Tuesday, November 27, 2012

I2P: It's all in the Mind

What level of Individual Responsibility do we each have in managing our Health and Well-Being, given that 40% of "total health" is due to lifestyle choices and behaviour and only 10% Healthcare Delivery? [1]

How much "free" healthcare, taxpayer funded, are we prepared to give individuals?
Should we limit it? How? Unlimited Free Goods guarantee unlimited demand for them.

Friday, October 26, 2012

YGBEHR: Conclusion - adhere to the same standards you set for others

Your Great Big Expensive Healthcare Reform: What measurable benefits will you deliver?

Part 4 of 4

[800 wds]

Free Speech is enshrined in Black-letter or Common Law in every Western Democracy, even in the Bill of Rights where extant.: one of our most precious Freedoms. But you don’t have the freedom to shout "Fire!" in a crowded place nor abuse anyone at anytime.

All Democracies have a tension between allowing robust conversations between citizens and silencing those whose agenda is anti-Democratic: mendacious, destructive, abusive or outright cranks and nutters. In the law, they are vexatious litigants.

 On the Internet, they’re called “Trolls”. [1] People whose sole purpose is to create mischief, turmoil and upset, not furthering debate or arriving at a consensus.

From my research for this piece, I can only conclude that FSM and their American parent, ISM, are Medical Trolls.
They mean no well, exist only to criticise, destroy and  intentional create mischief and spread dissension.

The test is quite simple: What are the positive elements of their Demands or Proposals?
None that I can make out in their published statements.

A hundred years of Flexner

Many sources describe the state of Medicine and Medical Education in the USA around the turn of the 20th Century as overcrowded, extremely poor and variable, driven by profits and dreams of riches with practitioner licenses handed out by poorly run Registration Boards via easily scammed exams. [1] [2] [3]

The US AMA was looking to properly regulate the profession and. while doing so, increase their power and influence and drive out of business competing “medical sects”.

This “cleaning of the Augean Stables” started well before 1904 and the AMA’s Council on Medical Education (CME) first proposals, pitched to, and taken up by, the Carnegie Foundation for their first report on “The Professions” in 1910.

YGBEHR: The Flexner Report – its background and relevance

Your Great Big Expensive Healthcare Reform: What measurable benefits will you deliver?
Part 3 of 4
The Flexner Report – its background and relevance

[850 wds]

Many sources describe the state of Medicine and Medical Education in the USA around the turn of the 20th Century as overcrowded, extremely poor and variable, driven by profits and dreams of riches with practitioner licenses handed out by poorly run Registration Boards via easily scammed exams. [1] [2] [3]

The US AMA was looking to properly regulate the profession and. while doing so, increase their power and influence and drive out of business competing “medical sects”.

YGBEHR: What measurable benefits will you deliver?

Your Great Big Expensive Healthcare Reform: What measurable benefits will you deliver?
Part 1 of 4
Introduction - Background and questions

[625 wds]

Government reform in healthcare is predicated on patients moving into a space that involves taking responsibility for their own treatment.

For this to properly occur, all health professionals have to engage with their patients and begin to mentor them to assist in understanding their health problems.
They must provide education and resources so that this process can occur.

To an extent this has successfully occurred, but only in the complementary and alternate medicine field, which is rapidly expanding compared to the mainstream medical model, albeit off a very low base so absolute numbers are still small.

YGBEHR: Models of real & successful healthcare improvement

Your Great Big Expensive Healthcare Reform: What measurable benefits will you deliver?
Part 2 of 4
Models of real & successful healthcare improvement

[695 wds]

After 5 years, if the ISM had a real and useful message from strong, credible people, it would be appearing everywhere. The US AMA’s site has just two references to ISM, both author affiliations in the same article. There are just 27  references to "science in medicine" on the site. Hardly noteworthy or impacting.

The US AMA has a dozen current “Advocacy topics” [1], none of which comes comes near the ISM/FSM position. They do have very clear strategies to address the most pressing healthcare problems:

Sunday, October 21, 2012

Arrogance, Ignorance and Incompetence: The State of Practice in Medical Care?

A 2010 Stanford piece on "How Teaching Hospitals could lead Medicine's Metamorphosis" details their processes for improving Patient Safety, Quality Improvement and reducing costs/improving Productivity.

I was struck by a simple question about the Stanford protocols, especially in the ICU:
If they aren't the minimum standard for non-teaching hospitals everywhere, then what do they know that Stanford doesn't?
I think that, especially in ICU, there is now no excuse for hospitals anywhere not to be following, albeit with a delay, the Best Practices researched and adopted by leading teaching hospitals. Reasonable practice would be: pick just one, or two, major teaching hospitals and mirror exactly what they adopt, but delayed by 12-18 months. You get the benefit of pick others' brains and having them iron out the bugs in the protocols for you...

For any management, including the CEO, responsible for hospitals' Quality of Care and Patient Safety, isn't ignoring known, documented Best Practice either Ignorance, Negligence, or Indolence? Any of which you'd hope in an ideal world, would be cause for instant dismissal.

Thursday, October 18, 2012

The Ugly Truth underpinning New Age Medical Care: What price a Life?

Update: Lateline ran a story on the ethics of End-of-Life care. They stopped short of examining Affordability and Rights to Basic Healthcare.

I was reminded on the radio yesterday of the simple question, "What price a life?"

This is the fundamental underpinning of Aged Care and End-of-Life Medical Care where a huge fraction, heading to 50%, of our total taxes gets spent.

As we Baby Boomers move to retirement and needing increasing levels of Healthcare and Residential Care, this is a question that must be answered, we can't adopt a Policy of "Head in Sand", "just do the Max".

If we don't have a nation-wide debate on this, consider it explicitly, we will have bureaucrats and politicians decide it for us, implicitly. The decisions they make and inherent resulting bias and who is selected as "privileged" won't please anyone, and probably not even the favoured few.

This is real, this is near, this is important, this affects every one of us.

State of the Art is the Oregon Healthcare Plan, formed with the explicit intention of more accessible, equitable care ("effective and efficient use of public money") and rationing benefits.

Sunday, October 14, 2012

I2P: The Internet Changes Everything: No more Dispensing Community Pharmacies

How many Community Pharmacies and Pharmacists will be needed for Australia in 2020?

I suspect, "Not as many as you think" because prescription sales will move on-line with lower prices and higher competition.
Australia Post will be leading a part of the Internet Shopping Revolution: physical delivery. They are providing secure "parcel lockers" accessible at any time. [1][2]

The Internet, as "bits and clicks", does browsing, shopping, payment and central fulfilment well, but the last link in the logistics chain, customer delivery, is weak. Secure, convenient, fast parcel delivery addresses this weakness. Can we assume that their courier service can access the lockers as well? [3]

Saturday, October 13, 2012

I2P: Caretrack and Beyond

July saw a landmark report published on the state of Primary Care by GP's in Australia: Caretrack [1][2][3]. The Caretrack project site notes:
The editor of the MJA, Dr Annette Katelaris, has described it as the most important study published in the MJA in the last 10 years.
The reasons for the study were twofold: an earlier American study suggested only 50-60% of GP's followed known Best Practice and with the explosion in Medical technology, drugs, treatment and published research, and GP's are finding it increasingly hard to stay abreast of all current research.

Friday, September 28, 2012

I2P: Challenging The Conventional Wisdom

Australia is many "Countries where they do things differently", not one uniform society, especially in things Medical.

This was brought home to me forcefully this week seeing a storefront in Moss Vale, NSW:
Pharmacist Advice: "Helping manage your medication, Helping you stay healthy"
In the 1960's I lived for a time in a small town in Far North Queensland. The first-call for small-boy medical adventures (ticks, tropical infections, wounds, burns, ...) was the Pharmacy and Ambulance station. Not Hospital Casualty nor the GP.

Saturday, September 8, 2012

FoSiM: More subtle anti-Alternatives Propaganda.

I recently tried to post a comment on the Choice Magazine website.

They've published an anti-Chiropractic article without declaring their interets. Very poor form.

FoSiM: Definitive Proof of systemic bias/prejudice against Alternative Medicine/Therapies

Here's incontrovertible evidence that FoSiM are not interested in "Science in Medicine", but specifically in attacking practitioners they don't approve of. They are "Doctors against Alternative Medicine" [DAAM].

There has been no mention/coverage of this piece of science on the DAAM/FoSiM website, even though it was done by one of their own senior members, Braitwaite.
CareTrack: assessing the appropriateness of health care delivery in Australia, 20-Jul-2012.
Conclusions: Although there were pockets of excellence and some aspects of care were well managed across health care providers, the consistent delivery of appropriate care needs improvement, and gaps in care should be addressed. There is a need for national agreement on clinical standards and better structuring of medical records to facilitate the delivery of more appropriate care.
There was a related MJA editorial (I can't see) by Chirs Del Mar, one of the Skeptic/DAAM heavy-weights.
A dog walking on its hind legs? Implications of the CareTrack study.
Despite its limitations, this important study highlights a genuine need for systematised performance monitoring
No mention on the DAAM/FoSiM site of this study, though there is a lot of other activity since 20-Jul-2012.

Monday, August 20, 2012

Quote from signatory to US Declaration of Independence: Medical Freedom is Right

This quote was pointed out to me. I think it's a stunner, especially considering the age of the original: 230yrs, 100yrs since Booth and its another 15+yrs since Wilk...

There is also an interesting counter quotation from Dr Benjamin Rush, a physician and signatory to the U.S. Declaration of Independence [1776]. 
He wrote, "The Constitution of the Republic should make provision for medical freedom. To restrict the art of healing to one class of men and deny equal privilege to others will constitute the Bastille of medical science. All such laws are un-American and despotic. They are vestiges of monarchy and have no place in a republic. " 
Wilk CA. Medicine, monopolies and malice.New York: Avery Publishing Group 1996;53.
ER Booth, History of Osteopathy and Twentieth Century Medical Practice, Cincinnati: Caxton Press, 1905 (1924):312.

Saturday, August 11, 2012

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

[Full post on other blog.]

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...

Thursday, August 9, 2012

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

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.

Here are his three books available on-line from Amazon:

A quick tour of the article:
  • Since the 1980's, the parts of the business world have progressed in leaps and bounds:
    •  Mass Customisation, Quality/Continuous Improvement, Performance Improvement and Process Re-Engineering and "Lean" (e.g. Toyota).
    • As embodied by the US's Cheesecake Factory - systematised delivery of consistent high-quality services where the outcomes, not the process/steps, are defined and checked.
  • Authority, Accountability and Responsibility for Service Delivery and Patient Outcomes are generally missing. Gives example of knee replacement under Dr John Wirth:
    • A large team working together with common procedures, checklists and guidelines based on proven Best Practice and Cost-Effectiveness.
    • Later he says:  "The fundamental question in medicine is: Who is in charge?"
  • The ability of successful, large-scale modern business to routinely roll-out significant changes every six months, versus the 15 years it takes for even half the medical establishment to pick-up simple changes (eg. beta-blockers).
  • He discusses "tele-ICU's", a remote monitoring station meant to double-check ICU operations and pick up errors or problems before they become injuries.
  • Gwande posits: "Reinventing medical care could produce hundreds of innovations" like:
    • email access to clinicians
    • more timely advice, reduced ER visits
    • smartphone App for chronically ill (eg Diabetics)
    • new ways to get specialist advice
    • systems to track outcomes and costs
    • instant delivery of "up to date" care protocols
  • and follows with "But most significant will be the changes that finally put people like John Wright and Armin Ernst in charge of making care coherent, coordinated, and affordable."
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. He uses as his 'hook' a night out at a favourite restaurant, something that all of us are familiar with and enjoy, and then uses that framework to hang all the concepts and examples he wishes to bring us. 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.

Some Quotes:

On "who's in charge?" and "who's responsible?":
The biggest complaint that people have about health care is that no one ever takes responsibility for the total experience of care, for the costs, and for the results.
On the rate of introduction of proven, effective new practices:
Even a month would be enviable in medicine, where innovations commonly spread at a glacial pace.
Intensive Care Units (ICU's) and tele-ICU centres being problematic to :
Although fewer than one in four thousand Americans are in intensive care at any given time, they account for four per cent of national health-care costs.
Across the country, several hospitals have decommissioned their (tele-ICU) systems. Clinicians have been known to place a gown over the camera, or even rip the camera out of the wall. 
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

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.

The FoSiM "Vision Statement" in their recruiting letter was:
"To reverse the current trend which sees government-funded tertiary institutions offering health care ‘science’ courses not based on scientific principles nor supported by scientific evidence”.
And from the ISM Policy paper on Regulation and Licensing all Healthcare Practitioners and Training:
As a consequence of these practitioners being legitimized through political rather than scientific means, the health of people worldwide has been put at significant risk.
Not hard to spot that both these statements 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.

ISM/FoSiM put "Science" at the centre of their Reform proposal and agenda.
Specifically, 'Science' applies to:
  • Practitioners,
  • Specialities,
  • Organisations,
  • Research, Academic or Commercial,
  • Professional Bodies,
  • Professions, and
  • Governance bodies and processes, such as defined by Government Agencies.
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.
ISM/FoSiM want to "Fix All Ills of Healthcare and its Systems" through More Science, amusingly without evidence that this can or will help. The evidence of the last sixty years of "More Science" in Medical Care is that costs rise astronomically (5% to 18% of GDP in the USA), while more people are untreated and Public Health outcomes do not seem commensurate change.

The ISM/FoSiM advocacy for more "Science in Medicine", even taken at face value, is a clear call for:
Better Healthcare!
Which is admirable in its intent.

Only, like all their efforts, it's vague, incomplete and unfocussed. It's posturing not a useful addition to the debate.

They are advocating for Better Healthcare:
  • For Whom?
  • Where?
  • How Measured?
  • Within what Cost and Resource envelope?
  • But mainly, How can their Reforms be delivered and Implmentation executed when the current Medical Care system is grossly understaffed, inefficient and already too expensive for ordinary folk?
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.

The only group of Patients, the only reason this field of work exists at all, who might benefit aren't just the "Top 1%", but probably the "Top 0.1%".

This is a proposal that will cost a whole bunch of money, mostly Public (ISM/FoSiM are universally silent on Cost and Efficiency Improvement) and the two groups to benefit are: themselves and their rich mates.

That's a really interesting proposal for spending piles of Public Money with no sense of Accountability and where the only evidence available is "It won't help, but will cost a whole lot more."

How does "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.

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.
What do we get for all that money? [slide 16]
  1. High touch -- patients value their relationship with a trusted clinical advisor more than any other element in health care delivery (the clinician-patient relationship)
  2. Rapid response -- the Rule of Rescue
Three classes of outcomes: [slide 65]
  • Physical outcomes
    • medical outcomes: complications and therapeutic goals
    • includes functional status measures (patient perceptions of medical outcomes)
  • Service outcomes
    • satisfaction: patients and families, communities, professionals, purchasers, and employees
    • includes access issues (e.g., waiting times)
  • Cost outcomes
    • just another outcome of a clinical process
    • includes the cost of the burden of disease
Medical outcomes are of four types: [slide 66]
  • appropriateness
    • (referral and procedure indications)
  • complications
    • (process failures / defects)
  • therapeutic goals / biologic function
    • (when stated in the negative, merges with defects)
  • the patient's ability to function
    • (functional status, as reported by the patient)
  • are process specific
    •  (different clinical conditions have different complications, different therapeutic goals, functional status measures)
  • Medical outcomes relate directly to health care costs
Service outcomes are of two types: [slide 67]
  • the clinician-patient relationship
    • (bedside manner: a "caring and concerned" clinician)
  • access issues: convenience vs. hassle
    • (scheduling, travel times, registration, physical comfort, wait times, etc.)
  • operate by a separate, general process that is independent of medical outcomes
  • Service outcomes directly affect market share, community perceptions and relations (that is, prestige and social status), and
  •  rates of malpractice law suits
Health care consumers seek value [slide 69]
  • Value = (Medical outcomes + Service outcomes) ÷ Cost outcomes
  • The goal is the best possible medical outcomes at the lowest necessary cost
It'd be interesting if ISM/FoSiM ever apply their considerable talent and resource to addressing just how their call for "More Science" will deliver better Healthcare outcomes in the structure given by DR James.

Tuesday, August 7, 2012

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

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.
Which may be true at one level from their output and reliance on a rather over-worked CEO with a penchant for hyperbole and aggressive deprecation of others.

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.

This isn't even "David and Goliath", nor even "Ant vs Elephant"... For every one dollar FoSiM have, more than a million is spent by the other players (guesstimate).

Not to mention that litigation at this, the Big End of Town, is not only normal, it's to be expected at some point - especially if you aren't careful with your words or if you put a contrarian viewpoint. The other existing players have deep pockets and aren't shy of protecting their positions: why would you willingly jump into a bear-pit like that without adequate resources to defend yourself?

What are they thinking, getting into this area without being backed by deep pockets?
Or is there something we're not being told?

Of the many Working and Retired Medical Practitioners and Researchers supporting FoSiM:

  • Have they carefully informed themselves of the FoSiM agenda, statements and actions?
    • Perhaps some, like the AMA Federal President, will drop out when they catch on.
  • Have they signed up, thinking the Medical world needs more strong representation?
    • If so, do they think FoSiM has the resources, knowledge and staffing to properly carry out that mission? There can be severe professional and political consequences to over-reaching and failing.
  • Do any of them think membership of FoSiM will be Career Advancing or Career Limiting?
    • It's very hard to see how an amateur/volunteer/hobby organisation, no matter who's names are associated with it, will ever have the clout or respectability to help advance Medical or Academic careers. Their sphere of influence and Lobbying power is necessarily limited by funds and staffing: at some point, they'll fail to meet promises or make savage PR or Political mistakes, without the resources to address or correct them...
    • The Internet creates a Permanent Public Digital record: belonging to FoSiM will not be forgotten. Those 500 supporters are punting their entire careers on FoSiM never being discredited or failing spectacularly. Looking at the credentials of the CEO and the extreme,  attacking language in publications by her and some of the other Founders, I can't see a future for FoSim without deep controversy, tumult and even serious litigation.

Dwyer's "Famous Five" Founders, come in 4 flavours:
  • Retired, Non-medical, non-scientist, "Consumer Advocate", Loretta Marron.
  • Working Medical, Academic: MacLennan, Costa
  • Working non-Medical, Academic: Morrison
  • Retired Medical, Academic: Dwyer
I can see why the Academics, working or not, would have an interest in Healthcare Reform, especially a reform that's Ideologically based. Be clear on this point: the ISM/FoSiM position is both extremist and fundamentalist. Advocating for "more Science in Medicine" might sound uncontroversial and obvious, but exam their policies and the implications, and they want to change laws of Healthcare practice around the world banning Healthcare Fields they consider wrong and urge authorities to "aggressively pursue" anyone violating those new laws.

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".

Given that Medicos, Teachers and Academics all suffer the Occupational Hazards of Professional Arrogance and Omniscience, Infallibility (and Absolutism: "One True Answer") with a tendency to personal narcism, even overbearing/berating behaviour, then in the confluence of all three, it must be rare to find people who are humble, self-deprecating and willing to listen to competing views.

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?

It isn't:

  • Career Advancement
  • Professional Interest, Practice, Recognition or Prestige
  • Funding research programs
  • Solving Medical or Scientific Puzzles
  • Creating a Better Healthcare system for the community
  • helping any individuals directly with improving their Healthcare outcomes
  • and not for the wages, according to what's public.
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

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 Brent James, executive director of Research and Quality at Intermountain HealthCare, Utah, (IHI) has extensively published hard data on Quality Improvement in Medicine, won prestigious Quality and Medical awards and co-authored landmark works on Patient Safety, Quality of Care and delivery of Best Practice Medicine. After 3 decades of implementing and executing successful reform programs at IHI, Dr James easily qualifies as one of the experts on Healthcare Reform.

Dr James, in his initial slides for his Advanced Training Program, ["Managing Clinical Processes: Doing Well by Doing Good"], lays out a lot of diverse material that underpins his Quality Improvement methodology and forms a consistent, well-formed theory driving his decades of successful Reform, not like ISM/FoSiM, a set of untested Ideological assertions.

On Slide 9, "Total health: How long, how well we live", Dr James lays out what the Evidence says on the contributors to Good Health. They are:
  • 40% - Behaviour under control of the Individual (loosely, 'lifestyle choices'). Tobacco, Alcohol, Movement Deficit Disorder [humour!]
  • 30% - Genetics
  • 20% - Environment and Public Health
  • 10% - Health care Delivery (Hospitals and Clinics)
On the next slide (10), "The Great Equation", he states [with sources cited]:
  • Health = medical care and medical care = "access to care"
  • "But the Great Equation is wrong ..."
And then goes into a lot of detail about why that is so.

In slide 29, "Dr. John Wennberg", he describes Wennberg's research/analysis:
  • Geography is destiny ("Who you see is what you get")
  • There is no health care "system"
  • Supplier-induced demand: [many examples follow]
In slide 31, "Care-associated injuries in hospitals", Dr James describes one of the primary source of waste in Medical care, which he addressed at IHI, providing net savings of 20-32% in delivering services. Not to mention much better Patient outcomes.
  • Injuries drive direct health care costs totalling $9 - 15 billion per year [Thomas et al. 1999, Johnson et al. 1992]
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.

Flexner and the Carnegie Foundation were critical of the medical profession, its standards and ethics of practice: what we'd now call 'governance'.

They also called for the general public to be trained in assessing doctors and requiring professional practice from them. Something not included in the ISM/FoSiM proposals.

The report also emphasises that all medical professions owe a Duty of Care to their patients which requires much higher standards that other work:
it is a 'public service' on which people trust their lives, not merely a business.
Today, Flexner and the Carnegie Foundation might phrase their argument in terms of "Quality of Care", "Patient Safety" and whole system effectiveness, not just single element "efficacy".
By professional patriotism amongst medical men I mean that sort of regard for the honor of the profession and that sense of responsibility for its efficiency which will enable a member of that profession to rise above the consideration of personal or of professional gain.
As Bacon truly wrote, "Every man owes a duty to his profession," and in no profession is this obligation more clear than in that of the modern physician.
Perhaps in no other of the great professions does one find greater discrepancies between the ideals of those who represent it.
The interests of the general public have been so generally lost sight of in this matter that the public has in large measure forgot that it has any interests to protect.
Flexner notes the importance of the basic Professional Charter: It's professional malpractice to repeat or allow, Known Errors, Faults and Failures.
"There the Clinical professor comes in to the Aid of Speculation and demonstrates the Truth of Theory by Facts,"
he declared in words that a century and a half later still warrant repetition;
"he meets his pupils at stated times in the Hospital, and when a case presents adapted to his purpose,
he asks all those Questions which lead to a certain knowledge of the Disease and parts Affected;
and if the Disease baffles the power of Art and the Patient falls a Sacrifice to it,
he then brings his Knowledge to the Test,
and fixes Honour or discredit on his Reputation by exposing all the Morbid parts to View,
and Demonstrates by what means it produced Death,
and if perchance he finds something unexpected,
which Betrays an Error in Judgement,
he like a great and good man immediately acknowledges the mistake,
and, for the benefit of survivors, points out other methods by which it might have been more happily treated."" [ An essay on The Utility of Clinical Lectures, by Thomas Bond, 1766.]
The writer of these sensible words fitly became our first professor of clinical medicine,1 with unobstructed access to the one hundred and thirty patients then in the hospital wards.
Flexner rather strongly states that "Medical Care" goes much further than treating diseases/conditions presented to the surgery, a position that would make him outside today's AMA:
The overwhelming importance of preventive medicine, sanitation, and public health indicates that in modern life the medical profession is an organ differentiated by society for its own highest purposes, not a business to be exploited by individuals according to their own fancy.
Flexner advocates for reform and states categorically the underlying drivers - that Patient-centric, not Practitioner- or Profession-centric solutions and specifically not intransigent Ideologies are required:
The public interest is then paramount, and when public interest, professional ideals, and sound educational procedure concur in the recommendation of the same policy, the time is surely ripe for decisive action.
Flexner specifically notes:
  • that mere Science, 'the instrumental basis of medical education', is woefully inadequate for a good Practitioner.
  • that physicians must be much more broadly trained and well-rounded individuals.
  • and they their education starts with their graduation, not finishes.
Just how was that to be done isn't said in that section. [Or at all?]

This non-disease view of Flexner and the Carnegie Foundation on Preventative Medicine and treating communities, not just individuals, is wildly at odds with the prevailing medical paradigm and the polemic of ISM/FoSiM...
The practitioner deals with facts of two categories.
Chemistry, physics, biology enable him to apprehend one set;
he needs a different apperceptive and appreciative apparatus to deal with other, more subtle elements.
Specific preparation is in this direction much more difficult;
one must rely for the requisite insight and sympathy on a varied and enlarging cultural experience.
Such enlargement of the physician's horizon is otherwise important, for scientific progress has greatly modified his ethical responsibility.
His relation was formerly to his patient - at most to his patient's family; and it was almost altogether remedial.
The patient had something the matter with him; the doctor was called in to cure it.
Payment of a fee ended the transaction.
But the physician's function is fast becoming social and preventive, rather than individual and curative.
Upon him society relies to ascertain, and through measures essentially educational to enforce, the conditions that prevent disease and make positively for physical and moral well-being.
It goes without saying that this type of doctor is first of all an educated man.
Flexner often uses the phrase "scientific medicine", but what did he mean?

This was 15 years before Karl Popper's theory of Falsifiability and more than 6 decades before the current notion of "Evidence Based Medicine" rose from the 1972 paper by Cochrane and Sacket's 1996 definition of the term.

Flexner left us a definition, even emphasising that arrogance and dogmatic insistence on "One Truth" is anathema to the Scientific Method:
The modern point of view may be restated as follows:
medicine is a discipline, in which the effort is made to use knowledge procured in various ways in order to effect certain practical ends. [italics added]
It is precisely the function of scientific method - in social life, politics, engineering, medicine - to get rid of such hindrances to clear thought and effective action.
Science believes slowly; in the absence of crucial demonstration its mien is humble, its hold is light. [italics added]
"One should not teach dogmas; on the contrary, every utterance must be put to the proof.
One should not train disciples but form observers: one must teach and work in the spirit of natural science." [Johannes Orth: Berliner Klinische Wochenschrift, vol.xliii. p.818]
Flexner lays out the philosophical basis of his recommended Medical Education system, based on the Scientific Method. He specifically addressed Education in "Medical Sects" (e.g. Homeopathy and Osteopathy) - as good a name as the ISM/FoSiM term "CAM" (Complementary and Alternative Medicine).

ISM/FoSiM don't just ignore that Universities now teach "CAM" courses according to Flexner's requirements, rather the reverse, they have called for the banning of exactly those courses.
The logical position of medical sectarians to-day is self-contradictory.
They have practically accepted the curriculum as it has been worked out on the scientific basis.
They teach pathology, bacteriology, clinical microscopy.
They are thereby committed to the scientific method ; for they aim to train the student to ascertain and interpret facts in the accepted scientific manner.
He may even learn his sciences in the same laboratory as the non-sectarian.
But scientific method cannot be limited to the first half of medical education.
The same method, the same attitude of mind, must consistently permeate the entire process.
To emphasise the point, Flexner wrote about acceptable education of non-Medical practitioners, defining objective tests based on process, not Ideology and preconception.

Substitute "Medical Sect" for "CAM" and Flexner defines for ISM/FoSiM the requirements that are now met by University courses:
Sectarians, in the logical sense above discussed, are
(1) the homeopathists,
(2) the eclectics,
(3) the physiomedicals,
(4) the osteopaths.
All of them accept in theory, at least, the same fundamental basis. 
They admit that anatomy, pathology, bacteriology, physiology, must form the foundation of a medical education, to use the words broadly so as to include all varieties of therapeutic procedure.
They offer no alternative to pathology or physiology; there is, they concede, only one proper science of the structure of the human body, of the abnormal growths that afflict it.
So far, they make no issue as against scientific medicine. [italics added]
Much is involved in agreement up to this point.
The standards of admission to the medical school, the facilities which the schools must furnish in order effectively to teach the fundamental branches, are the same for all alike.
A student of homeopathy or of osteopathy needs to be just as intelligent and mature as a student of scientific medicine;
and he is no easier to teach; for during the first and second years, at least, he is supposed to be doing precisely the same things.
At the beginning of the clinical years, the sectarian interposes his special principle.
But educationally, the conditions he needs thenceforth do not materially differ from those needed by consistently scientific medicine.
Once more, whatever the arbitrary peculiarity of the treatment to be followed,
the student cannot be trained to recognize clinical conditions,
to distinguish between different clinical conditions,
or to follow out a line of treatment,
except in the ways previously described in dealing with scientific medicine. [italics added]
He must see patients and must follow their progress, so as to discover what results take place in consequence of the specific measures employed.
A sectarian institution, being a school in which students are trained to do particular things, needs the same resources and facilities on the clinical side as a school of scientific medicine. [italics added]
Flexner showed, like ISM/FoSiM, an innate dislike for, and bias against "non-Medical" Healthcare Professions, but very clearly defined a set of Professional Principles that, if complied with, would him to accept the practice of any Medical Sect.

Instead of an authority against "CAM" as ISM/FoSiM suppose, Flexner definitively supports non-Medical Healthcare, if its Education process meets his requirements:
The law may require that all practitioners of the healing art comply with a rigidly enforced preliminary educational standard;
that every school possess the requisite facilities;
that every licensed physician demonstrate a practical knowledge of the body and its affections.
To these terms no reasonable person can object;
the good sense of society can enforce them upon reasonable and unreasonable alike.
From medical sects that can live on these conditions, the public will suffer little more harm than it is destined to suffer anyhow from the necessary incompleteness of human knowledge and the necessary defects of human skill.
On Medical Boards and Regulation, Flexner wrote they needed legislative power, and unlike ISM/FoSiM, did not conflate his report recommendations with the political lobbying needed to implement them. He also continues to underline the importance to the Profession of Public Duty.

There is another powerful, central principle of Flexner's: Medical Practitioners are not 'free agents', they first owe a duty of Public Service.
The power that validates the diploma with its license must have the strength to protect its issues against either debasement or infringement.
The physician, like the lawyer, is an agent of the state. [italics added]
If he proves unworthy, the same board that vouched for him must have power to recall its act; and its function must extend to the prosecution of fraudulent or unwarranted attempts to practise without its official sanction.
The state must therefore provide funds that will enable the board to defend its action in the courts.
A model state board law must therefore guard the following points:
  • the membership of the board must be drawn from the best elements of the profession, including - not, as now, prohibiting - those engaged in teaching;
  • the board must be armed with the authority and machinery to institute practical examinations, to refuse recognition to unfit schools, and to insist upon such preliminary educational standards as the state's own educational system warrants;
  • finally, it must be provided either by appropriation or by greatly increased fees with funds adequate to perform efficiently the functions for which it was created.
The additional powers needed in order to deal as effectively with the practice of medicine, lie outside the present discussion. [italics added]
Flexner lays out more criteria for Regulation/Licensing of the Medical Profession, including a criteria who's implications have not been explored by the Regulators, nor mentioned by ISM/FoSiM: for licenses to have uniform value, they cannot be issued for life, frequent certification retesting is necessary.

If that premise is accepted, then it also demands the Regulation/Licensing process itself cannot be static. It must be continually examined, refreshed and updated with new Knowledge as it becomes available. As has been done for decades in Aviation.
The creation of separate boards is thus a roundabout method of recommitting the errors that the main currents of scientific thinking and effort are endeavoring to remedy.
A single board should subject all candidates, of whatever school, to the same tests at every point.
The license of the state is a guarantee of knowledge, education, and skill.
The layman is in no position to make allowances.
The state's M.D. and the state's D.O. offer themselves for essentially the same purposes.
The state stands equally as guarantor of both.
No citizen can indeed be wholly protected by the state against his own ignorance, fanaticism, or folly.
[referring to a previous comment: men who don't "believe" in doctors can't be forced into treatment]
The state is powerless there.
But having undertaken to vise practising physicians for the protection of those who summon them, it must see to it that the licenses to which it gives currency bear a fairly uniform value. [Italics added]
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.

Sunday, July 29, 2012

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

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.
FoSiM was created by Loretta Marron and John Dwyer and three other of their little friends. It took them several months to incorporate an Association in NSW and register a website.  The five "Founders" were necessary under NSW law to form an Association.

Hall and Marron would've known of each other in 2007, both appearing in "The Skeptic" magazine (Australia) and possibly met at a "Skeptics" conference, such as James Randi's TAM7 (The Amazing Meeting) which had a large Australian contingent.

By 2009,  their names appear together in articles, they are both speakers on "The Skeptic Zone" by Richard Saunders and are both closely connection to a number of other high-profile Australian Skeptics like Rachel Dunlop, Kylie Sturgess and Karen Stollznow.

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:
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.
There is a test/development site at:
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':
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, specific Agenda:
  1. It is an explicit recognition that this is a Political not Academic or Scientific 'debate'. ["As a consequence of these practitioners being legitimized through political rather than scientific means, ...] 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.
    • They don't suggest a forum in which this 'debate' might occur and the formal bodies that will be charged with these judgements. There is no, and can never be, a Global Council of Science charged with making ultimate decisions of what is/is not "True Science".
    • Nor do ISM/FoSiM suggest whom has adequate qualifications in both Science and Jurisprudence to even suggest answers to these problems, define the Terms of Reference for any Tribunal convened and the training and selection of whom might be selected to sit in Judgement.
    • Do ISM and their "mini-me"s assume that Politicians will have sufficient knowledge, be free from bias and all Conflicts of Interest to sit on these Tribunals?
    • 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.

Just to emphasise this is a consistent, reiterated position, a quote from another article:
[From criticism of ISM/FoSiM in the MJA] Indeed, it is not melodramatic to point out that if Friends of Science in Medicine were to succeed in their stated aims, they would achieve a dystopia – a medical ‘1984’ where only one way of knowing the body in health and illness is permitted in public discourse. 
Well, for starters, it IS melodramatic to call FSM dystopian. Allow me to also point out that FSM are not talking about public discourse, they are talking about university training of health professionals. The logic of this argument rests on an assumption that scientific knowledge is not special. 
Again, No so! Read the ISM Policy...

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.

Are ISM and its clones seriously suggesting the public put their health, and the lives of all their foreseeable descendants, into the hands of an unaccountable, deeply discordant and divided profession with no alternatives whatsoever? That's not going to end well for us, the paying public.

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?

In the USA they've increased National Healthcare Expenditure (NHE) from ~5% in 1960 to ~18% now, with the numbers of uninsured and under-serviced folk steadily increasing, but without any commensurate improvement in the most basic of Healthcare Outcomes: Life Expectancy.
The USA is ranked globally around 80th on that measure, whilst spending 50-100% more of GDP...

Projections on the CMS site include that by 2050, NHE will account for 30% of US GDP. They don't suggest how much higher than the current ~25% the rate of uninsured will be.

Saturday, July 21, 2012

I2P #1: First, Do No Harm.

This is my first post written for "Information to Pharmacists", an interesting Industry Newsletter with a typically idiosyncratic Aussie approach: they welcome authors of any viewpoint and profession, as long as they are respectful to others, not libellous and can write on medical/pharmaceutical issues. And "no dot points, please!" - a challenge for me, leaving behind my favourite organising technique.

"Fist, do no Harm" not only embraces Systemic Quality, but better Economic outcomes and improved Efficiency and Effectiveness with reduced waste and Continuous Improvement. Learning and Process Improvement are common to both efforts as are monitoring outcomes: costs, clinical results and "process deviations", a.k.a. "errors".

Computing/I.T. and Medicine share a Fiduciary Duty to their clients, with the Amplifier effects of I.T. now the most cost-effective means of improving Patient Safety, Quality of Care and Treatment Effectiveness.

The enemy of Quality Improvement isn't only "Change Resistance" but faddism, like a cargo-cult adopting the outward signs whilst ignoring the underlying causes and principles.

This, not technical problems, will be the major obstacle to realising the benefits of e-Health initiatives here and overseas. Successful practice transformations have stemmed from Quality Improvement programs with electronic system assisting, not from the blind adoption of automation.

Who am I and what do I have to say that's interesting or useful to Pharmacists and related readers?

I'm a second-generation Computing professional, starting in 1974: in the first group since commercial computers arrived in 1950 to gain undergraduate degrees in Computing. It was still possible to cover in depth the whole field: transistors, hardware, systems, software, operations, business analysis and User Experience.

During a wide-ranging career, I developed an interest in Quality and Turnarounds, for the way out of a mess lies in Working Smarter and stopping wasted effort.
From working in one of the most technically demanding fields, Telco Exchanges where one hour of downtime a year is tolerated, I was imbued with the notion of "Client Service", the same "Fiduciary Duty" that underlies Medicine.
I also discovered for myself the maxim: "Quality isn't just Free, it's cheaper and faster to Do it Right, First Time" defining "Systemic Quality" that, through the work of James T. Reason and Charles Perrow, transformed Aviation after the mid-1970s.

Computers and I.T. are "Cognitive Amplifiers" in the same way that machines are force and skill amplifiers. They allow ordinary folk to easily perform extraordinarily, day after day.

Notionally, automated electronic systems are added to Business Processes to "provide a Business Benefit". Not unlike Marketing, for those Benefits to be realised, they have to be measured  and cannot be measured unless defined and designed in from the start, a practice rarely undertaken.

These ideas have often put me at odds with other technical staff and managers: they are antithetical to the untutored or Default Management Style of business which insists "Just Do It!" is more important than "think before you leap".

Don't all I.T. practitioners suffer the Occupational Hazard of "knowing everything about everything"?

Just about, with the worst offenders often in "Help Desks": everyone else is a fool, which is their experience from on-going "idiot user" calls.
This is a trap that I consciously try to avoid: any reminders from readers are welcomed.

Automated computing/I.T. systems cut across every part of an Organisation, often extending into other Organisations in ways few appreciate. No other Profession does this, not even management and accounting, requiring Business Analysts and Programmers to understand the work of other Professions better than they know themselves.

Programs and Systems are crystallised thought processes: they are exact, detailed, and hopefully complete, descriptions of the cognitive processes people use to execute tasks.
Often the hardest part of this work is uncovering Implicit Knowledge and converging on correct task definitions that will become universal for the first time.
Politics always trumps the Technical in this work, creating inconsistencies and contradictions in tasks.

To be good at Computing/I.T., you need to be both a 'quick study' of other Fields of Practice and be able to apply a raft of tools allowing you to understand their work better than they do.

Which often leads to a certain arrogance and hubris. It takes some humility and courage to admit that true Domain Experts have great talent and skill: Experts make their work look effortless and obvious, as seen in performances of sporting stars.

The irony is that the best Computing/I.T. experts have the same problem with 'management' and business owners: What they do looks simple and obvious to outsiders and is undervalued.

For completeness, many I.T. practitioners are not expert in this way. They make the job look hard, with the resulting systems being slow, difficult to use and wrong or buggy: for which they often get promoted for their "heroic efforts" slaying the Project Beast.

I.T. is fine, as long as it stays out of my way...

If this is you after too many fads, management or I.T., being foisted on you without consultation or thought for local consequences, you have my condolences and understanding.

I absorbed the many fads in the first 15 years of my career before wondering why nothing really changed and digging back into history. Fredrick W. Taylor and Henri Fayol wrote comprehensively about Management and Quality Improvement more than a century ago with Dr W Edwards Deming adding a definitive theoretical base sixty years ago.
Why then, did Michael Hammer re-invent, badly, the work of Taylor et al in the 1990's, then need to resile from it a decade later?

The Japanese transformed their Industrial processes this way, taking 3 decades to out compete the USA in making cars. During the 1990's, the US experienced fads of "the Japanese Way", but generally never understood or adopted Deming's core principles.
Then the "outsourcing" and "right sizing" fads took over with messy manufacturing being sent off-shore, becoming "Someone Else's Problem".

Systemic Quality: tying it all together.

Aviation proves three things about Systemic Quality: it can be achieved every day with ordinary people, it's the most cost-effective approach available and arises from a pervasive Safety Culture supported from the very top down.

There are some notable efforts to bring Systemic Quality to Medicine/Healthcare: Intermountain Healthcare with Dr Brent James, trained by Dr Deming, being responsible for 20 years of Quality Improvement, "Safety Leaders" website from Texas Medical Institute of Technology, National Academy of Science's Institute of Medicine and Donald Berwick's Institute for Healthcare Improvement.

Not only do they have hard data on their Cost, Safety and Error outcomes, they can show that it's 20-30% cheaper for them to Do it Right, First Time.

And for Pharmacists... You're important.

In the interview Dr James gave to Norman Swan in 2001, "Minimising Harm to Patients in Hospital", he said they used their Drug Information Systems to identify many Adverse Events, such as an opiate overdose requiring 'narcan' to be administered.

They also found these system-related Adverse Events 30-times more prevalent than reported Human Errors. Dr James said:

For ten consecutive years we tracked every adverse drug event and in parallel with that we tracked classic human errors. In ten years we had 4,155 confirmed human errors. In parallel with that we had 3,996 confirmed moderate or severe adverse drug events.
Norman Swan: In other words, what was actually happening to the patient him or herself?
Injuries. Those were injuries, those 3,996. The fascinating thing was the overlap. Among 3,996 confirmed injuries, 138 or 3.5% resulted because of a human error.
Norman Swan: So in other words most of the human errors didn't result in an injury.

Friday, July 13, 2012

FoSiM: Damned by their own words??

In February I commented on problems I had with "Friends of Science in Medicine's" Claims, Credibility and Transparency.

Part of my concerns about FoSiM's Credibility was a piece in the SMH 5 days earlier, recounting an amazing tale of illegal hacking of an SMH opinion poll ('gaming', or massive manipulation).

In following up a piece in "I2P" (Information to Pharmacists, edited by Neil Johnson) by Peter Sayers, "FSM Strategy has no Middle Ground" where I was mentioned, I saw that the FoSiM CEO, Loretta Marron/Mutton, had penned a piece mentioning the same SMH article where she accuses Blackmore's of being "Blaggards". I find such emotional and judgement-laden words hardly fitting or worthy of a group espousing an "Evidence Based approach" only to all Healthcare.

This was published two weeks after the SMH article and well after mine.

My comment, on that article, submitted today:
Marron is considerably less than honest in her reporting of the gaming of the Poll.
The SMH felt moved to write an article on this: it was highly unusual and, for them, highly disturbing behaviour. But Marron makes no mention of this.
She withheld the two most important facts, for me, from the SMH artilce: 
1. "The end result was 70 per cent no, 30 per cent yes."
[ie. the crude attempt from Blackmores et al was unsuccessful]
2. "The number of votes in the poll was about eight times more than the number of online readers of the story, a clear indicator that the poll had been gamed.
Fairfax technical staff said the poll logs all but confirmed that the voting had been manipulated."
==> After she saw a successful but unsophisticated attack on the "NO" vote, 'magically" the situation was reversed with poll gaming that was sophisticated enough that the SMH techs couldn't identify the source in their logs, unlike the simplistic "YES" votes from Blackmore's et al.
Marron is a self-confessed technical wiz as are a number of her fellows from Australian Skeptics Inc. We've no way of knowing if any of them took part in this sophisticated "poll gaming", but we absolutely know that the poll was gamed for both "Yes" and "No" votes and Blackmore's et al "Yes" vote was relatively crude and traceable.
I find it more than disingenuous that Marron doesn't comment on the final outcome of the poll or that supporters of the FoSiM position were far more "evil" in their approach, probably illegal hacking if done programatically.
Again Marron doesn't mention that FoSiM's Founder, John Dwyer, was approached by the SMH to comment on the poll and it being gamed...
Dwyer was appalled and surprised.
But not Ms Marron, despite her obvious technical knowledge and proficiency. 
Does this mean she:
  • didn't read the full SMH article,
  • didn't notice they'd won,
  • didn't understand the import of the article as a whole and its various questions,
  • didn't think it was very strange "her team" suddenly and untraceably surged ahead,
  • simply ignored inconvenient statements and questions or
  • did she know much, much more about this illegal hacking?
All we know if that she ignored what I regard as the most important, pertinent facts of the story that carry very serious implications of amorality and illegal action.
If I'd been on the "NO" side and noticed the opposition were gaming the poll - and had the interest, tools and lack of morals to do some sophisticated hacking - I'd have manipulated the result to be "just a win", NOT the better than 2:1 landslide it finished at... Why would you bring attention to yourself with such an obvious result?
An even more convincing outcome would've been to NOT game the poll with illegal hacking, just bring the crude attempts from Blackmore's to the attention of the SMH, suggest they write their article on poll gaming, identify the culprits (as was done) AND to remove all the suspect votes and republish the poll with a credible win for "NO'.
==> that approach would've been wholly legal and produced two wins, one on the corrected poll plus a moral victory against Blackmore's et al.
I can't believe that anyone without a very strong interest in the topic, which is FoSiM vs Everyone Else, could be bothered or motivated to game a poll in this way.
How could the large-scale, untracable "NO" vote be anything other than the work of FoSiM 'Friends'?? I can't see why anyone else would undertake such alarming illegal hacking, but then, I don't claim omniscience and would love to understand this.
It would also explain why Marron ONLY mentioned one this side of the affair, but so would many other things like bigotry, bias and "spin doctoring".
None of which bring Marron or her little "Friends" any credit.
I find what she's purposefully omitted from this article to be damning. Or was that just incompetence?

Monday, July 9, 2012

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

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?

The currently quoted figure for Healthcare costs as percentage of GDP is 9% in Australia [vs 23% in the USA]. The two growth figures quoted (38% rise in 20 years and a 40% rise in last 15 years) should alarm every taxpayer, patient and politician.

Especially the internal inconsistency: Medical Healthcare costs have grown at an increasing rate per capita for many decades, why would the rate suddenly decrease? Based on the last 15 years, we should be expecting 12.6% GDP in 2027, if not higher due to increased end-of-life care costs of Baby Boomers.

Here are my take-aways from the article. It is notionally about the PCEHR (Personally Controlled Electronic Health Record) introduced on 1-July-2012 by the Federal Government, but I find the other facts the author quotes much more interesting:
  • health spending is forecast to rise to 12.4 per cent of GDP in the next two decades [from 9% in ~2007]
  • That’s on top of a 40 per cent rise in healthcare costs per capita since 1997 [15 just years!].
  • A review by the National Health and Hospitals Reform Commission found that in Australia each year, the equivalent of 350 jumbo jets crashing and killing all on board is attributable to highly preventable medical ‘adverse effects’
  • these events can account for up to 15 per cent of a hospital’s costs. 
  • One new private hospital – Medica Centre in Sydney’s South – is seeing huge efficiency gains from simple management tools like inventory control and more effective scheduling of surgeries.
  • Clinical director Matt McKay says that for the first time he truly knows what a procedure should cost.
  • Matt McKay at Medica Centre says that so far, he has seen an increase in efficiency of 30 to 40 per cent, not only from managing his inventory better but also scheduling his surgeries to minimise theatre turnaround times.
  • If such inventory management existed in a competitive business, the company would have been sent broke long ago.
    • But in the health sector, those costs get shifted onto the patients, the insurers or the taxpayer.
  • A report by the OECD suggests that as much as 42 per cent of costs could be cut from common hospital procedures.
  • Australia’s Productivity Commission says that figure is about 25 per cent.

PRODUCTIVITY SPECTATOR: Your money and your life
Jackson Hewett
Published 7:33 AM, 9 Jul 2012 Last update 7:33 AM, 9 Jul 2012
Three hundred and six. 
That’s the number of people who signed up last week to the government’s new program to slash the cost of our medical spending.
It was a very soft launch for the Personally Controlled E-Health Record but the motivation behind it is right. An easily accessible database that ensures medical professionals have access to all of our medical activities should, if utilised correctly, reduce the enormous amount of waste and duplicate activities that drain federal and state health budgets. It also should help reduce mistakes caused by patients forgetting what previous symptoms they’ve had or drugs they’ve taken. 
Why is it so important? Because health spending is forecast to rise to 12.4 per cent of GDP in the next two decades. That’s on top of a 40 per cent rise in healthcare costs per capita since 1997.
A review by the National Health and Hospitals Reform Commission found that in Australia each year, the equivalent of 350 jumbo jets crashing and killing all on board is attributable to highly preventable medical ‘adverse effects’ – things like bad reactions to medication, incidents of infection, and medical device problems. Aside from the terrible human toll, these events can account for up to 15 per cent of a hospital’s costs. 
More complete records such as the PEHCR will hopefully reduce such incidents.
But there are many more ways for our tax dollars to be better put to work. One new private hospital – Medica Centre in Sydney’s South – is seeing huge efficiency gains from simple management tools like inventory control and more effective scheduling of surgeries. 
Medica Centre uses a highly technologically advanced dispensary called Pyxiss to allocate products for a surgery. Nurses must fingerprint scan to access items, and a computer will only let them take the exact number of products as defined by the surgeon. That means the hospital can track costs by surgeon and by patient, something they say is a first in Australia.
Clinical director Matt McKay says that for the first time he truly knows what a procedure should cost. At his former employers in both public and private hospitals, the best figure he could get for a procedure like a knee arthroscopy was $250 per patient in terms of consumables like bandages, syringes, sutures and the like. That was a figure derived by simple stocktaking. After a year using the Pyxis system, McKay now knows that figure should be closer to $500. The knowledge allows McKay to be far more effective in monitoring which surgeons overuse products, and react accordingly. He’s also using just-in-time ordering to reduce working capital. 
If such inventory management existed in a competitive business, the company would have been sent broke long ago. But in the health sector, those costs get shifted onto the patients, the insurers or the taxpayer.
A report by the OECD suggests that as much as 42 per cent of costs could be cut from common hospital procedures. Australia’s Productivity Commission says that figure is about 25 per cent. Matt McKay at Medica Centre says that so far, he has seen an increase in efficiency of 30 to 40 per cent, not only from managing his inventory better but also scheduling his surgeries to minimise theatre turnaround times. One surgeon has become so efficient that he has that number down to two minutes, and can do an arthroscopy in 20 minutes. By comparison, another surgeon takes up to an hour for the same procedure, and 20 minutes between them. That means more nurses, more downtime and higher costs. 
As a private hospital, Medica Centre can pick and choose what surgeries it will take, and what doctors will do them. Good doctors like to work there because the quicker they can get patients through, the more money they can make.
The public sector has little choice in either doctor or patient. But that doesn’t mean it can’t use some private sector ideas to save money along the way.