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.