Who’ll talk about us when we’re dead?

Antoni Peris

First of all, allow me to recommend that you rush out to see A ghost story (D. Lowery, 2017). It's not a ghost movie. It's a movie with ghosts. It's not a movie about grief. It’s a film about permanence, about memory, about the permanence of memory and our will to endure as human beings. We are asked, what will remain of the Ninth Symphony of Beethoven when a thousand years have passed. And what will remain of us? Who will remember our passing through this world? The presence of A ghost story (ironically presented as one of those phantasms of children's stories, with a bed sheet and holes to see through) is something that refuses to disappear, perhaps the boy that appears at the beginning of the movie, perhaps the ghost of the house, or of the place, or perhaps the accumulation of experiences that take form whilst trying to continue their existence; It’s a beautiful and serene film exploring whether our existence and memory make any sense.

On the subject of continuity of care in hospitals

Last week we debated how the longitudinal continuity of primary care affects the comings and goings of chronic patients to emergency services. Along this line, I would like to explore the difficulties that hospitals have in guaranteeing ongoing health care services especially at night and at weekends, and how this problem weighs on services when taking care of the most vulnerable groups.

Imagine that a frail person enters a hospital due to acute decom-pensation, according to the known evidence, a global geriatric eva-luation and an individualized therapeutic plan should be deve-loped in agreement with the primary care team, if the desired outcome is to have a reasonable chance of returning home as soon as possible and in the best possible condition. The problem originates in that the hospitals, not even the best of them, are able to give a continuous response to patients as described, since the usual medical equipment usually offers a continuous coverage of only 27% (From a 5 day week of 8 to 5). What happens in the remaining 73% of time (evenings, nights and weekends)? As our imaginary patient, although you would enjoy medical coverage on duty, the service you will receive is very likely far from guaranteeing the continuity necessary for the fulfilment of your personalized plan.

Dysphagia and "minimal mass interventions": ethics, management and value

Marco Inzitari

In recent times there is an increased risk that the relevant becomes unseen. I understand that readers are mainly from the world of health but did you know that in Barcelona, ​​at the end of September 2017, the European and world congress on swallowing disorders was organized? And that the current president of the European Society of Swallowing Disorders is very close to us because he’s Dr. Pere Clavé, gastroenterologist and academic director, teaching and innovation at the Hospital de Mataró?

I was fortunate to be invited to talk about Dysphagia in older people in this meeting, with the opportunity to review the advances in this area. I don’t aim to venture into any clinical treatise on Dysphagia, but I think it’s useful to disseminate some aspects that are in line with the "value practices" advocated by this blog.

Innovation or decadence. There’s no middle ground

Josep Maria Monguet

Innovation is not a fad; it’s a structural phenomenon of the future, largely a product of the acceleration in the production of new knowledge. Innovation was always part of our world, but there are two new factors nowadays:

1. Accelerated innovation: more novelty in products and services are observed more frequently.
2. It's everyone's business: each one of us are protagonists of innovation.

The status of the patient's experience throughout the world

Anna Sant

"The State of Patient Experience 2017" is a study carried out by The Beryl Institute, were officially published to expose a global patient's experience. The conclusions have changed with respect to the study presented in 2015.

The Beryl Institute and "The State of Patient Experience 2017" 

The Beryl Institute that I referred to earlier in this blog, is a community dedicated to improving the patient experience around the world through collaboration and shared knowledge. The organization, based in the United States, prepares this study biennially since 2011 to share the challenges and opportunities that health organizations around the world are finding in their approach to improving the patient experience.

Technological disruption in health

Salvador Casado

We all talk about the technological revolution being witness about how it is transforming our environment. First there were the travel agencies, then the taxis, later the tourist apartments rental, o online shopping, online education...

However, one question remains to be answered: how will health disruption affect health systems and their professionals and users?

From my point of view we can know something: the change will be progressive and will come from the successive implementation of technologies that provide advances in different aspects of clinical practice, management and organization of resources. We also know that health systems are huge organisations with high inertia and that health professionals tend to have a conservative profile when it comes to incorporating new technologies. Before we adopt them we need to have scientific evidence that is both useful and beneficial to the patient and society. The problem is that scientific evidence is costly and very slow. The average time for a new molecule to become an accepted drug is about ten years, which is unreasonable for products and services in the digital sphere.

Incentives to change unhealthy habits: Do they work? Are they ethical?

Pedro Rey

In a previous post I talked about the use of economic incentives to improve the quality of the prescription that physicians make. Today I want to focus on the other side of the problem, that of patients who try to self-stimulate or receive external incentives, to change their life habits towards healthier behaviour. There are two questions of interest for me: 1. Do incentives work? 2. Is it "ethical" to use "economic" incentives to induce changes towards healthier behaviours?

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.

Should we statinize society?

A 2011 Cochrane review concluded that there was not enough evidence to prescribe statins for people with a cardiovascular risk of less than 20% in 10 years, a claim that was consistent with the British NICE guideline (2006-2008) and with the American Heart Association (2011). The surprise came when, unexpectedly, the 2013 Cochrane review changed its mind and lowered the statin threshold to the 10% risk at 10 years, a recommendation that was quickly adopted by the NICE guidelines.

Strongly opposed to this change of approach, John Abramson (Harvard Medical School), and collaborators, in "Should people at low risk of cardiovascular disease take a statin?" ensure that with the criteria of 2011, in the population over 60 years, it would have been necessary to statin 16% of women and 48% of men, but with the recommendations of 2013 the market was extended to practically all the population of older people, given that age is the most influential cardiovascular risk variable in risk calculators. The authors have reviewed the meta-analysis that led to the change of criteria ("The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomized trials") and have reached conclusions that contradict the Cochrane recommendations of 2013:

Reflections on precision medicine

Precision medicine, or personalized medicine, is an initiative of the US government that aims to adjust, according to individual characteristics, the prevention and treatment of diseases with genetic, phenotypic, clinical, environmental and lifestyle data. For this reason, the federal government, through the National Institutes of Health (NIH), is financing projects to sequence more genomes, create large bio-banks and generate big data studies from electronic medical records and all types of electronic devices of diagnosis and monitoring (for more information we advise you to visit the post of Cristina Roure on the subject).

Innovation 3.8 over 10: a clear "not passing"

Josep Mª Monguet

Self-deception is the path to regression. A few years ago (in 2006), I was invited to speak at the opening course conference for one of the entities of my university. I spoke about the deficit in innovation observed in Spain, sustained by multiple data. The rector, who spoke later, did his best to deny it using the sole argument that the universities had a large scientific production [1]. It became clear that he didn’t understand the difference between innovation and academic scientific production. Well, ten years later, our country is still the same if not worse. We can continue doing nothing about it, but we must understand that for building an innovative country, the islands of excellence are essential, but not enough.

Non-pharmacological prescription, the first choice treatment

Cristina Roure

Regular physical activity, directed exercise, social prescription or cognitive therapies don’t perform miracles, but neither do the medications that are prescribed daily in consultations and instead we accept them as a necessary evil, allocating 1 in 5 euros that is spent on health to pay for medicines that are not always taken, that don’t always produce the expected benefits when they don’t cause more harm than good.

Surprisingly the medical community find it hard to accept the role that non-pharmacological interventions and particularly physical activity should have not only in the prevention and treatment of chronic diseases, but also to combat frailty in an aging population like ours which moreover, lives submerged in a lifestyle that, after the incessant search for comfort, avoids any effort.

Break the "ill-fated trio": falls-immobility-delirium, an outstanding issue in the quality of hospitals

Marco Inzitari

The pressure on the safety of patients and medical errors to which we are all subject, together with the fear of professionals for possible complaints resulting from adverse events within the hospital (Hospital Acquired Conditions - HAC, for Americans), are changing the hospital culture, prioritizing the prevention of falls, in many cases, on top of mobility, functionality and, finally, the well-being of patients.

This is what happened in the US from 2007-2008, when the Centre for Medicaid and Medicare Services decided to penalize the billing of episodes of patients affected by different HAC, including falls with injury, to the Affordable Care Act (Obamacare), which penalizes hospitals with worse results in this sense. In our context, in recent years some care areas have also been rewarded or penalized, at the contract level, according to an indicator of intra-hospital falls.

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.

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.

The ancestral optimism and the perfect storm

The optimism of patients

When people get ill, or are afraid of being ill, as a rule we tend to trust doctors and by extension, health systems. But do we really benefit? A systematic review, developed by researchers from the Centre for Research in Evidence-Based Practice of Bond University (Australia), based on 35 surveys (27,323 patients as a whole) concludes that 88% of people overestimate the real benefits of the clinical actions, while 67% underestimated the adverse effects.

See for example, the expectations of people in being able to reduce the risk of dying from secondary prevention programs for breast, prostate and bowel cancers are far above the real data. The dark part of the bars corresponds to the percentage of respondents who overestimate the benefits of the respective preventive tests, and the crosses on the right indicate for which of them this percentage is equal to or greater than 50%.

Effective communication for planning living will

Glòria Galvez

Planning living will is a key element for the care and attention of people with advanced chronic diseases and their families. In recent years, models and proposals have been developed throughout the Spanish territory, such as in Andalusia or Catalonia, based on respect for the person and framed in quality care, taking into account their wishes, expectations and preferences.

The communication within planning living will has been shown to have important benefits when a terminal process of the patient is expected, since a shared decision-making process is established in a trusting environment, at the same time as it’s incorporated in to the family and relatives care planning. Addressing these issues effectively involves doing so at the moment when the patient still retains his decision-making capacity, that is, at the earliest time of his hospitalization. Doing it later may pose a greater risk of aggressive and unnecessary treatments.

Despite their high therapeutic value, professionals report great difficulties in maintaining a fluid communication with a terminally ill patient. In a recent Canadian study published in the journal JAMA some of the reasons for this difficulty are described as: uncertainty of the prognosis, fear of causing distress or perception of patients being unprepared to talk about it.

The Catalan Institute of Oncology (ICO), a world reference centre in the design and evaluation of public palliative care programs for the WHO, with Dr. Gómez Batiste at the helm, has designed a new model of palliative care at the Institute in which it is proposed that communication with the patient follow a strategy based upon open questions, considered key to detecting their basic needs: How do you feel? How do you perceive your current state of health? What are you worried about? What do you think may happen in the future? What do you think would help you fight this situation? What do you need us to do for you?

Dr. Gawande, in his book Being Mortal, also proposes some key questions that can help professionals have a quiet conversation about the end of life process. Faced with this open approach, there are those who propose a closed script with previously prepared themes. This can be quite a challenge due to the different barriers that have been expressed by professionals, such as the fear of eliminating all hope that the patient may have regarding his illness.

Both strategies have advantages and disadvantages: the open format allows the patient to express fears or questions that the professionals had not foreseen, and the closed format could facilitate professionals in asking potentially difficult questions. To illustrate the post, I leave the video in which Dr. Meier, a doctor at Mount Sinai Hospital and director of the Centre for the development of palliative care (CAPD) in the USA explains the 10 essential steps in communicating with patients and family members receiving palliative care:

1. Review the patient's clinical situation.
2. Prepare a decent, comfortable space with privacy and confidentiality.
3. Present the attendees and comment with simplicity on the objectives of the meeting.
4. Find out what the patient knows about his illness.
5. Explore what the patient wants to know: ask/explain/ask. Ask about the required information.
6. Explain the thorniest details required by the patient.
7. Ask if they have understood the terms used and encourage them to repeat them in their own words.
8. When faced with difficult questions such as: Am I going to die? Simple and clear answers: Yes, you will die and we will be permanently by your side, watching over your welfare to the maximum.
9. Analyze the therapeutic options, without deceiving but without denying reasonable hopes.
10. Organize and plan the next visit.

Communicating is also being able to know how to listen; it’s a key aspect in knowing what the patient's situation is at each given moment. For active listening to work, it’s better to move away from paternalism and facilitate the patient's participation in the decisions that best preserve their dignity and freedom.

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.

The slow progress of clinical safety, a problem of "many hands"

Cristina Roure

In this section we usually discuss overdiagnosis and overtreatment, but today we will talk about the difficulty in achieving safe care environments for patients.

Some will remember the publication in the year 2000 of the report “To err is human. Building a safer Health System” by the Institute of Medicine's Quality Care, which created a big impact in the media due to the alarming figures of deaths caused by medical errors in the USA. (1). Since then, a lot of work has been done in order to improve patient safety, and a lot of progress has been made for the dissemination of the clinical safety culture, and a great deal of effort and resources have been devoted to the implementation of safe practices for reducing the risk of medical errors.

10 priorities for integrating physical and mental health, according to The King's Fund

Andrés Fontalba

The current health care model that classifies patients by system or medical specialty categorises care to for any health problem. The causal attribution to diseases according to the psychic vs. organic dichotomy inhibits seeing the process of the pathologies in their totality and contributes to the problem of patients taking their illness from one service to another, with the risk of overacting in some cases or of non-holistic intervention method of integrated solutions in other complex cases.

Health incentives: don’t shoot the behavioural economists!

Pedro Rey

The debate on the allocation of (economic) incentives associated with the performance of health professionals has been relevant for a long time. A few months ago, VOX has published an editorial with a very clear title: Paying Doctors Bonuses for Better Health Outcomes Makes Sense in Theory. But it doesn’t Work. The article cites numerous recent studies, such as this one on the United Kingdom or the United States, that show no effect of giving incentives to physicians either in their clinical practice patterns (inputs) or in health outcomes (outputs). A systematic review of studies on "pay for performance" (P4P) in the Annals of Internal Medicine reaches similar negative conclusions. However, a marked anti-economist tone of these articles emerges that I believe comes from a confusion. According to these articles, economists only know how to prescribe the use of incentives, without evaluating their effects, and also the incentives that we advise are only monetary and don’t appeal to the many different motivations, not only monetary, that can affect doctors decisions.

Do we need audits or indicators to control the quality and safety of health centres?

Mª Luisa de la Puente 

Are care indicators useful in detecting the quality problems in hospitals? This question, which seems obvious, has its crumb. Alex Griffiths, of the School of Management at King's College London, has just published the results of a study of the usefulness of health indicators as predictors of the quality of care of English hospitals and the conclusion is that you can’t trust them too much.

The Care Quality Commission (CQC) is responsible for ensuring the quality of health and social services in England (more than 30,000 providers). Due to the scarcity of resources to carry out on-site inspections, the CQC used statistical surveillance through health indicators to prioritize those hospitals that had quality of care problems and subsequently send inspectors to these centres. The inspectors’ mission is to analyze the situation and give support to the suppliers for the orientation of the improvements. What was surprising to see was that the instrument "Intelligent Monitoring" (IM, scale of risk composed of 150 indicators, among others waiting list, mortality, surveys of users and professionals, etc.) is not able to predict which hospitals present quality problems or discern between those that work well and those that need improvements (compared to the classification of sanitary inspectors).

Improving the emergency and territory services: defragmenting the system

Xavier Bayona

In several articles of this blog you can read that one of the challenges to overcome in our and in most healthcare systems is the excessive fragmentation in health care that inevitably leads to duplication of tests and other dysfunctions that create pockets of inefficiency and malfunction. Several proposals to improve the continuity of care and reduce fragmentation have been presented with the aim of improving the quality of citizen attention, increasing the effectiveness and efficiency of the system.

Fragmentation is also present in emergency services. So if we look to the NHS, we can find a report published by the Royal College of Emergency Medicine with the Patients Association (Time to Act-Urgent Care and A & E: the patient perspective) published in May 2015, which concludes that primary care emergency services should join with those of hospitals. In this regard, as early as 2013, Bruce Keogh, medical director of the NHS, made the same recommendation. it’s commented within 2015 report that joint placement services should include emergency physicians, family physicians, nurses, frailty care, palliative care and mental health teams. It’s also commented that pharmacists and dentists could also contribute to the efficiency and effectiveness of the service.

The red line of health data

Elena Torrente

The great technological giants (Google, Apple, IBM or Microsoft) are recruiting scientists and experts in medical research. Their commitment to transform medicine is decided, but John T. Wilbanks and Eric J. Topol warn of possible risks in this interesting article published in Nature. Given the difficulties that medical research has always encountered in obtaining health data, the authors believe that it may be tempting for clinical scientists to access large-scale Internet projects, with significant data collection capabilities and algorithms for analysis.

But there is a risk that Google or other smaller companies such as 23andMe, will access health data with the aim of controlling the methods used to offer certain services based on digital profiles. This is what in other sectors of the Internet is called the society of the "black box". There are ads that are only offered to certain groups of people and if these algorithms incorporate health data, the authors say that pre-existing biases in our society would increase along with inequalities.

Vinay Prasad: Why is 40% of clinical practice wrong?

On May 18, Vinay Prasad offered a conference in Barcelona as part of the 5th "Right Care" Conference of the Clinical Management Section of the Catalan Society of Health Management (SCGS), where we had the opportunity to invite him to explain why he had created (with Adam Cifu and other collaborators) the list of 146 clinical practices that would have to be reversed and what are the criteria they had been used.

What is medical reversal?

According to Prasad, a medical reversal is the need to stop a clinical activity because a well-done study, usually a clinical trial with finalist indicators, shows that in fact, the desired results are not achieved, or that the adverse effects do not compensate the benefits. The speaker gave some very diverse examples, such as the Swan Ganz catheterization to monitor the hemodynamic balance of patients in shock, the hormonal treatment for post-menopausal women in order to reduce coronary or cerebral vascular risk and the placement of coronary stents in patients with stable angina to reduce the risk of infarction, increase survival or even to delay the effort angina. In all three examples, consistent clinical trials have shown that these were clinical activities that, in practice, did not meet the set objectives, and in addition had side effects, which were not unimportant.

Radiologists and incidental imaging findings

A group of radiologists from several American university hospitals (Massachusetts General, Cleveland, Brigham and Women's, etc.) started a debate in the Journal of the American College of Radiology about the eventuality that radiologists would stop reporting the incidental imaging findings lacking clinical significance. "The traditional role of the radiologist," they say, "is to warn of everything they see, leaving the interpretation of the findings’ relevance to the referring physician”. However, we now open the opportunity to go further, and not just intervene by saying, for example, that an observed abnormality is benign, but also taking the decision not to report the milder ones, given the possibility that our opinion generates confusion and ends up causing excessive medical actions".

Regarding level I renal cysts of the Bosnian classification

The radiologists who authored the article used the findings of renal cysts, which are very frequent with a prevalence of 36% in patients over 80 years of age, in order not to inform of renal cysts of level I of the Bosnian classification in their reports, in accordance with the following criteria: a) the cyst is not the reason for the examination, b) doesn’t generate local problems, c) has no malignant potential, and d) is not likely to generate a polycystic kidney disease.