In the end, everything requires trust

Joan Escarrabill

Book stores are still important. Despite social networks and the avalanche of information, good libraries are still a source of surprises. If a book store doesn't surprise - if you only find common or the latest ones - you won’t return. 

When visiting the Central del Raval in Barcelona, I have never left without having found surprises. The latest is Comprender la Democracia (Understanding Democracy), by Daniel Innerarity. Eighty dense pages, with meaning and suggestive ideas. It is essential to read books from different disciplines to be able to establish parallels and systematically avoid shared and inbred ideas. Therefore, when we talk about patient participation, it is very useful to do so from a conceptual framework away from clinical practice. Now more than ever it is convenient to reflect on participation based on a conceptual framework described by people who think about democracy. 

When the health care does not work well, better not have?

Andreu Segura

Almost twenty years ago, the report of the Institute of Medicine “To err is human" estimated that medical errors caused more annual deaths than AIDS, breast cancer or traffic accidents. A few days ago, at The Lancet, Margaret Kruk and her Harvard global health team warned us that poor health care is causing five times more deaths than AIDS in countries with fewer resources. Even more deaths than those of people who die without being able to access health.

It is obvious that to be useful, health activities must have a positive effect on the health of the people served. In health and survival or, even more precisely, in survival in good health. Elementary. As it is also to think that this value depends largely on doing things right. And it is not enough to have facilities, equipment and health personnel. They need to work properly.

Primary care: reforms based on innovation

The primary care reform initiated in Spain in 1985 was inspired by the Alma-Ata statement that WHO had proclaimed a few years earlier. The need for change was evident since the previous model was characterized by access difficulties, the predominance of curative care, medical orientation focused on diseases and the absolute lack of teamwork. Thirty years later, primary care is in a crisis of exhaustion due to multiple factors, of which the lack of budgetary endowment, the ageing of the population and the rigidities and bureaucracies of which it has been endowed stand out, and for a long time the call for reforming the reformed has been heard and create a new model more appropriate to the present day.

How to build an agile experience for the patient?

Glòria Galvez

Our environment is subject to constant changes that organizations try to adapt to by becoming agile institutions, capable of developing projects quickly and flexibly. According to the report by the McKinsey consultancy, agile organizations are recognized by five key elements:

1. They are committed to open innovation, co-creating with different actors, from their professionals to the clients of the organisation.
2. Foster networks of autonomous people, free to devise disruptive proposals; a model of red arch versus one of hierarchy. 
3. They prefer to be quick and take risks than fall into excessive planning. 
4. The style of leadership gives prominence to people and encourages development talent. 
5. Integrate technology as a resource that provides agility to formulate new proposals. 

Some organizations undertake small transformations related to innovation or patient experience, but few dare to make a global transformation adopting an agile methodology. 

The urgencies and the elderly

Reflections (and proposal) in the face of the impending winter emergency crisis

@varelalaf

If nothing is done, vulnerable people will increasingly go to the emergency room because of their multi-pathology, the presence of certain symptoms that are difficult to manage from home or the problems of their environment, they call 061 increasingly often. And that is how hospital emergency services become refugee camps within health systems. A clinical trial conducted in 24 French hospitals, which included more than three thousand people over 75 years of age in a clinically critical situation, showed that the centres most likely to enter older people in critical units, in addition to not reducing their long-term mortality term, neither improved their functional capacity or their quality of life.

Recommendations of physical exercise and its relation to mental health

Andrés Fontalba

The Lalonde report marked a milestone in the 1970s, highlighting the importance of lifestyles in health, over the characteristics of the health system or the biology of the person and proposing a change of the model based on the “cure” for one that boosted "health promotion". Among the lifestyles, most related to health is physical exercise. Plato already warned us: "The lack of activity destroys the good condition of every human being, while movement and physical exercise preserve it."

Escape the biomedical bubble

Cristina Roure

One of the most recurrent citation in clinical management is the Porterian concept of health value, which must be established based on the interest of the patient and not the rest of agents, read professionals, managers, researchers, administration, biomedical industry, etc. According to this concept, the ultimate purpose of research and innovation in health should be to provide maximum benefit to patients and society. However, as I commented in my last blog post, I often prioritized research and the real needs of patients, but society goes in different ways.

We ask patients to change their habits, but what about us?

Anna Sant

The management of cultural change is one of the most critical factors in the implementation of programs to improve the quality, safety and experience of the patient. The same thing that happens to our patients when we ask them to modify their behaviour to have a healthier life happens to health professionals in our work environment: it’s not easy for us to change the way we do things.

In the process of change, there is a particular moment in which we already know the correct protocols, and we are clear about the systems and behaviours that we must address. Even so, after an initial period of systematic implementation, we tend to return to old routines, those that seem more natural and familiar to us.

Management according to Elon Musk. Tesla, SpaceX and SolarCity

Tino Martí

Elon Musk is one of the trendiest entrepreneurs and undoubtedly the most controversial one at the moment. He is the leader of Tesla, SpaceX and SolarCity, three young, ambitious and dynamic companies that show how far they are willing to go to change the world through the internet, renewable energy and the race to Mars.

In 2018, he made it to the headlines for different reasons. First, proposing technical solutions to rescue children trapped in Thailand and end up insulting their monitor. Second, and probably the most popular, with the announcement via tweet to privatize Tesla for $420. In the American financial and stock market context, privatizing a publicly-traded company means repurchasing all its shares. The action elicited strong reactions, and the board of directors concluded his position. Shortly afterwards, Musk again announced problems in the production of Model 3 and wanted to assure the market that he is giving it everything by announcing his strenuous workday: 120 hours per week. To top it off, in a live radio interview, he accepted smoking marijuana. No one can say that he goes unnoticed, regardless of his apparent privacy.

Narrative, expectations and relevant outcomes for patients

Gustavo Tolchinsky

At the beginning of my medical residency, I used to experience some frustration with some patients whom, despite having gone through a correct assessment and having been diagnosed with a treatable and straightforward pathology, when they were discharged, they were still not satisfied. After some time, I began identifying that at least one of my mistakes was in my approach to patients. Excessively focused on diagnosing a pathology as if I were to “nail it” in an exam, I wasn’t paying attention to what led the patient to visit me, their concern; this couldn’t be solved by giving a mere diagnosis and treatment. When we go through these situations, we find it traumatic, frustrating and disconcerting. On top of that, this may lead to over-acting that only leads to over-treatment due to repeated patient demand at different points of the system. This could be because the clinical solution we offer does not solve those concerns that went unidentified in the clinical interview, or that the patient's expectations are ill-adjusted to realistic results and these, therefore, are unattainable.

The early diagnosis of colorectal cancer, thirty years later

@varelalaf

Health systems have long-planned population programs for the early detection of certain cancers through diagnostic techniques arising from the clinical setting, such as prostate-specific antigen (PSA), mammograms, ultrasound or the study of faecal occult blood that is the case at hand. This issue is generating confusion in society because one thing is to take care of one's health and the other, quite different, is to undergo medical tests to discover tumours in their early stages. On the other hand, discomforts are also generated among professionals, because it’s not the same to treat patients who seek help for health problems, than to propose extensive tests to the healthy population.

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.

Please let me see my lifelong doctor

Paco Miralles

If you are a reader, likely, you will always go to the same hair salon, and surely you will like to be attended by your usual hairdresser. If you are male, you probably also appreciate finding a familiar face for cutting your hair, avoiding having to explain the type of cut you want every time. It’s even possible that on some occasion people delayed their visit a few days when they learn that the person who usually serves them is on holiday. This tendency is present in other sectors. We generally like our hair, our nails, our fish or our fruit to be dispensed by "our" trusted person and we are not often willing to change stores.

Is it ethical, correct and legal for a family doctor to treat 60 patients in one day?

Salvador Casado

My point of view: No, with exceptions.

Medicine is a highly regulated activity. Its exercise requires a high level of education and academic level, a high code of ethics and deontology and appropriate legislation. In other words, it cannot be exercised in any way because of the potential risk of damage for patients. 

Surprisingly, care overload is not defined, regulated or correctly managed. 

Hospital emergencies: the refugee camp of the healthcare system

@varelalaf

The society witnesses the emergence of population groups with social and health care needs that are difficult to fit in the current model of service offer. Thus, we see how fragile and vulnerable people are picked up by ambulances and go to hospital emergency rooms, which become like refugee camps, as Sara Kreindler, head of health systems innovation research at the University of Manitoba (Canada), likes to call them. Many initiatives, observed everywhere, aim to put an order in these refugee camps of healthcare: implantation of triage, observation units, geriatric units, new case management nurses, nurses trained in geriatric evaluation. To help us analyze a problem that we don’t know how to address, Sara Kreindler has developed a qualitative study in the framework of a region of Canada. The study has concluded that partial interventions aiming to improve the flow of urgent care for patient’s complex show three paradoxes:

Lost in translation: five parachutes for the "jumping into the void" at hospital discharge

Marco Inzitari

As in Sofia Coppola's melancholic and visual film of 15 years ago, the disorientation that is experienced during a phase of transition, which in the movie was a life transition whereas in our case a transition between care levels, could be converted into an opportunity to rethink the present and face the future with a renewed perspective. Especially if we are lucky enough to partner with good travel companions with whom we can share the same concerns.

A new clinical visit format: shared medical appointments (SMA)

Glòria Galvez

The model of patient-centred care suggests the need to redefine some models of care and look for others that respond at the same time to the needs of patients and professionals. An example of innovative care is that which affects the traditional medical consultation, which is insufficient to address certain diseases with a prominent psychosocial component.

The shared decision making through a behavioural economics view

Pedro Rey

Last year I participated in a session on shared clinical decisions between doctors and patients during the XXXVIII Conference on Health Economics of the AES, which this year was focused on shared decisions making, including a plenary talk by Alistair McGuire. As a behavioural economist, I find that informed decision-making in an area with as much uncertainty as health is precisely one of the fields in which a more interesting and, hopefully, more productive dialogue can be generated among health and behavioural economists. As I have commented in other posts, behavioural economics departs from the traditional economics assumption that which individuals are rational beings that always know what is best for them and make optimal decisions according to established and well-defined preferences. It’s obvious that this theoretical ideal is rarely met, especially in a context such as health where asymmetries of information, uncertainty about our own preferences or the difficulty in interpreting the risks associated with the multiple decisions that must be made makes it very difficult to choose well, and even evaluate ex post if the decision was optimal. Therefore, the premise from which the movement claims for more shared decision making between doctors and patients produces both hope and doubts.

Vertebroplasty and knee arthroscopy: two interventions questioned by the evidence

@varelalaf

The measurement of the clinical effectiveness of surgical interventions is, regrettably, not too frequent. In this field, the design of rigorously and well executed clinical trials has its complexities, especially when the control group undergoes sham surgery. For this reason, it’s worth disseminating the conclusions of consistent studies that arouse doubts about the effectiveness of the decisions made every year by the operating rooms to thousands of citizens, who must accept the risks, not negligible, inherent in surgical intervention. In this regard, I already mentioned the poor results that a clinical trial had shown for coronary angioplasties with stenting in patients with stable angina and, in the same vein, today I have selected two clinical trials related to orthopaedic interventions.

For a research based on value. The failed model of antibiotics

Cristina Roure

As we have commented on some occasion in this blog, neither the price nor the volume of investment in R&D of the medicines corresponds to the value they provide. Antibiotics, along with vaccines, have saved millions of lives, have allowed to address challenges such as transplants and complex surgeries with guarantees of success and, if this were not enough, they also add enormous value to the productivity of the agricultural sector.

More time to generate quality conversations with patients?

Anna Sant

The fight of the click in the consultation

Two studies published last year in the Annals of Internal Medicine and Health Affairs compared the time that doctors spend with the patient in consultation with the time they spend with the computer. Jordi Varela analyzed these results in his post dedicated to Danielle Ofri, a Bellevue Hospital doctor and professor at the NYU School of Medicine, who said, referring to the electronic medical record (EHR), that "The beast is insatiable and every time it needs more and more food. It ends up claiming all the time I dedicate to human interaction and, given that I ought to, I have to stay late, just to satisfy its cravings.” Both studies concluded that the time spent on the screen is longer than that dedicated to the patient.

A Viktor Frankl for the healthcare system

Gustavo Tolchinsky

“For only to the extent to which man commits himself to the fulfilment of his life's meaning, to this extent he also actualizes himself.” 

Viktor Frankl

Recently, in a meeting about the health of physicians, Dr. Clare Gerada, responsible PHP caring program for NHS doctors, commented on something that had never crossed my mind... How is it that we continue accepting that the Declaration of Geneva, which emanates from the Hippocratic Oath and was ratified in 2005 by the World Medical Association in France, keeps stating that "we (doctors) promise to consecrate our lives to the service of humanity"? Such a load seems unaffordable in these terms, but seeing the conditions in which we work, gives us the feeling that sometimes we are paying with a large part of our lives practicing as doctors.

Migration and mental health: the risk of exclusion

Andrés Fontalba

The human being has managed to colonize all habitable regions of our planet thanks to migrations. Due to cultural, economic, political or geographic movements, the population has moved en masse from prehistory to the present day, these movements being in some cases spontaneous and others forced. It is, therefore, a process of mobility intimately linked to us as a species.

Measuring the effectiveness and value of clinical practice

In the "XIV Conference of the Sign Foundation", Jens Deerberg-Wittram, Director of the Boston Consulting Group, gave the inaugural lecture entitled "From volume to value". It was a very timely speech, at a time when the obsessive control of budgets and waiting lists prevents clinicians and managers from reflecting on what contributes so much care activity to society. The concept of value expressed by the German speaker is very new for healthcare managers, who tend to understand clinical effectiveness as a rhetorical concept more typical of epidemiological studies.

Let's finish with the phrase "This has always been done like this"

Mònica Almiñana



There are more and more voices defending that our current model of health care ought to improve and that, if we don’t change it, it will change us.

But, to achieve this change, we need foundations from which to build upon. In my opinion, undoubtedly, there are three essential levers for this transformation: data intelligence (big data), patient safety and patient experience. The three are increasingly interrelated, and if not, read the report presented this year by the ECRI Institute: "Top 10 Patient Safety Concerns for 2018".

It’s estimated that the waste in biomedical research reaches 85%

In 2014, following concerns over the poor quality of biomedical research, The Lancet published a series of 5 articles analysing the scope of the problem and proposing solutions and as a result of this Reward Alliance was born, a platform that aims to defend the value of the research, from which I have extracted the scandalous figure of 85% and, according to Paul Glasziou and Iain Chalmers, two of the leaders of the movement, the volume of money squandered by biomedical research could reach 170 billion dollars annually, an amount higher than Hungary's gross domestic product. The two authors, who already predicted this figure in 2009, argue that this amount comes from an accumulation of up to three times 50%.

The individualistic short-sightedness of health care

The Global Action Plan for the prevention and control of non-communicable diseases of the WHO aims to reduce by 25% the premature mortality due to these pathologies by the year 2025 (strategy 25 x 25) and, therefore, concentrates on strategies that reduce the following 7 risk factors: a) alcohol consumption, b) insufficient physical activity, c) tobacco consumption, d) high blood pressure, e) excessive salt intake, f) diabetes, and g) obesity. Confronted by this individualistic drift of public health, an international group of researchers has published in the Lancet the results of a meta-analysis with 48 cohort studies and 1.7 million individual records, where they have shown that poverty has more explanatory force by itself over the number of years of life lost that many of the factors 25 x 25, in addition to having an undeniable cross-influence by enhancing the aforementioned risk factors. It’s important to clarify that the cohorts selected by the researchers correspond to first world countries, so the analyzed groups of low socio-economic level  represent poverty pockets that are basically concentrated in deprived neighbourhoods of large cities or in certain collectives such as the destitute or the immigrants.

On average, humans have one testicle

Joan Escarrabill

This article deals with the interpretation of data. The title is an example made by Daniel Levitin in his suggestive book Weaponized Lies: How to Think Critically in the Post-Truth Era (Penguin Random House, New York, 2017), about the mistakes that can be made and the lies that can be said according to how numerical data is exposed. Obviously, the title of the article is exact. If the proportion of men and women is about 50%, certainly humans, on average, we have a testicle (and an ovary).

Integrated care or person centred care?

At the 6th "Right Care" Conference of the Clinical Management Section of the Societat Catalana de Gestió Sanitària we had the opportunity to get to know Don Redding, director of Policy and Partnerships for National Voices of the National Health Service and a well known promoter of the involving people in their own clinical processes. Redding said that the integration of services doesn’t make any sense if it’s intended only as an exercise of resource rationalization. On the contrary, he argued that coordination must be conceived based on the specific needs of each person, stating that every patient can be involved in their own care plan in agreement with close involved professionals and working as a team to achieve outcomes perceived as valuable by the patients themselves.

The excesses of image diagnostics

The practice of modern medicine is subject to much pressure from the use of diagnostic imaging technologies, many of which are truly dazzling for the eyes of clinicians and patients and, as a result, health budgets are constantly increasing. This being the case, everyone agrees that more professional debate should be generated to put the matter in its place and avoid the excesses that damage resources, irradiate people and don’t add value to clinical reasoning.