What does it take to create a decision rule? In this episode of Radiology Firing Line podcast Saurabh Jha (@RogueRad) has a discussion with Robert W. Yeh MD MBA about the deep thought and complex statistics involved in creating a decision rule to guide therapy which have narrow risk-benefit calculus, specifically a rule for how long patients should continue dual anti-platelet therapy after percutaneous coronary intervention. They also discuss the motivation behind the legendary, and satirical, parachute RCT published in the recent Christmas edition of the BMJ, which delighted satirists all over the world.
In this episode of Radiology Firing Line Podcast, I speak with Bishal Gyawali MD, PhD. Dr. Gyawali obtained his medical degree from Kathmandu. He received a scholarship to pursue a PhD in Japan. Dr. Gyawali’s work focuses on getting cheap and effective treatment to under developed parts of the world. Dr. Gyawali is an advocate for evidence-based medicine. He has published extensively in many high impact journals. He coined the term “cancer groundshot.” He was a research fellow at PORTAL. He is currently a scientist at the Queen’s University Cancer Research Institute in Kingston, Ontario.
What are the challenges of bringing advanced imaging services to India? What motivates an entrepreneur to start build an MRI service? How does the entrepreneur go about building the service? In this episode, I discuss radiology in India with Dr. Harsh Mahajan, Dr. Vidur Mahajan and Dr. Vasantha Venugopal. Dr. Harsh Mahajan is the founder of Mahajan Imaging, a leading radiology practice in New Delhi, and now a pioneer in radiology research in India.
Listen to our conversation on Radiology Firing Line Podcast here.
Saurabh Jha is an associate editor of THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner.
I have a wide ranging conversation with Dr. Nicole Saphier for JACR’s Firing Line Podcast. Dr. Saphier is a radiologist specializing in women’s imaging. We discuss screening mammograms and the breast density law. Dr. Saphier, a frequent contributor to multiple major media outlets, tells us what it means for a radiologist to opine on health policy in the national media.
About the author:
Saurabh Jha is a contributing editor to THCB. He’s the host of JACR’s Firing Line Podcast. He can be reached on Twitter @RogueRad
Public reporting of doctors is fiercely controversial. I’m vehemently opposed to it. So I decided to find out why its proponents favor it.
I discuss public reporting with Ben Harder, Chief of Health Analysis at U.S. News and World Report, for JACR Firing Line. We disagreed for most parts, though we agreed that there are bad ways to rate doctors, and better ways, too. Listen to our discussion here.
Key points made by Ben Harder:
a) Reporting of quality is a decision support tool for patients and their caregivers. It is NOT to penalize or shame doctors but to engage consumers in their healthcare decisions. This is an important distinction.
b) If methods to rate quality are so bad how is it that hospitals which look after the sickest patients also have the highest rating?
c) Newer methods to rate quality make a huge effort not to compare apples (hip surgeons) with oranges (knee surgeons).
d) We are still suffering the legacy of poor risk adjustment.
This is the second part of Dr. Jha’s conversation with Dr. Jonathan Cusack, who was the former supervisor and mentor of Dr. Bawa-Garba, a pediatrician convicted of manslaughter of fetal sepsis in Jack Adcock. Read the first part of this series here.
Dr. Jonathan Cusack versus the General Medical Council
I spoke with Dr. Jonathan Cusack, consultant neonatologist at Leicester Royal Infirmary (LRI), and former supervisor and mentor of Dr. Bawa-Garba, the trainee pediatrician convicted of manslaughter for delayed diagnosis of fatal sepsis in Jack Adcock, a six-year-old boy with Down’s syndrome. We had drinks at The George, pub opposite the Royal Courts of Justice.
In the first part of the interview we discussed the events on Friday February 18th, 2011, the day of Jack presented to LRI. In the second part of the interview we talk about the events after fatal Friday – how the crown prosecution service got involved, the trial, the manslaughter charge, the tribunal and the General Medical Council.
Dr. Jonathan Cusack, a consultant neonatologist at Leicester Royal Infirmary (LRI), and a former supervisor and mentor of Dr. Bawa-Garba’s.
The Role of Dr. O’Riordan
Saurabh Jha (SJ): After Jack’s death what was Dr. Bawa-Garba’s immediate reaction?
Jonathan Cusack (JC): I think it’s one of those moments one neither forgets nor recalls. I imagine the most overwhelming feeling was one of incredulity. How and why did Jack decompensate? It’d have struck her as physiologically implausible. Though she was experiencing that grief familiar to all pediatricians when a child dies, she was trying to understand why. She didn’t know that he died from Group A Streptococcal septicemia, then.
After Dr. Hadiza Bawa-Garba was convicted for manslaughter for delayed diagnosis of fatal sepsis in Jack Adcock, a six-year-old boy who presented to Leicester Royal Infirmary with diarrhea and vomiting, she was referred to the Medical Practitioners Tribunal (MPT). The General Medical Council (GMC) is the professional regulatory body for physicians. But the MPT determines whether a physician is fit to practice. Though the tribunal is nested within the GMC and therefore within an earshot of its opinions, it is a decision-making body which is theoretically independent of the GMC.
The tribunal met in 2017, 6 years after Jack’s death, to decide whether Dr. Bawa-Garba, after the manslaughter conviction, should be allowed to practice medicine again, whether she should be suspended for a year, or her name be permanently erased (“struck off”) from the medical register. The GMC wanted Dr. Bawa-Garba to be struck off from the medical register because they felt that her care of Jack fell so short of the expected standard, that her return to practice would not only endanger patients but undermine public confidence in the medical profession. The GMC expected the MPT to agree with its uncompromising stance, and the MPT might well have, and probably would have, but for the efforts of Dr. Jonathan Cusack, a consultant neonatologist at Leicester Royal Infirmary (LRI), and a former supervisor and mentor of Dr. Bawa-Garba’s.
Cusack is unassuming even by British standards. You will not find him on social media or taking selfies. A soft-spoken northerner with a steely nerve and an uncompromising deference to facts, Cusack is both old-school and new-school. He has that unassailable integrity which is immeasurable but instantly recognizable. But he’s also savvy – and understands the British medical, regulatory and legal systems inside out. If Dr. Bawa-Garba’s license is reinstated, Cusack’s role would be akin to that of the code breakers in the Second World War. Dr. Bawa-Garba trusts him implicitly. Her legal team can’t function without him.
Cusack was loyally involved in both the rehabilitation of Dr. Bawa-Garba’s clinical confidence after Jack’s death, and her trial. I met him after the first day’s appeal hearing in the pub opposite the Courts of Justice. Originally hesitant to speak to me, being the ostentatious expat Brit that I am, he agreed to an interview on the condition that I not make too much of a song and dance about his contribution. I promised that I wouldn’t. I lied.
There is a rage against expertise these days. Data is all rage. What is the value of experience and judgment when we have abundant information, guidelines, and protocols? Can’t we just have a protocol for every situation? Are doctors overly concerned about making errors? I discuss these issues with Gary Klein, a renowned cognitive scientist and author of Streetlights and Shadows.
When Russian forces stormed the school held hostage by Chechen terrorists, over 300 people died. The Beslan school siege wasn’t the worst terrorist attack arithmetically – the fatalities were only a tenth of September 11th. What made the school siege particularly gruesome was that many who died, and died in the most gruesome manner, were children.
There’s something particularly distressing about kids being massacred, which can’t be quantified mathematically. You either get that point or you don’t. And the famed Chechen rebel, Shamil Basayev, got it. Issuing a statement after the attack Basayev claimed responsibility for the siege but called the deaths a “tragedy.” He did not think that the Russians would storm the school. Basayev expressed regret saying that he was “not delighted by what happened there.” Basayev was not known for contrition but death of children doesn’t look good even for someone whose modus operandi was in killing as many as possible.
There’s a code even amongst terrorists – you don’t slaughter children – it’s ok flying planes into big towers but not ok deliberately killing children. Of course, neither is ok but the point is that even the most immoral of our species have a moral code. Strict utilitarians won’t understand this moral code. Strict utilitarians, or rational amoralists, accord significance by multiplying the number of life years lost by the number died, and whether a death from medical error or of a child burnt in a school siege, the conversion factor is the same. Thus, for rational amoralists sentimentality specifically over children dying, such as in Parkland, Florida, in so far as this sentimentality affects policy, must be justified scientifically.
The debate over gun control is paralyzed by unsentimental utilitarianism but with an ironic twist – it is the conservatives, known to eschew utilitarianism, who seek refuge in it. After every mass killing, I receive three lines of reasoning from conservatives opposed to gun control: a) If you restrict guns there’ll be a net increase in crimes and deaths, b) there’s no evidence restricting access to guns will reduce mass shootings, and c) people will still get guns if they really wish to. This type of reasoning comes from the same people who oppose population health, and who deeply oppose the sacrifice of individuals for the greater good, i.e. oppose utilitarianism.