The woman who has been studying our medical regulator for decades just shocked me to my core.
Marie Bismark, a professor at the University of Melbourne and a doctor herself, has just one piece of advice after years of research.
Never go to the doctor by yourself. She has a husband and three adult children - if anyone needs to go to the doctor, there is a family roster set up so you never have to walk alone into a medical practice.
She's been researching how the Australian Health Practitioner Regulation Agency (AHPRA) and the National Boards work for decades. Their mission? To ensure that Australia's registered health practitioners are suitably trained, qualified and safe to practise. But it's hardly failproof.
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Little trace of the disease. Absolutely heartbreaking.
And yes, Simon Gordon's work prompted multiple complaints by clinicians and patients to hospital management and medical regulators. Nevertheless he persisted. He's retired now, apparently. At least I can't find him on the list of practitioners.
Milligan's story was terrifying. Complaints ignored, even complaints of fellow practitioners. Young women maimed.
What happens when we feel as if our medical professionals are letting us down? Bismark describes AHPRA as a system set up in order to protect patients. It's an avenue for complaints.
"The case shown on Four Corners tells us that the system is not always working as it should."
Bismark says there are real concerns about how the cases were triaged. Who made the decision about what level of investigation should be in these cases?
"Part of what we're seeing is the importance of having independent medical advice when a complaint is received rather than just relying on a response from a doctor which may on the face of it sound credible."
She points out that the independent medical advice should have expertise in the area. Love GPs but not sure they'd be all that good in considering the necessity of laparoscopic surgery.
Then Bismark makes another scary point. It's not about this case or that case - it's the pattern of all the cases.
"We know from our research that past behavior is the best predictor of future behavior. I have been very strongly advocating for AHPRA and Health Complaints commissioners to have a greater focus on identifying patterns of concern."
What she means is this: one case or another may not get across the line for disciplinary action. "But when you put the five cases together, it's like putting five pieces of a puzzle together and suddenly you can see a much clearer picture of concerns."
Of course, we patients don't get to see the whole picture. The AHPRA website is dodgy as. Can I see who is in trouble and for what? It tells you if there are conditions, undertakings or reprimands on a practitioner - but what happens if there are a series of complaints which end up going nowhere? That just disappears into thin air. We can't see a pattern because AHPRA appears to be very concerned with protecting reputations - and maybe not so much with protecting patients. Also, undertakings are voluntary and are a legally enforceable measure.
MORE OPINION:
Maybe Mark Butler needs to enforce a total overhaul of what is communicated to patients about individual practitioners because we sure as hell won't get any information from private hospitals who will protect their cash cows at all costs - even if that cost is the happiness and safety of patients. One senior surgeon says there are people who are raising concerns about the cultural factors and systems factors which allow for this kind of failure to happen - but until hospital management listens to whistleblowers and changes culture, patients will continue to be at risk.
A special note to the folks at Victoria's Epworth. As my mum might have said, maybe you need to take a good, hard look at yourselves. Money isn't everything.
Bismark tells me that there has for years been an approach by the medical system (not just AHPRA) to diminish women's pain. "There's not enough attention to the experiences of those women or enough credibility given to the experiences of being harmed by the medical system."
And Bismark's research shows that when complaints happen, AHPRA is more likely to act when the complaints are from another practitioner rather than from an unhappy patient.
But that may all be about to change. AHPRA's national manager regulatory experience and engagement is leading a project to really listen to those with lived experience - and the research began before the current problems were aired on television. There is another reason to believe people on the team can make change - some have personal experience of those who have lived with serious chronic illness and has advocated for them throughout their lives. Some came to AHPRA because they were already consumer health advocates.
And heaven knows, it needs several of those.
In the meantime, you can advocate for yourself. Never go to the doctor alone. If that's Marie Bismark's rule, it should be yours too.