Teaching the patients to pose a timely question

How can cancer patients get more engaged with their care? http://t.co/KWOy1zTR7N #patientengagement
— Peter Ubel (@peterubel) December 18, 2013

Peter Ubel is a doctor by profession and a researcher at Duke University in North Carolina, primarily in human condition and its relation to health, happiness and generally the way in which society works. He is the author of "Critical Decisions".

I chose this tweet because it leads to a blog of the Cancer Today, journal of the American Association for Cancer Research which states that posing the right question can help patients suffering from metastatic cancer to understand the risks and benefits of the treatments and to more appropriately formulate their personal goals. Palliative chemotherapy may improve the quality of lives for metastatic patients, but once the cancer spreads, the treatment decisions are increasingly complex, the conversations between doctors and patients are increasingly emotional and in such a delicate environment, the statistics may even mislead.

Coordination, integration (in Spanish Health Care System)

Each of the care system levels has become strong in a particular feature in Spain: in primary care, it has been the role of the gatekeeper; in hospitals, the hierarchization of medical services and in the socio-sanitary area, the offer of post-acute beds. And if we look at what these strengths have been translated into, we will rapidly agree that the primary care has achieved a performance of proximity and effectiveness in prevention, the hospitals have obtained very satisfactory levels of resolution in acute diseases and the socio-sanitary has contributed the essential decompression to the system.

These same strengths, which are certainly well recognized, become rigidities when new requirements that somehow question the status quo, emerge. However, I will demonstrate in 4 examples how the health system has been able to offer imaginative responses, without any hassle:

Adding value to doctor's remuneration

Perspective article: “Adding Value to Relative-Value Units.” See it on our #HealthPolicy page: http://t.co/2JG09NVWKW
— NEJM (@NEJM) noviembre 28, 2013

NEJM devotes an editorial and a couple of articles (they can be downloaded for free) to the new model for doctor’s remuneration by Medicare. This is a matter specific to the Americans, you’ll say. Therefore, it wasn’t necessary to choose it as this tweet to discuss. Although I have to admit that in these aspects of innovations in cataloguing and financing models, sometimes the Americans are right, as was in the case of DRG, then we all rush to import them into our systems.

Adjusting contracts to the value provided by services

'Commissioning for value'bona iniciativa del NHS per identificar els millors programes d millora de la salut http://t.co/7whaXuF2d4
— Dr J Vidal-Alaball (@jvalaball) noviembre 22, 2013

Dr. Josep Vidal-Alaball is a family doctor trained in England and passionate about public and community health. He’s a keen Twitterer, very active in innovation.

The link in Dr. Vidal Alaball’s tweet, directs us to the English National Health Service’ website, named "Right Care", where it is stated that the purpose of the health system is to deliver more value to people’s health and, according to this statement, proposes that service contracts should be adjusted in-line with this value (Commissioning for value) and clarifies that the NHS adopts Michael Porter’s definition of value: clinical outcomes in relation to costs.

"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 

Integrated Practice Units: trust us, we’ll deal with everything

Michael Porter’s book "Redefining Healthcare" provides the basis of the value chain of a clinical trial. He says: don’t worry so much about the clinical practice guidelines, focus, instead, in sharing with the patient the health goals that you reasonably expect to obtain, clarify either how much of the outcome depends on the patient or how much depends on the professionals involved. Then focus on measuring the achievements in order to know at what cost you achieved them and compete in the healthcare market with these values in hand.

The clinical process’ difficulties should not cause you to lose focus: the clinical effectiveness is the only objective.

According to the methodology Care Delivery Value Channel (CDVC), the creators of a clinical trial should be able to define how to address each of the stages of a clinical trial: prevention, diagnosis, preparation, response, recovery and follow-up or monitoring. At the same time it must be ensured that the patient flows through the process smoothly, without any surprises or poor coordination, but with assurances and being kept well informed.

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.