Why do good deeds sometimes fail to work?

Joan Escarrabill

Cities are looking for elegant solutions for severe and complex problems. Barcelona's Eixample can be a good example of an elegant solution. But in cities, sometimes, there are also critical points for which a good solution is never found. Glòries Square in Barcelona can be one of those critical points of bad solution: heavy traffic in all directions and subway and railway tunnels that pass very close to the water table. Many solutions have been proposed in recent years and the latest one has taken more than six years to come true. I do not know engineering or urban planning, but I am sure that the proposed design has been carried out by competent professionals who have sought the best solution or, at least, the best viable solution or the one that most minimizes the negative impact. I am also sure that the designers have thought about the needs of all the people who will be using the infrastructure. But from the very moment it opened, in early April, it hasn't worked and nobody seems to be happy about it. In real life, we have a difficult problem with the best possible solution and a bad result. How can it be that things well done sometimes don't work? I don't know, but I think the metaphor of Glòries Square in Barcelona helps me to comment on three articles I've recently read.

Is this the problem: too little (or no) innovation in service delivery?

Joan Escarrabill
 

Interdisciplinary team to evaluate patient experience

The meaning of words is sensitive to the determinants of space and time. The context gives meaning to the words. For example, what is the point of referring to cosmopolitanism as a remarkable quality when planetary interconnectivity is a generalized fact?(1) Without going into a debate about whether this "cosmopolitanism" is of any interest, can the same thing happen with innovation? The Mayo Clinic suggests that the main current problem is the lack of innovation in the provision of health services(2). The first question that this proposal suggests is whether innovation in the field of health has a "Darwinian" behavior, In other words, innovation is not linear, but is best explained by Stephen Jay Gould's (1941-2002) "punctuated equilibria" proposal: short periods of great agitation followed by long periods of calm or even lethargy(3). Maybe. Furthermore, perhaps innovation is not homogeneous in all fields.

Does anyone think about “the day after”?

Joan Escarrabill

It's all over. It's the way of life, as my grandmother would say. Health problems can end in different ways: a very specific treatment (the magic bullet), changes in the environment (sewerage and sanitary control of water), adaptation and coexistence with the disease (now there are people with tuberculosis, but we don’t need sanatoriums) and, for sure, we would still find others. The same thing will happen with the COVID-19 pandemic. Perhaps we will mitigate the impact of the pandemic with vaccines, perhaps we will have better diagnostic tools, and perhaps we will be better organized to follow up on cases or a combination of all of the above. It’s likely that, in the end, we will carry on living a long time with a highly contagious disease that, in some cases, has very serious consequences. What is certain is that this tension caused by the successive waves of the pandemic will end.

Pedal and ask

Joan Escarrabill

On November 18, 2019, the so-called Experience Exchange Space (EIE), a living lab, was inaugurated at the Hospital Clinic. Setting dates of notable events allows build ephemeris or, at the least, landmarks. They say that on November 18 William Tell shoot the apple from his son’s head (1307), on November 18 Mickey Mouse was also seen for the first time (1928) and it’s also the day of the year in which Niels Bohr died (1885-1962). Naturally, the inauguration of the EIE will not be part of any general reference, but it’s an important point in the approach to evaluating (and taking into account) the experience of patients in our Hospital. 

Disruption doesn't show on the tip of the iceberg

Joan Escarrabill

By chance, a couple of years ago, I found some images of Gediminas Pranckevicius, a Lithuanian graphic designer. Some of these images present a (small) upper part in which he describes familiar scenes, but the rest of the image (the lower part) is very complicated. The metaphor is automatic: there is (extraordinary) life in the submerged part of the iceberg.

Pinterest

Disruptive changes take place in the submerged part of the iceberg that, in a short time, change the image of the visible surface. Taxi is a service that is changing in a profound way. The digital press also gives us some clues. In New York, it appears that there are ten times more alternative taxis than conventional taxis, which has caused a decrease in the income of taxi drivers (by almost 30%), a reduction in the value of licenses and a negative impact on traffic due to the large number of vehicles that circulate without passengers. It's a significant problem from many points of view, and the most impressive thing is that these profound changes have taken place in less than five years.

In the end, everything requires trust

Joan Escarrabill

Book stores are still important. Despite social networks and the avalanche of information, good libraries are still a source of surprises. If a book store doesn't surprise - if you only find common or the latest ones - you won’t return. 

When visiting the Central del Raval in Barcelona, I have never left without having found surprises. The latest is Comprender la Democracia (Understanding Democracy), by Daniel Innerarity. Eighty dense pages, with meaning and suggestive ideas. It is essential to read books from different disciplines to be able to establish parallels and systematically avoid shared and inbred ideas. Therefore, when we talk about patient participation, it is very useful to do so from a conceptual framework away from clinical practice. Now more than ever it is convenient to reflect on participation based on a conceptual framework described by people who think about democracy. 

On average, humans have one testicle

Joan Escarrabill

This article deals with the interpretation of data. The title is an example made by Daniel Levitin in his suggestive book Weaponized Lies: How to Think Critically in the Post-Truth Era (Penguin Random House, New York, 2017), about the mistakes that can be made and the lies that can be said according to how numerical data is exposed. Obviously, the title of the article is exact. If the proportion of men and women is about 50%, certainly humans, on average, we have a testicle (and an ovary).

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.

Do we need "bonsai" hospitals?

Joan Escarrabill

The ideal size of the hospital and the minimal activity (number of procedures) it has to do to ensure quality is a recurring debate. Sometimes the issue of the hospital size is related to the primary care’s ability to solve and, therefore, the possibility of closing acute beds (and redistributing the budget that was intended for its operation). In the 2009 EESRI edition, in Table 10 (page 21), there’s a very significant information: the number of acute beds per 1,000 inhabitants. According to this document, in Catalonia we have 2.4 beds per 1,000 inhabitants and in the whole of Spain 2.5. Only Turkey (2.3) and Finland (1.9) have fewer beds per 1,000 inhabitants than we do. Despite the data, there are people who insist on the convenience of closing acute beds if the primary care resolution capacity increases. It seems to me that there’s a better question: too many beds or too many hospitals?

Men (of my generation) don’t cry

By Joan Escarrabill

Emotional training has changed over time. A part of the men of my generation were taught to contain their emotions. Men don’t cry. Publicly expressing certain emotions can be considered rude (or, worse, a weakness). Privacy (i.e. solitude) is the only space suitable for male emotions. The intimacy understood as a personal space that is never shared. Privacy is a right and, above all, a way of working. There are some things can only be the product of personal reflection, in the strictest privacy.

I know I simplify things. Maybe we should not talk about emotions and intimacy. Maybe we should talk about "privacy". But now there are a couple of phenomena related to digitizations that, at the very least, are at on the verge of privacy: the collective intelligence and transparency.

Collective intelligence challenges the individual reflection as a basic tool for understanding. Adding up is so powerful! Adding up from different perspectives gives unprecedented solutions to complex problems. But I will focus on transparency.

Facebook generation or my generation understand transparency differently. The generation of men who don’t cry understand transparency from a simple perspective "we must always tell the truth, but we don’t have to always tell it all" and the question is, "Can so much transparency become toxic?"

More material against low value clinical practices

How Many Contemporary Medical Practices Are Worse Than Doing Nothing or Doing Less? http://t.co/tUoybTcMSe & http://t.co/kXNYbBKMGR
— joan escarrabill (@jescarrabill) August 26, 2013

Dr. Joan Escarrabill is the Chronic Care Program Director of the Clínic Hospital. As a pulmonologist, he trained and developed his career in Bellvitge Hospital, where he had the opportunity to exercise various responsibilities in the field of clinical management. And now he has given us the selected tweet that leads to "Mayo Clinic Proceedings".

If you click on the two links from Dr. Escarrabill’s tweets, you’ll reach a project (and the introductory editorial) which reviewed over two thousand articles published over 10 years in the New England Journal of Medicine with the rank of "Originals". This work has identified 146 studies that advise stopping certain medical practices that are failing to demonstrate expected clinical outcomes.

Therefore, Dr. Escarrabill with his tweet, offers us a new key to strengthen programs calling for clinical practice to focus only on the actions that are known to add value to the health of people (see posts from: "Too much medicine", "Less is more", "Choosing Wisely", "Do not do" and "Projecte Essencial"). This movement of clinical containment led by professionals is taking shape in the United States under the name "The Right Care Alliance".