The rise and fall of the medical expert

The rise and fall of the medical expert

Has the election of Donald Trump signalled a new era? Expert advice and scientific evidence seem to be taking a backseat while populism and an anti-elite ethos are gaining momentum. In Australia this may further fuel non-scientific opinions and scepticism towards medical expertise and science in general. Trumpism is, of course, not new. Australia has had its fair share of health policy based on little or no evidence.

Throughout history experts and scientific evidence have often been viewed with suspicion. The election of Donald Trump is a case in point. “Donald Trump’s lack of respect for science is alarming,” said the Scientific American.

Indeed, Trump is doing nobody a favour by, for example, spreading the incorrect and unproven message that vaccines cause autism. Apparently seventy percent of Trump voters believe this is true, despite the existence of extensive scientific safety data demystifying the dangerous misperception.

In Australia there are also signs that medical expertise is undervalued. The funding withdrawal for several primary care research initiatives are illustrative of the common perception about objective sources of information.

A classic case of dismissing medical expertise is the My Health Record (formerly PCEHR). The first big cracks in this government project started to appear in 2013, when the medical leads decided to resign en masse. More recently we have seen similar issues with the Medical Home project, which had full support from the profession until it was radically changed.

Then there are the changes to legislation around medical cannabis, which have created a perception of easy access for patients. Although there are plenty of anecdotal reports from people who have experienced symptomatic relief with cannabis for a range of conditions, doctors are still waiting for the research to provide information on indications, efficacy, safety and quality of cannabis products.

Science vs everything else

Vested interests

“Most people are happier with experts whose conclusions fit their own ideas,” write Clarke & Lawler in The Conversation. “But the Australian suspicion of authority extends to experts, and this public cynicism can be manipulated to shift the tone and direction of debates.”

When trying to inform government policy, experts are up against lobbyists who often represent large corporate commercial interests. An example is the campaign by some of the large corporate after hours home visit services which seem to be mainly concerned about their profitability.

I’ve received reports from these services (who mostly employ non-GPs) delivering repeat prescriptions after hours – which is of course inappropriate use of tax-funded health services and is concerning, especially as Medicare funds are scarce at the moment.

The facts are clear: since the bulk-billing National Home Doctor Service in the ACT arrived, home visits rose from 1588 in 2013-14 to 20,556 in the last financial year. This trend is happening at a national scale and there is no reasonable explanation for the explosion in urgent home visits.

What we need is an ethical and efficient after hours service that works seamlessly with day-time medical services.

Another example where profit comes first is Pathology Australia, representing several big corporates, who transformed their public ‘don’t kill bulk bill’ to a backdoor deal with the government to reduce the rent they pay to family practices for co-locating profitable pathology collection rooms.

Vested interest campaigns have eroded confidence in experts and scientific evidence for a long time – and not just in the health industry (see video below).

Replacing experts

Other trends seem to indicate that experts are regarded as expendable and should be replaced by others – because it is deemed cheaper or more efficient. Examples are physiotherapists prescribing opiates in emergency departments, radiographers reporting on scans and non-medical staff performing gastroscopies.

Who thinks I should fly this plane?

There are situations where tasks can be safely delegated within a supervised team environment. However, the evidence that task substitution leads to better health outcomes or lower costs is minimal. The reality is, as always, more complex – think about the Canberra nurse-led clinic that did not ease pressure on the hospital but instead increased emergency department presentations.

The retail pharmacy sector is lobbying intensively to get their non-scientific business proposals approved by governments across Australia. Their justification for taking over parts of general practice is to ‘relieve pressure on busy GPs’. Again, this is misleading, incorrect and not supported by medical organisations.

Research suggests that it’s all about the business of pharmacy and that the sector shows little interest in working cooperatively with GP teams: only one-fifth of pharmacies participating in a Victorian experiment had contacted the GPs of the patients involved.

This is disappointing as we’re desperately trying to reduce fragmentation and work better together in the interest of our patients. At the same time there are many ways in which pharmacists could add value.

Having more options as health consumer sounds appealing but doesn’t necessarily make us healthier or happier. Sometimes less is more. For example, the Royal Australian College of General Practitioners (RACGP) recommends against a range of popular screening tests because of lack of evidence and the potential of harm for patients, not to mention the added costs to the health system.

The RACGP has also published a list of tests, treatments and procedures doctors and consumers should question. This is not always easy to explain to patients, but at the end of the day it’s the right thing to do for all parties involved.

Expertise: a subjective thing?

Annabel Crabb said in the Sydney Morning Herald: “Expertise is now a subjective thing. You can discover much about people’s deep ideological beliefs or prejudices simply by observing what advice they accept without question, and what they take with a grain of salt. Sometimes there is little logic to the position.”

The best defence is a good offence and when medical experts object to proposals or policy based on opinion instead of science, they are usually accused of defending their territory or ‘turf’ – which distracts from the real message of course.

Expert opinions and scientific evidence are not a fix for all our problems. There are other factors that need to be taken into account. However, as populist movements like trumpism are gaining momentum, the anti-elite ethos may further fuel non-scientific opinions and scepticism towards medical expertise and science in general. This is a real health risk and we should look at why this is happening and what we can do to improve things.

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

Video: Why aren’t people listening to science?

20 thoughts on “The rise and fall of the medical expert

  1. We need an international peer reviewed healthcare standards and ethics board like the accounting profession and the aviation industry only then can one restore integrity in the system

    Watch this video https://www.youtube.com/watch?v=sDwZORDNOJw on how to fight this perception. It is was recently cited in Dec 2016 in The Journal of American Physicians and Surgeons.

    Healthcare is not just another commodity.

    Like

  2. A powerful post Edwin.

    One mistake though – the ACT Nurse-led Clinic was not closed. Despite no evidence of it’s benefit and plenty of evidence of the poor cost effectiveness they relocated it elsewhere. And opened a second one. And promised during the last election to open three more. With no research or evidence to support the need or effectiveness of the clinics.

    The only justification for this is political goodwill and a perceived “free” service for the public. As a taxpayer I don’t really consider a taxpayer expense of $160 or more to briefly see a nurse as free
    http://www.health.act.gov.au/our-services/walk-centre
    http://www.abc.net.au/news/2016-10-09/act-election-labor-promises-health-canberra-liberals/7916308

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  3. Pingback: A powerful summary | Dr Thinus' musings

  4. Well said, Edwin. The cartoon of the passengers voting to replace the qualified pilots with one of their number who has decided that he can do the job better, illustrates the fascinating Dunning-Kruger effect in action:

    https://en.wikipedia.org/wiki/Dunning%E2%80%93Kruger_effect

    “The Dunning–Kruger effect is a cognitive bias in which low-ability individuals suffer from illusory superiority, mistakenly assessing their ability as much higher than it really is.”

    Some or possibly many of Mr. Trump’s followers and appointees might also demonstrate the Dunning–Kruger effect, and we undoubtedly have our own such people in Australia, some of whom are seeking roles in the health care system for which they really don’t have the skills, knowledge or training.

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  5. Good points Edwin. But… Falling into the trap of discounting people as dumb or stupid as the “Dunning-Kruger” effect suggests does no one any favours and only serves to create a sense of righteousness and indignation among the “Experts”. Important as it is to recognize the public perception of science and in our case medicine, more important is to step away from hubris and to understand why its all going wrong.

    Liked by 1 person

    • Excellent observation Ewen.

      This is how trump got it in. Calling people dumb does not make anyone more right. Apathy is the real challenge. It takes only one stronger leader with a clear vision to make the change.

      Until the profession see themselves and not politicians, the government or somebody else as the solution will this problem continue. When they see who the real enemy is and it is better to work together than against things will change dramatically. The profession needs to take ownership.

      Look at international models that work. Asking why and not what is wrong and how it is wrong is a crucial starting point.

      Asking the right question is more important than getting the right answer to the wrong question.

      Liked by 2 people

    • Nobody called anybody dumb or stupid. The issue is that some people, possibly only a few, significantly overestimate their own low competence in a particular area and feel that they can perform in that area as well as or better than people who are in fact more competent. The corollary of this is that other people of low competence in a particular area are aware of their low competence and are happy to defer to those who are in fact more competent in that particular area .

      How likely do we think that it is that a majority of the people in the cartoon would in fact vote to replace the trained pilots with the passenger who thinks that he can do a better job ? Most of our patients defer to us in our advice to them, because they expect that we are more competent than them in the specialised area of medical practice. They are not dumb or stupid and we don’t think of them as dumb or stupid .

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  6. A colleague commented on Facebook: ‘so now what are we to do?’

    Communicating scientific facts alone clearly is not convincing enough. I’ve got a feeling it is about better listening to the problems raised, not being condescending, telling compelling stories, coming up with solutions not just criticism, and building trustworthy relationships.

    This is exactly what we do as GPs everyday – so what’s missing?

    Liked by 1 person

    • No commonly peer reviewed agreed standards that are enforced by the profession. Instead leaving it up to lawyers and government which seems to be the preferred approach by some.

      Allowing no-one to be ultimately responsible for interpreting the Medicare item numbers is a case in point that have clear guidelines and enforcement. Medicare does not and is not allowed to accept this responsibility – it can only administer funding. Professional colleges need to play a greater role.

      Like

  7. Good piece Edwyn.We like to blame everything on Trump. The loss of regard for medical experts has much to do with the behaviour of these experts. Too often they have cried wolf( remember swine flu ) and have over reached. It is one thing to highlight that too much sugar is a problem. Calling for a tax is amounting else again. Plus they never admit when wrong, fats in the diet and e-cigarettes come to mind. Worst of all many are tainted by the same conflicts they rail against. http://www.healthnewsreview.org/2017/01/123967/
    We need to get our own house in order!

    Liked by 1 person

  8. Trump is just a symptom of the wider malaise of post-modernism which has been growing over the last few years. I don’t have ‘the’ answer about what to do next, but one might be to rethink how we communicate. People make decisions on feelings not facts. Perhaps we need to speak to peoples hearts, not their brains – as per Simon Sinek https://www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action (a great video which a very wise man recently reminded me of 🙂 )

    Liked by 1 person

  9. I think we have a long and difficult task. Trump is the quintessential specimen of a popular ‘expert’. (He presents himself as knowledgeable, with a very public persona. That is what Twitter can do.) He will deliberately take issue with a contemporary expert (scientific) concept – the conventional wisdom. By doing that he makes a ‘newsworthy’ statement (it will be presented and discussed in the public media, although it lacks reason and/or logical credibility) attracts a following of the ‘ill-informed’ (much of our society, Australian and American, is not well educated) as well as a coterie of the media – who choose to differ from the ‘conventional wisdom’. I do not wish to impugn the motivation, but I observe that questioning the ‘conventional wisdom’ provides public exposure. We now have ‘post-truth’, concepts that disagree with what is commonly accepted as ‘truth’, but now have touted and acclaimed credibility, based on that disagreement. Black is now white, because previously it was considered not to be white. I observe that a certain media baron, initially Australian, now American, who in the recent past backstopped J. W. Bush’s military foray into the Middle East, has had his commentators baldly presenting claims that the ‘inauguration crowd’ was actually larger than Obama’s, the photographs not withstanding. If you say things loudly enough, authoritatively enough, for long enough, your concepts can become the new ‘conventional wisdom’.
    With populism becoming anti-establishment and ‘anti-scientific’, we may need – in the individual clinical context – to present our perspective as just that. The best conclusion WE have been able to develop. Our patients are entitled to disagree with us, indeed not to take our advice. We will need to document that, when it happens. I consider that medico-legal law will continue to be based on contemporary clinical and scientific knowledge, experience and wisdom – our own experience, and what is published in the scientific literature. Where there is dispute, there is no authoritative position.
    Trump’s blanket prohibition of Muslims entering America is already being challenged, and the relevant government department is acknowledging exceptions. Of course, this is still being touted as the new system ‘working’! I wonder how long it will take Americans to realise that this new paradigm of bureaucracy can be frightfully slow and will rapidly be counterproductive.
    Congress has yet to consent to the cost of ‘the Wall’.
    In the medical scene, we may need to wait until the public realize ‘post-truth’ is simplistic propaganda for quacks and demagogues.

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  10. Great writing Edwin! I believe the analogy (and others in your article) with Trump is correct. I think we need to be honest that we are not perfect as GPs (we’ve got pros and cons). However GPs are the best they can get! (And from my discussions with remote decision makers I think this is the bit that is poorly appreciated). Fortunately in spite of all the hysteria and madness in this world, the majority of the public actually does understand.

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  11. The comment on standards by David Dahm is an interesting one. Yet difficult to achieve and describe in a complex health system. So often treated as an algorithmic factory line it is tempting to be very quantitative with health and care. By using linear models we miss important complexities of well being and how health contributes to downstream savings and community productivity. General Practice has an important intersection with public health measures and infrastructure and requires advocacy in this domain also. But most importantly funding and freeing health practitioners to deliver their training and not jump to linear KPI would be helpful.

    http://thelancet.com/journals/lancet/article/PIIS0140-6736(16)32302-9/abstract

    I also agree with many above that the “other guy” is not a politician or a government or even the Rogue Doc down the road but is within us all. Making sure we engage health practitioners in aspects of professionalism; the ethical risks of using business models designed only for product delivery and consumers versus service delivery and patients; role modelling and legacy building versus rampant self interest seems worthy.

    Finally there are continued structural barriers to practice ownership and political engagement for those with home based care duties and this aspect is in my opinion a significant issue for the medical profession. National child care policies have excellent evidence from Scandinavian countries for workforce participation and growth in GDP. Without the engagement of this cohort in ownership and politics I think progress will be slow.

    The well being of our workforce is also an important indicator of a quality professional outcome for patient care. This is often neglected and overlooked.

    https://www.researchgate.net/profile/Jane_Lemaire/publication/38025771_Physician_well_being_and_quality_of_patient_care_An_exploratory_study_of_the_missing_link/links/0deec53c5e7bc416d4000000.pdf

    Medical leadership advocacy and engagement are vital if we are to hold onto our profession. Looking inwards outwards and upwards is quite a skill.

    Well done Edwin on this aspect of the risks of populism. As always
    and with full support. Much work to do.
    Dr Karen Price.
    GP, co chair Women in GP,
    PhD Candidate
    GPDU admin.

    Liked by 1 person

    • Hi Karen

      A medical editor said to me astronauts have checklists why cant doctors? Are the risks, environments and variables anymore or less complex?

      Is there no point in starting the process? The weather is reported daily on the 6 o’clock news. Weather measurement and reporting came from the aviation industry so we could have international aviation.The impossible became possible and we all fly around the world a lot safer with instant weather report updates.

      The accounting profession is complex with international rules, laws and customs that move fast – our tax act alone is 10,000 pages and changes weekly.

      Yet each night we report reliably on stock prices and foreign exchange movements on the 6 o clock news. Why is this information seen as credible albeit but not perfect to warrant such importance. We do not have a nightly health index report.

      The accountancy profession in the late 60’s agreed something is better than nothing (in order to get rid of fraudulent trading and poor banking lending decisions). This built credibility and confidence and international trade and employment opportunities from different countries with different laws and cultures. The profession did this and not any single govt in the world. The accounting profession has a multi decade and govt tested framework that can easily be adapted to the health profession for research and promulgation.

      Today doctors cannot agree on a simple chaperone protocol. I think the problems are more cultural than impossible. While the professions continue fight of follow like sheep people outside are tearing the profession apart as there is no way of controlling or leading the many do good vested interests that breed every day while the profession fails to acknowledge the real enemy is from within and they are allowing others to take over their turf for better or worse.

      This is sad to witness over the last 25 years I have worked with medical profession all over Australia. The answers are a lot simple if people want to seriously talk about a practical solution and set aside preconceived ideas for a moment.

      Like

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