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

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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: The irrelevance of more "Science" in Healthcare Reform

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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.

Conclusion:

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.

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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.

FoSiM: The local "mini-me" of Institute of Science in Medicine: Same Bull, different faces.

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Dr Harriet Hall and her 26 "Founding Fellows" created the "Institute of Science in Medicine" [ISM] in mid-2009 as a "501(c)(3) organization for US federal tax purposes" registered in Colorado.

It self-describes as:

ISM is a non-profit educational organization dedicated to promoting high standards of science in all areas of medicine and public health.

and in PDF files includes:

Institute for Science in Medicine, Inc. (ISM) is an international, educational and public-policy institute, incorporated in the State of Colorado, and recognized as a 501(c)(3) organization for US federal tax purposes.

The local Australian variant, "Friends of Science in Medicine" [FoSiM] self-describes as:

 Our Association was formed at the end of 2011 out of concern about the increasing number of dubious interventions, not supported by credible scientific evidence, now on offer to Australians.

• Dr Hall appears in the first list of "Friends", January 2012.
• The "mini-me" relationship extends further with their DNS names:
• Dr Hall's group has the obvious website name:
• www.scienceinmedicine.org
• Where the local "mini-me" has a website name unrelated to it registered name, "Friends of Science in Medicine", but exactly congruent with being the local arm of ISM.
• www.scienceinmedicine.org.au 
• There is a test/development site at:
• www.loretta.fosim.org

Why does this matter?
If you read the first policy document of ISM [PDF] as a Declaration of Intent, it finishes with some very worrying 'Recommendations':

NEEDED POLICY

The world’s health care systems need to be rooted in a single, science-based standard of care for all practitioners.

Effective, reliable care can only be delivered by qualified professionals who practice within a consistent framework of scientific knowledge and standards.

Practitioners whose diagnoses, diagnostic methods, and therapies have no plausible basis in the scientific model of medicine should not be licensed by any government, nor should they be allowed to practice under any other regulatory scheme.

Any statute permitting such practices should be amended or repealed as necessary to achieve this policy.

Unscientific practices in health care should further be targets of aggressive prosecution by regulatory authorities.

 This unambiguous Declaration of Intent gives the ISM, and it's mini-me, FoSiM, a specific Agenda:

1. It is an explicit recognition that this is a Political not Academic or Scientific 'debate'. In no way are either of these bodies "Educational" or "about Science". They are only Political Lobby groups, yet aren't registered as such.
2. ISM/FoSiM want nothing less than making the practice of "Alternative" Medicines illegal ["change of statues"] and practitioners subject to "aggressive prosecution".
3. Who will judge what has, and has not, a "plausible basis in the scientific model of medicine"?
   • They don't define either "Science" or it antithesis, "Pseudo-Science", i.e. on the formal, strict basis for this rather extreme decision.
   • There seems to be no idea of Professions being able to defend themselves on any other grounds but an undefined "scientific model" and seemingly without means of Appeal or cause for Redress.
4. What isn't spelled out here, but is noted on the FoSiM site, is the assumed Dawkins Appropriation: anything ISM and their "mini-me"s decide is "Medicine" is automatically included in their Field of Practice. Which, by definition, makes that practice or technique now illegal for any other Profession to practice.

Given the extreme published position of ISM and the close alignment of ISM and its "mini-me", FoSiM, comments like this from Australian apologists strike me as ignorant, uninformed or disingenuous in the extreme:

Having an organisation like FSM to kick-start a public debate about the value of science in healthcare is invaluable. 

So to the extent that FSM can get the media and the general public thinking about how much they might value science as opposed to pseudoscience in their healthcare it can only be a good thing. That’s why I stopped sitting on the sidelines of the debate and signed up when I found out about them.

No, this is not a "debate", this is not something of little concern, an effort of well-intentioned, altruistic experts. It is anything but that.

ISM and their clones want any type of Healthcare they declare "not science" to be illegal, and practitioners "aggressively pursued". Once started, this is a very slippery slope.

Ultimately, internal Politics reliant on funding and 'connections' will determine what treatments are allowed and which will be deemed "unscientific".

The world of Medical Politics is already riven with such extreme dysfunction and violent internecine warfare that few outsiders understand how bad it is.

This campaign by ISM is hard-core Political Lobbying by the dominant Healthcare Profession for exclusive control of the domain.

They seem to not be happy with having captured over 99% of the Healthcare Dollar and now want everything, presumably in anticipation of making a grab for a much larger slice of our income.

After all, you wouldn't want to die from poor Medical care, would you?