Is there an ideal primary care team?

Jordi Varela
Editor

Have we ever heard that there are health centres in Finland that work as a multidisciplinary team, or that in Alaska there are groups of professionals who do admirable work with indigenous community health, or that in Scotland health and social services already they work in a very integrated way? And the question that comes to mind is: does the ideal primary care team exist?

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.

Debate with Vinay Prasad on the value of clinical practice and doctors’ training

Vinay Prasad (University of Oregon) and Adam Cifu (University of Chicago), authors of "Ending Medical Reversal: Improving Outcomes, Saving Lives" (Johns Hopkins University Press, 2015), point out 146 clinical practices that should be ditched because it has been proved that they do not deliver the promised results. The list of these practices affects the whole range of the health activity; however, making a detailed reading, it has been observed that these are mainly found in four specialties: cardiology, gynaecology, orthopaedics and family medicine. It’s because of this reason that the Section of Clinical Management of the Catalan Society of Health Management (SCGS), in its Annual Conference to be held on May 18, in agreement with the team of the project Essencial of AQuAS, has organized a debate between one of the authors of the book, Vinay Prasad, and representatives of the 4 mentioned specialties: Xavier Viñolas, president of the Sociedad Catalana de Cardiología (SCC), Juan José Espinós, gynecologist at the Hospital de Sant Pau, Joan Miquel, orthopaedist at the Hospital de Igualada and Marta Expósito of the Sociedad Catalana de Medicina Familiar y Comunitaria (CAMFIC). The debate, which will rely on the moderation of Sandra Garcia Armesto, director of the " Instituto Aragonés de Ciencias de la Salud ", aims to not only find out first-hand about the work of Vinay Prasad, but also to find out what the related specialists think of these practices and what is the impact on our situation, differentiated in many aspects from that of the United States.

On the other hand, Prasad and Cifu, in the book, propose to significantly modify the training programs in medical schools, in order to train new physicians that are more demanding with regards to scientific rigor, more critical of practices with poor value, more sensitive to the needs of patients and more oriented to the evaluation of results. The proposed formula is very simple: the clinical sciences should be the priority, while the basic ones (as we understand them today) should be complementary. It’s not about studying models and then checking them (current system), but about doing it the other way around: from the findings of the clinic, doctors should review (or accept) the theories. Given the importance of the proposal, we thought it appropriate to organize, in the same framework of the Conference, a second debate moderated by Xavier Bayona, with three academic authorities in the training of doctors: Francesc Cardellach (Universitat de Barcelona), Ramon Pujol (Universitat de Vic - UCC) and Milagros García Barbero, president of the Sociedad Española de Educación Médica and, logically, also inviting Vinay Prasad to join them.

The program of the Conference is attached, with the clear purpose of encouraging all readers to register, because nobody should miss out on the opportunity to listen to and pose questions to Vinay Prasad and all invited speakers.

Organizes:

• Clinical  Management  Section  –  Catalan  Healthcare  Management  Society 

In  collaboration  with:

• IDIBAPS.  Institut  d’Investigacions  Biomèdiques  August  Pi  i  Sunyer  
• Centre  de  Recerca  en  Economia  i  Salut  (CRES)  –  Universitat  Pompeu  Fabra  
• Institute  for  Healthcare  Management  -  ESADE  
• Agency  for  Health  Quality  and  Assessment  of  Catalonia  (AQuAS)  
• Hospital  Clínic  de  Barcelona  
• Aragonese  Institute  of  Health  Sciences 
• Catalan  Society  of  Family  Medicine  (CAMFIC)  
• Catalan  Society  of  Cardiology    
• Catalan  Society  of  Gynecology  and  Obstetrics  
• Catalan  Society  of  Traumatology  and  Orthopedic  Surgery  
• Cochrane  Iberoamérica  

Sponsors:

• Vifor  
• Unió  Catalana  d’Hospitals  
• Consorci  de  Salut  i  Social  de  Catalunya  
• Novartis  

"The values of clinical practice" Campaign for doctors in training

The Clinical Management Section of the Catalan Society of Health Care Management (SCGS) has just released a video to promote the values of the clinical practice among physicians in training.

To activate English subtitles go to "settings" in the lower right banner

I would like to highlight 10 keys that, according to the video, should allow a generational change in the practice of medicine:

1. Learn to listen patients and appreciate what their circumstances are.
2. Forget about persuasion and learn the technique of motivational interviewing.
3. Help patients to make clinical decisions for themselves.
4. Rate the burden of treatment and learn to deprescribe whenever necessary.
5. Take the time for clinical reasoning and adopt the Bayesian probabilistic thinking.
6. Request tests that make sense clinically, thinking about the value they will bring.
7. Learn to teamwork, specially when facing complex patients.
8. Watch out for overdiagnosis when practicing prevention and share it with target people.
9. Incorporate palliative methodology in your clinical practice and know how to have the proper conversation about the end of life with patients and their families.
10. Know how to get the "Right Care" sources.

Main "Right Care" sources

• The Cochrane Collaboration, active since 1993.
• Collection of articles Less is more in JAMA Network, since 1998.
• Campaign Too much medicine of the British Medical Journal, since 2002.
• Do not do. Recommendations arising from clinical practice guidelines from NICE, since late 2006.
• Choosing Wisely. ABIM Foundation Program. Collect recommendations from American scientific societies, since 2011.
• The "Essencial" Project from AQuAS. It has the support of Catalan scientific societies, since 2013.
• Diana Salud, a website of the epidemiology research network CIBERESP. Excellent searcher of 18 sources "Right Care" worldwide.

From this blog I wish the campaign "The values of clinical practice", promoted by the Clinical Management Section of the SCGS, to echo, both in medical schools and medical residents programmes.


Jordi Varela
Editor