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.

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.

[Post moved to other blog.]

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?

Your money and your life: What the AMA and Friends of Science in Medicine won't tell you.

[Post moved to other blog.]

This piece in Business Spectator has a bunch of 'interesting' facts that both Friends of Science in Medicine and the Medical Industry body, the AMA, ignore.

Why is this??

I'd have thought it was in the Medical Profession's interest to run their operations as efficiently as possible in order to maximise their result and the benefit to individuals and to the community. That is, if that's what their Prime Mission is.

As Don Berwick formulated in 1996 with his Central Law of Improvement:

Every system is perfectly designed to achieve the results it achieves.

So, if Medical Healthcare and Hospitals aren't run efficiently and 'accidentally' kill far too many people, Why is this so?

Just what is the current system designed to achieve, if its not Patient Safety, Quality of Care or Efficient, Effective use of Public Monies?

A superficial, simplistic analysis can't tell us...
But we do know that incumbents must benefit from the system: How?

Failed Professions: Definition, Impact, Consequences

I'd like to assert that (Australian) Medicine, Banking and Finance & Investment Advisors and Information Technology (I.T.) are Failed Professions.

The fields of Management and Politics, whilst notable for their egregious actions and errors and not just failing expectations of good governance, but actively harming or exploiting the general public, are not Professions: they fail the basic tests of "Body of Knowledge" and "Entrance Requirements".

What do I mean by a "Failed Profession"?
How do I support that view?

On Being a Professional: 3 Axions. Right Reasons, Attitude, Aptitude.

I've stated for a time my rubric of Professional Practice as a rhetorical question:

When it is ever acceptable for a Professional to repeat, or allow, a Known Fault, Failure or Error? [A: Never]

Some larger questions arise but won't be dealt with here, but they imply a meta-level, the "Profession":

• Define 'Known' (which needs a means of transmission), and
• What are, or should be, the Consequences of unprofessional conduct or performance?

Healthcare, Medicine and the Learned Professions (eg. Law) have a special (higher) onus of responsibility on them. In the scale of Professional Duty, they are the most stringent and demanding:

• Fiduciary Duty or Trust:
•  "involving trust, esp. with regard to the relationship between a trustee and a beneficiary" [Oxford American Writer's Thesaurus]
• Fair Go, Fair Treatment.
• No Rules, Buyer Beware.

I argue that the Fiduciary Duty implicit in the Practitioner/Patient contract and relationship is demonstrated in the Hippocratic Oath, "First, Do No Harm,..."

This is a very high standard.

I take it to mean that Practitioner always places the Patients' welfare and health above their own concerns and needs, and those of their employer, supervisors and Professional Bodies.

Internal to this, I assert that the more radical or extreme the effects or possible adverse outcomes of the treatment/procedure are on the patient, they higher the duty of care. A variation of "Your Life in Their Hands".

• A surgeon or Intensive Care Physician can trivially cause immediate death or terrible permanent injuries. They have the highest level of Fiduciary Duty towards their Patients.
• Whilst the maker of a prosthetic device needs to avoid transmission of diseases, the use of toxic elements and have the device work safely. There is still a Fiduciary Duty towards the Patient, but it is much closer to the "Fair Go, Fair Treatment" level.

I'm positing three axions of Professional Practitioners, especially those with a Fiduciary Duty to their clients:

• Clean Motivation of Entry into and Practice in the Discipline: not Money, not Status, not Power/Prestige/Influence.
• If a Clinician is practicing because of the money, not primarily for providing good Patient Outcomes, they will routinely fail in their Fiduciary Duty.
• This is counter to the best interests of the Patient.
• A focus on pecuniary rewards will not sustain a Professional for their full working life. Once immediate goals are satisfied, what then? More of the same, or Just Cruising, not Caring?
• Caring for others outcomes is the first requirement for Quality and Continuous Improvement.
• Those who espouse, or act out, "Care Factor Zero", will not and cannot provide good Quality practice. If they have a Fiduciary Duty to others, they should be relived of duty without delay.
• Continuous Active Learning and Improvement.
• This isn't the 20-hours/year of mandated CPD (Continuing Professional Development).
• It's an inherent self-monitoring, self-examination of process, procedures and outcomes leading to Improvement in Quality of Care and Process (efficiency and effectiveness) and Adaptation and Improvement of Practice.
• A trusting and safe environment, "The fundamental Clinical Requirement", for the patient to "open up" into a full, frank and unstinting clinical communication.
• As human beings, we have 90 seconds to make a first impression. Recovering from a poor or antagonistic first impression is possible, but lengthy and time-consuming.
• Within that time, any clinical professional has to establish a basis of communication with the patient where they can be fully open, honest and complete in the clinical dialogue.
• "Why didn't you tell me before/when I asked" is the calling card of failure in this fundamental clinical requirement.
• Patients are both fully informed experts and ignorant. They know absolutely the experience of their own bodies, but can not be Clinical experts, even if they are trained in the field. This contradiction requires the clinician to both respect, not discount or ignore, what the patient is telling them and to fully draw out the patient experience. The patient will not be aware of apparently trivial or obvious details that are critical for swift, correct diagnosis by the clinician.

Lastly, there's the matter of Talent.

Some people are gifted in a field and given the same degree of training and practice, outperform us "mere mortals" by many times. Some might say "orders of magnitude".

The proof is Elite Athletes and Professional Sports. Talent counts, not just perseverance, determination and desire. Professional teams pay massive amounts for their stars, not 'the pack'. In professional tennis and golf, it shows up in earnings, both tournaments and sponsorship. The notional performance differences between #1 and #100 are small (<1% or 0.01%), but earnings are different by powers of ten. Talent counts as much in the clinical setting as on the sports field - and the results are similarly different.

Professions don't do themselves favours by allowing those of limited Talent to practice.

It diminishes the field and fails the patients.

Ironically, through the Dunning-Kruger effect (tone-deaf performers self-assess as virtuosos), this can institutionalise perverse selection and assessment regimes:

   when the professors are tone-deaf, they reward those like themselves and remove all others.

Exemplified by the claim: "I'm the Best XXX in the South-West/North/Area/City/State/..."

It's an error of logic of the kind: "compared to what? by whom?"

The Dawkins Appropriation: Not just wrong, dangerous

[Post moved to other blog.]

Richard Dawkins is credited with the observation:

there is no alternative medicine. There is only medicine that works and medicine that doesn't work. [italics added]

Sounds reasonable, sounds obvious, sounds good. But it is wrong.

As Medical practice subsumes other techniques and modalities, how well does it do it?
How well can it do it?

This is the same problem as learning a new language.
Without the Culture and Context, the learning is seriously compromised.

Yes, you might have some fluency, some ability to get yourself understood and able to hold modest conversations.

My thesis:
 the Culture, Theory, Practices and implicit knowledge and models underpinning a technique, therapy, practice or modality cannot be separated from it.

 Secondly, it's called "practice" for a reason. Like playing a musical instrument, to become accomplished in the art, you need a lot of practice to build the skill. But then you have to maintain the level of practice to maintain the skill. Mere performances won't maintain concert-level skill, and worse, infrequent performing result in lessening of skills. At some point you are back to "amateur" status.

"Cherry Picking" can only lead to sub-optimal results, or worse, real harm to patients through ignorance and poor techniques.

Specifically:
Can Doctors perform Acupuncture or Spinal Manipulations as well as native trained, specialist practitioners? Those who practice their craft daily.

I argue, not nearly.

So why does Dawkins make his statement, if it works, it ours? It's so trivially wrong and dangerous as to be absurd.

At best it is an ignorant and unwise sentiment, at worst disingenuous and mendacious.

It's a great sound-bite and simplistic rationalisation - and has been endlessly repeated by the proponents of the Medical Healthcare Treatment Only (all other banned/illegal) school of thought.

If Dawkins had said:

Medical Healthcare will embrace and accept as whole specialities what are now regarded as Alternative Modalities or Treatment when they are shown "Safe and Effective",

then I'd agree with him.

Dawkins thinking on this seems to be mechanistic, based on the Classical Science/Physic notions of absolute knowledge and predictability.

A balanced post on the EBM vs Alt.Med Debate.

[Post moved to other blog.]

I thought this article balanced and informative. I liked the stated intent "moving beyond virulence" in the title. Of course, Doctors and Friends against Alt.Med did their usual scorn and bile attack in the comments.

"Evidence-based medicine v alternative therapies: moving beyond virulence", 23-March-2012.

Main arguments:

• The absent patient
• Lack of critical reflection (on philosophies of health and the politics of medicine)
• Evidence-based medicine (the critical analysis of EBM)

There is a long comment by 'Anne Cooper', Osteopath, that I thought was good. [click on "show full comment" to see it all]
Her ending is very strong:

So instead of the FoS attempting to take a high moral ground, and at the same time appropriating the term ‘medicine’ (not to mention the title ‘Dr’), perhaps it could instead lobby for funded, high quality research that will enlighten us all as to why these unsubsidised therapies are able to attract and treat so many hundreds of thousands of Australians every day. Now that would be useful. Failing that, their campaign looks to be little more than a turf war.

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."

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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"...

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]

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].

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".

• They are a thinly disguised branch of a very shady reactionary group.  Most, if not all, the 'Executive' of FoSiM have garnered awards from "Australian Skeptics Inc". [More on A.S. Inc's machinations and their real politck.]

• "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.

• A recent piece in The Journal of Patient Safety, "An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate"  by both experienced, highly-competent Aviators and Medicos makes a very strong case for in both describing the systemic problems (the figures on waste, fraud and over-servicing are horrifying) and for outlining a solution.

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.

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.

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.

Friends of Science in Medicine: Hypocritical call to action

[Post moved to other blog.]

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

From a report on the Editorial and associated articles.

Professor Stephen Myers, SCU [Southern Cross University]:

“the real benefit of an appropriately mentored and approved university education is the exposure of students to the biomedical sciences, epidemiology and population health, differential diagnosis, safe
practice and critical appraisal."

Professor Paul Komesaroff, Monash University, on MacLennan's MJA in editorial in March-2012:

“exceed the boundaries of reasoned debate and risk compromising the values that FSM claims to support”.

Professor Komesaroff:

"while there was now an extensive evidence base in relation to complementary therapies, the concept of evidence-based medicine was highly contested and debated within Western medicine itself." 

"It is not appropriate for doctors or scientists with a particular view of medicine to impose those views on the whole community; rather, they should respect the rights of individuals to choose the approach to health care they feel is suitable for them." 

“It is important that those who seek to be friends of science do not inadvertently become its enemies. We call on the members of FSM to revise their tactics and instead support open, respectful dialogue in the great spirit and tradition of science itself”

---

In writing an inadvertently long piece on the Irrelevance of Marron and Dwyer's "Friends of Science in Medicine", I had to reflect on what what a convincing "short version" would be. Here's an attempt:

• Dwyer, as a respected and long-serving medico, has to be aware of the estimated 18-35,000 preventable deaths in Australian Hospitals each and every year. [1995 QAHCS report, disputed.]
• He must also be aware of the lack of good data on Adverse Events (AE) and Iatrogenic Injuries.
• Similarly, the extra $2B/year estimated additional cost of treating AE's in hospitals.
• He should also be aware of Dr Brent James reports (2001) from Intermountain Health, Utah, that only "3.5% (of patient injuries) resulted because of a human error" and from the APSF report on Iatrogenic Injuries (2001)  "The causes of iatrogenic injury appear to be systemic".
• There is also a 2004 report on the effects and additional preventable deaths from overcrowding in Accident and Emergency. 

All of which could be used to suggest by Dwyer and friends:

Australian Medicine and Hospitals do very well in the face of insurmountable odds and lack of Political will and funding. [A justification used by AMA President Rosanna Capolingua in 2008, below.]

Only it isn't so...

Compare the complete lack of an Evidence Base for Patient Outcomes for Australians and any coherent, credible, co-ordinated plan to address this with the UK's Civil Aviation Authority's current Safety Plan. 

Secondly, Dr Brent James reported a 20% reduction in costs by reducing Patient Injuries through a "Do it Right, First Time" approach to Quality. This corresponds with the 2002 results from Ehsani, Jackson and Duckett. As Berwick suggests, organisational change is required to address systemic issues. Unless the system is changed, results won't change.

The CAA's Safety Plan [excerpted below] conspicuously shares a feature unknown in Australian Medical literature and seemingly in Hospital improvement plans: The Most Important Problems List.

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

Where this line of reasoning leads to:

After 50 years of large jet aircraft being used in Commercial Aviation, 'we' know exactly what has to be done to economically achieve good, reliable and safe Public Services, so why isn't this approach being advocated and adopted by Medicos and Hospitals?

From Dr. James, we also know that it is cheaper to fix systemic issues through a "Get it Right First Time" Quality approach, so after more than a decade of being known in Australia is this not being done?

How many "Adverse Events" are there in the Australian Hospital system? We don't know.
But the best evidence available is that they are not reducing. [below]
The most conservative estimates, "Sentinel Events", counts around 270 adverse events/year.
The QAHCS report estimated 18,000, the difference being direct, provable causality.
While the Australian Doctors Fund (ADF) would like us to use the American UTCOS report figure of 3.3 times less, of ~5,500 per year.

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

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

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

Friends of Science in Medicine: Irrelevant and Inconsequential?

[Post moved to other blog.]

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

In researching a follow-on piece to Peter Jeans', I took 4,500 words of notes - without covering anywhere near the number of topics I wanted to bring together. I wrestled with:

a) how to meaningfully condense such a wide field, and

b) Just what is the story here?

The crux of my dismay and discomfort with FoSiM, Marron and Dwyer is their outrageous attack on a relatively benign and low-impact Healthcare Services ("Complementary and Alternative Medicine" [CAM]), whilst ignoring massive, real and pervasive fundamental problems with mainstream Medical Healthcare.

FoSiM, Marron and Dwyer are asking us to shutdown and prevent from practicing those who account for under 1% of Medical fatalities and errors, whilst comprehensively ignoring the major problems. What is going on here???

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

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

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

Some observations on the FoSiM goals:

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

Queensland Public Hospitals Commission of Inquiry, 2005:

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

Initially I was going to start this piece with this bunch of aphorisms relevant to FoSiM and their performance and bias:

• "by their actions you will know them"
• "ends must match the means"
• "first remove the log from your own eye"

While these are still relevant and appropriate, indicating that FoSiM, Marron and Dwyer are being driven by a hidden agenda, I was derailed by the next thought:

Just how Professional are Mainstream Medical Practitioners? (could they really withstand a serious Inquiry?)
For example Jayant Patel (JMP), "Doctor Death" of Bundaberg.

Reading the ~550 pages of the Davies Inquiry report I was struck by many things:

• The only reason there was ever an Inquiry is that a single nurse, Toni Hoffman, sacrificed her career by whistle-blowing. Otherwise none of this would have happened, raising the question: "How many incidents like this had happened previously without comment?"
• Although Patel's "Mortality and Morbidity" statistics implicated him in 30 or more deaths, the legal system requires proof of causality. Hence he was only prosecuted for a small number of cases.
• Jayant Patel was by far not the only "renegade" practitioner identified by the Inquiry, nor the only person whom the Inquiry made recommendations about.
• There were multiple other hospital districts found to be delivering unsafe care to patients. This is further evidence of wide-scale, systemic failures in Queensland Health.
• There were serious systemic problems within Queensland Health, including its treatment of local medical graduates and GP's (as VMO's, Visiting Medical Officers).
• These origins of these problems is complex and due to Political, Public Service Administration and Medical Profession issues - going back 30-40 years.

• Margaret Cunneen SC, in "The Patel Case – Implications for the Medical Profession (Medico-Legal Society of NSW, 2010), points out:
• Queensland has a "Criminal Code of Law" which made the criminal prosecution of JMP possible.
• Patel, and any doctor acting maliciously, could not be charged with a criminal offence in NSW and most other Australian jurisdictions.
• Cunneen says little has changed in NSW in over a century:
  She reviewed an 1893 case of a person practicing as a doctor, but not legally qualified. He failed to deliver a baby, causing it severe injuries and death - but the charges were dismissed because the man had no case to answer under the law then, or now.
• Cunneen, a senior prosecutor, says:
  "because of this expectation that doctors will not do something maliciously against a patient, that they will only make a mistake which may or may not be civil negligence."
• There have been no calls by the Australian Medical Profession to address these problems of Jurisdiction, consistent Medical Board judgements or malicious injury by doctors.

• In late 2011, Premier Anna Bligh "dismantled" Queensland Health following a $16M fraud. Five years after the Davies Inquiry, it seems there has been little change or improvement.

There is overwhelming evidence that Queensland Health has had pervasive, systemic problems for decades. Is that Politically acceptable or a proper use of Public Monies?

The most critical question is:

What has fundamentally changed so that any of this could not happen again, that these lives lost and unnecessary injury inflicted has not been in vain? [Nothing?]

My rubric for Professionals:

Is there ever a reason for any Professional to repeat, or allow, a known Error, Fault or Failure?

By this test, Aviation professionals and technicians, at least here in Oz, are overwhelming more Professional that every registered Doctor. Part of the proof lies in the Open and Transparent collection and reporting of critical outcome data.

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

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

---

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

Learning points:

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

THE CENTRAL LAW OF IMPROVEMENT

Not all change is improvement, but all improvement is change.

The relation derives from what I will call the central law of improvement:

every system is perfectly designed to achieve the results it achieves.

The central law reframes performance from a matter of effort to a matter of design.

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

"Friends of Science in Medicine": Credibility, Claims and Transparency

[Post moved to other blog.]

Yesterday I wrote up what I'd been able to find out on the web about "Friends of Science in Medicine" (FoSiM) - but it only begs more questions without any good answers. For a lobby group espousing the Scientific method in its very name and demanding the highest standards of evidence and rigour of others, this absence of transparency, rigour and completeness should be anathema. That it hasn't been addressed in a month starts to suggest this is no accident.

It's a long piece (3,000 wds) and, disturbingly, I could find few hard facts, only rather a lot of uncorroborated snippets. It's mostly "all smoke and mirrors".

Monday 30th January, 2012, I heard Fran Kelly of ABC Radio National, interview Prof. John Dwyer and Dr. Kerryn Phelps in "New lobby opposes teaching alternative medicine" and audio download.

Really interesting and important stuff, more so that someone whom I respect and consider a 'serious' journalist should seek to interview a former professor of Medicine and Oncology [in places falsely attributed as "Cervical Cancer Vaccine creator" - that was Ian Frazer, also a member of FoSiM] and an ex-President of the AMA and a very high-profile leader of "Integrative Medicine" in Australia.

I jumped on the 'Net and tried to find out more, but drew a blank.

Even though there has now been significant coverage in the mainstream media and a veritable barrage on-line, it's very difficult to get any information, let alone good answers, on anything to do with this lobby group.

Even something as simple as: "Who are you and what do you stand for?"
On-line, they are a vague, shadowy, even slippery group.

The ASIC "National Names" database has them incorporated in NSW (INC9896756) on 13-Feb 2012, which isn't consistent with the claim from "Quack Treatments Duck for Cover" republished/included by Neil Johnston.

It is all welcome news to the Friends of Science in Medicine (FSM), an Australian organisation formed in December of 2011...

A busy retirement: Loretta Marron, CEO FoSiM

[Post moved to other blog.]

A shy, retiring stay-at-home person the new CEO of "Friends of Science in Medicine" (FoSiM) is not, twice being declared "Australia Skeptic of the Year", appearing on TV and being written up in the media.

She become well known by Australian media, a 2009 piece, "Loretta Marron, Health Hero, On Australia’s A Current Affair", describes her as "a science graduate with a business background".

All this leaves me with questions about Loretta Marron and her motivations.

• Just what is Marron's background and expertise?
  She has no on-line CV, Publication list or Bio and makes a number of different claims about her expertise and working life.

• Just who is funding "Friends of Science in Medicine"?

• If FoSiM is a modern Association wanting to be taken seriously, where is its on-line presence?

• Is FoSiM just one person, working from home without pay?
  Is this whole thing just Marron engaging in a media beat-up and outrageous self-promotion?

• Marron demonstrated in her Crikey! piece that she has considerable networking and self-promotion skills and a fine ability to influence and persuade academics, researchers and medical experts to support her position and campaigns.
  Is FoSiM just the latest and largest version of this?

• Is Marron and FoSiM a 2012 rerun of Sheryle Moon and "Alliance of Australian Retailers" in 2010?
  Articles: SMH, ABC radio, Lateline.
  AAR Website and Disclosure statement:
  
  • We are supported by:
    
    • British American Tobacco Australia Limited (ACN 000 151 100);
    • Philip Morris Limited (ACN 004 694 428); and
    •  Imperial Tobacco Australia Limited (ACN 088 148 681).
    •  Authorised by R. Stanton for the Alliance of Australian Retailers Pty Ltd (ACN 145 378 589) of 14 Ross Street, North Parramatta, NSW, 2151.

All my concerns and questions can be summed up simply:

Show me the same Evidence about yourself and "Friends of Science in Medicine" that you are demanding of others.