Comments on the “International Guidelines”

Comments on the "International Guidelines" by a former patient and professor of marketing from Stockholm university, Sweden.

  1. There were many acronyms in your memo that I do not understand: EHS, AHS, RCT, CMAJ, etc. It is always irritating when such acronyms appear but I understand you did not write for me but for a very informed group. I have not taken time to try and decipher them. I had not expected my short comments to raise so much interest but I am pleased it did. This commentary is too short to motivate my conclusions and it could also be better structured. But my time is in short supply!
  1. "Aggressiveness of the industry". I am not sure what you mean by industry but one could be mesh manufacturers. I don't know how big an industry it is but I learnt that a mesh can be quite expensive so it may be a considerable industry. One thing that constantly disturbs me is that data used to prove a claim is taken from articles published in "top" (how is "top" defined and secured?) medical journals in the English language, a language that is spoken by less than 10% of the world's population but understood by some more percentages. Other languages like German, French, Spanish etc. do not count; they are non-existent. Those who submit journal articles are in the hands of editors and reviewers and others who help make an article "publishable". Today evidence-based medicine has appointed itself to the gold standard of science. It is nothing of the kind. Having been in marketing and management all my life I sense when the marketing thought process takes over. It may well be that evidence-based and life science are labels that have been invented by PR-people and lobbyists and are used to impress ignorant people, i.e. fool them. About a year ago I published a book called "Case Theory in Business and Management" (2017, SAGE, UK, 368 pp.). It took 7 years to write and one of its conclusions is that quant studies with lots of statistics are inferior to case studies in learning about the real world. The guidelines from the Hippocratic oath and its revisions, are much better than any statistics although statistics can be used when chosen with good intentions and are factual and objective – (which they seldom are).
  1. Medical research and practice is controlled by various industries and official agencies. The control is through government regulations, licenses for doctors, research grants, promotion to higher positions, gifts and even outright bribes and payments to tax havens. Health care is very much a financial operation. Those medical scientists and practicing doctors who stay true to their calling often have to play a balancing game not to get into trouble. Usually they don't get much in a way of research funds and sponsorship.
  1. In free markets -- which we claim to have in the western world -- there is competition and a variety of solutions. Basically, the health care sector is there to serve the citizens with solutions to health problems and their prevention. But there are several stakeholders in the market other than patients. Producers of health care must be able to survive and thus earn an income, which can be paid through patient fees and private, regional or national insurance. Health care may well be the most complex sector of society. If it goes too far in maximizing "shareholder value" this will easily be to the detriment of patients. In a communist country it will be controlled by politicians and civil servants, a situation which leads to inertia and bureaucracy but also to illegal practices like bribes to government officials. A standard for all people, even for the whole world, leads to monopoly, something we try to avoid in the western world. Forcing everyone to use mesh in hernia surgery is an effort for suppliers to create a monopoly for themselves and keep a market. A very difficult instance is vaccinations which are now forced on everyone in some countries. Rumors are started about expected plagues, but we often do not know if they are justified or just a marketing gimmick for creating new markets. There is a risk that people are bribed to spread the rumors about upcoming epidemics. Because of the lack of time, vaccines are often sold without enough testing. It is a dilemma; honesty and integrity are the best solutions.
  1. Today, we hear incessantly that everything is global, anybody can reach anybody with just a click on the computer or phone. It is a silly myth. International, now baptized to global to make it more interesting, is not new. It has just taken new forms. The Vikings from Scandinavia were global, the Silk Road from Asia to Europe was global, World War II was very global. Religions have been global. Some people think we are all the same. We are not. So, when someone talks about a World Standard for hernia surgery -- based on mesh -- it is a token of outright stupidity and psychopathy: I want to control you. Just what dictators want: Stalin, Hitler, Mao and others. Medicine cannot call itself a science if its ultimate goal is to control everybody.
  1. In my book "Case Theory" I try to trace what is meant by science, research, knowledge etc. I find that very few ordinary people, as well as scientists, know what they are talking about. Most "scientists" are measurement technicians, they know one or two techniques and they stick to them but they do not really appreciate what they are. In my book I talk about "explicit knowledge" -- knowledge that can be communicated through words, numbers, pictures etc. -- and "tacit knowledge" which consists of experience, common sense, intuition, sound judgement, hunches etc. Tacit knowledge is usually discarded by "scientists" despite the fact that they use it at all time. How many judgement calls do you have to make in a statistical study that is presented as "rigorous research"? In my book I mention that a simple statistical survey asking people and grading answers on a Likert 5 item scale or as yes/no/don't know, requires some 30 judgement calls, i.e. application of tacit knowledge. The results are shown as numbers, sometimes even with decimals. This is nonsensical mathematics. I talk about "pragmatic wisdom" as the best knowledge, a combination of explicit and tacit knowledge directed to create action and results. A good doctor both knows the techniques that could work and has a personal perception of the patient. Great doctors also feel the "vibes" of a patient.
  1. Science should not expect everyone to be the same. Needs and situations differ, there is great diversity and variation. True science considers this. I recall the story when the electric shaving machine had come and one machine was a box in which you put your head to be shaved. Somebody objected … but we have different faces! Answer: No, not after the first shave.
  1. A problem you have, especially in the US is bringing in lawyers and the courts. We do not have this in Sweden -- yet; here it is extremely unusual that a doctor is sued. Most of such cases in the US are based on doing business, a lawyer sues and the client pays only if he/she wins. No monetary risk-taking for the client. So, justice has also become business and is not only about what is right or wrong.
  1. I had hernia surgery on my right side about 20 years ago, in my early 60s. It was in the Stockholm area, Sweden. When I suspected I had hernia I called a medical clinic at Stockholm University where I could go as a university employee. I told the nurse on the phone that I had a hernia and asked how I should proceed. I had already read up on the symptoms so I knew it was a hernia. My father had had one when I was growing up and so had a friend in the military service so I had a good idea of what a hernia was. The trend was that patients had to stay in hospital for two weeks. Our doctor can see you tomorrow and check the symptoms, she said. I went there and the doctor agreed I had hernia and got me an appointment with a private clinic that had an agreement with the national health insurance so it would not cost me anything. The doctor referred me to a surgeon who could see me 3 days later. After his examination he asked when I wanted to have the surgery. When is it possible, I asked. Next week, he replied. I was stunned and told him that I always heard the waiting time for surgery was very long. He then explained that in the 1980s the waiting for a hernia operation in Stockholm was 6 years, but he and another surgeon finally got permission to test day surgery. And in one year the waiting line was gone! But until very recently they did not have any follow-up statistics of patients but it was guessed that 20% or even more of the patients got problems after the operation. The reason for waiting-lines was political. Sweden was ruled by the Social Democrats, a milder version of communism. In communism you must wait and wait, the waiting-line gives power to the state employees, the only power they will ever have. So, they create lines and get more money from the state and probably also take bribes. Waiting in line is considered democratic. In Eastern Germany, officially the German Democratic Republic, which was liberated as late as in 1990, the waiting line for a car was 12 years for an ordinary comrade -- communist party officials got it right away. It was like George Orwell noted in his imaginative book "Animal Farm" in the 1940s: "We are all equal but some are more equal than others".
  1. I could say more about these things but this has to do for now. You are absolutely right in going against the International Standard Nonsense. Even if “International” has been left out now I don't trust the people who made it up. You may show this to others if you want to and refer to me. As I am not an MD and on top of that, emeritus and they can do little evil, except a course sue me for defamation of character or send a hit man!

1 Comment

  1. Daryl Urquhart on July 15, 2018 at 2:21 pm

    Dear Evert, you are now and have always been such a clear thinker and able to communicate your thoughts in such an adroit manner. Reading your comments is both refreshing and educational. Your non medical but eminently educated perspective transcends the myopic views of so called medical science to bring about a logical curiosity that if adopted by more scientists might truly result in real science. Bravo! Ian honoured to know you. Carry on bravely and be well.

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