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.

Make Evidence-Based Medicine Great Again!

Cristina Roure
 

“Make Evidence-Based Medicine Great Again!” is the provocative title of a conference that Dr. Domenico Pagano delivered at the 56th Congress of the American Society for Cardio-thoracic Surgery, calling for the need to restore professionalism, integrity, and trust in data and evidence in medicine. The conference is long, it lasts 55 minutes, but Pagano makes a brilliant presentation on the increasing manipulation that has led us to the swamp in which evidence-based medicine (EBM) currently inhabits.

Taking action in patient-centred care

Nacho Vallejo

 

Frame of the series New Amsterdam

Talking about patient-centred care in our healthcare organizations may sound hollow or a tradition of good intentions. There are very attractive topics such as "patients first". In any case, putting patients first, abandoning traditional medical paternalism, has at times become an excuse to configure a variety of intentions that risk being left in symbolic speeches. I believe that one of the reasons that don't allow progress in this task is the need to specify it in actions that the ordinary professional can understand and carry out, checking its benefits and its results.

Shared decisions, evaluate to advance

Jordi Varela

Editor

The progress of shared clinical decisions is being almost negligible and, for this reason, attention should be paid to the results of the clinical trial by Víctor Montori's research group, an evaluation that was carried out with almost a thousand patients with atrial fibrillation. which ones had to decide if they wanted to take anticoagulants and, if they did, which one they would choose. In the trial, the intervention group of patients tested a shared decision support instrument, while the control group followed the usual clinical pathway.

The individualistic short-sightedness of health care

The Global Action Plan for the prevention and control of non-communicable diseases of the WHO aims to reduce by 25% the premature mortality due to these pathologies by the year 2025 (strategy 25 x 25) and, therefore, concentrates on strategies that reduce the following 7 risk factors: a) alcohol consumption, b) insufficient physical activity, c) tobacco consumption, d) high blood pressure, e) excessive salt intake, f) diabetes, and g) obesity. Confronted by this individualistic drift of public health, an international group of researchers has published in the Lancet the results of a meta-analysis with 48 cohort studies and 1.7 million individual records, where they have shown that poverty has more explanatory force by itself over the number of years of life lost that many of the factors 25 x 25, in addition to having an undeniable cross-influence by enhancing the aforementioned risk factors. It’s important to clarify that the cohorts selected by the researchers correspond to first world countries, so the analyzed groups of low socio-economic level  represent poverty pockets that are basically concentrated in deprived neighbourhoods of large cities or in certain collectives such as the destitute or the immigrants.

Cancer research: little science, big data or big science

Apparently, the duration and costs of clinical trials of new oncological drugs could be reduced if surrogate measures, such as tumour reduction or time to progression, were to be used instead of survival, but a meta-analysis of 146 clinical trials of colorectal cancer and 191 of lung cancer found that only 10-16% of survival was explained by these variables; obviously a poor correlation. On the other hand, there is the question of the methodology used. A review of 43 studies found that, in 81% of the cases, promising results from phase II (without a control group) failed to transfer to phase III (double-blind randomized trial). The latter is another finding unfavourable to the rush with which many oncological drugs are introduced in the market. Perhaps it’s for this reason that, in an observation of 94 articles on the subject, Abola and Prasad have discovered that in half of them, the editors had resorted to adjectives of the type: miraculous, revolutionary, innovative, wonderful, transformative, etc...

Cumulative complexity and minimally disruptive medicine

The clinical model based exclusively on the diagnosis and treatment of chronic diseases is precipitating medicine to fail. Addressing complex realities from partial positions is, at least, unfortunate, and despite this evidence, health care systems continue to finance the fragmented provision of services. Mary Tinetti and Terri Fried warned us in 2004, in "The end of the disease era", that it should evolve towards a bio-psycho-social model, prioritizing the integral evaluation of each person, adjusting the therapeutic plans to each reality and offering integrated services. The analysis was timely except that the authors were wrong when they predicted that, the old model would end with the advent of the new century.

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."

Prediabetes epidemic in sight

Prediabetes is a terminology that, recently, is used when a person is detected with higher than normal levels of blood glucose, but there is no pathology. Prediabetes could be understood as a disposition to develop diabetes in the future, a disease that, in turn, represents a condition that puts one at risk of serious affections such as nephropathy, retinopathy or cardiovascular disorders, among others. Due to this chain of risks, and with a healthy intention to reduce morbidity and mortality, the American Diabetes Association (ADA) led a study to consider that glycosylated haemoglobin (HbA1c) is a test that can be done without any preparation or need for fasting and see if it can become a new criterion for detecting prediabetes. The concern arises when, according to this diagnostic extension, it’s estimated that in millions of pre-diabetics would show up: in China 493, in the US 86 and in Spain 6, to cite three countries from which I have data.

The Patient Revolution according to Victor Montori

In 2016, Victor Montori, a professor of medicine and diabetes doctor at the Mayo Clinic, launched The Patient Revolution, a foundation whose mission is to help make truly patient-centred treatment a reality. In his new book, Why We Revolt, Montori argues that “industrial medicine” has corrupted the mission of medicine to the point where doctors are now incapable of caring for the people who place their trust in them (for further information about the author in this same blog, search for “Montori, V." entries in the tags [top-right-hand column].

Shared clinical decision: Dr. Montori’s lessons

If you want to understand what the shared clinical decision is and have 16 minutes to spare, don’t hesitate and watch this interview from Dr. Selma Mohammed and Dr. Victor Montori.

Minimally Disruptive Medicine

"With regards to the chronic diseases, less can be more." The Wall Street Journal published that statement on the 8th of April last in an interview with Dr. Victor Montori, a diabetologist and Director of "Health Care Delivery Research Program" at a Mayo Clinic in Rochester. Dr. Montori told the journalist that one of the best strategies for the clinical management of patients with more than one chronic disease is to know how to slow down, namely how to give clinical practice some rest.

Reporter: What is minimally disruptive medicine?

Dr. Montori: Is the health care designed to achieve objectives of improved health for patients with various chronic conditions leaving the smallest possible footprint in their lives? To achieve this, patients and clinicians should jointly make decisions about which treatments are best suited to the patient’s lifestyle.