Monday, 17 September 2018

About the bicentenary of the stethoscope

Xavier Bayona

If there is a universal symbol of the health profession, besides the white coat, we certainly find it in the stethoscope. Laennec, in 1816 at the Necker Hospital in Paris, began his first studies in auscultation by means of an instrument he gave the name of stethoscope, derived from the words στηθος (chest) and σκοπεω (examine). Until that moment the auscultation was performed with direct listening placing the ear on the chest (already performed by Hippocrates). This direct listening had its practical limitations both in the transmission of sounds and for issues of modesty related to the gender of the patient if she was a woman (the doctors were mostly men) or for hygiene.

But technology has moved ahead and at this time clinical ultrasound, also called the "new phonendoscope", is now available to all healthcare groups. The ultrasound has improved its resolution and has decreased in size, becoming more portable and its price has also dropped. In this sense, some media such as the National Post recently wondered if the stethoscope is in its final stages following a congress held in Canada. Diagnostic ultrasound or sonography, popularly known as ultrasound, has had a very rapid evolution thanks to its innocuousness, facilitating the possibility of repeatedly performing echographic scans to the same patient, without risks, without expensive preparations and at a relatively low cost.

The news is good: improvements in ultrasound technology and its generalization allow improvements in the accuracy of diagnoses. But as in everything, when technology is more achievable, new difficulties appear. In the first place; a few years ago the debate began on the competences regarding which specialists can be adequately accredited and for what use. It has already been demonstrated that, for example, the "focal ultrasound" for systems, focused on clinical problems (and not conventional exploration), it improves treatments by improving the diagnosis (in precision and time of performance). The use of ultrasound in emergencies and urgent situations encompasses numerous new fields oriented in the use of ultrasound by the same specialist who treat critically ill patients both in in-hospital settings (such as in emergency or intensive care rooms) and in pre-hospital settings. In non-critical patients, the use of clinical ultrasound in primary care has also demonstrated added value by improving diagnosis, avoiding referrals and in short, bringing the resolution closer to the citizen's bedside.

The concern of professionals specialized in diagnostic imaging, or other specialties that use ultrasound as the usual diagnostic mechanism, is logical: how should the generalization of the examination be made to specialists from other settings with all the necessary guarantees? Fortunately, the different scientific societies involved in the process and the administrations have been working for a few years now to build the framework that guarantees the suitability for the implementation of the exploration outside the diagnostic services for the image and the ultrasound rooms.

Thanks to all these efforts, progress in ultrasound extends both in and out the hospitals and imaging diagnostic services. The use of ultrasound extends to almost all specialties and especially to primary care doctors and ultrasound commonly exists in many community health centres. Primary care health professionals need the means to support them in their work in order to provide the best assistance to the patient and ensure their diagnosis. Ultrasound is a technique that can help and support this clinical decision process.

Looking ahead to the near future, what will become of the stethoscope? My vision is that for several years it will continue to coexist with the extension of ultrasound in more generalist profiles. But in a few decades, most likely when ultrasound is taught in university medical studies, the "phonendoscope" will end up being a means of residual exploration.

Monday, 10 September 2018

Tolerate uncertainty: the pending revolution

Arabella Simpkin (Harvard Medical School) and Richard Schwartzstein (Beth Israel Deaconess Medical Center) have published "Tolerating Uncertainty - The Next Medical Revolution?", An article that inspired me to continue with the speech I began in "Against the medicine of manual ", following the reading of “When doctors don’t listen” by Leana Wen and Joshua Kosowsky.

"Although physicians," the authors say, "know that the uncertainty lies in clinical work, the current culture of medicine pushes them to give unequivocal answers, often impossible or even implausible yes/no answers, essential for labelling codes, which pretend, clumsily, to pick up narratives full of nuances, coming from people full of doubts or even forgetful. "

Monday, 3 September 2018

The potential of shared decisions

The “Essencial” project of the Quality Agency and Health Evaluations of Catalonia (AQuAS) held a day of reflection on the level of implementation of the recommendations to avoid low-value clinical practices hence those responsible for “Essencial” had the good idea to invite Glyn Elwyn, a researcher specialized in shared decisions at the Dartmouth Institute, to give the inaugural lecture in Barcelona.

According to Elwyn, as seen in the slide: "Shared decisions are a way of acting in which doctors and patients make decisions together, making use of the best available evidence on the probabilities of benefits and adverse effects of each option, relying on patients receiving the necessary support to obtain contrasted information about their preferences." Along this line, a systematic review of the Cochrane Collaboration shows that people who have had the opportunity to make clinical decisions with the support of specific materials (decision aids) admit feeling more prepared, more informed and have the clearest ideas about the value of their clinical processes, and they are probably more aware of the risks of each step they take.

Monday, 27 August 2018

Against cookbook medicine

"How can modern medicine be so dehumanized?" is a question posed by Dr. Leana Wen and Dr. Joshua Kosowsky in “When doctors don’t listen”. According to them, with a few exceptions, the practice of medicine is subjugated by the dictatorship of guidelines, algorithms, codes, protocols and rules. "Cookbook medicine" they call it. Everyone is aware that many requested tests are unnecessary and that many people are subjected to anxiety induced by the prescribed manual diagnostic processes to rule out infrequent pathologies. The theory of the book is based on the fact that the process to arrive at a diagnosis is complex, requires an interview in which the patient can frankly express the story of what is happening to him, a physical examination according to the hypotheses that arise and a clinical reasoning participated by the patient himself; all this, very far from a manual practice.

Monday, 20 August 2018

The ancestral optimism and the perfect storm

The optimism of patients

When people get ill, or are afraid of being ill, as a rule we tend to trust doctors and by extension, health systems. But do we really benefit? A systematic review, developed by researchers from the Centre for Research in Evidence-Based Practice of Bond University (Australia), based on 35 surveys (27,323 patients as a whole) concludes that 88% of people overestimate the real benefits of the clinical actions, while 67% underestimated the adverse effects.

See for example, the expectations of people in being able to reduce the risk of dying from secondary prevention programs for breast, prostate and bowel cancers are far above the real data. The dark part of the bars corresponds to the percentage of respondents who overestimate the benefits of the respective preventive tests, and the crosses on the right indicate for which of them this percentage is equal to or greater than 50%.

Monday, 13 August 2018

Effective communication for planning living will

Gloria Gálvez

Planning living will is a key element for the care and attention of people with advanced chronic diseases and their families. In recent years, models and proposals have been developed throughout the Spanish territory, such as in Andalusia or Catalonia, based on respect for the person and framed in quality care, taking into account their wishes, expectations and preferences.

The communication within planning living will has been shown to have important benefits when a terminal process of the patient is expected, since a shared decision-making process is established in a trusting environment, at the same time as it’s incorporated in to the family and relatives care planning. Addressing these issues effectively involves doing so at the moment when the patient still retains his decision-making capacity, that is, at the earliest time of his hospitalization. Doing it later may pose a greater risk of aggressive and unnecessary treatments.

Despite their high therapeutic value, professionals report great difficulties in maintaining a fluid communication with a terminally ill patient. In a recent Canadian study published in the journal JAMA some of the reasons for this difficulty are described as: uncertainty of the prognosis, fear of causing distress or perception of patients being unprepared to talk about it.

The Catalan Institute of Oncology (ICO), a world reference centre in the design and evaluation of public palliative care programs for the WHO, with Dr. Gómez Batiste at the helm, has designed a new model of palliative care at the Institute in which it is proposed that communication with the patient follow a strategy based upon open questions, considered key to detecting their basic needs: How do you feel? How do you perceive your current state of health? What are you worried about? What do you think may happen in the future? What do you think would help you fight this situation? What do you need us to do for you?

Dr. Gawande, in his book Being Mortal, also proposes some key questions that can help professionals have a quiet conversation about the end of life process. Faced with this open approach, there are those who propose a closed script with previously prepared themes. This can be quite a challenge due to the different barriers that have been expressed by professionals, such as the fear of eliminating all hope that the patient may have regarding his illness.

Both strategies have advantages and disadvantages: the open format allows the patient to express fears or questions that the professionals had not foreseen, and the closed format could facilitate professionals in asking potentially difficult questions. To illustrate the post, I leave the video in which Dr. Meier, a doctor at Mount Sinai Hospital and director of the Centre for the development of palliative care (CAPD) in the USA explains the 10 essential steps in communicating with patients and family members receiving palliative care:
  1. Review the patient's clinical situation.
  2. Prepare a decent, comfortable space with privacy and confidentiality.
  3. Present the attendees and comment with simplicity on the objectives of the meeting.
  4. Find out what the patient knows about his illness.
  5. Explore what the patient wants to know: ask/explain/ask. Ask about the required information.
  6. Explain the thorniest details required by the patient.
  7. Ask if they have understood the terms used and encourage them to repeat them in their own words.
  8. When faced with difficult questions such as: Am I going to die? Simple and clear answers: Yes, you will die and we will be permanently by your side, watching over your welfare to the maximum.
  9. Analyze the therapeutic options, without deceiving but without denying reasonable hopes.
  10. Organize and plan the next visit.

Communicating is also being able to know how to listen; it’s a key aspect in knowing what the patient's situation is at each given moment. For active listening to work, it’s better to move away from paternalism and facilitate the patient's participation in the decisions that best preserve their dignity and freedom.

Monday, 6 August 2018

Clinical practice guidelines versus shared decisions

In the April post I was talking about the call for the end of clinical practice guidelines. This is an issue that is generating controversy and I think it’s worth revisiting, especially following the publication of “Making evidence based medicine work for individual patients” by Margaret McCartney and collaborators, where they say that there is concern because the guidelines, instead of reducing variations and improving the quality of assistance have managed to bureaucratize medicine, while at the same time reinforcing historical authoritarianism. This happens because, according to the authors, based on the evidence, the guides encourage doctors to ignore the real needs of the people they serve. In addition and to top it all, a review concluded that 62% of the guidelines were based on irrelevant evidence for health problems affecting people visiting the family doctor.