Clinical competences hidden in the curriculum and in coding

Gustavo Tolchinsky
 

José, 85, has a fever again. His wife is no longer worried; she knows that what has always worked is taking her husband to the emergency room. On the way she writes in the family chat that they are on their way to the hospital, but no one should move until she’s told if he gets admitted or remains under observation. Her children live in the suburbs and they always volunteer so that she doesn’t have to spend the night with José. Dementia has taken its toll on José and everything is more complicated; his urine infections, which previously warned with recognizable symptoms, have now become something abstract, but the fever is what always alerts the family. In the last year, José has been admitted several times for processes similar to this one, that started with urinary infections due to the underlying urological pathology. This time, on arrival at the emergency room, his wife thinks he is worse than ever, although his vital signs are OK and the Labs are quite anodyne, except for a slight worsening of kidney function. Again, as always, José is prescribed antibiotic treatment (guided by the latest available antibiogram) and fluid therapy, fever control and nursing care. But on this occasion, despite the fever disappearing, he is exhausted, probably due to delirium, he doesn’t cooperate with the care, the peripheral line is removed several times, he refuses to eat and the fever reappears. The family doesn’t cope well with this situation, José either. Family members are informed that imaging test could be performed, to asses  again with the urologist, and even to perform a procedure such as placing a urostomy could be considered if they suspect that there is an obstructive process. However, Jose's deterioration is not solved by treating only the current episode. The family and the healthcare team agree to make one more attempt with some changes in the treatment and, if he doesn’t improve, assume that only palliative treatment will be carried out.

From the humanisation of medicine to the dehumanisation of professionals

Gustavo Tolchinsky

The well-being of doctors is an issue that has a direct impact on the quality and quantity of care that healthcare systems can deliver to society. You only need review several of the entries of recent months and certain articles that even quantify the cost and waste that burnout implies for healthcare organisations. As has been shown in these articles, organisational factors, workloads, alienation from the values of organisations and professionals, the autonomy of professionals to manage their work, and even the type of clinical information management programs and their usability affect professional well-being.

The rise of artificial intelligence will bring changes...

Gustavo Tolchinsky

During 2017, the exhibition "David Bowie is" passed through Barcelona, which reviewed the life and all the creative facets of one of the musical geniuses of the 20th century and personally, author of some of my most beloved songs, such as Changes. One of the curiosities that visitors could discover in it was the Verbasizer, a computer program that offered random combinations of words to generate new opportunities to create phrases, as a creativity assistant. Bowie was avant-garde in many ways and he demonstrated this by risking not only with groundbreaking designs but with the incorporation of technological tools. 

Narrative, expectations and relevant outcomes for patients

Gustavo Tolchinsky

At the beginning of my medical residency, I used to experience some frustration with some patients whom, despite having gone through a correct assessment and having been diagnosed with a treatable and straightforward pathology, when they were discharged, they were still not satisfied. After some time, I began identifying that at least one of my mistakes was in my approach to patients. Excessively focused on diagnosing a pathology as if I were to “nail it” in an exam, I wasn’t paying attention to what led the patient to visit me, their concern; this couldn’t be solved by giving a mere diagnosis and treatment. When we go through these situations, we find it traumatic, frustrating and disconcerting. On top of that, this may lead to over-acting that only leads to over-treatment due to repeated patient demand at different points of the system. This could be because the clinical solution we offer does not solve those concerns that went unidentified in the clinical interview, or that the patient's expectations are ill-adjusted to realistic results and these, therefore, are unattainable.

A Viktor Frankl for the healthcare system

Gustavo Tolchinsky

“For only to the extent to which man commits himself to the fulfilment of his life's meaning, to this extent he also actualizes himself.” 

Viktor Frankl

Recently, in a meeting about the health of physicians, Dr. Clare Gerada, responsible PHP caring program for NHS doctors, commented on something that had never crossed my mind... How is it that we continue accepting that the Declaration of Geneva, which emanates from the Hippocratic Oath and was ratified in 2005 by the World Medical Association in France, keeps stating that "we (doctors) promise to consecrate our lives to the service of humanity"? Such a load seems unaffordable in these terms, but seeing the conditions in which we work, gives us the feeling that sometimes we are paying with a large part of our lives practicing as doctors.

Precision medicine cannot turn its back on emotions

Gustavo Tolchinsky

Two weeks ago in his post, Jordi Varela brought us a critical vision of precision medicine, which shows us a somewhat less triumphalist scenario than expected. Precision medicine was born with the intention to give better answers to spaces of uncertainty regarding clinical problems from different areas of medicine such as genomics or big data. Linking with this theme, we shouldn’t forget that even being more effective than what has been proven at the moment, we still depend on the human factor to reach the best possible result. When it comes to decision making, multiple factors are involved. There is a rational part, which we believe we control, but above all there is an emotional part that ends up directing us towards that scenario in which we believe we are going to be more comfortable in.

Montori points out that the tools he uses in decision-making only serve as a support, aware that the emotional factor needs to be guided with the least abstract information possible. In addition to that, our verbal communication carries more than one message: the explicit and the symbolic. The explicit derives from the literal meaning, what we call Verbatim, very limited and of an exact, unequivocal definition, and doesn’t give rise to mistakes of understanding by itself. The symbolic is that which derives from the context, the interpretation and the value of those who understand it in their own way, what we call it Gist.

The attitude of the doctor when faced with the biological opportunity of death

Gustavo Tolchinsky


During one of my postings in a small county hospital I found myself in the resuscitation room. A colleague had been trying for some time to understand how to tackle the cascade of problems harbored by an elderly patient: the monitor roars at 150 beats per minute, the pulse-oximeter shows 78%, despite the FiO2 1 of the high concentration mask; the patient, with a blank stare, the breathing strongly audible and the arterial tensions hardly captured. While the nurses are desperate to find a vein, to probe, to administer the prescribed corticosteroids and digoxin, to perform the electrocardiogram and to anticipate the next steps that the emergency doctor will order. Around her, another nurse points out, with great conscientiousness, what time it is and what procedure has been performed.

Faced with this situation it is reasonable to act by instinct driven by our eagerness to ‘solve’ the problem. I had already framed a first diagnosis. The patient presents a fall in rapid atrial fibrillation in the context of acute respiratory failure due to a respiratory infection, perhaps caused by bronchoaspiration. The hypotension is secondary to the haemodynamically poorly tolerated tachyarrhythmia. At this moment, knowledge put into practice demands that you slow down the heart rate, indicates serum therapy to overcome stress and starting treatment with antibiotics, relieving symptoms, etc.