Monday, February 20, 2012

Friends of Science in Medicine: Irrelevant and Inconsequential?

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?

This piece is in several parts:
  • an introduction,
  • a quick assessment of FoSiM and their likely future,
  • some specific observations on FoSiM and
  • the part of my research that really disturbed me - the 2005 Queensland Public Hospitals Commission of Inquiry, including but far from limited to, the actions of Jayant M. Patel, "Doctor Death" of Bundaberg.
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???
Compare FoSiM and MEAG: The Medical Error Action Group started in 1992 after an avoidable, severe medical outcome to a family member ('the needless death of ...'). They've since gone on to document and support many injured parties.

Marron has taken it upon herself to:
a) pursue action on behalf of others, those whom she doesn't even know, and
b) presumes to appoint herself Judge and Jury of Everybody Else, whilst not just turning the same searchlight on the most dangerous and outrageous Medical Practitioners, but the opposite: trumpeting them as exemplars of Best Practice and Science.

It is more than ironic that the most documented example of a failed healthcare system is in Marron's home state, Queensland.

This isn't simple bias, but something much deeper and much more sinister...
Why didn't Marron join one of the long-established groups to pursue her aims of Medical Reform?

Just to show this isn't limited to Queensland or Victoria, from NSW, the recent Grace Wang injury - a young mother permanently disabled in a preventable, foreseeable repeat incident - that has not led to an Inquiry or personal consequences to those responsible. How has this simple error leading only to permanent disability or death, been allowed to be repeated with apparent impunity?

Criticism is all too easy and so very simple, but where's the proof that something better is possible?
The sort of systemic and fundamental changes that FoSiM and its supporters should be putting their considerable energy and time into supporting and furthering?

More than 5 years before Patel fled the country in disgrace, the following piece was broadcast nationally. There is no excuse for any Medical practitioner or Medical Administrator to not be fully cognisant of the proven/demonstrated methods, contents and claims from one of the their own:

Dr Brent James, Intermountain Healthcare: Minimising Harm to Patients in Hospital", (2001).
It reports definitive results of a "Do it Right, First Time" approach to Quality, and
the prior major US report "To Err is Human: Building A Safer Health System" (1999).

A 1996 article on the topic by Donald A. Berwick, from the British Medical Journal, is referenced with excerpts at the end.

To underline the bias and misguided intent, excerpts from the FoSiM "Invitation" letter recruiting supporters [including comments, thusly]:
Our Vision Statement:
"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”.
[Note: this doesn't acknowledge the serious problems within mainstream Medical Healthcare, nor that they are the overwhelming danger to patients.]
We hope to provide the voice of reason and credibility to help the public make informed choices in medical care and not be subjected to false claims of efficacy nor take unnecessary risks of harm from unproven therapies or from delay in seeking proven treatment.
[Note: removing everything after 'from unproven ...' changes this to a credible and laudable sentiment or aim.]

Friends of Science in Medicine:

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".

FoSiM is poorly organised, lacks PR skills (no website or verifiable email address), possibly is unfunded and run by "a one-(wo)man band" and hence unable to effectively lobby politicians, commission expert reviews or reports, respond or initiate litigation - all the normal and required activities of a real Lobby Group. Perhaps their intention is to gain notice/notoriety, and then leverage that into financial support. Not unlike the "Association of Australian Retailers" being funded by Big Tobacco.

FoSiM are incredibly naive politically and misguided in their approach. They cannot stop the advance of Complementary and Alternative Medicine now, any more than they can command the sea to turn back. 40-50 years ago, they may have stood a chance, but that opportunity is long gone.

If FoSiM have real concerns about public Health Services and standards, not just running a Power Play or shamelessly self-promoting themselves, Dr Hambleton, in Peter Jean's piece, gives them a very precise recipe to achieve real, lasting change [my paraphrasing]:
work with, not against, the alternative practitioners that the public have demonstrated they prefer to mainstream medicine.
To reverse the trend away from Mainstream Medicine, positive attributes must be demonstrated to draw the public back, not throw mud at the perceived opposition. (Throwing mud is never a good tactic, you can never get away clean.)

Hurling accusations, insults, abuse and belittling or denigrating comments around is easy and attracts media coverage. It has given Marron and her projects a public profile.
But if anyone decides to ask FoSiM for the same Evidence of Claims they require of others, it isn't going to be pretty.
There's the risk of Defamation actions, Class Actions from harassed groups (starting with injunctions on media comments) and even an ACCC action under "false or misleading advertising".
Spouting off in the press its "pseudoscience" or "voodoo and witchcraft" is one thing, defending that claim with proof, either academically or legally, is another.

There have already been two recent successful actions in Australia against those attacking CAM practitioners and their practices. Thinking that the recent Simon Singh case (vs UK Chiropractors) gives legal immunity is bizarre and incredible.
The final ruling of "Lord Judge" is clear and specifc: Libel cannot be held in Scientific debates.
Making unproven statements in the general press by non-scientists, or those not engaged in true "scientific debate", rather character assassination etc, won't be protected.

Friends of Science in Medicine is as irrelevant and inconsequential to the Healthcare Services debate as "One Nation" is now to Australian Politics.

I don't know if they will become the same laughing stock, but I expect like them, they will attract rabid followers and the attention by "shock-jocks" and tabloid media. Cheap shots and stunt-media always get ratings.
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.

None of which will create lasting change, but will cause grief to the groups and individuals they choose to target and a lot of stirring copy in the media.

Which raises the question: Is this group (FoSiM) prepared or able to defend itself from media or legal campaigns directed against it? They are picking a fight, but do they know they can win it?

FoSiM have uncertain staffing and funding, no political and media experience, appear poorly organised, but worst of all, don't have a clear agenda or set of goals - no simple, defining purpose, and seemingly just for fun have decided to grab a sleeping tiger by the tail and shake it up.
For me, it would be an incredibly problematic organisation to have my name publicly linked with.

As soon as "a line is crossed" and there is public outcry with an investigation by the 'serious' (not tabloid) media, many of the FoSiM "supporters" will realise the implications of FoSiM's full agenda and probably flee. Focussing the spotlight on the "rusted on" adherents and leaving the Association officials to carry the can and defend themselves.

A very uncomfortable, costly and unflattering position for anyone to find themselves in.

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. This is a dangerous double-edged sword that can rebound and inflict more damage on those wielding it.
  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. They are no longer "King of Castle" and are resentful of interlopers claiming their patients. Respect and Trust cannot be demanded, they must be earned and actively maintained. Doctors have lost the unquestioning confidence of the public, who decided to look elsewhere for compassionate, engaged care. They've created this problem themselves and have to actively address it to win back at some public support.
  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.
    Any approach addressing this has to work across the entire Healthcare Services area.
    There are two sides to the equation: Client and Practitioner.
    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.
    What's needed is a bi-lateral approach, with the public getting information, support, and training on avoiding and dealing with crooks and frauds, and all Medical practitioners having incentives to keep their own disciplines "clean" and report any suspect activity, especially not try to "deal with this in-house" or attempt cover-ups.
  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.
    People in the thrall of a conman cannot, and will not, hear anything against them until they are ready to accept it.
  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.
    Currently, we have the PIP implants scandal - implicitly advertised as "safe" because of the regulatory approval. The devices "failed to provide the advertised service" (be safe), so in any other business, the women would have the right both to a full refund, but free removal.
    The same goes for incorrect diagnoses and missed conditions: at least all the "second opinions", tests and treatments paid for by the client pre-correct diagnoses/treatment should be automatically refunded.
    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.
    If she is looking for a way to usefully fill her time in retirement, this is not constructive or helpful.
    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.
    In other times, a village would deem these the actions of an interfering gossip.
  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"
  • be unreproachable, a prerequisite for Credibility, "first, get your own house in order"
  • to comment or adjudicate on an issue, you can't have an interest. i.e. "I don't have a dog in this fight".
    • Medical practitioners can't directly judge another field: they have an inherent Conflict of Interest.
    • hence, they should be asking for an Independent body to be set up to do a review.
  • FoSiM's approach is attack-only, the tactic of "wedge politics". It's:
    • divisive and destructive only, not about finding solutions. It isn't about "best serving the community together", but annihilation of the enemy/opposition.
    • all modalities and all practitioners are "tarred with one brush" by FoSiM.
      Patently, not true, there are some extremely good 'Evidence based' practitioners and disciplines out there, probably the overwhelming majority of CAM practitioners.
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?"
    • It took many years for nurse Hoffman to be heard by anyone, despite being a highly-experienced and competent Healthcare practitioner.
    • All "checks and balances" at the Bundaberg Base Hospital failed. That this went undetected and unnoticed is a massive systems failure in itself.
    • The Inquiry was only setup after a journalist investigated Patel and was published. This followed tabling of claims under Parliamentary privilege. Hoffman had been unable to garner Media interest for many years previously. Just when are dead patients "Newsworthy"?
  • 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).
    • At one time nearly all UQ medical graduates stayed in the State, now almost none do.
    • The participation rate of VMO's has halved, stressing the hospitals and compromising continuity of patient care.
    • Over 30 years, the population of QLD has doubled, but the number of medical training places (225) at UQ has remained static.
  • These origins of these problems is complex and due to Political, Public Service Administration and Medical Profession issues - going back 30-40 years.
  • Both the Director of Medical Services (Keating) and District Manager (Leck) escaped prosecution in QLD, despite the Inquiry recommendations, have fled to Western Australia and are practicing "in public health". Keating cancelled his QLD Medical Board registration before deregistration proceedings were taken against him.
  • 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?]
We know that in Aviation that problems like these are sought out and not allowed to occur in stable democracies, like UK, USA and Australia.
In Indonesia and PNG, the systems in Aviation are not nearly as strong, showing this outcome is neither accidental nor due to improved equipment or higher funding.

These less-than-successful organisations resulted in the 2007 Yogjakarta crash: it was Predictable, Preventable and Repeatable. [Only the pilot-in-command was tried and sentenced.]

From a follow-up on ABC TV a year later, demonstrating a lack of systemic change:
Colin Weir of the Queensland based aviation safety auditing firm Flight Safety Pty Ltd, says that another crucial factor contributing to the crash is the fact the Yogyakarta airport was effectively unlicensed at the time, because, put simply, its runway is too short and he says the same disaster would occur again if a jet landed today at the same speed.
COLIN WEIR: We carried out an audit about three weeks ago and the runway and safety area has not been extended.
This begs a serious question:
Who is the better "Professional", the QF32 pilot (the A380 in which exploded an RR Trent-900 engine over Indonesia) Cpt. Richard Champion de Crespign, who saved 469 lives or your average Specialist on ~$1M/year, probably 4-5 times the pilot wages?
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 quick on-line search yielded two responses by the Medical profession to the QPHCI report.
Both MJA articles called for action by others and no changes to mainstream Medical practice and oversight.

The Bundaberg Hospital scandal: the need for reform in Queensland andbeyond. MJA 2005; 183 (6): 284-285 [19-Sep-2005?]  Martin B Van Der Weyden
When will Australians be able to count on receiving health care that is safe?

Reflections on the Bundaberg Hospital failure. MJA 2005; 183 (6): 328-329.Anthony P Morton
Present-day public hospitals are often lacking in humanity, costing more and doing less, and run by executive staff with minimal clinical knowledge

[Dr Morton referenced the 1996 Berwick article in the BMJ]

"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.

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.]

[This piece 3,900 words]

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