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.

and

ER Booth, History of Osteopathy and Twentieth Century Medical Practice, Cincinnati: Caxton Press, 1905 (1924):312.

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.

Conclusion:

From the hard-data evidence presented by Dr James based on more than 3 decades of successful Healthcare Reform, we know:

• The ISM/FoSiM proposals address the least important, least useful areas of change. 

• Addressing Lifestyle Issues and Environment/Public Health would have six times the impact of attempting to improve "Health Care Delivery" through more "Science".  

• Even then, ISM/FoSiM are either vague or silent on just what benefits their proposals, if adopted, can deliver. If they want to turn Healthcare around the world inside out, with considerable disruption, cost and upheaval, then they need to first inform us of the exact benefits we can expect.

• The ISM/FoSiM proposals are irrelevant to the common "Top 5" Challenges faced by Healthcare Systems around the world: None benefit from more "Science", they are all about Quality of Care and Effectiveness of Delivery and Implementation.

• All successful and effective Healthcare Reform, since and including Flexner, has been Patient-centric. The ISM/FoSiM proposals aren't just wrong, but exactly the opposite of what is documented to have worked. Practitioner- and Profession-centric reforms, such as "More Science in Medicine" do not deliver better outcomes for Patients.

ISM/FoSiM consistently demand high-quality Evidence and rigorous Science from those in its sights, yet fail to apply the Scientific Method and their Rules of Evidence to their own proposals and assertions.

To be consistent and credible, ISM/FoSiM must:

• Meet the same standards of "Evidence", Research and adherence to the Scientific Method as they demand of others.
• Demonstrate and Quantify how more "Science" will improve Quality of Care, Patient Safety, Equity of Access and Systemic Waste and Cost-Effectiveness issues identified as "Top 5" Healthcare Reform Challenges by the leading experts in the field.
• First define their own "Top 5" Healthcare Challenges, and
• provide research backed by verifiable, hard-data on the Efficacy of their own proposals, their own favourite criticism of non-Medical Healthcare.

If ISM/FoSiM criticise the Effectiveness of non-Medical Healthcare, we must in turn ask them to demonstrate the Effectiveness of their own proposals. If they set Rules and Standards for others, they need to follow them themselves, even better, demonstrate by superior example.

---

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.

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:

www.scienceinmedicine.org

Where the local "mini-me" has a website name unrelated to it registered name, "Friends of Science in Medicine", but exactly congruent with being the local arm of ISM.

www.scienceinmedicine.org.au 

There is a test/development site at:

www.loretta.fosim.org

Why does this matter?

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

NEEDED POLICY

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

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

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

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

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

 This unambiguous Declaration of Intent gives the ISM, and it's mini-me, FoSiM, 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.

First, Do no harm: Patient Safety and the central fallacy of the "Friends of Science in Medicine" position.

"First, Do no harm"... Or so the Hippocratic Oath is presumed to begin.

The Dwyer/Marron "Friends of Science in Medicine" campaign against the teaching, insurance/reimbursement-for and ultimately practice of Alternative Therapies and Medicines of which they, and they alone, do not approve, is based on a central fallacy:

People are much safer being treated by the Medical Establishment not using Alternative Therapies and Medicines, but exactly the reverse is true. 

The number of Patient Injuries and Fatalities from 'standard' Medical and Hospital care and treatment is more than 1,000-fold greater than Alternative Therapies and Treatments, even on the flimsy data we do have on Establishment Healthcare. Why isn't there good data on our $50B/year spend of Public Money? That's another story.

This debate is "all about Evidence", as in hard-data, but Patient Safety and Quality of Care must be examined first before any debate on Effectiveness can even be started.

The flip-side is the erroneous logic that "Good Science" is somehow causally linked to "Good Patient Care", but FoSiM ignore the Golden Rule of Execution: 

Science and Knowledge don't deliver outcomes, Practice does.

Before the Dwyer/Marron group can argue against any Therapy, Treatment or Medicine, by its own strict rules ("there must always be very strong Evidence"), it must:

Show us the Data! As complainants, the onus is on the Dwyer/Marron group to prove their case, not for everyone else to justify their existence to their satisfaction (which, being undefined, will never be forthcoming.)

Where is their Evidence, the "Good Science" they want from everyone else, to demand any changes? If the modalities they are so implacably and virulently opposed to are harmful, then there must be plenty of irrefutable Evidence, not mere anecdote or self-selected collections/surveys, to support their case. If there isn't already enough, the group should go and create some definitive studies, given their self-confidence it should be extremely easy to do so.  It should take them no time at all to collect and publish some statistically robust studies in a well recognised, peer-reviewed Journal.

The worst logical trick and intellectual swindle played by the Dwyer/Marron group is their conflation and confusion of terms:

• A slew of unrelated practices are strung together in one long line of gibberish, with no distinction between recognised, well-controlled modalities and others, with all presumed to be 'equivalent'.
  If the Dwyer/Marron group cannot, or will not, distinguish between a piece of crud and a gem, what relevance or vracity do their arguments have? None whatsoever, they fail their own test of "Good Science", which requires correct, unassailable logic, not sensationalist tabloid anti-logic, innuendo and guilt-by-association.

• In Australia, there is a trivial and essential differentiator between all Medical Therapies, Practices and Medicines:
  • Is there a AHPRA Registration Board? and hence
  • Do Practitioners have a Medicare Provider Number?
  
  The failure of the Dwyer/Marron group to make this simple and essential distinction invalidates all their arguments, because:
• just who are they vociferously and ferociously objecting to?
• The properly certified, regulated and trained Practitioners, approved and controlled by expert Government bodies, or
• the unregulated, unregistered minority?

• For the Dwyer/Marron group to disagree with Government Policy and Processes is their Democratic right.
  For them to not understand the way these decisions and processes are changed is via Lobbying and the Political process is both ludicrous and naive.
  The best outcome they can have by attacking Alternate Therapy and Medicine Practitioners is to create a media spectacle and feel righteous and self-satisfied with themselves.
  Without ever once having the possibility of effecting change, because they are lobbying the regulated, not the regulators - the only people in the system with the power to implement their desired changes are being ignored by the Dwyer/Marron group.

Whilst the Dwyer/Marron group and their FoSiM purport a wish "to foster Good Science in Medicine", their actions and statements belie a rabid bigotry, bias and prejudice.

Even in their Constitutions' statement of Object, they don't define or elaborate on their terms:

• "Good Science" is a vague, ill-defind term. To quote Shakespeare's Macbeth:
  "it is a tale told by an idiot, full of sound and fury, signifying nothing".

• There are "scientific methodologies" (hypotheses, test, result) and "(apparently) good or valid studies/experiments" with "strong evidence", but "Good Science" is at best a lay-person's term, not something any Professional in the field would use.

• Likewise, "Medicine" is a broad church...
  There is no definition ever offered for FoSiM's frequently used acronym, "CAM", presumably "Complementary and Alternative Medicine". This has some mysterious meaning only known to the Inner Sanctum of the Dwyer/Marron group. I expect it falls in the category of "I know it when I see it", a throughly undisciplined, non-rigourous and unscientific methodology - because it is inexact, ill-defined and non-repeatable.

I like the Richard Dawkins definition: "There is no alternative medicine. There is only medicine that works and medicine that doesn't work."

Where does that leave the Dwyer/Marron definition of "CAM"?
Invalid and irrelevant, like the rest of their bluster, assertion, dogma and prejudice parading as "the opinion of experts", because they can provide no test or Evidence to show, as Dawkins says, "what works and what doesn't".

The very real risk they face with their simplistic and naive thinking is that if they ever construct testable definitions, then a good deal of their own Establishment Medicine would be found wanting. Not an outcome most Medical Practitioners would embrace.

It comes down to this:

The Dwyer/Marron group have no documented process or methodology to define the Alternative Therapies and Medicines of which they, and they alone, do not approve. They have a loose, informal, self-referential definition: "Good Science, it's what we say it is".

They are self-appointed experts and judges, without credentials, special expertise or relevant experience, who are presuming to force their opinions, biases and prejudices upon the rest of us.

Whenever they cry "Show us The Evidence" or "That's not Good Science", all they are displaying is their own ignorance, ineptitude and biases.

Friends of Science in Medicine: Hypocritical call to action

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

From a report on the Editorial and associated articles.

Professor Stephen Myers, SCU [Southern Cross University]:

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

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

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

Professor Komesaroff:

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

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

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

---

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

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

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

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

Only it isn't so...

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

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

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

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

Where this line of reasoning leads to:

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

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

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

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

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

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

---

From the UK CAA's Safety Plan 2010-2013:

The CAA ‘Significant Seven’ safety issues were identified following analyses of global fatal accidents and high-risk occurrences involving large UK commercial air transport (CAT) aeroplanes. 

This Plan has been developed by the CAA in partnership with industry because although the CAA has a safety oversight responsibility, industry has prime responsibility for managing their safety risk. 

We are taking a proactive approach to safety and our Plan is outcome focussed with great emphasis on safety performance. 

 We must deliver results that make a measurable difference, and ensure that we make the very best use of our available resources. 

‘Significant Seven’ Safety Issues (in priority order)
 1. Loss of Control
 2. Runway Excursion
 3. Controlled Flight into Terrain
 4. Runway Incursion
 5. Airborne Conflict
 6. Ground Handling
 7. Airborne and Post-Crash Fire 

Key Capabilities Required for the Total Aviation System
 * Integrated Safety Risk Management Process
 * Continuing Airworthiness
 * SMS [Safety Management Systems]
 * Just Culture
 * Human Factors
 * Performance-Based Oversight
 * Fatigue Risk Management Systems
 * Total System Threats

---

"The incidence and cost of adverse events in Victorian hospitals 2003–04", Ehsani, Jackson, Duckett. MJA 2006; 184: 551–555

Results:
During the designated timeframe, 979 834 admitted episodes were in the sample, of which 67 435 (6.88%) had at least one adverse event. 

Patients with adverse events stayed about 10 days longer and had over seven times the risk of in-hospital death than those without complications. 

After adjusting for age and comorbidity, the presence of an adverse event adds $6826 to the cost of each admitted episode. 

The total cost of adverse events in this dataset in 2003–04 was $460.311 million, representing 15.7% of the total expenditure on direct hospital costs, or an additional 18.6% of the total inpatient hospital budget.

---

Medical Errors Australia on "Needless Deaths":

quote from:

"The Quality in Australian Health Care Study", Wilson, Runciman, Gibberd, Harrison, Newby and Hamilton. MJA 1995; 163: 458-471

A review of the medical records of over 14,000 admissions to 28 hospitals in New South Wales and South Australia revealed that 16.6% of these admissions were associated with an “adverse event”, which resulted in disability or a longer hospital stay for the patient and was caused by health care management; 51% of the adverse events were considered preventable. In 77.1% the disability had resolved within 12 months, but in 13.7% the disability was permanent and in 4.9% the patient died.

Australia-wide estimates
The number of patients dying or incurring permanent disability each year in Australian hospitals as a result of AEs is estimated to be:
18 000 deaths (95% CI, 12 000–23 000);
17 000 (95% CI, 12 000–22 000) cases with permanent disability (> 50%); and
33 000 (95% CI, 27 000–37 000) cases with permanent disability (< 50%).
There are estimated to be 280 000 (95% CI, 260 000–310 000) AEs resulting in temporary disability.

---

Hospital deaths not decreasing: new study

Wednesday, 22 December 2004

The number of fatal accidents in South Australia's hospitals is not decreasing despite greater knowledge of how they occur, according to new research at the University of Adelaide.

The findings are contained in a thesis written by PhD graduate Dr Carol Grech in the University of Adelaide's Department of Public Health.

Dr Grech found that many solutions have been proposed over the years to reduce the incidence of fatal errors in South Australia's hospitals, to little effect.

"The Coroner regularly and repeatedly identifies the same factors underlying fatal adverse events," she says.

"Despite this knowledge, and the fact that many adverse events are predictable and preventable, there is little evidence that the incidence of medical fatalities is appreciably declining.

"If government and health bureaucrats are serious about preventing fatal adverse events, then significant attention needs to be given to implementing recommendations handed down by the Coroner."

"Consumers of health care services, as well as those who work in the health system, are deserving of a safer hospital system," Dr Grech says.

"Recommendations arising from impartial, transparent and objective inquiries into hospital-related fatalities have the potential to improve public health by ensuring a safer healthcare system," she says.

"This is conditional, of course, on intended recipients of such recommendations actively learning from the findings and translating this knowledge into policies that are embedded into clinical practice."

If this does not occur, Dr Grech says, the government should either amend the Coroner's Act or consider abolishing the office.

The aim of Dr Grech's research was to establish whether the Coroner's findings have contributed to quality improvement in hospitals.

---

Politics and publishing: the Quality in Australian Health Care Study

"In medical research, the real news is the evidence, not the public claim" [disputing the QAHCS]

MJA 1995; 163: 453-454

---

Reducing the Incidence of Adverse Events in Australian Hospitals: An Expert Panel Evaluation of Some Proposals, 2007, Professor Jeff Richardson, Foundation Director, Centre for Health Economics, Monash University

Objective:
The aim of this paper is to demonstrate a method for identifying policy options for reducing adverse events in Australia’s hospitals, which could have been adopted, but was not adopted, in the wake of the landmark 1995 ‘Quality in Australian Health Care’ study, and to indicate the lapse time before these measures could be expected to have a major effect.

Results:
... expertise, position and publications in the area of adverse events and quality assurance. Forty-one options were identified with an average lapse time of 3.5 years. Hospital regulation had the least delay (2.4) years, and out of hospital information the greatest (6.4 years).

Conclusion:
Following identification of the magnitude of the problem of adverse events in the ‘Quality in Australian Health Care’ study a more rapid response was possible than occurred. Viable options for reducing adverse events remain.

---

[The Australian Doctors Fund is making a case for using the American UTCOS report of 3.3 times fewer 'adverse events' than QAHCS.]

Quality in Australian Health Care Study: Examined OR Exposed?

Stephen Milgate
Executive Director
Australian Doctors' Fund
25 February 2003

"In medical research, the real news is the evidence, not the public claim."

References and quotes:

The Medical Journal of Australia, Vol 163, 6 November 1995
"The idea that every time there's an injury we write a rule, that just makes the world so hopelessly complex, it would probably increase injury rates." 

Minimising Harm to Patients in Hospital. Broadcast Monday 1 October 2001. Radio National. With Dr Brent James, Executive Director of Intermountain Health Care in Salt Lake City, Utah. 

"Most adverse events referred to are systems problems and not the failings of an individual clinician."

---

A year after the QAHCS was released a virtually identical US study, Utah-Colorado Study (UTCOS) with dramatically different results for the same base year, was published by the very reputable Harvard School of Public Health.

This forced the Federal Government to commission the Harvard School of Public Health to investigate why QAHCS and UTCOS had produced such a wide discrepancy in results using identical methodology.

In response, the Harvard School of Public Health and others producedtwo papers, A comparison of iatrogenic injury studies in Australia and the United States 1: Context, methods, casemix, population, patient and hospital characteristics and A comparison of iatrogenic injury studies in Australia and America 11: Reviewer behaviour and quality of care.

These studies were embargoed and not published until 1999 when they finally appeared in the International Journal for Quality and Health Care.

---

Year	Country	Study
1977	US	Report on the Medical Insurance Feasibility Mills DH
1991	US	Harvard Medical Practice Study (HMPS)
1995	AUST	Quality in Australia Health Care Study (QAHCS)
1999	US	Cost of Medical Injuries with Utah and Colorado (UTCOS)
1999	US/AUST	A Comparison of Iatrogenic Injuries in Australia and America
1999	US/AUST	A Review of Behaviour and Quality of Care
2001	AUST	Iatrogenic Injury in Australia

---

"Brent James: 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."

Minimising Harm to Patients in Hospital. Broadcast Monday 1 October 2001. Radio National. With Dr Brent James, Executive Director of Intermountain Health Care in Salt Lake City, Utah.

"Most problems result from a sequence of system failures rather than a single mistake by an individual."

Data for Action, A key to safer health care, Safety and Quality Council, 1/8/01.

"The causes of iatrogenic injury appear to be systemic. The remarkable constancy of pattern across the Australian and US health care systems for serious injuries bears witness to the fact that despite all of the differences in structure, training and practice, similar patterns of iatrogenic injury are observed."

Iatrogenic Injury in Australia. A report prepared by the Australian Patient Safety Foundation, WB Runciman, October 2001, p 106

"I believe the system is much more often responsible for problems than individual practitioners."

Dr Ross Wilson, Radio National ABC, 7 July 1997. [QACHS]

---

Brent James: ... For example, my current Big Six list, this is based upon expert opinion, so it's probably going to get changed.

An examination of real time adverse events in hospitals in the US reveals the likely source of the underlying patterns of adverse events which exist almost uniformly across the system.

1. Adverse drug events and drug reactions (in many cases a first time unpredictable reaction)
2. Hospital acquired infections
3. Bed sores or pressure sores
4. Venus thromboembolism
5. Patient falls
6. Blood product transfusions

Minimising Harm to Patients in Hospital.

---

If a three-month prognosis is included in a study of adverse events the results change dramatically.

"However, after considering 3-month prognosis and adjusting for the variability and skewness of reviewers' ratings, clinicians estimated that only 0.5% (95% CI, 0.3%-0.7%) of patients who died would have lived 3 months or more in good cognitive health if care had been optimal, representing roughly 1 patient per 10,000 admissions to the study hospitals."

"Conclusions: Medical errors are a major concern regardless of patients' life expectancies, but our study suggests that previous interpretations of medical error statistics are probably misleading. Our data place the estimates of preventable deaths in context, pointing out the limitations of this means of identifying medical errors and assessing their potential implications for patient outcomes."

Estimating Hospital Deaths Due to Medical Errors, Preventability is in the Eye of the Reviewer, Australian Medical Journal, 25 July 2001.

---

The number of deaths from adverse events are in the eye of the beholder.

"ABS data suggest 88.5 deaths per year can be attributed to adverse events as a direct underlying cause of death, but this increases to 2,678 deaths per year if you count where an adverse event may have contributed to their death. On the other hand, extrapolation of coronial data suggests approximately 700 patients may suffer an adverse event that contributes to their death each year, while the results of the Quality in Australian Health Care Study suggest a range between 8,600 and 18,000 deaths per year."

Media Release. Data for Action: A key to safer health care.
Safety and Quality Council. 8 August 2001.

"The figure most often quoted by the media is from the Quality of Australian Health Care Study, which reported and adverse event rate of 16.6 per cent associated with hospital admissions. However, reanalysis of the study following the methods of a similar study in the US found that the Australian and US studies had a virtually identical rate of serious adverse events – about 2 per cent of cases (1.7 per cent leading to serious disability and 0.3 per cent to death). It is thought that overall, about 10 per cent of hospitals admissions in Australia and other developed countries are likely to be associated with an adverse event. Most of these are simple problems."

First National Report on Patient Safety. Safety and Quality Council. August 2001.

---

Conclusion

In the eight years since the QAHCS was first published, the priorities in improving the quality of health care and making medical treatment safer are now just being heard above the headlines of "18,000 people killed each year from medical mistakes".

Remarkably the identified problem areas have been known for many years.

Any one of them could have been nominated by any active experienced medical practitioners over the last 20 years.

There is a strong desire among all professionals in the health care system to strive for greater quality and safer care.

However, a desire and good will is not enough.

There are currently 230 million transactions between the medical system and patients each year in Australia.

Health care systems are expensive and medical intervention, particularly in the frail and elderly, is high risk and becoming riskier.

A safer health care system will certainly add costs to health care and those costs eventually have to be born by those who demand a safer and better system.

---

Don't put faith in hospital care, expert warns
From: The Australian October 28, 2008 12:00AM

PATIENTS need to ditch the "it'll be right" attitude to hospital visits and take more responsibility for their own care, a health expert says.

It has been widely accepted for the past decade that about one in 10 Australian patients will have something go wrong during a hospital visit, University of NSW Institute of Health Innovation director Jeffrey Braithwaite said.

Australian Medical Association president Rosanna Capolingua said the reason things were more likely to go wrong in hospitals now than in the past was because the system was underfunded.

“Sure, patients do have a role in self-responsibility but I don't think it can be matched with the role that the system has in responsibility to the patient,” she told AAP.

“Things are more likely to go wrong in hospitals because the system is underfunded, stretched and under pressure and then there are system failures that occur.”

[data, sources]

---

From: www.solicitoradvice.com Medical Error Stats

New report says 1500 people die each year in Australian public hospitals because of overcrowding
A UNSW report for the Australasian College of Emergency Medicine also states that Perth’s big hospital emergency departments were the worst in the country for overcrowding.
Source: "Dying risk up 30% in crowded hospitals," The West, 10.09.08.

---

Dying risk ‘up 30pc in crowded hospitals’ [via Internet Archive]
10th September 2008, 6:00 WST
CATHY O’LEARY

People who need treatment in Perth’s overcrowded hospital emergency departments face as much as a 30 per cent higher risk of dying,a national summit on hospital overcrowding will warn this week.
 
A University of NSW report for the Australasian College of Emergency Medicine meeting in Melbourne on Friday estimates more than 1500 people die in Australia’s public hospitals each year because of overcrowding.

Australian Medical Association WA emergency medicine spokesman Dave Mountain, who will speak at the summit, said WA faced some of the worst levels of overcrowding and the situation had reached critical levels in Perth hospitals in recent weeks.

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".

Introduction:

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.

THE CENTRAL LAW OF IMPROVEMENT

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

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

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

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

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

[This piece 3,900 words]