Hard News: A Real Alternative
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Green had a pet theory.
Quite a controversial one at the time.
He set out to prove his theory suing data gatered from unsuspecting human guinea pigs. otherwise known as patients at National Women's. Over several decades.
If that doesn't constitute an "experiment" with rather large ethical issues, what the f does? -
I'm not sure "theoretical" was a put-down. Heslop's article had 1 reference compared to 50 in the other paper.
Funny thing on the number of references - I heard Ian Wishart tell an attentive audience of 200 Gisborne farmers three weeks ago that his book demonstrating that anthropogenic global warming was a giant con by the thousands of scientists working on behalf of the United Nations towards world government - (pause for breath) his book was the real deal on the science because he had 18 references from peer-reviewed journals on one particular aspect, whereas Gareth Morgan's pathetic effort "Poles Apart" had only 2 references on this vital matter.
And I've worked many years on the interface between practitioners and researchers (in totally non-medical fields), I recognise the tensions and the language, I reckon in the context "theoretical" was a put-down. And it's germane to the subject, because the context is the confusion between clinical practice and research (and teaching), all of them evolving over decades, but not at all smoothly with a number of lumpy individuals involved, and seemingly no inbuilt processes for resolving the problems.
Consensus is a problematic word - does it mean unanimity, an overwhelming majority, 60%, 51%? And minority views may be right. If the question was a research one subject to hypothesis testing, then consensus of whatever degree is irrelevant.
But was the right research question posed? As Heslop pointed out - if H. Green's hypothesis was really as stated that CIS/CIN3 does not lead to cervical cancer, then one case disproves it, and publishable data was available in the 1960s to other senior people at National Women's, who did not act till the 1980s. So a systemic problem, rather than one unfortunate experimenter, who was really a practitioner. And the real questions were much more complex, but scarcely addressed, so again a systemic problem. Shades of grey.
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Just a few more thoughts as I've had a chance to digest on the walk home and while cooking dinner.
I thought (contrary to some others here), that the Kim Hill interview was pretty fair. She mostly listened, and some of the things she pushed on I think were fair enough.
In particular, given that Bryder's argument revolves around her conclusion that there was no consensus at the time, I'm surprised that she was very slow to comment on whether she thought there was consensus now, and kind of implied that she thought it better to defer to experts. In contrast, the experts (including Charlotte Paul) seem pretty clear that Green was defying what they considered consensus. Also, I wonder whether Bryder's finding of lack of consensus reflected the fact that she was working in the Oxford library and that those who were disagreeing were British.
Bryder also makes quite a lot of the fact that Green was denying them an invasive treatment which would impair their child-bearing ability. However, I think she exaggerates the proportion that received hysterectomy in the interview. She also claims that a cone biopsy is quite invasive, but I can't comment on that.
Finally, in terms of the 'experiment', apart from the smoking gun mentioned above, various researchers have had very full access not just to Green's patients, but all patients from the period. I'd assume they would have noticed if there was no appearance of Green's treatment not being different to other consultants.
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Thanks for all the comments regarding the interview last Saturday.
Kim Hill will be talking to Charlotte Paul tomorrow after 9:00am, plus there's a load of listener feedback that came in too late to read in air.
I'm going to compile all the feedback and put it on our website page later today, and link to this discussion as well.
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Bryder also makes quite a lot of the fact that Green was denying them an invasive treatment which would impair their child-bearing ability. However, I think she exaggerates the proportion that received hysterectomy in the interview.
James: First, if Bryder is basically pulling numbers out her arse she should be called on that. But could you share with us the tipping point where it stops being acceptable for women to be subject to a radical and invasive surgical intervention (and I don't think we need to split hairs about whether hysterectomy qualifies) being performed for unwarranted and unnecessary reasons?
I certainly wouldn't be quite so blase if an oncologist was trying to bulldoze me into consenting to having my balls cut off.
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Craig, you expect to be asked for your consent? You mean the doctor has to ask your opinion, not just reassure you in a kindly manner that he knows best so you don't have to worry your pretty little head.
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You mean the doctor has to ask your opinion, not just reassure you in a kindly manner that he knows best so you don't have to worry your pretty little
I'm so relieved that sentence ended the way it did.
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Craig, you expect to be asked for your consent? You mean the doctor has to ask your opinion, not just reassure you in a kindly manner that he knows best so you don't have to worry your pretty little head.
Well, I certainly know a few women who wish they weren't (effectively) bullied into having hysterectomies back in the day because, you know, what the fuck did they know?
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Well, I certainly know a few women who wish they weren't (effectively) bullied into having hysterectomies back in the day because, you know, what the fuck did they know?
Isn't that... kinda the point?
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Hi Craig, thanks for not giving me the benefit of the doubt and jumping straight down my throat, it really made my morning.
What I thought I said was that there are several types of 'adequate' treatment that were withheld, including cone biopsy and hysterectomy. Cone biopsy is apparently done under general anaesthetic, so I assume its not entirely minor, but it does allow women to still have children etc., and is certainly not as radical as hysterectomy. However, Bryder mostly talks about hysterectomy, when I assume quite a lot of them may have only had a cone biopsy for treatment. She made no mention of any figures involved, so I'm certainly not saying she was pulling anything out of her arse. I am suggesting that she overemphasises the most invasive of a continuum of treatments. Of those McCredie et al (2008) in the Lancet Oncology article who were considered to be treated adequately, 33% of those women had a cervix amputation or hysterectomy. Almost all of the remaining 2/3s had a cone biopsy.
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Apparently Bryder has stopped doing interviews as "she's not part of the debate".
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That apparent quote from Bryder may be symptomatic of what I would take to be her real concern, that the subject is vast and her evidence and conclusions are complex, multifaceted and perhaps subtle, recorded thoroughly in a book that as yet is unread, but not well suited to compression to brief interview and soundbite. So the new Listener has a 1-page article on Phillida Bunkle's response and two pages of letters including a lengthy one from Jo Manning, Ass.Professor of Law including "Bryder suffers from the misunderstanding that ...", to which Bryder replies "... All the points she raises are addressed in the book, which arrives at very different conclusions ...".
Seems fair enough really, come back when you've read the book.
Significant participants and others have contributed much feed-back on the Kim Hill interview.
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Seems fair enough really, come back when you've read the book.
Then release the bloody book at the same time you stoke the discussion, not afterwards.
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That Kim Hill feedback page is worth reading all the way.
It includes some very well-informed contributors including those who were central to the Cartwright Inquiry, and in implementing the changes since. Also some unimpressed practitioners with different viewpoints as you'd expect.
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kudos to Mr. Cubey for being so well organised.
(and kudos to Kim Hill for being so well...Kim Hill)
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Hi Craig, thanks for not giving me the benefit of the doubt and jumping straight down my throat, it really made my morning.
Oh, tush... I asked a serious question and thanks (really) for the serious and useful answer which clarified a few thing for me. .
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You know Craig, I consider myself to have pretty thick skin, but I almost didn't come back to this thread when I saw you'd re-posted this morning. Thanks for being more cordial this morning.
Having listened to Charlotte Paul, I can now confirm the hysterectomy v. other treatment argument. On finding a Carcinoma In Situ (CIS), normal treatment would have been to cut it out (the cone biopsy), hoping to remove all the CIS, plus a margin of healthy tissue around it, to make sure it's all gone (rather like if you've ever had a mole removed). On the other hand, Green was likely to biopsy some of the CIS, but not remove it all (deliberately), and then continue doing this multiple times over several years. So Paul argues rather than a less invasive treatment, a series of invasive procedures that also didn't remove the problem (She also notes that the side effects from these multiple procedures would be worse than from a single procedure). Further, if he did find cancer in one of the later biopsies, he would re-analyse the earlier tests himself, and decide that they'd had cancer from the beginning, and exclude their data from his analyses.
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I enjoyed the interview and feel vindicated. I was annoyed (more than) that the Listener had fallen for Bryder's revision of history so quickly.
Then I was shocked when I heard last week's interview. Thank God National Radio has followed it up so well.
Did someone say there was more in this coming week's Listener?
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Well, the Listener can kiss my big toe before I read another- next week! omg! story. I'm not shocked: the Listener is a sad travesty these days.
But I can't read Joanne Black's smugly triumphal prose for more than par or so before having to run outside and sit in a cold puddle, waiting for the steam to stop coming out my ears.
Who wants to pay for that? -
So Paul argues rather ...
That part seemed key to me. James, would you consider reviewing the book for us? You have a medical insight the rest of us don't. I'll send it to you asap, if so.
I don't expect you to speed-read it -- and I find the fact that there was an embargo on the book until Wednesday a bit troubling. Did The Listener require it?
It might have been better to give independent reviewers a run-up at this one, given the splash made by the two launch interviews.
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I just spent an hour preparing a post here with my thoughts on Prof. Bryder's points (as reported) and their implications, submitted it, and subsequently saw a "Page does not exist" screen and the loss of the entire thing. Christ.
Serve me right for not waiting for the book to come out. I probably wouldn't have done much more than showcase my ignorance here anyhow.
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Unfortunate Revision
This is the headline to a very interesting Herald feature this am. I wouldn't have known but read it in a cafe in Kaiwaka!
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Alright, because I can't resist - in a nutshell I think that if you accept them, Prof. Bryder's points still do not indicate for a second that Green didn't do anything wrong - obviously, he did some terrible things, with unspeakable consequences for patients. Nor do they invalidate the Cartwright inquiry wholesale, or the positive changes that have come from it so far.
However, they do give more historical perspective on where Green's views sat in relation to other medical practitioners, and why he did what he actually did. IMO, that is the sort of information that might be good to know in understanding how these things happen, and hopefully in making sure they don't happen again.
It's also the sort of stuff that only gets dug up by historians who are willing to spend years researching and arriving at nuanced conclusions that are hard to pithily sum up and defend in the media.
Just my two cents as I'm waiting for the book like everyone else. Ignore at will...
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I just spent an hour preparing a post here with my thoughts on Prof. Bryder's points (as reported) and their implications, submitted it, and subsequently saw a "Page does not exist" screen and the loss of the entire thing. Christ.
Bugger. Although "page does not exist" isn't an error I've seen before. I did shorten yesterday's thread from three to two pages by removing several adventures in YouTube linkage, but not this thread.
As a general rule, if you've spent an hour typing into a text window on PA System, it is always best to assume that your login could have dropped off, and to just select and copy what you've typed.
It should be better with the upcoming forums upgrade.
Just my two cents as I'm waiting for the book like everyone else. Ignore at will...
Kind of summarised and clarified my thoughts, actually.
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