I2P: Challenging The Conventional Wisdom

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

This was brought home to me forcefully this week seeing a storefront in Moss Vale, NSW:

Pharmacist Advice: "Helping manage your medication, Helping you stay healthy"

In the 1960's I lived for a time in a small town in Far North Queensland. The first-call for small-boy medical adventures (ticks, tropical infections, wounds, burns, ...) was the Pharmacy and Ambulance station. Not Hospital Casualty nor the GP.

FoSiM: More subtle anti-Alternatives Propaganda.

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

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

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

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

There has been no mention/coverage of this piece of science on the DAAM/FoSiM website, even though it was done by one of their own senior members, Braitwaite.

CareTrack: assessing the appropriateness of health care delivery in Australia, 20-Jul-2012.
https://www.mja.com.au/journal/2012/197/2/caretrack-assessing-appropriateness-health-care-delivery-australia
Conclusions: Although there were pockets of excellence and some aspects of care were well managed across health care providers, the consistent delivery of appropriate care needs improvement, and gaps in care should be addressed. There is a need for national agreement on clinical standards and better structuring of medical records to facilitate the delivery of more appropriate care.

There was a related MJA editorial (I can't see) by Chirs Del Mar, one of the Skeptic/DAAM heavy-weights.

A dog walking on its hind legs? Implications of the CareTrack study.
https://www.mja.com.au/journal/2012/197/2/dog-walking-its-hind-legs-implications-caretrack-study
Despite its limitations, this important study highlights a genuine need for systematised performance monitoring

No mention on the DAAM/FoSiM site of this study, though there is a lot of other activity since 20-Jul-2012.

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.

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

[Full post on other blog.]

My formulation of the Professional mandate:

It's "unprofessional" to repeat or allow, Known Faults, Failures and Errors.

That sounds complete, perhaps obvious, but let me unpack this some more...

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

Atul Gawande's piece in the New Yorker on "Big Medicine: Can Hospital Chains Improve the Medical Industry?" is a tour de force on the issues, benchmarks, solutions and challenges facing us in the current Healthcare Reform debate.

At 9,500 words, while it was a riveting read for me, it may be a tad long for many people.

Even if you only read a page or two, you'll be well rewarded.

This is the work of an insightful, competent and engaged (Medical) Professional who is actively looking to mend the US Medical system and has taken considerable time and effort to construct a readable and informed piece to bring the issues, challenges of Real World change to Healthcare to the general public and even posits some solution.


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

• The Checklist Manifesto: How to Get Things Right by Atul Gawande (Jan 4, 2011)
• Better: A Surgeon's Notes on Performance by Atul Gawande (Jan 22, 2008)
• Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande (Apr 1, 2003)

A quick tour of the article:

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

Generally, I was impressed that Gawande didn't invoke Aviation as his Gold Standard, but used people and places the general public know and visit everyday and indeed, many will have worked for, and the majority will personally know someone who works in them.

He quietly and unobtrusively lets us know that he's done a bunch of real journalistic research to write this piece, pounding the pavements, spending hours or days with people in their workplace and asking tough questions. He uses as his 'hook' a night out at a favourite restaurant, something that all of us are familiar with and enjoy, and then uses that framework to hang all the concepts and examples he wishes to bring us. This was a carefully planned, researched and executed piece, possibly months in the making. It would've taken a few weeks to edit down and polish into this relaxed, chatty style.

Some Quotes:

On "who's in charge?" and "who's responsible?":

The biggest complaint that people have about health care is that no one ever takes responsibility for the total experience of care, for the costs, and for the results.

On the rate of introduction of proven, effective new practices:

Even a month would be enviable in medicine, where innovations commonly spread at a glacial pace.

Intensive Care Units (ICU's) and tele-ICU centres being problematic to :

Although fewer than one in four thousand Americans are in intensive care at any given time, they account for four per cent of national health-care costs.

and

Across the country, several hospitals have decommissioned their (tele-ICU) systems. Clinicians have been known to place a gown over the camera, or even rip the camera out of the wall. 

He ends with:

The critical question is how soon that sort of quality and cost control
will be available to patients everywhere across the country.
We’ve let health-care systems provide us with the equivalent of
greasy-spoon fare at four-star prices, and the results have been ruinous.
The Cheesecake Factory model represents our best prospect for change.
Some will see danger in this.
Many will see hope.
And that’s probably the way it should be.

It's not a rant or tirade, it can't be mistaken for "personal attack" nor does it need a naive disclaimer like FoSiM's ("If you misunderstand what we've written, that's your problem, not ours."

To Dwyer and his little Friends in FoSim, this is what a real contribution to the healthcare Reform debate by a competent Professional/Journalist looks like. Compare and Contrast to the vapid, vitriolic and self-righeous outpouring of Ms Marron, your unpaid "CEO". It'd be unkind to say that she remains unpaid because nobody with money would pay for her efforts, though it may be accurate. Fanaticism and Zealotry in a cause, as demonstrated by FoSiM, don't make for persuasive journalism.

ISM/FoSiM: "Inversion" - Putting the Cart before the Horse in Healthcare Reform

One of the amazing arrogances and Blindspots of the fanatics and zealots of ISM and their "mini-me", FoSiM, is they've got the Healthcare Reform debate turned around completely. Colloquially, they've put the cart before the horse.

The FoSiM "Vision Statement" in their recruiting letter was:

"To reverse the current trend which sees government-funded tertiary institutions offering health care ‘science’ courses not based on scientific principles nor supported by scientific evidence”.

And from the ISM Policy paper on Regulation and Licensing all Healthcare Practitioners and Training:

As a consequence of these practitioners being legitimized through political rather than scientific means, the health of people worldwide has been put at significant risk.

Not hard to spot that both these statements aren't backed by any Evidence, any Theory but only Absolutist Assertion: it shows from the start that this is only Ideological based, not based in fact or need, nor indeed arrived at by any valid, credible process.

The "Inversion" of ISM/FoSiM is who they put at the centre of their Healthcare Reform proposal in their call for more "Science in Medicine", ignoring their one-eyed bias where they never examine the Practice or Science of their own, Medical Care.

ISM/FoSiM put "Science" at the centre of their Reform proposal and agenda.
Specifically, 'Science' applies to:

• Practitioners,
• Specialities,
• Organisations,
• Research, Academic or Commercial,
• Professional Bodies,
• Professions, and
• Governance bodies and processes, such as defined by Government Agencies.

What's completely missing is The Patient. This is the Inversion. It's Practitioner- and Profession-centric, not Patient-centric.

This is the Big Lie, the massive horn-swoggle that ISM/FoSiM are attempting to pull off:

The Patient, their Outcomes, the Quality of their Care and their Safety under Medical Care is completely absent. And most importantly, Patient Accessibility and Affordability are missing.

ISM/FoSiM want to "Fix All Ills of Healthcare and its Systems" through More Science, amusingly without evidence that this can or will help. The evidence of the last sixty years of "More Science" in Medical Care is that costs rise astronomically (5% to 18% of GDP in the USA), while more people are untreated and Public Health outcomes do not seem commensurate change.

The ISM/FoSiM advocacy for more "Science in Medicine", even taken at face value, is a clear call for:

Better Healthcare!

Which is admirable in its intent.

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

They are advocating for Better Healthcare:

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

More "Science" won't deliver Better Medical Care, it can only deliver more expensive, less accessible and less effective care, and further stress already over-worked and failing individuals and organisations.

"More Science" does involve more money for research, more expensive devices, drugs, equipment and services and, for the very few that can afford it, much more expensive interventions ("Rescue Care") for extreme conditions. It's a Bonanza for everyone making money out of the process, the Companies, Practitioners and Researchers, and a FAIL for everyone else: the Patients, the Healthcare workers and the Governments funding it.

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

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

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

How does "More Science" equate to "Better Healthcare"?

Not in the Real World and not at all for Ordinary People who'll be paying for it... 

This is a scheme dreamed up by the privileged, for the privileged, of the the privileged.

---

If you'd like to know what Better Healthcare looks like, here's the definitive guide, with actual research references:

"Managing Clinical Processes: Doing Good by Doing Well" by Dr Brent James.

What do we get for all that money? [slide 16]

1. High touch -- patients value their relationship with a trusted clinical advisor more than any other element in health care delivery (the clinician-patient relationship)
2. Rapid response -- the Rule of Rescue

Three classes of outcomes: [slide 65]

• Physical outcomes
• medical outcomes: complications and therapeutic goals
• includes functional status measures (patient perceptions of medical outcomes)
• Service outcomes
• satisfaction: patients and families, communities, professionals, purchasers, and employees
• includes access issues (e.g., waiting times)
• Cost outcomes
• just another outcome of a clinical process
• includes the cost of the burden of disease

Medical outcomes are of four types: [slide 66]

• appropriateness
• (referral and procedure indications)
• complications
• (process failures / defects)
• therapeutic goals / biologic function
• (when stated in the negative, merges with defects)
• the patient's ability to function
• (functional status, as reported by the patient)

• are process specific
•  (different clinical conditions have different complications, different therapeutic goals, functional status measures)
• Medical outcomes relate directly to health care costs

Service outcomes are of two types: [slide 67]

• the clinician-patient relationship
• (bedside manner: a "caring and concerned" clinician)
• access issues: convenience vs. hassle
• (scheduling, travel times, registration, physical comfort, wait times, etc.)
• operate by a separate, general process that is independent of medical outcomes
• Service outcomes directly affect market share, community perceptions and relations (that is, prestige and social status), and
•  rates of malpractice law suits

Health care consumers seek value [slide 69]

• Value = (Medical outcomes + Service outcomes) ÷ Cost outcomes
• The goal is the best possible medical outcomes at the lowest necessary cost

It'd be interesting if ISM/FoSiM ever apply their considerable talent and resource to addressing just how their call for "More Science" will deliver better Healthcare outcomes in the structure given by DR James.