It took over four years and, one might surmise, an extraordinary amount of money (likely many hundreds of thousands of dollars) for the Professional Standards Committee (PSC) that oversees disciplinary cases against medical professionals, to reprimand a dedicated doctor for referring a patient to complementary therapies and failing to describe to the patient the distinction between medical evidence based treatments and complementary treatments.
The Committee found that there was no actual harm caused to the patient other than what was referred to as ‘economic harm’, by way of $70 paid for a massage that was said to be unhelpful (not harmful).
It was a seemingly inconsequential story if contrasted to the usual fare the media concerns itself with – for instance the more salacious stories about doctors who have gone astray and actually harmed their patients with terrible consequences such as sexual molestation, maiming or even death.
A small cohort of the media was waiting to pounce – not because the case against Dr Kim really fit in any of their usual material set to incite and entice an audience, but apparently because he could be associated with Universal Medicine.
The headlines or key lines all exposed this fervour, with numerous references to Universal Medicine. One article referred to Universal Medicine 17 times, keyword loading it for greatest effect. The fact that the case was actually about referral practices (and not the standard of medical care that was applied) was lost in the journalists’ pursuit of a topic that had gained traction from their previous reporting.
There was no direct harm to a single patient, however the media reporting that followed the Medical Standards Committee decision was out of proportion to the actual findings and was assured to harm a dedicated physician whose quality of medical care had not been questioned.
It gave some reporters an opportunity to revisit old ground and personal antipathies they appear to have fostered over time regarding Universal Medicine.
Dr Sam Kim, exemplary physician
Dr Sam Kim is an exemplary physician. He offers his specialist services as a pulmonary physician in both Brisbane, Queensland and in a regional centre in Goonellabah, Northern New South Wales. His Goonellabah clinic was set up at great cost to himself, simply because he was aware that it was a needed service for a rural area, otherwise not provided outside a major city.
It is commonly known that there is a dearth of specialists in regional Australia and that communities are desperate to get good specialists to provide services in country areas. Dr Sam Kim has done exactly that. Not only has he done that, but he has provided ‘state of the art’ on-site specialist equipment at enormous expense to himself, simply so that he could provide the best respiratory care for his patients without them being required to travel to Brisbane for crucial testing.
Dr Sam Kim would not be likely to recoup the costs of this equipment from his local consultation, but had provided it because of his profound dedication to patient well-being and an immense love and care for people.
Dr Sam Kim is known in his local community, and also amongst his medical colleagues, as having an extraordinary decency and an unerring commitment to humanity. His dedication to his profession illustrated not only by his provision of services in a regional community, but also by his multiple degrees, engagement in active research, travelling to learn state of the art techniques to support his patients with, along with providing his time weekly, without charge, to provide education for medical students.
Dr Sam Kim’s dedication to his patients is second to none, and he is well known for providing extra time in consultations for in depth explanations for their conditions and showing a deep care and time for his patients on rounds after his long working day, giving time to talk with his patients, often returning home late at night because he has been literally out in the field caring for his patients.
However, the world was not to learn these extraordinary facts about Dr Sam Kim. Instead, the public was served up a concoction of media reports that focussed upon a recent PSC hearing where Dr Kim had been disciplined, not for want of his medical care of a patient (that, as per usual for the dedicated physician, had been exemplary), but for making referrals for complementary medicine.
A critique of The Medical Board Decision
The media did not reflect upon the nature of the PSC decision, although it could have.
It was an extraordinary four year effort to end with a reprimand for referring a patient to complementary therapies and apparently not adequately explaining the difference between conventional medical treatments and a massage. Importantly, the PSC found that there was no actual harm caused to the patient other than what was referred to as ‘economic harm’, by way of $70 paid for a massage that was determined to be unhelpful (not harmful).
Finding no fault with his medical management of his patient, they instead took issue with the fact that he did not specifically state that the ‘esoteric massage’ he recommended his patient consider was ‘complementary’ and not ‘conventional’ and explain that difference.
However, an objective observer might conclude that ‘blind Freddy’ would be well-aware that there is a difference between medical care and a massage without the need for stating it overtly.
Consider this carefully – Dr Kim referred his patient to have a massage and the PSC took issue with that. A massage. No physical harm was suffered from the massage, although the Board determined paying $70 amounted to ‘economic harm’. We note that $70 is cheaper than seeing a chiropractor, a treatment for which many people might avail themselves of, with little evidence of efficacy.
It is also important to consider that Patient A gave consent to have the massage with the practitioner that she saw – she agreed to have a massage and pay for it. That she later considered it was not helpful, does not mean that the consent was not given.
Much was made by the PSC and their advising medical specialist about the so called potential risk of the massage – the harm was never specified but hinted at or inferred by the medical specialist referring to the patient as having osteoporosis – yet the patient described the esoteric massage as gentle ‘stroking’ to their back. The Board justified their decision in part on the possibility of harm that might have arisen from the massage.
But there was no evidence of even the potential for harm, except for the medical adviser to the PSC stating there was this possibility.
A review of the medical literature reveals no randomised controlled trials reporting on the harms of massage and certainly no randomised controlled trials mentioning the serious harm of light touch massage, which is what Patient A said she received. Also, there was no actual evidence that the specific massage offered, one of many Universal Medicine therapies, had ever harmed anyone.
There are no case reports of significant harm coming from light touch massage reported in medical literature.
The fact that the PSC made what could be called an evidentiary leap of faith in this regard should be considered more carefully.
The mere fact that a complementary therapy is not ‘evidence based’ does not mean that it can be assumed to be harmful. Yet this is the assumption that informed the PSC decision that considered referral to complementary therapies as ‘unethical’ on the basis that such therapies are not ‘evidence based’. In this regard, the medical board was sitting within a paradigm that champions ‘evidence based medicine’.
A sector of the medical community considers that the best and only evidence of effective medicine or health care is the double blind controlled trial. However, it does so without consideration that the so called ‘gold standard’ of evidence in medicine is sorely lacking – a review of the evidence has shown that 40.2% of treatment study results will be reversed after 10 years1 with 15% of medical treatment being shown to be harmful.
The strict proponents of evidence based medicine eschew the patient experience and research based on case studies, which ironically informs much of daily medical practice. Those who adhere to this approach generally fail to question the flaws in their own paradigm, particularly that there is no way of knowing whether a current treatment that is being prescribed (as recommended by evidence based studies which evaluates medical treatment on a cohort) will work or be harmful to an individual patient.
Conventional medicine clearly has enormous benefits and we champion its efficacy and great importance in the diagnosis and treatment of disease, but there are also serious risks and harms we should not be blind to.
A paradigm of strict scientism not only champions the randomised controlled trial, it excludes observational evidence that informs a large part of clinical practice for medical professionals. This is well seen in the treatment of psychiatric disease where many patients will have to try different combinations of drugs and amounts to effectively treat their disease – there is no ‘one size fits all’ as a randomised trial might suggest.
The Board’s decision (sitting squarely in the scientism paradigm) that Dr Kim must only rely upon evidence based medicine in any referrals he is to make, flew in the face of the evidence it was prepared to accept in its own deliberations on the supposed risks of the massage given to ‘Patient A’. The specialist’s inference that physical harm might arise from the gentle massage that was applied, simply had no evidence to back it up. For the specialist and the PSC, the mere fact that massage was ‘complementary’ appeared to obviate any requirement for evidence of harm.
Any risk of harm was pure supposition.
In contrast, side effects from appropriately prescribed prescription medications is the fourth highest cause of death in the USA. Prescription drugs have a 1 in 5 chance of causing a serious adverse reaction. In the USA, 1.8 million people are hospitalised annually as a result of serious adverse effects from an appropriately prescribed medication. Furthermore, adverse events from hospital admissions, such as serious risk of infections, should be considered a calculated risk – research shows that 10% of hospital admissions in the United Kingdom result in adverse events (or 850,000 incidences) and 18% of Europeans have experienced serious medical errors in hospitals.2
In contrast, massage does not generally rate on the scale of the risk of causing death and there is no evidence of widespread harm occurring from any ‘massage’ resulting in mass hospitalisation.
It thus seems that Patient A was far more likely to come to harm from appropriately prescribed medications than the massage she received.
The PSC abandoned any requirement for evidence of the potential for harm in reaching the conclusion that there was a possibility of harm from ‘the massage’. It came to this conclusion even though the evidence before it was that the massage did not cause harm as the patient was not harmed by it. Nor was there any actual harm recorded from any other complementary care Patient A sought.
Is it somewhat ironic that a professional committee that called for Dr Kim to only rely upon scientific evidence was able to dispense with any need for evidence of harm in their decision making?
Either evidence is needed to form a conclusion, or it is not.
Universal Medicine offers a multi-dimensional approach to health care
The PSC also appears to have departed from its own requirements that experts should only offer opinion within their field of expertise. Their specialist medico, Dr Yates appears to have gone beyond her own professional knowledge in offering an opinion that Universal Medicine was not a religion but an ‘attitude towards the origins of disease and illness’. We assume that Dr Yates is not trained in theology or an expert in religious expression, or indeed philosophy, yet the PSC reported this opinion without questioning the doctor’s standing to offer it.
That Dr Yates considered that conventional medicine abandoned a spiritual dimension to illness and disease in the 19th century may represent the current dominant view in medicine, but ignores a growing acceptance that there are psycho-spiritual dimensions to healing that need to be embraced in the application of conventional medicine.3
Even with enormous advances in medicine, conventional medicine is not arresting the exponential increase of chronic disease across the globe and health authorities are drowning in the increased need for services for treating diabetes and lifestyle related diseases.
Universal Medicine rather than being lost in the dark ages of a less enlightened era, as Dr Yates and the PSC asserted, considers that the future of medicine and a sustainable public health policy requires a multi-dimensional understanding of health-care.
The World Health Organisation defined health as:
‘A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ 4
In this regard, a wider definition of health should embrace:
‘A state of complete physical, mental, social and spiritual well-being and not merely the absence of disease or infirmity.’ 5
A multi-dimensional health-care embraces more than the physical body (the focus of conventional medicine) and includes spiritual health as well. Thus, responsible health-care should involve all aspects of a person’s life, not merely physical function, and be based upon a vital concern for people’s physical, emotional, mental and spiritual well-being.
Modern medicine still works with the human person in a fragmented way. Its area of expertise is working with physical (and to some extent the psychological) aspects of illness and disease. It is not so adept with the emotional and spiritual realms that accompany illness, disease or good health. And while it would admit that it is not as adept in these respects, until recently conventional medicine also denied or at least diminished the role of these aspects in any reasonable understanding of health and wellbeing.
The model of conventional medicine demanding a strictly evidence based approach necessarily excludes a multi-dimensional approach, since the spiritual and psycho-spiritual aspects of health and well-being are not readily approached with a double-blind controlled study, and thus it is proposed that that model fails the standard of responsible health care. It is to this model that the PSC and their expert Dr Yates were bound.
In a multi-dimensional model, complementary health-care becomes a necessary adjunct to conventional medicine. In this partnership, aspects of a person’s health that do not relate to the pharmaceutical and surgical treatment of medically diagnosed disease can be addressed.
Recent surveys record that patterns of health care already reflect a high level of acceptance of the multi-dimensional model. Indeed 70% of Australians are accessing complementary medicine in some form – whether it be supplemental medications, or practitioners.6 Furthermore, in a national Australian survey, 30% of GPs admitted to practising integrative medicine.7
The fact that 30% of GPs prescribe complementary medicine and 70% of Australians access complementary medicine, suggests that conventional medicine does not provide the full picture for health-care. It also suggests that consumers seek and are obtaining a perceived benefit from various forms of complementary medicine.
In the evidence-based model, the individual’s subjective evaluation of their own well-being is secondary to the scientifically evaluated treatment on offer and the medical professional’s knowledge of it (if not entirely dismissed). This is not to say that doctors should not properly offer patients enough information for them to make an informed decision about the benefits or otherwise of using complementary medicine in addition to their conventional treatment, but the standard that is applied to the information given should not be placed higher for complementary care. This decision appears to do just that.
Doctors’ referral practice to friends and associates
Dr Sam Kim additionally was reprimanded for not telling his patient that the person he was ‘referring’ her to was his partner at the time. It is important for the medical profession to disclose their relationships if they are to gain an advantage from any referrals, however, it is hardly a criminal offence, requiring public humiliation and a 4-year investigation, to have referred a patient to his partner for a massage, the cost of which was a mere $70. What a huge conflict of interest!
It appears, if the simple outcome is considered, that the PSC took over 4 years, using an intimidating adversarial process, to discipline a doctor for referring a patient for a massage and not disclosing that the practitioner was his partner where no actual harm was occasioned, other than the $70 fee for a massage. Is this a crime for which a great physician should be publicly dressed down?
Did these events warrant a 4-year investigation? Would perhaps a simple conversation and reminder have sufficed to have improved Dr Kim’s practice?
Yes, it is true that professional standards require such familial relationships are revealed in the process of referral. However, the PSC went further to suggest that Dr Kim was required to reveal any social connection or the fact he had studied with anyone who was associated with Universal Medicine.
Medical professionals refer people to their friends and associates, daily, without ever disclosing the precise nature of those relationships. Many professionals are likely to mix with one another in social settings, on the golf course, or may have previously studied together at university. Medical professionals refer patients to people who they know are good, and, who they know. Generally, medical professionals will make referrals to other professionals with integrity, whom they know they can trust. All doctors have their own networks, and it appears high handed and perhaps hypocritical to apply a different standard to referrals made for complementary care.
Doctors do not detail the nature of the relationships of people they refer to, they do not discuss how they know them, for how long they’ve known them or if they are of the same religious faith or church group and so on. There is something vaguely disturbing in such a requirement.
It was suggested by ‘the expert’ advising the Committee that Dr Kim display signs in his practice notifying his patients of his association with Universal Medicine so that patients are ‘clearly informed of his potential bias’. Yet no Catholic is required to display signs of their Catholicism so that patients are aware they may have a bias when referring to catholic doctors or doctors working at a Catholic hospital, to give patients all information to support them in making an informed decision.
Such a demand should be considered abhorrent in a society that values human rights, including religious freedoms and freedom of association.
In accord with this same logic, should all medical professionals refer to their religious affiliations, social networks or sporting clubs in their receptions?
Dr Kim was said to be unethical for not discussing with his patient the differences between complementary medicine and conventional evidence based medicine. Yet there are significant risks associated with conventional medicine, and issues with the evidence that conventional medicine is said to rely on.
Under the same logic and consideration of ‘ethics’, should all doctors have a dissertation in their waiting rooms explaining the limitations of conventional medicine so that patients can be fully informed regarding the medical profession’s limitations and potential bias?
Most medical professionals are not expected to discuss with their patients the limitations of conventional ‘evidence based’ medicine to allow their patients to be able to make a full informed decision. Why should a physician be required to explain in detail that complementary medicine is not evidence based, yet the credible limits of evidence based medicine or its risks do not need to be divulged by any doctor?
It is unlikely that any doctor would explain fully to their patients the basis of their reliance upon conventional medicine and the evidence that supports that reliance. It is assumed to be without question or need for explanation. It must be asked what conversation the PSC expected to occur when discussing the difference between conventional medicine and complementary therapies? Would they have expected a conversation that details the risks of conventional medicine and the problems with the evidence base as detailed above?
If a medically trained doctor were to tell a patient of the percentage of adverse outcomes from medical treatment it might erode patient confidence and prevent a patient accepting necessary care.
What should a medical professional tell a patient if they are going to apply the standards of full disclosure?
If a medical professional was really to describe the difference between complementary health care and conventional health care should they be obliged to tell the truth?
A consultation with a client might go something like this:
Perhaps doctors should be obliged to inform patients that:
Media Interest – Why?
What should be noted about the Professional Standards Committee (PSC) decision is that there was no actual harm suffered by the patient and the medical care afforded the patient was not questioned. Any aspects of medical treatment, such as Vitamin B12 injections for mouth ulcers, was determined to be effective and appropriate.
If that fact alone is considered, this case sits oddly with the reported disciplinary cases against doctors who have violated their positions of trust as doctors in cases of medical malpractice or criminality where there has been serious harm to a patient, mutilation, sexual abuse or death. This case in no way resembled that.
It is extraordinary that this particular PSC decision was given any attention by the print media, let alone national media. The print media usually confines its reporting to the more salacious examples of doctors who have overstepped moral and ethical boundaries.
It is interesting that a recent story of alleged serious malpractice, where in Lismore (NSW) a local gynaecologist was reported by the Northern Star as having dozens of cases of sexual assault being reported against him, did not make it to the national press; yet, extraordinarily, Dr Kim’s reprimand over referrals for complementary care in respect of only one patient did.
Dr Kim’s treatment by the press appears extraordinarily out of proportion with the so-called ‘crime’ and it is to this we will turn in Part 2.
1. Prasad, et al. (2013). A decade of Reversal: An Analysis of 146 Contradicted Medical Practices. Mayo Clinic Proceedings. 88(8):790-798.
2. WHO, Patient Safety – Data and Statistics http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics )
3. Koenig HG. (2000). Religion, spirituality and medicine: application to clinical practice. JAMA. 284 (13):1708
4. WHO. (2016). Mental Health: strengthening our response http://www.who.int/mediacentre/factsheets/fs220/en/
5. Koenig HG. (2000). Religion, spirituality and medicine: application to clinical practice. JAMA. 284 (13):1708.
6. Xue CC., Zhang AL., Lin V., Da Costa C., Story DF. (2007). Complementary and alternative medicine use in Australia: a national population-based survey. J Altern Complement Med. 13(6):643-50
7. Brown JMT., Adams J., Grunseit A., et al. (2009). Complementary medicines information use and needs of health professionals: general practitioners and pharmacists. Sydney: National Prescribing Service; 2009.
8. Makary, M. and Daniel, M. (2016). Medical error—the third leading cause of death in the US. British Medical Journal. 353:i2139 doi: 10.1136/bmj.i2139
9. Clarke, O. (2014, January 16). 20% of NHS work does no good, says Welsh minister. BBC News. Retrieved from: http://www.bbc.co.uk/news/uk-wales-25753591