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.

Monday, 30 July 2018

The slow progress of clinical safety, a problem of "many hands"

Cristina Roure


In this section we usually discuss overdiagnosis and overtreatment, but today we will talk about the difficulty in achieving safe care environments for patients.

Some will remember the publication in the year 2000 of the report “To err is human. Building a safer Health System” by the Institute of Medicine's Quality Care, which created a big impact in the media due to the alarming figures of deaths caused by medical errors in the USA. (1). Since then, a lot of work has been done in order to improve patient safety, and a lot of progress has been made for the dissemination of the clinical safety culture, and a great deal of effort and resources have been devoted to the implementation of safe practices for reducing the risk of medical errors.

Monday, 23 July 2018

10 priorities for integrating physical and mental health, according to The King's Fund

Andrés Fontalba


The current health care model that classifies patients by system or medical specialty categorises care to for any health problem. The causal attribution to diseases according to the psychic vs. organic dichotomy inhibits seeing the process of the pathologies in their totality and contributes to the problem of patients taking their illness from one service to another, with the risk of overacting in some cases or of non-holistic intervention method of integrated solutions in other complex cases.

Monday, 16 July 2018

Health incentives: don’t shoot the behavioural economists!

Pedro Rey



The debate on the allocation of (economic) incentives associated with the performance of health professionals has been relevant for a long time. A few months ago, VOX has published an editorial with a very clear title: Paying Doctors Bonuses for Better Health Outcomes Makes Sense in Theory. But it doesn’t Work. The article cites numerous recent studies, such as this one on the United Kingdom or the United States, that show no effect of giving incentives to physicians either in their clinical practice patterns (inputs) or in health outcomes (outputs). A systematic review of studies on "pay for performance" (P4P) in the Annals of Internal Medicine reaches similar negative conclusions. However, a marked anti-economist tone of these articles emerges that I believe comes from a confusion. According to these articles, economists only know how to prescribe the use of incentives, without evaluating their effects, and also the incentives that we advise are only monetary and don’t appeal to the many different motivations, not only monetary, that can affect doctors decisions.

Monday, 9 July 2018

Do we need audits or indicators to control the quality and safety of health centres?

Mª Luisa de la Puente 


Are care indicators useful in detecting the quality problems in hospitals? This question, which seems obvious, has its crumb. Alex Griffiths, of the School of Management at King's College London, has just published the results of a study of the usefulness of health indicators as predictors of the quality of care of English hospitals and the conclusion is that you can’t trust them too much.

The Care Quality Commission (CQC) is responsible for ensuring the quality of health and social services in England (more than 30,000 providers). Due to the scarcity of resources to carry out on-site inspections, the CQC used statistical surveillance through health indicators to prioritize those hospitals that had quality of care problems and subsequently send inspectors to these centres. The inspectors’ mission is to analyze the situation and give support to the suppliers for the orientation of the improvements. What was surprising to see was that the instrument "Intelligent Monitoring" (IM, scale of risk composed of 150 indicators, among others waiting list, mortality, surveys of users and professionals, etc.) is not able to predict which hospitals present quality problems or discern between those that work well and those that need improvements (compared to the classification of sanitary inspectors).

Monday, 2 July 2018

Improving the emergency and territory services: defragmenting the system

Xavier Bayona



In several articles of this blog you can read that one of the challenges to overcome in our and in most healthcare systems is the excessive fragmentation in health care that inevitably leads to duplication of tests and other dysfunctions that create pockets of inefficiency and malfunction. Several proposals to improve the continuity of care and reduce fragmentation have been presented with the aim of improving the quality of citizen attention, increasing the effectiveness and efficiency of the system.

Fragmentation is also present in emergency services. So if we look to the NHS, we can find a report published by the Royal College of Emergency Medicine with the Patients Association (Time to Act-Urgent Care and A & E: the patient perspective) published in May 2015, which concludes that primary care emergency services should join with those of hospitals. In this regard, as early as 2013, Bruce Keogh, medical director of the NHS, made the same recommendation. it’s commented within 2015 report that joint placement services should include emergency physicians, family physicians, nurses, frailty care, palliative care and mental health teams. It’s also commented that pharmacists and dentists could also contribute to the efficiency and effectiveness of the service.

Monday, 25 June 2018

The red line of health data

Elena Torrente




The great technological giants (Google, Apple, IBM or Microsoft) are recruiting scientists and experts in medical research. Their commitment to transform medicine is decided, but John T. Wilbanks and Eric J. Topol warn of possible risks in this interesting article published in Nature. Given the difficulties that medical research has always encountered in obtaining health data, the authors believe that it may be tempting for clinical scientists to access large-scale Internet projects, with significant data collection capabilities and algorithms for analysis.

But there is a risk that Google or other smaller companies such as 23andMe, will access health data with the aim of controlling the methods used to offer certain services based on digital profiles. This is what in other sectors of the Internet is called the society of the "black box". There are ads that are only offered to certain groups of people and if these algorithms incorporate health data, the authors say that pre-existing biases in our society would increase along with inequalities.

Monday, 18 June 2018

Vinay Prasad: Why is 40% of clinical practice wrong?








On May 18, Vinay Prasad offered a conference in Barcelona as part of the 5th "Right Care" Conference of the Clinical Management Section of the Catalan Society of Health Management (SCGS), where we had the opportunity to invite him to explain why he had created (with Adam Cifu and other collaborators) the list of 146 clinical practices that would have to be reversed and what are the criteria they had been used.

What is medical reversal?

According to Prasad, a medical reversal is the need to stop a clinical activity because a well-done study, usually a clinical trial with finalist indicators, shows that in fact, the desired results are not achieved, or that the adverse effects do not compensate the benefits. The speaker gave some very diverse examples, such as the Swan Ganz catheterization to monitor the hemodynamic balance of patients in shock, the hormonal treatment for post-menopausal women in order to reduce coronary or cerebral vascular risk and the placement of coronary stents in patients with stable angina to reduce the risk of infarction, increase survival or even to delay the effort angina. In all three examples, consistent clinical trials have shown that these were clinical activities that, in practice, did not meet the set objectives, and in addition had side effects, which were not unimportant.

Monday, 11 June 2018

Radiologists and incidental imaging findings








A group of radiologists from several American university hospitals (Massachusetts General, Cleveland, Brigham and Women's, etc.) started a debate in the Journal of the American College of Radiology about the eventuality that radiologists would stop reporting the incidental imaging findings lacking clinical significance. "The traditional role of the radiologist," they say, "is to warn of everything they see, leaving the interpretation of the findings’ relevance to the referring physician”. However, we now open the opportunity to go further, and not just intervene by saying, for example, that an observed abnormality is benign, but also taking the decision not to report the milder ones, given the possibility that our opinion generates confusion and ends up causing excessive medical actions".

Regarding level I renal cysts of the Bosnian classification

The radiologists who authored the article used the findings of renal cysts, which are very frequent with a prevalence of 36% in patients over 80 years of age, in order not to inform of renal cysts of level I of the Bosnian classification in their reports, in accordance with the following criteria: a) the cyst is not the reason for the examination, b) doesn’t generate local problems, c) has no malignant potential, and d) is not likely to generate a polycystic kidney disease.

Monday, 4 June 2018

Coronary Bypass and Hemodynamics: the amount matters








In the article "Comparing hospital performance within and across countries: an illustrative study of coronary artery bypass graft surgery in England and Spain", signed by a Spanish-English team in which Sandra García Armesto (IACS) and Enrique Bernal (REDISSEC) participated, it was concluded that the Spanish hospitals of the study operated in general with a smaller number of cases than the English (it was coronary bypass). Therefore, it is suggested that the number of cases intervened should be a tracer that could explain why mortality from this process is twice as high in Spain as in England.

European Collaboration for Healthcare Optimization (ECHO) is a European network of administrative databases for the analysis of clinical practice variations. In the following article: "Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine Safe Threshold", carried out by almost the same authors as the previous one, based on data from the ECHO project, confirms that for interventions of coronary bypass there is a clear relationship between volume and mortality and concludes that the minimum limit of interventions of a cardiac surgery team, if you want to safeguard the safety of patients, should be 415 per year. In the following graph (from the previous article) it is observed how the Spanish hospitals that participated in the study (dark spots), generally underwent fewer coronary bypasses (many did not reach 200) and showed greater mortalities.

Wednesday, 30 May 2018

In the rescue of health leaders and health guides

Salvador Casado





In the area of public health, where I have been working for a long time, we have suffered a profound crisis of leadership. Although all positions of responsibility are well filled and more and more management positions are being designed, paradoxically it is rare to find managers or professionals who lead teams towards specific objectives or missions that open new paths.

The usual path is the protocol, not to get out of the established, to avoid changes and innovation and not to leave the office or the consultation to skip hazards.

This attitude in management staff is being imitated by ordinary professionals who follow their instructions. The overload of care and institutional neglect cause family doctors to barely leave their offices to implement some community activities, nurses and social workers the same and in hospitals everything is considered within the service interacting as little as possible with primary care services or other agents.

Monday, 28 May 2018

Overdiagnosis in depression: there are doors better left closed

Andrés Fontalba




A young Cecilia, aged 13, in Sofia Coppola's brilliant film based on the homonymous novel, "The suicide virgins" advised:

-Obviously doctor, you were never a 13-year-old girl.

It’s obvious that depression in children and adolescents is an important cause of disability and generates great suffering for the person and his or her environment, requiring specific management adapted to the needs of that peculiar age. Based on the severity of this pathology, the availability of effective screening tools in the detection of depression, and a treatment that improves prognosis, the United States Preventive Task Force in 2009 recommended the screening for depression in all adolescents in a medical and integrated with mental health services setting, despite not having any previous trials that would justify this intervention.

Monday, 21 May 2018

The English surgeon, talking about Henry Marsh








Not too long ago, after having read his book "Surgery, the ultimate placebo", I wrote about Ian Harris, an Australian traumatologist. I remember that Harris defends the rigor in the surgical indications after having observed that more than half of the surgery that is practiced does not have enough support of consistent scientific evidence. Now I have finished the book "Do no harm", by Henry Marsh, an English neurosurgeon at the lintel of retirement, and I am inevitably immersed in the comparison between the two texts: first, Harris's, is written by someone who loves surgery and believes that too often is practiced with little rigor, while the second, Marsh’s, is a biography of great literary level, elaborated from the notes that the surgeon has been taking throughout his career, not in vain has he received several recognitions. Marsh, like Harris, is passionate about his work, but his literary contribution comes not from scientific exaltation but from the knowledge he has accumulated from his own mistakes. The veteran English neurosurgeon has not published any revealing research nor has he led any innovative discovery. His honesty and his hands are his strength.

Monday, 14 May 2018

Self-management: Buurtzorg Identity








Frederic Laloux in "Reinventing organizations" describes the teal-evolutionary companies as those based on the personal growth of their employees and chooses Buurtzorg Netherland as an organization to which we should be paying attention to if we are among those who believe that the time to do things differently has arrived.

What is Buurtzorg Netherland?

Buurtzorg Netherland is a non-profit company, which was founded in 2007 in the Netherlands, when a group of community nurses rethought their work and came to believe that, instead of only going to homes and exercising the functions of their profession, they should advance to becoming the patients’ referee and take charge of attending to their global needs.

Monday, 7 May 2018

I don’t know ... but it seems to me that times are changing

Joan Escarrabill




Health care’s future is an issue that is debated multiple times. The most academic visions or those that start from the observation of reality have common elements. Increasing the number of professionals (more doctors and nurses are needed, is strongly agreed), to the extent that the weight of the hospital will be reduced and interventions in the community will gain prominence, health education of the population is very important or in what way are we going to create sustainability in a system that has contributed significant improvements during the last years, can be just a few examples of these common places of all the debates.

Monday, 30 April 2018

Could we organize ourselves in a different way?








Frederic Laloux, in "Reinventing Organizations", a revealing book, at least for me, invites us to rethink the way we manage companies. The age of the internet, he says, has precipitated a new vision of the world that contemplates the possibility of a distributed intelligence instead of a vertical hierarchy. According to Laloux we should be able to invent a more powerful and meaningful way of working together if we would change our belief system.

In the first part of the book, the author makes an evolutionary analysis of the way in which humans organize companies, which I found colourful and insightful, and that is why I have prepared a summary (for more details I recommend going to the tables that are at the end of chapters 1.1 and 2.3):

Wednesday, 25 April 2018

Weapons of mass distraction in the National Health System

Salvador Casado




When we go to a health professional's office there are recurring constants, white coats, stretchers, blood pressure monitors and a computer on the table. The medical record is no longer a folder full of paperwork, but an electronic form on which health professionals work. There is no doubt that it has many advantages over the previous format but it has not yet been able to correct its major flaw: its great power of distraction of the professional who uses it.

The limitations of design and usability mean that at each clinical meeting a considerable amount of time has to be devoted to registering, filling in numerous protocols and making requests for analyses, consultations to other professionals or issuing prescription, bureaucracy  or reports of any kind.  The perception of many patients is that health professionals look at their screens more than they do at themselves, and that's usually not cool.  Nor is it a dish  for nurses and doctors who see how their limited time is spent on tasks that prevent them from devoting dignified attention to the people they attend.

Monday, 23 April 2018

Debate with Vinay Prasad on the value of clinical practice and doctors’ training








Vinay Prasad (University of Oregon) and Adam Cifu (University of Chicago), authors of "Ending Medical Reversal: Improving Outcomes, Saving Lives" (Johns Hopkins University Press, 2015), point out 146 clinical practices that should be ditched because it has been proved that they do not deliver the promised results. The list of these practices affects the whole range of the health activity; however, making a detailed reading, it has been observed that these are mainly found in four specialties: cardiology, gynaecology, orthopaedics and family medicine. It’s because of this reason that the Section of Clinical Management of the Catalan Society of Health Management (SCGS), in its Annual Conference to be held on May 18, in agreement with the team of the project Essencial of AQuAS, has organized a debate between one of the authors of the book, Vinay Prasad, and representatives of the 4 mentioned specialties: Xavier Viñolas, president of the Sociedad Catalana de Cardiología (SCC), Juan José Espinós, gynecologist at the Hospital de Sant Pau, Joan Miquel, orthopaedist at the Hospital de Igualada and Marta Expósito of the Sociedad Catalana de Medicina Familiar y Comunitaria (CAMFIC). The debate, which will rely on the moderation of Sandra Garcia Armesto, director of the " Instituto Aragonés de Ciencias de la Salud ", aims to not only find out first-hand about the work of Vinay Prasad, but also to find out what the related specialists think of these practices and what is the impact on our situation, differentiated in many aspects from that of the United States.



On the other hand, Prasad and Cifu, in the book, propose to significantly modify the training programs in medical schools, in order to train new physicians that are more demanding with regards to scientific rigor, more critical of practices with poor value, more sensitive to the needs of patients and more oriented to the evaluation of results. The proposed formula is very simple: the clinical sciences should be the priority, while the basic ones (as we understand them today) should be complementary. It’s not about studying models and then checking them (current system), but about doing it the other way around: from the findings of the clinic, doctors should review (or accept) the theories. Given the importance of the proposal, we thought it appropriate to organize, in the same framework of the Conference, a second debate moderated by Xavier Bayona, with three academic authorities in the training of doctors: Francesc Cardellach (Universitat de Barcelona), Ramon Pujol (Universitat de Vic - UCC) and Milagros García Barbero, president of the Sociedad Española de Educación Médica and, logically, also inviting Vinay Prasad to join them.

The program of the Conference is attached, with the clear purpose of encouraging all readers to register, because nobody should miss out on the opportunity to listen to and pose questions to Vinay Prasad and all invited speakers.






















Organizes:
  • Clinical  Management  Section  –  Catalan  Healthcare  Management  Society 
In  collaboration  with:
  • IDIBAPS.  Institut  d’Investigacions  Biomèdiques  August  Pi  i  Sunyer  
  • Centre  de  Recerca  en  Economia  i  Salut  (CRES)  –  Universitat  Pompeu  Fabra  
  • Institute  for  Healthcare  Management  -  ESADE  
  • Agency  for  Health  Quality  and  Assessment  of  Catalonia  (AQuAS)  
  • Hospital  Clínic  de  Barcelona  
  • Aragonese  Institute  of  Health  Sciences 
  • Catalan  Society  of  Family  Medicine  (CAMFIC)  
  • Catalan  Society  of  Cardiology    
  • Catalan  Society  of  Gynecology  and  Obstetrics  
  • Catalan  Society  of  Traumatology  and  Orthopedic  Surgery  
  • Cochrane  Iberoamérica  
Sponsors:
  • Vifor  
  • Unió  Catalana  d’Hospitals  
  • Consorci  de  Salut  i  Social  de  Catalunya  
  • Novartis  

Monday, 16 April 2018

To optimise the expense, the cost must be reduced

Josep Mª Monguet




It’s well known that the budget allocated to health services has endured brutal cumulative reductions over recent years. This is a detrimental fact, but one can not deny the merit of having suffered and then having survived the cut, the professionals - in the first instance and the users alike. It’s sad but praiseworthy.

The health budget is unlikely to improve in the short to medium term because the situation is what it is and by definition the public deficit has a ceiling. Lamenting that resources were not well managed during the "good times" doesn’t change anything. Although it seems a contradiction, the financial management cannot be improved if the health system and its users, collaboratively, are incapable of reducing the avoidable costs that weigh us down. Only thus we can free up resources and allocate them to make the system more efficient.

Monday, 9 April 2018

Home sweet home and some other lessons

David Font




An article in the New England Journal of Medicine explains that the Department of Health in Victoria, Australia in 2010, announced the construction of a 500-bed hospital without using bricks. This virtual hospital currently receives 33,000 patients per year. And the introductory paragraph of the article ends by asking: What was the incredible technological progress that made it possible? Caring for the patient at home!

Let's continue without leaving the house. I remember post by Jordi Varela introducing the experience of Buurtzorg Netherlands, the Dutch home care company, described as a success story by King's Fund. During a Congress in Barcelona, I heard Jos de Blok, the leader of the project, explaining the experience as a paradigm of innovation success. Let's see why.

Monday, 2 April 2018

Plea for the end of clinical practice guidelines








James McCormack, a professor of pharmacy at British Columbia University, posted on his YouTube channel, a video clip that adapts the song of the Traveling Wilburys group, "End of the Line", to become "End of the Guidelines". The video begins with a scene from “Life of Brian" where the actor Graham Chapman as a fake Jesus Christ, addresses his followers from the window of his house and says: "You are wrong; you have no need to follow me. Follow no one; be yourselves, each of you is a different person."




Monday, 26 March 2018

Inappropriate use of large healthcare structures








The healthcare system has many resources that can be used appropriately, or not. Think of the child with fever who leaves the paediatrician’s office with a prescription of antibiotics, the elderly lady who ends her days in an intensive bed, when, in their case, a palliative action would have been more appropriate or the person with a moderate headache, without other neurological manifestations, which, by insistence, ends up undergoing a tomography. George Halvorson, in "Health care will not reform itself", echoes an investigation that, after reviewing 5 million medical records, concluded that waste due to clinical practices that don’t add value could be considered to reach at least 25% of the total health expenditure.

This waste affects practically all areas of healthcare, but now I would like to focus on what happens with the inadequacy of the use of large health structures: operating theaters, emergencies units, intensive care units, wards and primary care.

Monday, 19 March 2018

Experience versus evidence, regarding Ian Harris








Professor Ian Harris, author of the book, "Surgery, the ultimate placebo", is a traumatologist who directs a research unit focused on the results of surgical practice in Sydney. Harris says in the book's introduction: "Lack of evidence allows surgeons to practice techniques for the simple reason that they have always been done, because they learned them from their mentors, because they are convinced that it works or simply because it does everybody. It's easier to have no problems if you behave like most colleagues, my argument, says the author, is that trusting tradition and perceptions often leads, in terms of clinical effectiveness, to unconvincing results."