Interpreting the texts: Mr M

The case against Mr M seems to be entirely built on a particular interpretation of words which doesn't seem possible to put into question.

For example, the first allegation was that Mr M 'failed to immediately' act on the patient. I heard that the unfortunate man had suffered a heart attack in his car, and when the ambulance crew arrived Mr M commenced the procedures when the patient was on the trolley. The lawyer interpreted the guideline's word 'immediately' in a very literal way, and did not consider the context or pose questions about Mr M's decision. The printed word was 'immediately', and this was unambiguous according to the lawyer.

Secondly, a point about responsibility. The crew was made up as follows: Mr M plus one other, not qualified as a paramedic but of long service and experience. Ms J arrived a little later and joined them in the ambulance to the hospital. Mr M was the senior member and filled in forms stating that he took responsibility for this call. Much of the physical action (of resuscitation and so forth) was carried out by the two other members of the team. The question of delegation became transformed into 'abdication' as the fact was established that Mr M's hands had not actually performed the tasks.

The question at the heart of the hearing seemed to be more concerned with the fact that he wrote that he took responsibility whereas 'in fact' the other man pumped the heart while the woman pumped the air. What I'm driving at here is this: from my lay-person's perspective, I am not at all shocked to hear that a senior member of staff takes responsibility for the subordinates' actions. This is every day ordinary life. I didn't hear anyone say that the actions of the subordinates were dangerous or ill-conducted - no-one said that the outcome of this team's work resulted in a disaster for the patient. What seems to be of interest to the lawyers at the HPC was that Mr M was lying! This is a very strange interpretation of the text, but I do believe there's a very good chance that this was indeed the level of the allegation.

Mr M seems to have been severely punished (struck off the register, and his details published on the website) because he took responsibility, delegated to his staff, and made decisions according to the actual circumstances rather than mindlessly following the guidelines. I cannot see anywhere how the public was put in peril by his work.

One other thing. I was struck by Ms J's witness statement. She said she had been doing this work for about 20 years, had seen the other two team members around, and had no doubt whatsoever about their ability to manage the situation that day. She also said that she was someone who 'liked to help out'. I think this is probably why she had agreed to be at the hearing. My guess is she will be shocked at the panel's decision. I don't think it occurred to her that the hearing would be anything other than fair and reasonable. I wonder what she will think of the representation of her words in the report. They have her say that 'she recalled that [Mr M] had taken little part in the direct care of the patient'. I didn't hear her say that, and I didn't interpret her words as in any way damaging to Mr M. The summarising of her position in this way makes me very uneasy indeed.

Prof Michael Rawlins comes out against hierarchies of knowledge

An article from the Independent, 16 Oct 08 (click heading to go to the original page) quotes Michael Rawlins, head of NICE clearly, acknowledges the place of professional judgement. Apparently this counts as news in 21st Century Britain.

Michael Rawlins: Statistics can help, but doctors must also use their judgement

Nowhere is the longstanding argument over the choice between inductive and deductive approaches more hotly argued than in the nature of the evidence that should support the use of therapeutic interventions.


The dispute about the evidential basis of modern medicine has become particularly apparent with the emergence of "hierarchies" of evidence. Such hierarchies place randomised controlled trials (RCTs) at their summit with observational studies nestling in the foothills. They are used to provide some intimation of the "strength" of the underlying evidence, and to then "grade" therapeutic recommendations.

But the notion that evidence can be reliably placed in hierarchies is illusory: judgements are an essential part of the decision-making process. As Bradford Hill, the architect of the RCT, stated so cogently: "Any belief that the controlled trial is the only way would mean not that the pendulum had swung too far but that it had come right off the hook."

At root, the problem with hierarchies is that they attempt to replace judgement with an over-simplistic assessment of the quality of the available evidence. But as William Blake observed: "God forbid that truth should be confined to mathematical demonstration."

Decision-makers have to incorporate judgements in reaching their conclusions. Experiment, observation and mathematics have a crucial role to play in providing the evidential basis for modern therapeutics. Arguments about the relative importance of each are an unnecessary distraction. Hierarchies of evidence should be replaced by embracing a diversity of approaches.

This is not a plea to abandon RCTs and replace them with observational studies. Rather, it is a plea to investigators to continue to develop and improve their methodologies; to decision-makers to avoid adopting entrenched positions about the nature of evidence; and for both to accept that the interpretation of evidence requires judgement. It is scientific judgement – conditioned by the totality of the evidence – that lies at the heart of making decisions about the benefits and harms of therapeutic interventions.

Professor Sir Michael Rawlins chairs the National Institute for Health and Clinical Excellence. ...