Doctor Munchausen: Judge & Jury

Editorial Note: This is the sixth in a Dr Munchausen series of posts. It was originally going to be entitled ‘Dr Munchausen joins your local Hospital Board’.

Crash & Holocaust denialism

In JG Ballard’s novel Crash, covered in the last post, we slip from the solid world in which we think we move to a dreamworld – the dreamworld in which we are now living. In this dreamworld perceptions connect with a logic that is different to the logic we got used to when climbing trees or faced with wasps as children. In this new realm, risk management is key. Management of the perception of risk.

The first people to talk about risk management were the corporations; pharmaceutical companies, oil companies, and GM food companies. For pharmaceutical companies risk management means managing the risks to them should a patient develop a side effect on medication. They are not concerned about the patient. They are concerned about the risk to the reputation of their product and the risk to the company should the product get “ill”.

There is now an industry geared around managing risk perceptions through organizations like Sense about Science.

Companies might appear to show concern about what has happened the patient but this is only in so far as this gives the company an entree to interview the patient, interrogate his medical records and pull out details from his past such as the ingrown toenail he had at the age of eight to which they can attribute homicidal behavior on the anticonvulsant he was recently given at the age of fifty.

This is no exaggeration. See John Scheel’s extraordinary report on why there is no point reporting to HealthCanada.

The task of attempting to work out whether a drug causes a problem or not is traditionally pitched in terms of distinguishing a signal from the noise. For companies the trick is to add as much noise as possible to the mix. This is the reason why it is close to pointless to submit reports of adverse reactions to FDA or MHRA. The bureaucrats working there will have to balance your account against accounts submitted to them by companies making it close to impossible for them to make a judgement call – if they treat all accounts as equal, as they have to do according to Good Bureaucratic Practice (GBP).

In the public domain, companies long ago learnt that if they shell a building housing children, simply denying it was anything to do with them often works wonders – do we know the children weren’t playing with explosives? They have this down to a fine art. Chemie-Grunenthal’s handling of thalidomide makes it clear even Holocaust Denialism is not beyond them.

From the company to the clinic

Behavior like this is shocking enough in a pharmaceutical company but it is now happening in hospitals all over the world from Ontario to the socialist heartlands of Wales. Welsh Government have close to imposed risk management approaches on clinical practice.

Hospital managers may think they must be benefiting patients but in fact what happens is healthcare staff are forced to manage the risk to Hospitals or Health Boards rather than any risk to the patient. Having boxes ticked and grids in place to show that various things were considered puts the health board in a medico-legally stronger position.

There is no evidence that risk management helps the patient. It leads in fact to worse care and worse outcomes.

Were the Chairman of the Health Board here to turn up with his partner in the ER Department agitated and perhaps suicidal at ongoing difficulties in overseeing the growing mess that is healthcare, he might have to wait 8 hours to locate someone to see him. If hearing of the situation just before I head home in the evening I intervene and say I’ll see him in the psych department, even though the two departments are only a few hundred yards apart, its likely to be an hour or more before I’d get to see him because he will not be let walk over with his partner.

He will have to wait for an ambulance to transport him to comply with the risk management policy – a psychiatric patient poses a potential risk of suicide. He cannot be let walk twenty yards over a strip of road he has often walked over before.

But the policy does not reduce the likelihood of a suicide happening. It creates a situation where the man’s partner is much more likely to see him as risky than she had done before and this will have an enduring impact on their relationship. Trying to make sure nothing goes wrong on the hospital premises sends entirely the wrong message.

Policies like this are now leading to inappropriate admissions and deaths.

If anyone blows a whistle on problems, they find that just as a pharmaceutical company would the hospital manages the message through a public relations department. The hospital brand is at stake after all, and brands count for more for managers than patients do.

But beyond that these risk management approaches are leading to a culture change that endangers everyone. This kind of risk management locates the problem in the Chair of the Health Board rather than in what the health board or anyone else may be doing or not doing.

For instance faced with an agitated, maybe suicidal Chairman, I’m encouraged to draw up a risk management plan – but this won’t ever include the risks to the Chair posed by the fact that close to the entire medical literature on antidepressants is ghostwritten and access to the data from the clinical trials that have been done is blocked.

Individualizing risk, corporatizing deniability

Current risk management in healthcare is the equivalent of privatizing profit and socializing losses of neo-liberalism but in this case it is a matter of individualizing risks and corporatizing plausible deniability.

If we were to ask the General Medical Council in the UK or registration bodies elsewhere whether it is Good Medical Practice to put the interests of an employing organization ahead of your patient’s – their answer will be no. But none of these bodies are picking up this new issue. Rather than leading, they want to leave the fight to individual doctors or patients.

On a wider front, this kind of risk management leads to the kind of biomedicine that is bitterly complained of in mental health. If the risks are located in the Chairman, drugs become an ever more attractive prospect as they offer a way to be seen to enter him and perhaps derisk him or at least offer the rest of us cover.

Judge & jury

The miracle of medicine used to be about making tentative diagnoses about a real problem a person had brought to you and then taking a risk by giving a poison to try to produce a benefit. This wasn’t risk management – it was about embracing risk often in desperate situations in the hope of liberating the person from a prison.

The best way to manage the risks linked to real problems is to have good people handling them. The worst way is to have an organization full of temporary staff because no-one worth their salt wants to spend endless time ticking even the most perfect set of boxes about notional hazards.

But what used to be medicine has been replaced by programs that find notional risks in healthy people and force poisons that a branding process and defense of the brand insist are risk free on them. The newly imprisoned patient has no say anymore.

What was Diagnosis and Treatment has become Charge and Sentence at the hands of a doctor who has become both Judge and Jury. We have crashed into a realm that until recently was medically unimaginable – giving poisons on an industrial scale to people who in fact have nothing wrong with them.

It is this that gives modern medicine such scope to kill. It is this that transforms many who would have been good doctors forty years ago when Crash was written into Doctor Munchausens now.