The laws of medicine

Siddhartha Mukherjee, oncologist, researcher and professor at the University of Columbia, is the author of a small essay, The Laws of Medicine: field notes from an uncertain science (2015), which I found interesting enough to recommend to clinicians who desire to think a little more about what they do. "In the medical school," says the author, "they taught me a lot of facts, but they did not prepare me to navigate the immense spaces between these facts. Right now I could write a thesis on the physiology of sight, but I feel lost when I try to understand the conniving network that makes a man, who was prescribed home oxygen, give a false address to the service providers, embarrassed (I later learned), because he lived on the street."

Social addiction to biometrics

Salvador Casado

Mirrors are polished surfaces that reflect the image projected on them.  It is a technology that the ancient Egyptians and Greeks already knew and that has evolved over time. Today the majority of the population carries a pocket mirror that also allows immortalizing the images that come to it in the form of an auto-photo. In addition, modern mirrors reflect multiple variables and information of their owner. They measure his steps and the distance he travels, his activity pattern, his movements, his level of communication. They can measure the sleep/wakefulness rhythm and give a report on the quality of sleep and if we connect some specific gadget they can measure blood pressure, blood sugar and even do an electrocardiogram.

Treatments, tested

The other day, Xavier Bonfill and Iain Chalmers presented the Catalan edition of the book Testing Treatments. Better Research for Better Healthcare. This caught my attention and after 12 years of delay, I was motivated to read the work. It’s necessary to clarify that in 2006, the year of its first edition; I was a hospital CEO and had neither the head nor the time for this. Maybe one day we will have to talk about what the executives read. Be that as it may, this text is considered one of those that have laid the foundations of modern clinical management, which concentrates its focus on effectiveness, a goal as coveted as it is difficult (1).

Journalist Nick Ross, in the presentation of the first edition of the book, wrote: "This book is good for health; it shines light on the mysteries of how decisions about life and death are made. It goes to show how these criteria are generally lacking and it challenges doctors from around the world to change their ways.” On the other hand, Ben Goldacre, in the prologue of the second edition (2011), provides a really interesting quote: "The true purpose of the scientific method is to make sure that nature doesn’t mislead us into thinking that we know something that we don’t really know".

The problem is the persistence in fragmentation

The model of health services provision is a combination of professional bureaucracy and political-administrative bureaucracy, passed through the filter of organizational rationalization. The fact is that a third (approximately) of clinical processes adapts well and logically, show good results. Let's say: programmed surgical interventions, acute medical pathologies of low-medium complexity, stroke code or heart attack code. So far so good, but it’s inescapable that there are two thirds of the case-mix that don’t fit with the rigidities of what’s offered; we speak, logically, of chronic disease and geriatric frailty, but also of degenerative diseases when they begin to be limiting in the clinically complex processes of difficult labelling. Additionally, in society there are a lot of people in delicate situations, maybe they live alone, maybe they are poor or immigrants or maybe because they live in unstructured environments, to give four examples; people who either don’t access the services or, if they do, they don’t know what to make of them.

About the bicentenary of the stethoscope

Xavier Bayona

If there is a universal symbol of the health profession, besides the white coat, we certainly find it in the stethoscope. Laennec, in 1816 at the Necker Hospital in Paris, began his first studies in auscultation by means of an instrument he gave the name of stethoscope, derived from the words στηθος (chest) and σκοπεω (examine). Until that moment the auscultation was performed with direct listening placing the ear on the chest (already performed by Hippocrates). This direct listening had its practical limitations both in the transmission of sounds and for issues of modesty related to the gender of the patient if she was a woman (the doctors were mostly men) or for hygiene.

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. "

The potential of shared decisions

The “Essencial” project of the Quality Agency and Health Evaluations of Catalonia (AQuAS) held a day of reflection on the level of implementation of the recommendations to avoid low-value clinical practices hence those responsible for “Essencial” had the good idea to invite Glyn Elwyn, a researcher specialized in shared decisions at the Dartmouth Institute, to give the inaugural lecture in Barcelona.

According to Elwyn, as seen in the slide: "Shared decisions are a way of acting in which doctors and patients make decisions together, making use of the best available evidence on the probabilities of benefits and adverse effects of each option, relying on patients receiving the necessary support to obtain contrasted information about their preferences." Along this line, a systematic review of the Cochrane Collaboration shows that people who have had the opportunity to make clinical decisions with the support of specific materials (decision aids) admit feeling more prepared, more informed and have the clearest ideas about the value of their clinical processes, and they are probably more aware of the risks of each step they take.