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Leading medics publicly accuse RCP of misleading docs about non-doctor ‘associates’

Published by Anonymous (not verified) on Tue, 26/03/2024 - 10:58am in

Open letter to Royal College of Physicians officers cites false claims, failure to declare conflicts of interest and disregard for patient safety

Twenty-nine Fellows of the Royal College of Physicians (RCP) have accused the RCP’s leading officers of misleading doctors and hiding conflicts of interest in an attempt to persuade them and other RCP Fellows into voting down a key motion, tabled at last week’s RCP Extraordinary General Meeting (EGM), calling for a slow-down in the expansion of ‘physician associate’ (PA) roles pushed by the government, which ninety percent of doctors believe are endangering patients.

Last week, Skwawkbox covered the extraordinary scenes at, and outraged reaction to, the EGM and the conduct of the RCP panel as it refused to engage with doctors’ questions and misleadingly presented statistics to inflate support for the way in which the government is (ab)using PA roles, which do not have a medical degree, to replace fully-trained doctors – and to excuse the RCP’s continued support for the government’s programme. The RCP was exposed as having a huge financial interest in the programme.

The Fellows, senior doctors and medical professors, sent their letter to the RCP expressing concern at the ‘terrible harm’ the RCP leadership has done to the College’s reputation and detailing the issues with the way the EGM was run and data were presented by the RCP panel in the debate – and the way in which the College mishandled the need to come clean after the issues were exposed, failing to let doctors know before the close of the vote on the five motions that they had been misled. The motions, including the fifth one that the RCP board had urged doctors to reject, passed overwhelmingly:

STATEMENT OF CONCERN

The events of the last week have done terrible harm to the reputation of the College and the trust that its members and the wider public have in the leadership of the organisation.

Prior to the extraordinary general meeting (EGM) on 13th March 2024 to discuss issues around Physician Associates (PAs), members of the College who are not eligible to vote on the motions were surveyed. Their views were important to inform Fellows voting on the EGM motions about the impact of PAs on patient care and doctors’ training. It has become apparent that the Senior Officers of the College presented selected survey data at the EGM on 13th March, that in our opinion was manipulated in a way that can only have been intended to mislead fellows of the college.

Of note, the Deputy Registrar who presented the survey data, but who we understand did not prepare the slides, resigned from their post immediately after the EGM.

Following the EGM, multiple formal written requests were made to the CEO and Senior Officers to release the survey data. The CEO and Senior Officers refused for 5 days to release the survey results, only doing so after sustained public and direct pressure and multiple written requests. PRCP also cited the same misleading, manipulated survey data in an email to Members and Fellows of the College after the EGM.

The survey results were published on the RCP website at 9am on Monday 18th March, but no attempts were made during the voting period which ended on 20th March, to directly inform members or Fellows of the College that the data presented at the EGM were misleading, although PRCP emailed members on related matters.

During this time, Fellows voted on the 5 motions presented at the EGM, and they were doing so informed in part by the misleading information presented to them at that meeting.

The 5 motions presented at the EGM have been approved by a substantial majority of the Fellows of the College including Motion 5, which the Senior Officers had advised Fellows to vote against, despite the patient safety concerns raised in relation to PA scope and practice.

Discussions at the EGM and events leading up to and following the meeting raise serious concerns about the conduct, governance, and performance of the RCP, especially in relation to patient safety.

These concerns include but are not limited to a number of issues over several years:

  1. Apparent failure of the RCP to adequately monitor the role and scope of PAs since the College agreed to house the Faculty of PAs (FPA) in 2015
  2. Apparent failure to communicate clear parameters and scope for PAs from 2015 to March 2024, including failure to clearly communicate that PAs are not doctors and PAs must not replace doctors.
  3. Apparent failure to respond to the concerns of the RCP Training Committee in relation to PAs raised in 2015 and subsequently with regard to loss of training opportunities for doctors and patient safety.
  4. Apparent failure to respond to patient safety concerns raised by Fellows of the RCP with Senior Officers during 2023.
  5. Providing false assurance from 2015 onwards to Members and Fellows of RCP and the wider public that PAs were safely working in their intended scope of practice.
  6. Apparent failure to acknowledge that PAs in substantial numbers are and were working outside the intended scope despite being provided with evidence that this was the case.
  7. Apparent failure to acknowledge that PAs are and were working in place of doctors in General Practice, and that PA locum agencies were facilitating this using NHS ARSS funding despite being provided with evidence that this was the case.
  8. Apparent failure to acknowledge that PAs in substantial numbers are and were working in place of doctors on medical rotas in hospitals.
  9. Apparent failure to act on evidence ]Provided by DAUK and the BMA that PAs are and were systematically replacing doctors in General Practice and hospitals.
  10. Apparent failure to work collaboratively with NHS England, the FPA and GMC to ensure that PA Schools educate and communicate with PAs in line with their agreed scope, including but not limited to the principle that PAs are not doctors and must not replace doctors.
  11. Apparent failure to adequately monitor and analyse the performance of PAs in clinical practice to determine patient safety, performance, clinical outcomes and cost effectiveness.
  12. Apparent failure of Senior Officers to act on patient safety concerns raised by Members and Fellows and the wideir public because of the potential financial impact on the College.
  13. Apparent failure of the Senior Officers to fully declare their Conflicts of Interest.
  14. Apparent failure of the Senior Officers to adequately determine the Conflicts of Interest of the FPA leadership team.
  15. Apparent failure of the Senior Officers and CEO to act in accordance with the RCP Code of Conduct.
  16. Apparent failure of the Senior Officers to act in accordance with GMC Good Medical Practice.

This non-exhaustive list highlights that the Senior Officers and CEO have failed on multiple accounts to adhere to the RCP Code of Conduct.

Whilst, given the time pressures, there must be an immediate action plan to ensure that PAs are working within their scope of practice and not in place of doctors, there is a parallel urgent need for an independent review of the Senior Officers with a particular focus on governance and probity.

Dr Asif Qasim FRCP
Professor Alexander Ford FRCP
Professor Charlotte Bolton FRCP
Professor Trisha Greenhalgh OBE FRCP
Professor Martin McKee CBE FRCP
Dr Dagan Lonsdale FRCP
Professor Shah Ebrahim FRCP
Dr Taryn Youngstein FRCP
Professor Nick Hopkinson FRCP
Dr Vinoda Sharma FRCP
Dr Barry Monk FRCP
Dr John Stephens FRCP
Dr Arjun Ghosh FRCP
Dr Scot Garg FRCP
Dr Shrilla Banerjee FRCP
Professor Liz Lightstone FRCP
Professor Mamas Mamas FRCP
Professor Raanan Gillon FRCP
Dr David Nicholl FRCP
Dr Animesh Singh FRCP
Professor Jim Nolan FRCP
Dr Philip Pearson FRCP
Dr David Cohen FRCP
Professor Shahrad Taheri FRCP
Dr Rajiv Sankaranarayanan FRCP
Dr Nasser Khan FRCP
Dr Kevin O’Kane FRCP
Dr Zoe Wyrko FRCP
Dr Muhammad Ahsan FRCP

23rd March 2024

The use of PAs, which is considered by nine out of ten doctors to be dangerous to patients and confuses many patients, who do not realise that they have not been seen and treated by a fully-qualified medic, is being pushed by the government as a way of ‘downskilling’ the NHS, reducing costs and allowing increased profits for private providers, under the guise of the so-called ‘NHS Workforce Plan’ as part of the ‘Integrated Care Systems’ (ICS) project.

ICS, formerly called ‘Accountable Care Organisations’ (ACOs) after the US system it copied, were renamed after awareness began to spread that ACOs were a system for withholding care from patients and that care providers were incentivised to cut care because they receive a share of the ‘savings’. The system remained the same, but the rebranding disguised the reality.

The government used a ‘statutory instrument’ (SI) to pass these changes, avoiding proper parliamentary scrutiny, but both the Tories and Keir Starmer’s Labour support these and other measures to cheapen the NHS for private involvement and only independent MP Claudia Webbe spoke against them during the brief SI debate. Green peer Natalie Bennett’s motion in the House of Lords to attempt to kill the instrument was defeated by the Tories with the help of Labour peers.

Some of the signatories, such as Keele University Professor Mamas A Mamas, have added a demand for a full investigation into the actions of the RCP leadership – and ‘urgent action’ to prevent the government’s push for physician associates to operate beyond safe boundaries:

Despite the government’s attempt to keep this cost-cutting, care-degrading manoeuvre below the radar, it is rapidly becoming a major public issue – yet both Labour and the Tories are committed to continuing it, despite the avoidable deaths among patients that it has already caused.

If you wish to republish this post for non-commercial use, you are welcome to do so – see here for more.

How Not To Do Great Science (The Lost Post)

Published by Anonymous (not verified) on Fri, 16/02/2024 - 6:24am in

This post was originally published on Discover Magazine on September 16th 2013, but has since vanished (although most of my other Discover posts are still available). Luckily, I saved a backup. So here's the original "How Not To Do Great Science".

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This post is a bit special. For the first time ever, I've collaborated with an artist, Erene Stergiopoulos. Her webcomic is here and she's on Twitter here. I think you'll agree that the artistic standard is a little higher than I usually achieve. Anyway, here's what we did:

It would be silly to expect that every architect should finish buildings at a certain rate. That would make it impossible to anyone to build certain things. Some things take longer to build than others, and most great things take a great deal of time. Faced with a sufficiently demanding quota, builders might be reduced to rushing out follies that might look impressive from a distance, but that are no more than hollow shells. Yet, as silly it would be to make uniform demands of architects, this is what is happening to scientists.

Rather than build, scientists are expected to publish - and publish fast - or perish. My worry (and that of many others) is that the pressure to publish often fundamentally changes not just how much scientists write, but what they can write about. It turns researchers into prolific doers of small deeds, but it leaves them little time to think about, let alone complete, great works. Though the mills of God grind slowly...

Yet the problem is not just the speed of science today, but also the direction: go to a scientific conference and you'll see perfectly good data in the process of being oversold, misinterpreted, and p-hacked into a 'publishable' form.

Much has been said about how this leads to false positives - impressive follies that don't stand up to scrutiny. What's less discussed - and the point of this piece - is the opportunity cost. New theories come out of attempts to explain 'negative' data - negative from the perspective of the old theory. Null results are the foundations of future progress, but only if they are allowed to lie there awhile; not if they are torn up and used to prop up tottering old structures.

The trouble with posting graphs and statistics on social media

Published by Anonymous (not verified) on Mon, 15/01/2024 - 11:00pm in

Reflecting on a salutary lesson in how not to post statistics on social media, Jonathan Portes discusses the limitations of posting statistics and data visualizations online and how simple visualizations can often take on unintended meanings. When I tweeted this, as part of a 14-tweet thread on the November migration statistics (reproduced in full here), … Continued

Escape from Model Land: How Mathematical Models Can Lead Us Astray and What We Can Do about It – review

Published by Anonymous (not verified) on Thu, 30/11/2023 - 9:58pm in

In Escape from Model Land: How Mathematical Models Can Lead Us Astray and What We Can Do about It, Erica Thompson explores how mathematical models are used in contexts that affect our everyday lives – from finance to climate change to health policy – and what can happen when they are malformed or misinterpreted. Rather than abandoning these models, Thompson presents a compelling case for why we should revise how we understand and work with them, writes Connor Chung.

Escape from Model Land: How Mathematical Models Can Lead Us Astray and What We Can Do about It. Erica Thompson. ‎Basic Books. 2022 (Hardback; 2023 paperback).

Find this book: amazon-logo

Book cover of Escape from Model LandWorld is on track for 2.5°C of global warming by end of the century.” “US recession odds are falling fast.” “New wave of Covid predicted as UK’s return to school and social mixing hit.” Amidst the challenges of recent years, mathematical modelling has become an ever-more-important tool for understanding our world. Done right, this can empower us. Distilling complexity into bite-size pieces, after all, can be a key step towards changing things for the better.

Embedded within every model are certain assumptions about how the world works. Sometimes, they do the job. Yet, other times, our visits to model land go awry. Thompson fears that modern society never learned to tell the difference

Yet modernity’s faith in modelling has come with a dark side, suggests statistician Erica Thompson in Escape from Model Land: How Mathematical Models Can Lead Us Astray and What We Can Do about It (Basic Books: 2022). Embedded within every model are certain assumptions about how the world works. Sometimes, they do the job. Yet, other times, our visits to model land go awry. Thompson fears that modern society never learned to tell the difference, and that as a result, we’re becoming trapped in a mirror-world of our own making.

The core problem? That it’s all too easy to approach models as sources of objective scientific fact. Yet “[s]uch naive Model Land realism,” Thompson warns, “can have catastrophic effects because it invariably results in an underestimation of uncertainties and exposure to greater-than-expected risk.” “Data, that is, measured quantities, do not speak for themselves,” and at nearly every stage of finding the story, the world finds ways of seeping in.

It’s all too easy to approach models as sources of objective scientific fact.

Let’s say, for example, you want to know how climate change will impact GDP. A preeminent tool for doing so is the DICE model family. As recently as 2018, its factory settings concluded that global warming of 4˚C by 2100 would reduce global economic output by only around 4%. The Intergovernmental Panel on Climate Change, meanwhile, has warned that such warming would bring about “high to very high” planetary risks “in all reasons for concern.” So how does one conclude that a world of cataclysmic weather, of cities swallowed up, of climate-driven refugee and food crises would barely register in the economic metrics?

First, there’s what’s fed into the model: since costs and benefits of building a solar farm or passing a clean energy regulation don’t play out all at once, one must instruct a model how much to value the present versus the future. This variable (one of many dials to which DICE is highly sensitive) is called a “discount rate,” and no amount of math can hide the fact that it’s ultimately a moral judgment. As its main creator, Yale economist and Nobel laureate William Nordhaus, has himself written, “[t]he choice of discount rates is central to the results” – DICE can be made to say just about anything depending on what inputs are chosen. Relatedly, there’s what’s not fed into a model: models are informed by pre-existing knowledge. As a consequence of history, less economic and climactic data are readily available from the developing world, for instance.

Models are informed by pre-existing knowledge. As a consequence of history, less economic and climactic data are readily available from the developing world

Then follows the construction of the model itself.  As economist Nicholas Stern and co-authors point out in a recent paper, certain presumptions of rational actors, of market efficiency, and of exogenous technological progress are embedded into DICE’s fundamental wiring. More broadly, Thompson notes, DICE takes as granted that “the burden of allowing climate change can be quantitatively set against the costs of action to avoid it, even though they do not fall upon the same shoulders or with the same impact.

Models are by nature parsimonious: their utility derives from reducing complex phenomena to a much smaller set of parameters. Yet the real world is full of higher-order impacts (good and bad) beyond what gets specified in the math

Then, there’s how results are generalised to the world at large. Models are by nature parsimonious: their utility derives from reducing complex phenomena to a much smaller set of parameters. Yet the real world is full of higher-order impacts (good and bad) beyond what gets specified in the math. And when models set the bounds of what’s possible, viable, or optimal (DICE, Thompson points out, is enshrined in policy analysis pipelines at some governmental and intergovernmental agencies), nuance risks being lost in translation: “The whole concept of predicting the future can sometimes end up reducing the possibility of actively creating a better one.”

None of this is to say that DICE is useless. Assumptions, even simplistic ones, are necessary for making decisions about complex phenomena. But at the same time, they indelibly embed the modeller in the modelled, and we get nowhere by ignoring this reality.

Thompson isn’t the first to point out that model-making is a deeply human endeavour. But it is in these case studies of present-day debates in the modelling community, as informed by first-hand expertise, that her work really shines. Alongside DICE, Thompson deftly pries open black box after black box in cases ranging from financial markets to public health to atmospheric dynamics, finding in each case that turning morality into a math problem doesn’t purge the human touch. It only buries it just below the surface.

Models emerge as ‘tools of social persuasion and vehicles for political debate’ as much as they are quantitative processes

Models emerge as “tools of social persuasion and vehicles for political debate” as much as they are quantitative processes. And since “we are all affected by the way mathematical modelling is done, by the way it informs decision-making and the way it shapes daily public campaigns about the world around us,” it becomes a real challenge for modern democratic society when models are insulated from understanding or accountability.

The easiest response at this point might be to surrender – to declare that the ineffability and complexity of the world makes mathematical modelling inadequate. And yet… there’s also the pragmatic reality that, amidst compounding crises, models have quite simply proven useful. The empirical record has largely vindicated scientists’ (and, for that matter, literal fossil fuel companies’) climate predictions. Energy system simulations from Princeton played a key role in passing the Inflation Reduction Act, one of the most globally significant pieces of climate legislation to date. And modelled pathways from the International Energy Agency are playing key roles in guiding a rapid buildout of clean energy – and in challenging fossil fuel expansion.

How does one ensure that, in grappling with the social nature of modelling, the baby isn’t thrown out with the bathwater?

History, after all, is full of seemingly progressive (and indeed radical) critiques of objectivity, scientific consensus, and expert practice that end up merely reinforcing the status quo: just take the long history of social constructivist scholarship being used by allies of the tobacco and fossil fuel industries to support and justify their misinformation campaigns. Meanwhile, the climate denialist camp has long had the reliability of climate modelling in their sights. So how does one ensure that, in grappling with the social nature of modelling, the baby isn’t thrown out with the bathwater? It’s a tough needle to thread, yet something Thompson manages to do with grace. Just as there is “a problem in trusting models too much,” she writes, “there is equally a problem in trusting models too little.” Although “failing to account for the gap between Model Land and the real world is a recipe for underestimating risk and suffering the consequences of hubris,” she counters that “throwing models away completely… lose us a lot of clearly valuable information.”

More transparency and intentionality about the role of expert judgement, Thompson suggests, might help close the ‘accountability gap’ between the models and the humans acting on them

This may be the book’s most valuable contribution: it’s ultimately a call not to abandon model land altogether but instead to become better travellers. This begins with seeing the social nature of models as a feature, not a bug. More transparency and intentionality about the role of expert judgement, Thompson suggests, might help close the “accountability gap” between the models and the humans acting on them. Similarly (echoing a rich literature in the philosophy of science), she notes that greater institutionalised diversity of methods and standpoints might result in fewer unseen biases and blind spots.

Ultimately, this book is a plea for humility. It’s wrong, Thompson tells readers, to presume that we’ve somehow created the capacity to transcend the limits of human rationality. Instead we must realise that “taking a model literally is not taking a model seriously,” as Peter Diamond noted in his Nobel acceptance speech – that only by cultivating an ethos of responsibility can we truly treat our creations with the care they deserve.

Such a conclusion may be uncomfortable, but it’s also deeply pragmatic advice for better modelling, better truth-seeking, and better public reason in an empirical age. Modellers, scientists, policymakers, and more would do well to take it to heart.

This post gives the views of the author, and not the position of the LSE Review of Books blog, or of the London School of Economics and Political Science. The LSE RB blog may receive a small commission if you choose to make a purchase through the above Amazon affiliate link. This is entirely independent of the coverage of the book on LSE Review of Books.

Image Credit: Mingwei Lim on Unsplash

Cultural Donations on the Rise

Published by Anonymous (not verified) on Thu, 26/02/2015 - 10:17am in