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.

Monday, July 2, 2012

Failed Professions: Definition, Impact, Consequences

[Full post on other blog.]

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

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

What do I mean by a "Failed Profession"?
How do I support that view?
I've posited a Theory of Professions to support this view.

Particularly, the level of Duty practitioners, organisations and the Profession owe towards their clients and their Community.

Of my list, Medicine and Banking/Finance/Investment-Advisors Professions, have the highest level of Duty towards their patients and clients: a Fiduciary Trust or Duty.

They are required to always put the concerns and welfare of their clients/patients before all else, particularly ahead of their own interests (especially pecuniary), ahead of their colleagues, employer and organisation and ahead of their Profession.

A first attempt at Medicine as a Failed Profession.

Aviation: A model for what can be done

Aviation is not Perfect, but it is the closest thing we have to it.

It shows that whole Industries, on a global scale, can embrace Quality Improvement and Safety programs whilst still being Profitable and advancing new technologies.

It's a culture and mindset and a willingness to admit weakness and error as a first step to correcting them.

Aviation succinctly answers the Professional Question:
When is it acceptable for a Professional to repeat, or allow, a Known Error, Fault or Failure?
When, not if, they are discovered, individuals and organisations will be held to account and suffer direct, personal consequences.
So why are other Professions allowed to practice outside this minimum standard?