Cities are looking for elegant solutions for severe and complex problems. Barcelona's Eixample can be a good example of an elegant solution. But in cities, sometimes, there are also critical points for which a good solution is never found. Glòries Square in Barcelona can be one of those critical points of bad solution: heavy traffic in all directions and subway and railway tunnels that pass very close to the water table. Many solutions have been proposed in recent years and the latest one has taken more than six years to come true. I do not know engineering or urban planning, but I am sure that the proposed design has been carried out by competent professionals who have sought the best solution or, at least, the best viable solution or the one that most minimizes the negative impact. I am also sure that the designers have thought about the needs of all the people who will be using the infrastructure. But from the very moment it opened, in early April, it hasn't worked and nobody seems to be happy about it. In real life, we have a difficult problem with the best possible solution and a bad result. How can it be that things well done sometimes don't work? I don't know, but I think the metaphor of Glòries Square in Barcelona helps me to comment on three articles I've recently read.
Hughes et al.(1) contemplate why integrated care interventions do not achieve the expected goals in the UK. The term integrated care is imprecise enough to make comparisons difficult. In any case, several models try to coordinate care (and social) devices to care for patients with serious chronic diseases at home. Perhaps integrated care focuses more on the organizational model between professionals and only responds to part of the resources that the patient needs to deal with his illness. Coordinating resources to reduce admissions or avoid visits to the emergency room is important, but patients with serious chronic illnesses have other needs that must be addressed for them to be at home in comfort and safety.
Boehmer et al.(2) describe the conceptual framework of minimally disruptive medicine (MDM), of which some basic elements are respected for the values and preferences of patients and the proposal of therapeutic plans that are as individualized as possible, taking into account the needs of patients and emphasizing the need to revisit the care process to ensure proper coordination and promote the role of the generalist. The authors acknowledge that, after ten years, this project has not been widely implemented. Perhaps interventions need to assess more carefully the treatment burden and the patient's capability to cope. Furthermore, from a clinical point of view, it is not easy to think about the perspective of MDM in patients with multimorbidity. Yamb BP(3), in the editorial accompanying the article, suggests a play on words. We do not have good tools to measure capacity or treatment overload, so instead of aspiring to practice a MDM we should try to practice a medicine that minimizes disruption. Ask the patient if they have been asked for their opinion on the suggested treatment and find out the personal and environmental context in which they will have to apply the therapeutic proposals so that an approximation can be made to assess to what extent the patient will be able to assume the burden of this treatment. In short, discuss what comes first: the load or the capacity.
The third article I read is about personalized medicine and genomics. Roberts et al.(4) explain that more than twenty years ago genomics generated many expectations regarding the potential benefits it could bring, but the transfer of research to the first line of care is much more limited than might be expected and perhaps genetic studies have been developed solely in the academic field, without taking into account other factors. The context (how the health system will be able to incorporate these innovations) and the real world (what is the composition of the population served) are key elements. But the authors also suggest that research should incorporate evidence-based implementation strategies that take into account planning, education, changes to be made, or economic impact. In addition, let's consider genomics with a perspective of collaboration between all those involved (patients, service providers, researchers, health managers or community leaders). Boehmer et al. spoke of the treatment burden for the individual as a key factor. Perhaps in the case of genomic medicine, we should think about the burden of treatment that genomic innovation represents for society. I won't go into it in-depth, it's just a suggestion.
Perhaps good projects are not implemented well because we haven’t thought about two things: the real needs of the people who will receive them and the burden of applying the proposals (both from an individual and collective point of view).
Needs and load: two interesting concepts to think about. And I return to Glòries Square. Given the circulation problems generated by the new development of the square, a senior municipal official (whose name I will not mention so as not to misrepresent the orientation of the debate) stated: "It is highly recommended that citizens do not use the new Glòries tunnel between 7:00 and 9:30 in the morning. It is good advice. Outside these hours the tunnel is very valuable. But this proposal does not take into account two things: the needs (a very important percentage of citizens start work early in the morning) and the burden that the alternative represents (public transport does not provide the required response in many cases).
Not aiming at a professional intrusiveness in the field of engineering or urban planning, I would dare to say that when we formulate a care proposal we try to answer a couple of questions: have we asked what are the needs of the people who are to benefit from this proposal? And, secondly, does the proposal we make represent a personal or community load that makes it unattainable?
I want to thank Joan Fernando PhD and Anne-Sophie Gresle MP, for their comments on the manuscript.
Bibliography
1. Hughes G, Shaw SE, Greenhalgh T. Why doesn't integrated care work? Using Strong Structuration Theory to explain the limitations of an English case. Sociol Health Illn. 2022;44:113-129.
2. Boehmer KR, Gallacher KI, Lippiett KA, Mair FS, May CR, Montori VM. Minimally Disruptive Medicine: Progress 10 Years Later. Mayo Clin Proc. 2022;97:210-220.
3. Yawn BP. Can We Work Toward Medicine to Minimize Disruption? Mayo Clin Proc. 2022;97:202-204.
4. Roberts MC, Kennedy AE, Chambers DA, Khoury MJ. The current state of implementation science in genomic medicine: opportunities for improvement. Genet Med. 2017;19:858-863.
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