Angelina Jolie, every adolescent man’s (read every male given brain development) video game fantasy woman declared earlier this year that she had undergone a double mastectomy and breast reconstruction as genetic testing had determined that she had a very high risk of developing breast cancer. Her own personal story includes a mother who died from her own hereditary risk of cancer which she unknowingly passed to her daughter.
Angelina essentially cited the evidence (let’s call this science), common sense and a strong desire to protect the future of her children. In the latter case it was the ability to raise them to adulthood and seeing their own destinies unfold.
Let’s compare and superimpose these arguments on the debate around climate change.
The science says the planet is warming and it is our fault. If the planet keeps warming then there will be increasing numbers of climate related disasters, sustained food and water insecurity and economic failure i.e. planetary cancer.
Common sense says that even if these predictions aren’t 100% accurate (Angelina’s chances of cancer are not 100%) then at least it takes reasonable steps to mitigate them. In the case of climate change the common sense argument is even stronger: we can see with our own eyes the current effects of man on the environment and we can take active steps to reduce our so called carbon-footprint.
Finally, Angelina acted to on behalf of her children. In the case of climate change let’s consider our children and future generations. I saw a great mock advertisement today of an ever thinner iPad being handed to an ever thinner African child. Perhaps, if we don’t act on climate change then this will be our legacy. Angelina acted, maybe society should too?
It was nice to read the article Michael Mosley’s Five Biggest Health Myths this weekend. On the same weekend I was in a store and overheard a conversation between customers about managing their common colds – they related their remedies of high doses of vitamin C and echinacea and were disappointed that it was still too cool to indulge in salt water. The first two methods are unproven in randomised trials and well, the latter, who knows.
Although I didn’t agree with all of Mosley’s advice (and he admitted some of it was based on early data) his underlying point is correct. We use our health knowledge (or health literacy) to inform our health choices.
Unfortunately many people really have poor health literacy – a lady I’ve treated for ovarian cancer for 18 months recently asked me where her pelvis is. The problem is aggravated by a proliferation of health myths. A lot of common information about diet and exercise is basically wrong or was ill-formed and made part of wide-spread public health initiatives.
One of the things we need to do to promote preventive medicine is actually provide accurate health information about diet and exercise rather than old-fashioned myths.
After that we need to know how to nudge people to follow the advice but that will be part of another blog post.
Today my wife and I cooked pound cake but instead of equal parts sugar, flour, butter and eggs we substituted almond and hazelnut meal for the flour and stevia for the sugar. The recipe was from a book by Peter Reinhardt that contains gluten ad sugar free recipes. It might sound bizarre to want sugar-free cake but our current diet is heavily influenced by Gary Taubes’ book on Why We Get Fat – which lays the blame on carbs and sugars (not fats and /or total calories). This got me thinking about health food stores.
Many of these stores are no doubt profitable but what is their purpose? Health food stores send extremely mixed messages – the users can be looking for unusual cooking ingredients, be after weird and unproven alternative medicines, gluten-free, organic food, free-trade food, locavore food, body-building supplements, or peace, love and mung bean sprouts, just to name a few things.
I think the problem is that health food stores themselves haven’t defined what constitutes health, let alone health food. Essentially it could be anything that isn’t in the supermarket next door….although they are creeping in on the market.
I’d like to see heath food stores be more pro-active and evidence-based: let them define what they consider to be health and then sell stuff that fits the evidence and the vision rather than a bit of everything for everybody.
When something adverse happens in hospital, for example, a patient is given the wrong medication, then we are supposed to log a report in the Incident Information Management System or IIMS. It is especially the case that this system should be used when harm to the patient is the result of the error. This is a good system but under-utilised and poorly designed – nonetheless we should continue to promote it.
We should in fact promote it’s extension to medical administration. If we really want accountability about the health care system, and in particular management of the budget, then we need an incident management system for the administrators. Let’s take the human resources department as one example. I have a potential employee for whom I could offer a job, No offer has been made even though the interview occurred 3 weeks ago. The hold up has been with the HR department and their need for more paperwork, etc, etc…..none of which was communicated as advice prior to the advertisement being released. Overall the whole process has been f’d-up, not to mention slow and expensive. So why shouldn’t I log this to IIMS.
Health care management in the Australian public health system is littered with examples of poor practice for which we should have an IIMS system……this is the way to achieve health care reform.
Australia is in the midst of a Federal Election and for the next 3 weeks we are going to be hearing a lot of promises being made.
Reflecting on this election I’ve been thinking about the similarities between some of the medical consultations I conduct and electioneering.
Many patients come to me wanting be to impart hope. I might get them to live just that little bit longer by giving a new chemo or drug treatment. In political terms this is the promise of money. If you re-elect me I’ll give your electorate/community/organisation X million dollars to build Y & Z. Or I will cut a tax and reduce an expense.
But we (the electorate) are not iterate about these matters. We aren’t prepared to accept the real story…..that throwing some more dollars into the ring isn’t going to change much..it could ecen be wasteful. In the same way many patients are pursue the path that offers hope even though, in reality, the solution offered has little chance of changing the overall situation.
The politicians probably do actually understand the reality of the situation but they choose to play politics. The doctors also understand the reality of situations and either choose not to or are unable to communicate it effectively to patients.
The underlying problem in both circumstances concerns literacy. The economically literate would say you can’t increase spending without increasing revenue (aka taxes). Likewise the health literate individual would be able to acknowledge you sometimes run out of options.
The Wiki Leaks Party is proposing to promote ‘scientific policy’; decision-making based on research, evidence and clear, transparent principles. It is also supporting Internet freedom: “the WikiLeaks Party will be fearless in its opposition to the creeping surveillance state, driven by globalised data collection and spying agencies, both state and corporate controlled. We will demand that all information on data seizure and storage of citizens’ data by government agencies and allied corporations be made public.”
Both of these are laudable aims.
Now explain to me how the Wiki Leaks Party will operationalise these actions in relation to health care and health care data. Over the last few decades best practice in health care has been driven by the evidence based medicine (EBM) movement so the Wiki Leaks Party has a solid platform to base its’ promotion of scientific policy making. Interestingly EBM is now coming into collision with the era of big data. The problem is that we don’t have enough access to the data we already have and we aren’t collecting and using enough of the data we need to really inform the decision making process. By we I mean health care providers both Governmental and private.
I guess the trite response is that the approach to health care data will be through the principle of transparency. Well there are already many claims about transparency from the existing powers and health care providers. So lets have some detail about the the Wiki Leaks Party will handle big health data.
The first of the Australian National Quality and Safety Health Service Standards (2012) is “Goverance for Safety and Quality in Health Service Organisations”. There is little doubt that the processes of governance for clinical safety and quality are critical for health service organisations to achieving clinical excellence. But this standard seems to exist in isolation from the reality of running a health service organisation – in particular large public hospitals. Hospitals have budgets with finite sources of revenue and huge capacity to generate expense in excess of revenue.
Health services organisations should have governance processes that have consider safety and quality as well as the relevant budgetary considerations. By this I do not mean that cost should necessarily be taken in to consideration as a matter of primacy. Cost, efficiency, productivity, safety and quality all interact closely in a complex system and the governance processes should be designed to manage this complexity to produce the best overall outcome. Currently, in many institutions, these matters are considered in isolation and without understanding the whole system or model of care in question. The consequence is that when cost savings need to be made then it is largely expressed in terms of disinvestment rather than reviewing practice and considering reinvestment for net gain (or savings). The consequence is a cycle of deteriorating then improving budgetary positions trailed by deteriorating and improving performance in quality and safety KPI.
The governance models that will facilitate a global view of the organisation need to be models that reduce asymmetries of information. In too many organisations the managerial staff don’t understand the perspective of the front-line staff and visa versa. Too little of the data needed to manage organisations is used and when it is it is presented in ways that don’t favor analysis and interpretation. Activity based funding is an incentive to better use the big data available to hospital governance – it is time this data was readily available and we had training how to use it.
A step forward for overall health care in Australia is not just good governance for safety and quality but also for fiscal effectiveness.
So one of the Australian National health care standards is having adequate governance structures in hospital to support quality and safety of healthcare. Notably, however, public hospitals are more likely to appear on the cover of the newspaper for the state of their finances rather than quality of safety.
My hospital network has had its’ financial position downgraded by the Ministry of Health as unexpectedly it is in deficit – or at least more deficit than anticipated. So the consultants have been brought in to assist in saving dollars and recovering the financial position.
What bothers me is there is no governance standard for budgets and finance in our public hospitals. Now whilst I acknowledge that in a public health system we will never actually go out of business there is no reason why we shouldn’t have financial standards that resemble of those of corporations, but perhaps without the legal ramifications. The NGO I work with needs to comply with the Corporation Act and not trade as an insolvent entity. This concept can’t really apply to public hospitals but they should be accountable for their financial management.
Despite this the financial management of hospitals and the governance of this management seems to be ad hoc and left to the local sites. My experience of this is that all finance & budgeting is hospitals is forensic rather than planned and projected.
Hospital staff need to demand good governance practices for hospital budgets and ideally these standards should be harmonized between hospitals. I should be able to turn up to an administrative meeting and see a balance sheet that I understand and can react to in a timely and appropriate manner. As it stand we chase our tails.
One of the things they didn’t teach in medical school is advocacy. There are different meanings for advocacy – in this case I refer to the broader meaning of advocating for patients and communities to achieve an end to their benefit. An example might be supporting the funding of a new drug or campaigning for increased resources for a hospital.
Simplistically advocacy can just be about being vocal but there can be problems with this approach.
To be an advocate it is important to be able to see all points of view so as being able to bring a cogent argument to the table. Often times advocates are dealing with political situations and positions and invariably these become polarised – it is important to diffuse this polarisation to get the party with whom one is lobbying to also be able to see the arguments in favour of your position. Advocates need to be prepared to compromise to achieve small but important wins rather than overnight revolution.
Advocates need to be careful about their motivations for lobbying. For example it is not uncommon for drug companies to ask doctors to provide support for a new treatment. If this happens there needs to be transparency about the reasons for lobbying and full disclosure of any conflicts of interest.
Similarly advocates need to be careful that their lobbying is not seen as some form of whistle-blowing – this is because some employment contracts prohibit this activity. In this case being part of a community of advocates is important. There is strength in numbers.
There are many tools for advocacy – the main one is conversation and the new medium for conversation is social media. Mastery of social media and branding the advocacy message is a new skill for the medical graduate advocate.
Australia, like many parts of the world, has an approach to alternative medicine and therapies that involves turning a blind eye to therapies that at face value seem harmless and able to be regulated with a lower level of rigour than conventional medicines. These therapies provide often provide false hope for patients with life threatening illnesses like cancer. Equally they are misleading for less immediately life-threatening problems. My wife is constantly receiving spam/junk advertising for weight loss programs that promise unrealistic weight loss – some of these have been in the press for serious side effects (and of course no weight loss except that attributable to the complications).
The alternative therapy industry is critical of the profit motive of ‘big pharma’ but these guys could equally be called ‘big herbal’. Australia spends approximately 9-10 billion dollars per annum on conventional medications and direct costs to patients accounts for 10-15% of this. Yet in 2005 more than 3 billion was spent on alternative therapies. If Australia parallels the US then current expenditure on alternative therapies might be 6 billion dollars or more.
A tax on these therapies – which bear minimal costs for development and proof of effectiveness and which rely predominantly on marketing for sales – could potentially raise enough funds to save 5% on the national medicines budget. There is no reason why a tax couldn’t be imposed – the government does it for tobacco, alcohol and luxury goods. And realistically – isn’t alternative medicine a luxury good.