Professional Organisations or Professional groupings/Associations.
    • There are commonly large numbers of "best quality" practitioners and organisations for consumers to choose between:
      • The operation of a large Free Market prevents prices ratcheting up faster than inflation.
      • Market forces (Supply and Demand) act to regulate the number of Practitioners and Organisations offering the Service, including per location.
      • Sometimes there can be a "race to the bottom" caused by new entrants (e.g. Chinese Dental Laboratories) that undermine demand even for high-quality local practitioners.
    • Consumers often can find adequate Service Substitutes, either direct or within the Profession.
    • When the Service is only offered by a sole supplier, often the Public Service or a single Government Licensee, a Natural Monopoly and market competition cannot keep Service, Quality, Safety and Price in check.
      • Often in these situations, Audit and Governance ("Industry Watchdogs") organisations are formed in an attempt to restrain outrageous excesses.
So what's needed of Practitioners, Professional Organisations and Profession Groupings/Associations in "high standard" Professions?

The New Oxford Dictionary defines "Fiduciary" as:
involving trust, esp. with regard to the relationship between a trustee.
I use a more colloquial formulation:
Put the clients interests ahead of your own, every time, and in every way.
In Law, Business and Accounting, this problem is known as Agency Theory: How do you get an 'Agent', such as an employee, trustee or representative, to always put your Best Interests first, even to the detriment of theirs, either directly or through "Opportunity Loss" a.k.a. Insider Trading?

"High standard" Professions suffer multiple problems:
  • They are Natural Monopolies without good substitutes (think Law, Medicine and Public Service).
    • Where can the Public go if they don't like the Professions' Services? Nowhere...
    • The rich always have more options like privileged access to other countries and systems, which creates its own special Conflicts of Interest in both countries.
  • If they don't internally regulate, who can or will regulate them?
    • Nobody else can properly assess their performance, errors, omissions and over-servicing.
  • Because they are Natural Monopolies:
    • The Monopoly is usually explicitly granted by the State.
      • meaning there are Registration Boards and Licensing Examinations.
    • They are highly desirable as a choice of Work: well paid, "protected" jobs for life,
    • Numbers are tightly controlled,
    • There is intense competition for admission, often on criteria irrelevant to good Professional Practice, such as Academic prowess.
    • There is usually little effort in identifying desirable High Performer Professional characteristics and less effort or attention in selecting or evaluating against those criteria.
    • All emphasis is placed on The Barrier to Entry, gaining a License, close to none is spent on ensuring All Licences are of Equal Value (a 1910 notion of Flexner's), which implies frequent full competency checking, against all current Knowledge and Best Practices, to retain a license.
  • The traditional Learned Professions are backed by an extensive heritage of Common Law and Statues that create especial problems:
    • They usually embody, explicitly or tacitly, a No Harm or No Fault clause:
      • Medical Doctors, even unqualified frauds, are generally regarded as not ever having criminal intent to harm patients.
      • This unfolded in Australia with the "Dr Death" of Bundaberg case. Whilst strict Academic-quality Evidence indicted him with causing many deaths and huge numbers of injuries, the legal system requires direct causal Evidence, reducing the criminal charges to "harming" a very few patients and a 5- or 7-year sentence. For any "mid standard" professional acting this way, they would've been found guilty of multiple counts of murder and received a probable life sentence.
      • The 2011 sentencing of the "Butcher of Bega" underlines the on-going nature of this problem and jurisdictional inconsistencies.
  • If the Profession in a country systemically fails to regulate itself against Conflicts of Interest, particularly Financial, then you end up with the US Healthcare system:
    • 18% of GDP is spent on US Healthcare, versus 9% of GDP in Australia.
      • In 1960, the US spent 5% of ts GDP on Healthcare, almost a quarter current levels.
      • But Australians have universal Medical care access, out-live and have better health outcomes that US citizens, except for "Rescue Care", where the USA beats everyone.
    • Arnold Relman and Marcia Angell, editors from 1977-2000 of the New England Journal of Medicine, have run a very long campaign against Medical Profession "Conflicts of Interest", starting in 1980 with Relman's, "The New Medical Industrial Complex".
      • Despite unequivocal data and many high-powered, highly influential internal voices/activists, the US steadily increases the proportion of its whole economy spent on Healthcare and the proportion of uninsured people who are uninsured continues to climb.
      • Perhaps in-line with the increasing disparity between the Rich (top 1%) and the bottom 30-50%.
My observations on "high standard" Professions achieving near a uniform, on-going delivery of Fiduciary Duty to Clients are:

  • It's a war without end, every new generation has to discover their own solutions to the constantly evolving challenges. The Internet Changes Everything, including how Professions now experience Conflicts of Interest and the methods to address them.
  • Perfection in managing Conflicts of Interest, like Quality, Security and Safety, is a journey, not a destination.
    • If a Profession's Monitoring and Reporting systems are detecting nothing, they have failed.
    • Human Nature hasn't changed in the 400 years since Shakespeare, it's not changing soon.
    • The US "Medical Industrial Complex" that Relman and Angell have spoken against for 30 years versus the inexorable rise in Healthcare costs is definitive proof that without strong external intervention (from Politicians, pushed by the general public) a whole Profession can be wilfully blind to serious Conflicts of Interest.
      • Without specific Agencies with real teeth, nothing changes.
      • Simple, unequivocal definitions and tests are needed for the Qualitative Tests.
      • Absolute and rarely changed quantitative measures are needed to convert Qualitative goals to measurable, reliable data.
  • The NTSB/FAA example of separate, well-funded Investigation and Compliance, Licensing and Testing organisation staffed by selected dual-experts: they have to be both amongst the most Competent and Knowledgeable Practitioners and expert in Governance, Quality and Safety.
    • These organisations and their staff also take care to constantly monitor, test and train themselves, with periodic "refreshes", or systemic re-examination and redesign.
  • Initial Practitioner Selection and Testing and then through on-going Training, Testing and ReCertification regimes are necessary to even start to achieve high, uniform standards of "Fiduciary Duty" amongst Practitioners and Professional Organisations, along with Competency, Knowledge and Practices.
    • Initial Practitioner Selecting and Training needs to be targeted at selecting for High Performance Practitioner Traits and Characteristics.
    • Which implies they must be first researched, documented then kept current.
    • And explicitly not to default to mere Academic Prowess as the sole entrance test.
  • Fully public, Open and Transparent reporting of all Professional issues, Conflict of Interest and Practice of Individuals and Organisations is a minimum requirement.
    • Without full data, the Profession internally cannot know "how it is travelling" and be able to take corrective actions as necessary.
    • Without full public access, nepotism, cronyism and lax standards are inevitable and unavoidable. "We discipline our own, in private" is the hallmark of a Failed Profession.
      • It also invariably leads to a pernicious and pervasive Inversion of Loyalty and Duty: Professionals swap their perceived Duty to Clients to a Duty to Protect the Profession at the expense of the Public they serve.
      • This attitude of "We look after our own" is an absolute corruption of a Profession.  
    • Professions with strong Duty and Safety Cultures and full disclosure don't need expensive and embarrassing Royal Commissions or Courts of Inquiry: they are doing the job of ensuring Good, Competent Practice and reinforcing the Culture each and every day.
  • Structural elements have to be in place to prevent putting people in the way of temptation or compromise:
    • Laws and Regulations allocating Blame and Liability to individual Practitioners for Ordinary Accidents and Failures must be replaced with Indemnifying Individuals within Organisations, provided they have acted properly and followed all relevant processes and procedures.
      • Practitioners who exhibit unprofessional behaviours, should be stripped of all Professional protections and indemnities and be subject to stiffer Criminal charges and Penalties than the general public.
      • Failing in your Professional and Fiduciary Duty is not an extenuating circumstance, it calls for harsher treatment. Those taking more Responsibility must be held to higher standards.
      • Any Practitioner who self-reports Errors early on should be indemnified from censure for that event, though not for unprofessional action, such as repeating Known Errors, Faults and Failures.
      • Any Practitioner who fails to self-report or report anothers' Error should be metered out harsh penalties. The Professional Mandate requires everyone involved to "own up" to their mistakes - and to make sure everyone else does as well. "No Error goes unreported, ever."
    • Professional Organisations, and their managers, must be Criminally and Civilly liable for malpractice and failures in their Fiduciary Duties.
      • In order to Indemnify individuals within Organisations who act properly and professionally, legal liability and Onus of Responsibility have to transfer somewhere.
      • There also have to be powerful incentives for non-Practitioner Managers and Administrators to uphold the Professions' Fiduciary Duties, Competence, Knowledge and Practice standards and adherence to Quality and Performance Improvement.

Saturday, August 11, 2012

The Professional Mandate: Don't repeat Known Mistakes, yours or anyone else's.

My formulation of the Professional mandate:
It's "unprofessional" to repeat or allow, Known Faults, Failures and Errors.
That sounds complete, perhaps obvious, but let me unpack this some more...

What's "unprofessional"?

If you're a cleaner, mower mechanic or dish-washer, i.e. not someone held to the highest Professional standards, then it's probably "skiving off" or doing a dodgy or substandard job. It might get you reprimanded if detected and if its your normal mode of work, in most places it'll get you fired. But only if detected, and that's only going to happen in better run organisations that routinely check work.

If you're someone who holds other people's lives in their hands, especially in a Profession that owes a profound Duty of Care to them, like Aviation and Medicine, then you should be held to a much higher standard.

These are the usual types of "unprofessional" behaviour and generally not considered "criminal":
  • malfeasance: deliberate/wilful wrong doing/actions (in the discharge of public obligations)
  • misfeasance: wrong action (esp in the discharge of public obligations)
  • nonfeasance: didn't do what needed to be done (esp in the discharge of public obligations).
  • negligence: didn't pay enough attention or care to the execution of the task, inexpert or incomplete action.
  • incompetence: can't do the job, use the tools or know the process properly or incorrect action(s).
  • indolence: lazy, idle, a "failure to perform".
But we know there are more types of "unprofessional" behaviour:
  • failing to act in a timely manner, i.e. tardiness,
  • "wrong inaction" when action was necessary,
  • rushing to act without sufficient information, or on an incorrect and unquestioned judgement,
  • acting when "inaction" or waiting was necessary,
  • deliberate harm through acts committed or withheld,
  • systematic harm to cohorts of people through deliberate, "wilful blindness" of not reviewing previous outcomes or not implementing known "Best Practice" or continuing with known "Bad Practices".
  • deliberate and systematic "gouging" - resolving "Conflicts of Interest" in favour of monetary outcomes for the Practitioner, against the interests of clients or the public.
  • over servicing, over charging and deliberate price gouging (selecting high priced alternatives over technically equivalent or superior lower priced ones).
  • ignoring or failing to deliver adequate service to individuals and large cohorts of the public for whom they should be responsible.
  • acting whilst intoxicated or drug-affected.
  • deliberately under-performing, not giving or doing your best in all circumstances, including "phoning it in" or "just going through the motions".
Which leads to two questions:
  • In this, the Internet Age, can a Profession even call itself a "Profession" if it doesn't detect all deliberate or unintended errors of commission or omission and impose Professional Penalties on organisations and managers responsible for allowing preventable harm, injury or death to those for whom they were responsible, as they unequivocally fail the "Professional mandate"?
    • Individuals who've are appropriately trained and with current certification, correctly follow organisational guidelines, checklists and processes and attempt to deliver their best Professional performances, or at least self-report Errors, Faults and Failures or omissions, should be protected from legal liability. Professionals need to be explicitly protected from being made "the fall guy" for Organisational or System Errors or managerial malpractice. Doing your job well, to the best of your ability/competence, should never be cause for censure or penalty.
    • Organisations have a Duty of Care to the General Public, Community and the State to ensure the Professionals under their direction are properly selected, adequately trained, including on-going testing/training cycles, are properly informed of the latest/current Organisation Standards, Processes and Procedures and all Professional Performance properly and adequately checked and corrected and if necessary, individuals reassigned, stood aside or removed.
    • If you are a Private Professional Practitioner, you undertake to competently and adequately provide, and perform to, both the Organisational and Individual Professional Standards, being personally liable at both levels. In most current fields, with Knowledge and Skills/Processes/Tools/Equipment doubling every 3-5 years, not within the Professional working lifetime as it once was, this is now beyond even the most competent and able Professionals.
      • I believe Registration and Certification Boards should be acting to prevent Sole Professional Practitioners from getting in over their heads in this way. 
  • What should now constitute Criminal Action or Criminal Negligence by Professionals and their managers/organisations when they deliberately, or with "wilful blindness" or disregard, continue with, or allow harmful Professional behaviour?
    • In Corporations Law, individuals and boards are deemed liable "if they knew or should have know". Ignorance is not a defence, in fact, failing to be informed is in itself an offence.
      • Is there any reason Professionals directly responsible for Human Life should be held to a lesser standard than Corporate managers and boards?
    • What should constitute Evidence of such Criminal Action or Negligence when it can be clearly demonstrated statistically there were adverse outcomes for multiple clients, though individual attribution of harm, injury, death or wrongful act may not possible.
      • Statistics, and their use in the Analysis and Review of Professional Performance of individuals and groups, are well established and universally accepted, with appropriate "Confidence Intervals", as the highest level of Evidence in Research and Scientific investigations.
      • Why should these same tools and results not be acceptable Civil and Criminal Evidence? What counts as indisputable Scientific Evidence should be acceptable in a modern Court of Law.
      • Judges and members of the public empanelled on juries can, and should, be knowledgable in, or able to be tutored in, these concepts, tools and their interpretation and subtleties.
And a bigger question:
Are "high standard" Professionals liable for Errors and Injuries directly attributable to poor management decisions or yielding to "management pressure" to perform unsafely or continually at unsustainably high levels of 'commitment', either excessive hours, excessive supervisory load or "above my pay-grade work", i.e. substantially above their Professional level of competence?
I argue that Dr Brent James' notion of "Professionals owe a Fiduciary Trust to their clients" (and in return are given the right to Professional Self-Determination) applies. Managers, especially if current or once practicing Professionals, should not, either knowingly or not, put those they direct in these invidious position, in effect putting them in a "Conflict of Interest" situation: chose between your employment or career and the safety of those clients or the public for whom you are responsible.

It's not Good Practice, let alone acceptable Professional behaviour, to ever work a continuous 40-hour shift or 100+ hours/week when you may endanger others' lives.
Personally, I consider knowingly working whilst impaired in any way (alcohol, drugs or fatigue/exhaustion), isn't just Professional malpractice, but Criminal, especially if a repeated, even normal, action.

The Nuremberg Defence, "I was just following orders", is as unacceptable and specious, especially for high-standard Professionals, now as it was 6 decades ago. Professionals are solely responsible for their actions and must be held to account for them, in the same way that Managers can't transfer their Responsibility and Accountability to the Professionals that they direct.

Which creates another addendum to The Professional Mandate:
It's unprofessional to accept, or allow, tasks and responsibilities beyond your, or others, competence level or act whilst notionally or practically impaired, incapacitated or impacted by external factors. If you can't competently and adequately do the job before you, you should not be doing it. If others put you in the position where you feel you cannot decline a job/task/role outside you ability/competence, you are obliged to report both your own action and the situation, before, during or as soon as practicable after the event.
Specifically, I reject the widespread notion or "meme" for mangers deliberately demanding unprofessional conduct:
"You're a Professional, you have to 'do whatever it takes'" -  especially to fulfil roles, responsibilities or deadlines/commitments that you yourself did not commit to, but were imposed externally on you.
Any Professional who makes an explicit, not tacit, undertaking to deliver a Professional outcome should reasonably expect to be held to that Promise. Attempting to flip Accountability and Responsibility from Management to Professionals is a variation of this "Blame Assignment" technique and should result in personal liability for those attempting to assign blame.
The resulting Corollary is:
Professionals don't just have an implicit Right, but a Professional Duty, to refuse directions, including work rostering, that may, or will, result in unsafe Practice or a failure in their Professional Duty to clients or the public.
Or more simply: Professionals reserve the right to say "NO!", and make it stick, to unreasonable or unsafe management direction and be protected against reprisals, harassment or recriminations for such action.

Doing The Right Thing must be rewarded, never penalised.

Elsewhere, I've attempted to layout the context of Professional Behaviour within Professions. It isn't just about not doing the wrong thing, but also doing the right thing.

How a "professional" gets to know "What Works and What Doesn't" is another beyond this, "the Professional Mandate".

A relevant extract:

Barry Boehm neatly summaries the importance of the Historical Perspective as:
Santayana's half-truth: “Those who cannot remember the past are condemned to repeat it”

Don’t remember failures?
  • Likely to repeat them
Don’t remember successes?
  • Not likely to repeat them
The critical insight here is that there are two sides to improvement:
  • What not to do,
  • What to do.
So my rubric must be extended to include something like "and practice What Works (ie. proven)".

Thursday, August 9, 2012

Message to ISM/FoSiM: this is what Real contributions to the Healthcare Reform debate look like.

[Post moved to other blog.]

Atul Gawande's piece in the New Yorker on "Big Medicine: Can Hospital Chains Improve the Medical Industry?" is a tour de force on the issues, benchmarks, solutions and challenges facing us in the current Healthcare Reform debate.

At 9,500 words, while it was a riveting read for me, it may be a tad long for many people.

Even if you only read a page or two, you'll be well rewarded.

This is the work of an insightful, competent and engaged (Medical) Professional who is actively looking to mend the US Medical system and has taken considerable time and effort to construct a readable and informed piece to bring the issues, challenges of Real World change to Healthcare to the general public and even posits some solution.

Generally, I was impressed that Gawande didn't invoke Aviation as his Gold Standard, but used people and places the general public know and visit everyday and indeed, many will have worked for, and the majority will personally know someone who works in them.

He quietly and unobtrusively lets us know that he's done a bunch of real journalistic research to write this piece, pounding the pavements, spending hours or days with people in their workplace and asking tough questions.

 This was a carefully planned, researched and executed piece, possibly months in the making. It would've taken a few weeks to edit down and polish into this relaxed, chatty style.

He ends with:
The critical question is how soon that sort of quality and cost control
will be available to patients everywhere across the country.
We’ve let health-care systems provide us with the equivalent of
greasy-spoon fare at four-star prices, and the results have been ruinous.
The Cheesecake Factory model represents our best prospect for change.
Some will see danger in this.
Many will see hope.
And that’s probably the way it should be.
It's not a rant or tirade, it can't be mistaken for "personal attack" nor does it need a naive disclaimer like FoSiM's ("If you misunderstand what we've written, that's your problem, not ours.")

To Dwyer and his little Friends in FoSim, this is what a real contribution to the healthcare Reform debate by a competent Professional/Journalist looks like.

Compare and Contrast to the vapid, vitriolic and self-righeous outpouring of Ms Marron, your unpaid "CEO".

It'd be unkind to say that she remains unpaid because nobody with money would pay for her efforts, though it may be accurate.
Fanaticism and Zealotry in a cause, as demonstrated by FoSiM, don't make for persuasive journalism.

ISM/FoSiM: "Inversion" - Putting the Cart before the Horse in Healthcare Reform

[Post moved to other blog.]

One of the amazing arrogances and Blindspots of the fanatics and zealots of ISM and their "mini-me", FoSiM, is they've got the Healthcare Reform debate turned around completely. Colloquially, they've put the cart before the horse.

It's not hard to spot that the "vision statements" of both ISM and FoSiM aren't backed by any Evidence, any Theory but only Absolutist Assertion: it shows from the start that this is only Ideological based, not based in fact or need, nor indeed arrived at by any valid, credible process.

The "Inversion" of ISM/FoSiM is who they put at the centre of their Healthcare Reform proposal in their call for more "Science in Medicine", ignoring their one-eyed bias where they never examine the Practice or Science of their own, Medical Care.

What's completely missing is The Patient.

This is the Inversion. It's Practitioner- and Profession-centric, not Patient-centric.

This is the Big Lie, the massive horn-swoggle that ISM/FoSiM are attempting to pull off:
The Patient, their Outcomes, the Quality of their Care and their Safety under Medical Care is completely absent. And most importantly, Patient Accessibility and Affordability are missing.
The ISM/FoSiM advocacy for more "Science in Medicine", even taken at face value, is a clear call for:
Better Healthcare!
More "Science" won't deliver Better Medical Care, it can only deliver more expensive, less accessible and less effective care, and further stress already over-worked and failing individuals and organisations.

"More Science" does involve more money for research, more expensive devices, drugs, equipment and services and, for the very few that can afford it, much more expensive interventions ("Rescue Care") for extreme conditions. It's a Bonanza for everyone making money out of the process, the Companies, Practitioners and Researchers, and a FAIL for everyone else: the Patients, the Healthcare workers and the Governments funding it.

How can "More Science" equate to "Better Healthcare"?
Not in the Real World and not at all for Ordinary People who'll be paying for it... 
This is a scheme dreamed up by the privileged, for the privileged, of the the privileged:
ISM/FoSiM are Medical-Political Lobby groups aimed directly and solely at attracting More Money to themselves using the ruse of Better Healthcare through More Science.
The ISM/FoSiM pitch:
Better Healthcare is all about us, not the patient, it's More Expensive, More Profitable Business for us, everyone else is irrelevant!

If you'd like to know what Better Healthcare looks like, here's the definitive guide, with actual research references:
"Managing Clinical Processes: Doing Good by Doing Well" by Dr Brent James.

Tuesday, August 7, 2012

FoSiM: Motivations of Founders and Members. It doesn't add up...

[Post moved to other blog.]

The more I've researched the field of Medicine and Healthcare Reform, the more I've come to wonder:
Just why did Dwyer and his Famous Five setup the ISM "mini-me", Friends of Science in Medicine (FoSiM) in the first place?
Why have over 500 practicing and former Medical Practitioners and Researchers publicly identified as supporters of FoSiM?
The usual rubric is "Follow the Money!".

But from what FoSiM tell the world, there's no (real) money involved.

The problem is, I find that either an altruist, hobby/amateur or volunteer organisation just doesn't make sense in one of the largest, most important sectors of the economy, with the most powerful/aggressive vested interests (think Big Pharma) of any Industry including Tobacco, with so many powerful Political and Industry Lobby Groups already extant it makes your head spin and with the decades of research, published material and competing proposals from many sources, each highly funded and staffed with Academic, Practitioner and Maths/Stats experts.

The "Science in Medicine" movement is Ideological not rational, not theory-based, only values based. Insisting that their one model is all that can be and they'll just keep changing the goal-posts so all non-Medical Healthcare is deemed wrong and hence they'd like it to be illegal.

The very process they tout, "Follow the Scientific Method" and "Show me the Evidence", they do not apply to themselves nor their Reform Agenda. There is a huge body of Evidence and prior work out there on what the real problems are with Healthcare and what the implementable solutions to them are: none of that work calls for "More Science".

The fact that FoSiM do not reference the established Field of Healthcare Reform, nor cite the Evidence, screams "This is an Ideological Jihad/Crusade against the Non-Believers, they shall be brought to heel or we will die trying". Anything but "Scientific" or "Evidence Based", which is wonderfully ironic...

The Retired folk - yes, it's a way to spend time and energy, to be involved, to still be relevant, perhaps even to make a difference. I can image Dwyer has a lot of pent-up frustration, regret and resentment resulting from feeling impotent to act against people, well intentioned and not, who attempted to treat his early HIV patients with "non science".

So I 'get' the four Academics: they believe they have are Right and want to change the world in their image.

I 'get' those who practice or research in Medicine: they know their field of practice and can't envision any alternative approaches.

For those still working, it may even be useful in advancing their career, even securing project funding.

But Marron, a non-medical, non-Academic in retirement, what's driving her?

More importantly, what does she get out of this gig, both personally and professionally?
So if she's spending her own time and money, what does she get back in return, especially as she's retired, this 'work' can only only be done For Personal Interest.

This is Psychology 101: Humans need Motivation to continue engaging in an activity.

I can't figure Marron's motivation - it isn't anything Professional nor about helping Individuals, which leaves Internal emotional-defiicit drivers, as far as I can see.

Sunday, August 5, 2012

ISM/FoSiM: The irrelevance of more "Science" in Healthcare Reform

[Post moved to other blog.]

ISM (Institute of Science in Medicine) and their Australian "mini-me", FoSiM (Friends of Science in Medicine), are advocating a rather extreme version of Healthcare reform:
Medicalisation of all Healthcare, under the guise of advancing "Science in Medicine".
These extreme views are published in an ISM Policy paper on the Licensing of non-Medical Healthcare practitioners. They advocate changing world-wide statues/regulation to only allow "science-based" Healthcare (code for Only Medical Care) and finish with:
Unscientific practices in health care should further be targets of aggressive prosecution by regulatory authorities. [italics added]
They don't just want to wind the clock back to The Grand Old Days of the Fifties, but a whole Century. The authority they cite is the 1910 Carnegie Foundation report on Medical Education by Flexner.

Flexner tossed around a bunch of concepts, many more than the State Regulation of Medicine and Medical Schools on which ISM/FoSiM base their calls for increased Healthcare Regulation, a.k.a. "Science in Medicine", as the definitive solution to all the ills of all Healthcare Systems in the world.

In the second half of this piece, Flexner's original thesis and concepts are examined - and not wholly surprisingly they support the opposite position of ISM/FoSiM.

Firstly, What do the world's best experts in Healthcare Reform identify as the local and/or common challenges to Healthcare?

And, How do the proposals of ISM/FoSiM address these Medical Millennium Challenges?
Dr James is also quoted in a forum organised by his University, PANEL ON HEALTH CARE REFORM – FALL 2008, Continuum, Utah University.

This is what he has to say on the Challenges facing Healthcare around the world:
JAMES: Another point is that we’re getting exactly what we pay for. We tend to pay for procedures and rescue care, so we get lots of procedures and lots of rescue care. This is a key factor.
Another thing you need to know is that other countries have exactly the same problems. So don’t look for solutions in Europe. Don’t look for solutions in Canada.
I get a ton of those guys coming through visiting to see how care’s delivered in Utah, believe it or not, because they face exactly the same problems.
There’s a standard working list of the top five problems within health care, and nobody’s solved them.
Travel the world and it’s the same list of five things:
1. The first problem is variation in care on a geographic basis.
It’s so high that it’s impossible that all Americans are getting good care, even with full access.
2. The second biggest problem is high rates of care directly judged to be inappropriate.
This is where the medical risk treatment outweighed any potential benefit to the patient and we did it anyway . . . usually in a rescue setting.
3. The third problem is unacceptable rates of care-associated injury and death.
This is where the care delivered actively killed somebody, whose death was judged to be preventable upon review.
4. The fourth problem is that the system does it right only 55 percent of the time.
There are things that we know for a fact should be done every time but the system does right only 55 percent of the time.
Now, that’s better than zero, but it’s not nearly 95 percent or 98 percent, where it ought to be.
5. And the last one is that there’s at least 50 percent waste in the system.
This is non- value-adding from a patient’s perspective, and that’s where the opportunity exists.


From the hard-data evidence presented by Dr James based on more than 3 decades of successful Healthcare Reform, we know:
  • The ISM/FoSiM proposals address the least important, least useful areas of change. 
  • Addressing Lifestyle Issues and Environment/Public Health would have six times the impact of attempting to improve "Health Care Delivery" through more "Science".  
    • Even then, ISM/FoSiM are either vague or silent on just what benefits their proposals, if adopted, can deliver. If they want to turn Healthcare around the world inside out, with considerable disruption, cost and upheaval, then they need to first inform us of the exact benefits we can expect.
  • The ISM/FoSiM proposals are irrelevant to the common "Top 5" Challenges faced by Healthcare Systems around the world: None benefit from more "Science", they are all about Quality of Care and Effectiveness of Delivery and Implementation.
  • All successful and effective Healthcare Reform, since and including Flexner, has been Patient-centric. The ISM/FoSiM proposals aren't just wrong, but exactly the opposite of what is documented to have worked. Practitioner- and Profession-centric reforms, such as "More Science in Medicine" do not deliver better outcomes for Patients.
ISM/FoSiM consistently demand high-quality Evidence and rigorous Science from those in its sights, yet fail to apply the Scientific Method and their Rules of Evidence to their own proposals and assertions.

To be consistent and credible, ISM/FoSiM must:
  • Meet the same standards of "Evidence", Research and adherence to the Scientific Method as they demand of others.
  • Demonstrate and Quantify how more "Science" will improve Quality of Care, Patient Safety, Equity of Access and Systemic Waste and Cost-Effectiveness issues identified as "Top 5" Healthcare Reform Challenges by the leading experts in the field.
  • First define their own "Top 5" Healthcare Challenges, and
  • provide research backed by verifiable, hard-data on the Efficacy of their own proposals, their own favourite criticism of non-Medical Healthcare.
If ISM/FoSiM criticise the Effectiveness of non-Medical Healthcare, we must in turn ask them to demonstrate the Effectiveness of their own proposals. If they set Rules and Standards for others, they need to follow them themselves, even better, demonstrate by superior example.

The Flexner report doesn't just say "Regulation and Licensing is necessary" as ISM/FoSiM seems to think, it also says many things still relevant today:
  • it asks for common standards and basic clinical education with laboratory practice,
  • suggests the 'Best Practices' as used by the Europeans,
  • says that Medicine is a Performance Discipline [my words] - that Theory and Practice/Experience together are needed by competent Professionals ("Head and Hands"),
  • that Medicine is not primarily a commercial enterprise, but has a very large "Public Service" component, with a Duty of Care not just to individuals treated, but the larger Community,
  • and explicitly recognises "all medical sects", and they be based on good clinical education.
It also contains an implicit commentary that demands:
  • As part of good Professional conduct, the systematic elimination of Known Errors, Faults and Failures, ("To Err is Human", but repeating preventable mistakes is malpractice of the highest order) and
  • From the Flexner principle of "licenses bear a uniform value":
    • Continuing certification retesting of all license holders, not a lifetime grant of license.
    • the adoption of practices that have been demonstrated to have value in assuring Professional competence and skills/knowledge currency at every point in time for all license holders. From Aviation, we know these techniques work:
      • Frequent (2 monthly) "Check Pilot" assessment of the in-situ performance of every Practitioner,
      • Simulator checks of "worst-case" situations. (Quarterly)
Why would we expect Medicine to have lower Quality and Practitioner Certification standards and processes than other fields? Heatlhcare should be the leader in Practice Efficacy, Quality, Safety and Cost-Effectiveness.

In conclusion, Flexner talks of Duties, Ethics and the need of the Medical Profession to guard against the corrupting effects of commerce. Exactly the same "Conflict of Interest" message that Arnold Relman and Marcia Angell started writing about in the New England Journal of Medicine in 1980.
Like the army, the police, or the social worker, the medical profession is supported for a benign, not a selfish, for a protective, not an exploiting, purpose.
The knell of the exploiting doctor has been sounded, just as the day of the freebooter and the soldier of fortune has passed away.
It's fitting to end with a quote from Arnold Relman ("A Drumbeat on Profit Takers"):
“It’s clear that if we go on practicing medicine the way we are now, we’re headed for disaster.”
If the things the best and brightest minds in the world of Medical Science are writing, researching and talking about, and have been doing so for 3 decades, are completely different to what ISM/FoSiM started advocating in 2009, then who should we give credence to?

My vote goes to the existing experts who can provide hard-data to back their stories, not mere puffery, exaggeration and "spin" as offered by ISM/FoSiM.