Humanism and reasoning versus cookbook medicine

Soledad Delgado
 

From "criaderas" to "soleras"

At the onset of autumn, my land fills with the smell of must. Freshly extracted from the pressed grape, it ferments and then passes to American oak barrels for ageing. The containers are stacked at three levels. From the lower one, the "solera", a third of its content is extracted for consumption. That part is filled with wine from the intermediate level, the first “criadera", and the same happens with this one, which receives wine from the upper level, the second “criadera". It's the one who receives the fresh must, full of life and potential. This wine, still young, is mixed during its ageing with matured wine, from which it takes some characteristics and to which it gives back the freshness of new aromas and flavours. The two wines are enriching each other, sheltered by the flower veil that promotes biological ageing. 

Lack of nurses: a serious social problem

Alba Brugués
 

The nursing shortage is a well-known problem throughout the world and has been exacerbated by the effect of the pandemic. According to a WHO report published in 2020, there are 28 million nurses in the world, constituting 59% of health professionals. Currently, the shortage of nurses is estimated at 5.9 million. The report highlights that if action is not taken, by 2030 there will be a shortage of 10.6 million nurses worldwide. In Spain, it is estimated that there are 120,000 missing and in Catalonia 24,000.

Quality Land

Mª Luisa de la Puente
 

In the world of healthcare, quality is everyone's business and it covers everything. This assertion, generically true but with little operational, is coming in stronger in recent years. This concretion to a specific context is driven by the necessary adaptation to the escalation of healthcare costs, the economic context, the influence of the business world to obtain more performance from resources, the demands of its clients or professional discomfort due to the little recognition of what it is.

Training is essential for change management

Nacho Vallejo

The actors who intend to get involved in the orchestration of changes in our healthcare system tend to agree on the difficulties and barriers that limit the development of improvement strategies for healthcare organizations. We have already seen it in previous posts on this blog, where we asked ourselves what has become of the professional's experience and how to "unclog" our institutions.

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. 

How to ensure that healthcare professionals read clinical practice guidelines?

Laura Diego Del Río & Pedro Rey 

During the last decades, there has been a dramatic increase in the clinical information available to healthcare professionals and best-practice reference documents have been established in different areas of medicine. An example of this is the numerous clinical practice guidelines developed by various institutions. Despite the vast amount of criticism bout their limitations; their elaboration implied a great effort to establish quality standards and a significant publication of literature on adoption strategies in clinical practice. However, given this abundance of information, there are certain doubts about whether they are being read and followed through. Let us analyze the main reasons and see what can be done to change this (lack of) practice, under the prism of behavioural economics.

Medical Schools: reductionism versus empiricism

Competitive eagerness has reached the medical faculties and now produce batches of new doctors with a higher scientific preparation, priorities arranged by factor of impact, a competitiveness for research funds and, to a lesser extent, clinical practice. Young doctors know that in order to fight for the most coveted places they must show a resume full of publications, while the clinical skills, although present, will not be the differential element. What is observed, then, is that the educational reforms driven by academic success.

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. "

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.

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.

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  

Medical schools: reductionism versus empiricism

The current competitive drive has reached the medical schools to the extent that it now delivers batches of new doctors with higher scientific preparedness whose priorities are influenced by their impact, competitiveness for research funds and, to a lesser extent, clinical practice. Young doctors know that in order to fight for the most coveted positions they will have to show a curriculum full of publications, while the clinical skills, although present, will not be the element that differentiates them. What is apparent is that educational reforms are part of the mechanism which is focused on academic success.

Hospitalists: functions and competencies

Don’t panic, it’s not about defending a new specialty, it’s about thinking what should be the roles and responsibilities of the physicians in charge of hospital wards if they want to improve safety, quality and continuity of admitted patients’ care.

In 1996 Dr. Robert Watcher and Dr. Lee Goldman described for the first time the term hospitalist as a doctor specialized in the practice of hospital medicine. This matter was experienced then as necessary for the organization of hospital wards in the US, due mainly to the multitasking of specialists who caused that the management of admitted patients was often disorderly. Almost twenty years later the Society of Hospital Medicine reports that there are more than 30,000 hospitalists working in 3,300 hospitals.

In the video, you can see Dr. Chris Addis explaining the main contributions of hospitalists to the admitted patients’ care, in summary: a) assume the coordination of specialists, b) know how to communicate the patient's clinical information in a simple manner, c) ensure continuity of care, and d) be the referent for family doctors both during admission and during the transfer.

The road to excellence

Antoni Peris

We often ask ourselves whether we are still good professionals or whether we are stagnating; whether our work is good or whether it can be better; whether we treat our employees well or whether they’re taking the Mickey; In this case, can we ask more from them? How do we inspire them to do better?

Whiplash has been one of the best rated films of the season. The story of Andrew, an ambitious young man who wants to become the best jazz drummer, enrols in the world’s best school in New York and has to face a teacher who demands everything he has to offer and a lot more. Whiplash shows us the path to excellence, assumed by teacher and student. However I think it’s very far from what we need to think about in our organizations.

Family doctors: it’s time to strongly support

The number of places for family doctors at the last resident doctors (MIR) call from the Spanish government is of 1,671, only 25% of all specialties convened. The question is: Will this annual promotion of family doctors cover the future needs of an increasingly aging population? If we’d pay attention to a report from British experts, "Securing the future GP workforce" the answer would be clearly negative. This document ensures that to meet the challenges in chronic disease from primary care, half of medical students who now graduate would need to become family doctors. But how to make the profession more attractive if its disrepute is so big that each year, at the MIR call, there are many vacancies left and the dropouts during training reach 15%?

In a survey (“Why doctors flee and shun the family medicine?” by Gonzalez B, Barber P and Ortún V) undertaken with students from the sixth grade of the medical course, a surprising finding stands out: students prefer generalist specialties, including family medicine. The surprise, however, doesn’t last long, because after strenuous preparation for the MIR test, most of, by now graduated doctors, shift in preference and opt for more technical specialties. The same survey warns that, this in this shift, we can detect not only the influence of MIR but also other relevant issues such as working conditions, pay and prestige.

"The values of clinical practice" Campaign for doctors in training

The Clinical Management Section of the Catalan Society of Health Care Management (SCGS) has just released a video to promote the values of the clinical practice among physicians in training.

To activate English subtitles go to "settings" in the lower right banner

I would like to highlight 10 keys that, according to the video, should allow a generational change in the practice of medicine:

1. Learn to listen patients and appreciate what their circumstances are.
2. Forget about persuasion and learn the technique of motivational interviewing.
3. Help patients to make clinical decisions for themselves.
4. Rate the burden of treatment and learn to deprescribe whenever necessary.
5. Take the time for clinical reasoning and adopt the Bayesian probabilistic thinking.
6. Request tests that make sense clinically, thinking about the value they will bring.
7. Learn to teamwork, specially when facing complex patients.
8. Watch out for overdiagnosis when practicing prevention and share it with target people.
9. Incorporate palliative methodology in your clinical practice and know how to have the proper conversation about the end of life with patients and their families.
10. Know how to get the "Right Care" sources.

Main "Right Care" sources

• The Cochrane Collaboration, active since 1993.
• Collection of articles Less is more in JAMA Network, since 1998.
• Campaign Too much medicine of the British Medical Journal, since 2002.
• Do not do. Recommendations arising from clinical practice guidelines from NICE, since late 2006.
• Choosing Wisely. ABIM Foundation Program. Collect recommendations from American scientific societies, since 2011.
• The "Essencial" Project from AQuAS. It has the support of Catalan scientific societies, since 2013.
• Diana Salud, a website of the epidemiology research network CIBERESP. Excellent searcher of 18 sources "Right Care" worldwide.

From this blog I wish the campaign "The values of clinical practice", promoted by the Clinical Management Section of the SCGS, to echo, both in medical schools and medical residents programmes.


Jordi Varela
Editor 

Teachable moments: a new strategy against waste

Para irlo siguiendo...A Simple Way for Physicians to Take Action Against Overtreatment http://t.co/4JQQg7PHrj vía @wordpressdotcom
— Benito Fontecha (@manxego) November 6, 2013

Dr. Benito Fontecha is a geriatrician and Twitter user, he is not too active on the network, but he is very selective and the other day had the good idea of writing a tweet alerting us of the appearance of a very interesting post on the JAMA Internal Medicine blog. This article, linked to by Dr. Fontecha, is signed by two medical editors of a commendable section of the magazine called: Teachable moments.