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.

Default options in healthcare

Pedro Rey

Although we talked extensively about the shared clinical decision between doctor and patient, many decisions made in health care are not chosen fully consciously. Among these "decisions", one powerful example is the power of default options: those established protocols that indicate what will be done if no other decision is actively made.

Taking action in patient-centred care

Nacho Vallejo

 

Frame of the series New Amsterdam

Talking about patient-centred care in our healthcare organizations may sound hollow or a tradition of good intentions. There are very attractive topics such as "patients first". In any case, putting patients first, abandoning traditional medical paternalism, has at times become an excuse to configure a variety of intentions that risk being left in symbolic speeches. I believe that one of the reasons that don't allow progress in this task is the need to specify it in actions that the ordinary professional can understand and carry out, checking its benefits and its results.

Shared decisions, evaluate to advance

Jordi Varela

Editor

The progress of shared clinical decisions is being almost negligible and, for this reason, attention should be paid to the results of the clinical trial by Víctor Montori's research group, an evaluation that was carried out with almost a thousand patients with atrial fibrillation. which ones had to decide if they wanted to take anticoagulants and, if they did, which one they would choose. In the trial, the intervention group of patients tested a shared decision support instrument, while the control group followed the usual clinical pathway.

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.

Shared decisions at the end of life

Paco Miralles

Maria was an endearing lady clinically that I have supervised for more than two decades, time enough to know each other well. We had commented several times on how we would act (speaking in the plural) if she was ever diagnosed with an incurable or terminal illness. She would not like to spend the end of her days, if possible, in a hospital. She preferred to be at home surrounded by her folk. She was a religious person and wanted to receive spiritual assistance before leaving this world. The time has come for her to be 88 years old. She was on home palliative treatment for a few months. In the last month, it began to decline without improvement. A few days before the end of her life she asked me to see a priest. I was surprised. Did I have to take care of this if her family was there? It was a lesson for me. She had agreed to her last days with me, it was part of her treatment. Just as I was asking for a dose increase for the pain, she wanted to seek spiritual relief. For her, it was perhaps more important than physical discomfort(1).

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.

Arrogance, condescension and indifference in communication with patients

Glòria Galvez

In traditional society, men have had an authority role and women a secondary and subordinate role. As a result of this form of behaviour comes the term mansplaining, a combination of the words man and explaining. The term appears for the first time in a text by Rebecca Solnit “Men explain things to me” to define the habit of some men to express their opinion with authority, condescension and a paternalistic tone on all kinds of subjects, even if their experience is little or non existent.

John Launer, in the article published in the Postgraduate Medical Journal, talks about medical condescension or "docsplaining" that, like mansplaining, has to do with paternalistic and condescending behaviour. In this case, it’s the professionals –men and women– who, to maintain control of the conversation with patients, address them with a certain arrogance exercised from parental ambiguity.

Surgery and the elderly

@varelalaf

More and more elderly people are being seen in the operating room, especially for large joint replacement interventions, for colorectal cancer resections or for vascular pathologies, to cite the most frequent casuistry. Many of these actions are aggressive and generate risks of postoperative complications, which often require catheters, serum, transfusions, intubations, etc. Therefore, a lot of clinical circumstances are generated that induce immobilization, a situation that adds a new chain of risks, especially thromboembolism, bedsores, infections, disorientation, delusions, malnutrition and dehydration.

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. 

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.

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.

Raiders of lost clinical reasoning

In a previous post, "Against manual medicine," I analyzed the concern of two internal physicians at Brigham and Women's Hospital for the excesses of manual medicine in their book When doctors don’t listen. Avoid misdiagnoses and unnecessary tests. on this same subject I want to talk about Jerome Kassirer, John Wong and Richard Kopelman, three authors who in 1991 published Learning Clinical Reasoning, a reference work that laid the foundations of clinical reasoning through the inferential process of hypothesis generation diagnosis, its subsequent refinement with the elaboration of a diagnosis of work, the sustained request of complementary tests, the management of Bayes' theorem, the causal models, the diagnostic verification and the taking of therapeutic decisions. Twenty years later, the same authors published the second edition of the book, and in their presentation said they were forced to update it because in recent times, the practice of medicine had undergone very profound changes. According to them, rapid triage in emergencies and reduction of hospital stays are forcing doctors to be less contemplative and they are often seen short-circuiting the diagnostic process, or by cutting out minutes of time spent in interviewing or exploring where they try to compensate by quickly sending patients to perform diagnostic tests. This obsession with the performance of physicians is detrimental to the reflection on what has been learned in the observations made and the establishment of a qualified relationship with the patient. The authors state that the diagnostic process, as it was known, has been replaced by "take a look and ask for a CT".

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.

Against cookbook medicine

"How can modern medicine be so dehumanized?" is a question posed by Dr. Leana Wen and Dr. Joshua Kosowsky in “When doctors don’t listen”. According to them, with a few exceptions, the practice of medicine is subjugated by the dictatorship of guidelines, algorithms, codes, protocols and rules. "Cookbook medicine" they call it. Everyone is aware that many requested tests are unnecessary and that many people are subjected to anxiety induced by the prescribed manual diagnostic processes to rule out infrequent pathologies. The theory of the book is based on the fact that the process to arrive at a diagnosis is complex, requires an interview in which the patient can frankly express the story of what is happening to him, a physical examination according to the hypotheses that arise and a clinical reasoning participated by the patient himself; all this, very far from a manual practice.

Clinical practice guidelines versus shared decisions

In the April post I was talking about the call for the end of clinical practice guidelines. This is an issue that is generating controversy and I think it’s worth revisiting, especially following the publication of “Making evidence based medicine work for individual patients” by Margaret McCartney and collaborators, where they say that there is concern because the guidelines, instead of reducing variations and improving the quality of assistance have managed to bureaucratize medicine, while at the same time reinforcing historical authoritarianism. This happens because, according to the authors, based on the evidence, the guides encourage doctors to ignore the real needs of the people they serve. In addition and to top it all, a review concluded that 62% of the guidelines were based on irrelevant evidence for health problems affecting people visiting the family doctor.