Humanism and reasoning versus cookbook medicine

Soledad Delgado
 

From "criaderas" to "soleras"

At the onset of autumn, my land fills with the smell of must. Freshly extracted from the pressed grape, it ferments and then passes to American oak barrels for ageing. The containers are stacked at three levels. From the lower one, the "solera", a third of its content is extracted for consumption. That part is filled with wine from the intermediate level, the first “criadera", and the same happens with this one, which receives wine from the upper level, the second “criadera". It's the one who receives the fresh must, full of life and potential. This wine, still young, is mixed during its ageing with matured wine, from which it takes some characteristics and to which it gives back the freshness of new aromas and flavours. The two wines are enriching each other, sheltered by the flower veil that promotes biological ageing. 

Express authorization of medicines, a double-edged sword

Cristina Roure

The approval of Aducanumab by accelerated route, by the Food and Drug Administration (FDA), for the treatment of Alzheimer's has been carried out against the unanimous opinion of its Advisory Committee on this matter, which has raised enormous dust. It is the first drug that attacks a supposed cause of the disease instead of its symptoms and has generated great expectations in a therapeutic area in which the gap is notable.

Healthcare must be imbued with value

Paco Miralles
 

The 22nd National Congress of Hospitals and Health Management featured an organizational success that augurs a certain post-pandemic "normalization"; many congressmen and a program with a significant presence of value-based medicine. I take this opportunity to congratulate the organizing committee for the great work done.

Much has been said about the paradigm shift in the healthcare system, about the need to do things differently, about value as a solution for humanization, for the cohesion of professionals, for the alignment of funders and providers, and for the sustainability of a system in which without value everything is much more expensive.

Make Evidence-Based Medicine Great Again!

Cristina Roure
 

“Make Evidence-Based Medicine Great Again!” is the provocative title of a conference that Dr. Domenico Pagano delivered at the 56th Congress of the American Society for Cardio-thoracic Surgery, calling for the need to restore professionalism, integrity, and trust in data and evidence in medicine. The conference is long, it lasts 55 minutes, but Pagano makes a brilliant presentation on the increasing manipulation that has led us to the swamp in which evidence-based medicine (EBM) currently inhabits.

The risks of doing the wrong things

José Joaquín Mira
 

The New Yorker

In all disciplines, we find some questions in search of an answer that stands out above all other questions, but without finding an adequate solution. The correct treatment, for the right person and at the right time (therapeutic adequacy), is one of those holy grails that affect, in this case, health disciplines.

Doctor, give me a checkup and make it a full one.

Xavier Bayona
 

The need to reduce anxiety due to the uncertainty of the possibility of getting sick and dying is one of the most frequent reasons behind the demand for a "preventive" health study, popularly known as a checkup. The purpose of the checkup is to detect the disease early, prevent it from developing, and/or provide reassurance. General health studies (checkups) involve multiple tests on a person who doesn't feel ill and is a common element of medical care in the Western world.

Risk-based medicine, a hieroglyph full of traps

Jordi Varela
Editor

 

Gerd Gigerenzer, Director of the Harding Center for Risk Literacy at the Max Plank Institute for Human Development in Berlin, was featured in this blog in 2016 following the publication of "Risk Savvy. How to make good decisions." Gigerenzer's crusade against risk manipulation and its consequences are consistent and tenacious, and that's why we should use more of his materials to help overcome the traps of malicious numbers if we want to practice proportionate medicine to address the real risks to peoples health. The following video which was edited in February 2020 by the Gigerenzer factory,  turns out to be essential in differentiating between absolute risk and relative risk.

Five-point plan to increase the value of clinical practice

Jordi Varela
Editor

In an article recently published in Clinical Medicine, Five recommendations to increase the value of clinical practice, I proposed a plan with a view to a more valuable clinical practice and, given the timely topic, I allow myself to partly reproduce in this post. You should note that this plan does not support pilot tests or halftones, but should be implemented with a perspective of in-depth organizational change, aiming to generate an institutional profile of value and excellence.

Could test cascades be avoided after an incidental finding?

Jordi Varela
Editor

 

Incidental findings resulting from a diagnostic test or screening are being a headache for modern medicine, a problem that is only growing hand in hand with the refinement of imaging technology and genomics. In some cases, the investigations that follow the incidental findings indicate the existence of silent pathologies, or in the initial phase, and timely clinical intervention is effective, although in often, the cascades of tests that are derived end up being unproductive, as well as potentially dangerous, for patients. It’s a phenomenon that generates anguish in hypothetical patients and burnout in professionals, who don’t know how to stop it, since once there is a probability that what is found is dangerous, the pressure to reach the end is unstoppable. Unfortunately, the evidence shows that there is no evidence that compliance with clinical practice guidelines is capable of ending these cascades once they have started and, on the other hand, it has not been possible to demonstrate that the establishment of economic penalties or co-payments can stop the phenomenon.

Providing courage, balance and humanity in the emergency services

Nacho Vallejo
 

@varelalaf

Urgency is a unique environment in healthcare. It works intending to deal with situations that can put the person's life at risk, but it’s also a "safety net" or, as we have defined it on some occasion in this blog, "a refugee camp of the health system". The care for people in this field of health isn’t only due to pathological and physiological disorders, but sometimes those who go to the emergency room do so as a consequence of dysfunction of our healthcare system that manifests itself with "collateral damage" derived from poor accessibility and, in other cases, from an excess of activity.

Artificial Intelligence: an opportunity for a more humane medicine?

Jordi Varela
Editor

Changing doctors for robots is a recurring theme in science fiction, but the appearance of devices with digital assistance, such as Alexa or Siri, and the promotion of self-care through smartphones, admitted The Lancet in an editorial, now seems a plausible reality. On the other hand, Harvard Medical School Professor Warner Slack said that if a doctor can be replaced by a computer, then this doctor deserves to be replaced by a computer. In this context, Eric Topol in "Deep Medicine" brings light to this debate with the defence of an open thesis: "artificial intelligence (AI), instead of replacing doctors, should become an aid for them to recover lost humanism."

Lessons from the opioid crisis, a case of overtreatment with devastating consequences

Cristina Roure
 

If you are regulars of American series such as House, The Affair or This is us, you will be familiar with the classic protagonist who, after an episode of acute pain, ends up becoming addicted to prescription opioids such as Vicodin®, OxyContin® or Percocet®. Do not think that this is a writer’s exaggeration.

In 2015, life expectancy in the United States changed the trend and began to decline for the first time since the First World War. Among the causes, the epidemic of deaths from opioid overdoses, which multiplied by six between 1999 and 2017 (1), surpassing deaths associated with AIDS at its worst or those related to the Vietnam War. The epidemic was declared a national emergency by the United States Department of Health in 2017 and, despite the campaign deployed to combat it (2), 130 people still die in that country every day from opium overdose. If you are interested in the subject and want to delve into it, read the supplement that Nature dedicated to it in September last year.

A new study detects 396 clinical practices that should be reversed

A medical reversal is the need to stop a clinical activity because a well-done study shows that in the real world the desired results are not being met, or that the adverse effects don’t outweigh the benefits. In a previous review (2013) of over 2,000 NEJM articles, Vinay Prasad and his team already discovered 146 clinical practices that should be reversed and, given the significance of the finding, the Catalan Society of Healthcare Management (SCGS) invited Vinay Prasad to explain it to us live, which he did on March 18, 2018 (you can see the video of the conference at the link).

High blood pressure: please don’t lose your head

Xavier Bayona
 

Although I am sure that we well know the difference between a risk factor and a disease, I allow myself the license to start this post by defining them. Risk factor (hypertension, hypercholesterolemia...) is that situation that has been related to the development of a disease (maybe the disease never develops despite having one or more risk factors), while the disease is the alteration in the organism's state or of any organ that interrupts or disrupts vital functions, affecting the state of health (ischemic heart disease, embolism...).

Since Julian Tudor Hart, in an article published in the British Medical Journal in 1993 after following a cohort of hypertensive patients for 21 years, concluded that the basis of treatment is the detection of hypertension and that the most important measures are hygienic-dietary and working from the community, countless articles have been written. But the essence of management remains: detect it, decrease sodium intake, increase physical exercise, abandon toxic habits and if they do not achieve the desired objectives, start pharmacological treatment.

The same challenge in Sao Paulo, Dallas and Phoenix: how to reduce unwarranted clinical variability?

David Font

Triple Aim, Right Care, Less is More, Nothing with Me without Me, Lean are concepts, principles and methodological approaches that are increasingly present in healthcare institutions and which we frequently discuss in the posts on Advances in Clinical Management. All of them aim to make better use of resources and allocate them to what adds value to the patient, thereby advancing sustainability, quality and safety. While it is clear that this is the way, the real challenge is how to put it into practice in each of our institutions. And so it is essential to read and travel to learn from other institutions.

Centralisation of complex surgery: clear, obscure and proposals

@varelalaf

A large group of European and North American surgeons have published in Annals of Surgery a review of the difficulties of centralising complex surgery around the world. The complex issue has multiple actors, starting with governments and respective funding models and continuing by the hospitals, the doctors involved and their corresponding scientific societies. It is surprising, however, that patients rarely appear in such discussions.

Some proposals to reduce the things we do without reason

Nacho Vallejo

Reducing unnecessary tests and treatments in our organisations can be a complicated task, especially in its implementation. To facilitate its development, and in line with the previous reflection on the search for things we do without reason, we have new references that can serve as support.

Canadian Choosing Wisely's Diving into Overuse in Hospitals campaign aims to sensitise institutions to participate in this analysis by making changes (small or large) to reduce this excessive use. On their website, professionals have access to a large number of resources such as a "starter kit", webinars and other exciting supports.

In search of the things we do without reason

Nacho Vallejo

In healthcare, there is usually a special appreciation for tradition or antiquity, which does not always translate into better clinical care. The reality is that there are things that we professionals do without the contrast of adequate evidence or, simply, without these actions providing sufficient value.

The Choosing Wisely initiative was launched a few years ago from a private North American institution. It was necessary to suggest to the scientific societies of that country the development of recommendations on clinical practices that both doctors and patients should rethink.

Medicine based on customs

@varelalaf

The universe of my childhood was full of incontestable rules; most of them had to do with the precepts of religion, although the matter affected all aspects of daily life. I remember that you could not bathe in the sea or in the pool if you had eaten or drank within a minimum period of two hours, a period that the strictest families extended to three. When you were a teenager and you protested, the parents told you all kinds of calamities that could happen to you if you failed to comply with the rule, according to a lot of legends that were passed down from generation to generation.

For a more conservative medicine

@varelalaf

Last week I discussed the influence of machine learning on clinical practice, a dynamic loaded with chiaroscuro and, for this reason, I think it is worth echoing today the manifesto "The case for being a medical conservative" written by four doctors: John Mandrola (cardiologist), Adam Cifu (internist), Vinay Prasad (oncologist -haematologist) and Andrew Foy (cardiologist). The authors clarify that their manifesto has nothing to do with politics, but that, given the dazzle of technology and the pressure of consumerism; they are forced to embrace conservatism, a way of saying enough when nobody is willing to do it.