"Being Mortal" by Atul Gawande: The End Matters

Dr. Atul Gawande is a surgeon, researcher and dilettante but also a writer as he describes himself in his twitter account. Dr. Gawande is also known in the field of clinical safety for his previous book "The Checklist Manifesto". The author of "Being Mortal" masterfully explains that life can also be valuable as we get older, frail and defenceless and that there comes a time when we can no longer fend for ourselves. The end matters, as sports enthusiasts know it so well, when pushing your luck at the last minute can lose the whole game strategy.

In his book, Dr. Gawande reflects on the end of life stage of many people from his experience as a doctor, to the extent that one of the best documented cases is that of his own father. In the video that I have chosen for you, you will see how he and his mother talk about it.

Early Palliative Care: + Life Quality + Life Quantity

More evidence supporting early palliative care:Study Identifies Factors Linked to ED Visits by Cancer Patients http://t.co/jdHwJUIZ99 #hpm”

— Jordi Amblàs (@jordiamblas) 3 de enero de 2015

A meta-analysis (you can access it through the link provided by the tweet from Dr. Jordi Amblàs) of 30 studies in 5 different countries and with a participation of more than one million patients shows that patients who had received palliative care were accessing the emergency wards less in the last month of life, which is very positive, considering that many emergency practitioners confess they are not equipped to properly address this type of patients, and also a trip to an emergency service increases the risk that people in advanced stages of illness are subjected to disproportionate actuations. As for the transcendent matter of the moment of the introduction of palliative care, although there are indications that precocity is positive, this meta-analysis fails to reach conclusions due to the heterogeneity of the selected studies.

About the 16th International Conference on Integrated Care

Last week, Barcelona was the host of the 16th International Conference on Integrated Care, a conference that brought together more than one thousand of health and social professionals in order to discuss the integration of services in response to the fragmented practice. Nick Goodwin, President of the International Foundation for Integrated Care (IFIC) in the Conference’s presentation video says that we often think about the integration of services as a mechanism for reducing unnecessary hospitalizations, or even to reduce costs of the waste caused by lack of coordination and inappropriate actions, but Goodwin points out that we should make no mistake: the main objective of this movement is to generate opportunities for care coordination in order to improve the experience and quality of life of patients, especially of those in need of complex health and social care.

Advanced practice nurses: it’s time to strongly support

According to International Council of Nurses, an advanced nursing practitioner is a specialist who has acquired the expert knowledge, the capabilities of making complex decisions and the necessary clinical competencies for expanded practice.

The concept emerged in the US, in the 70s, in the areas of obstetrics and anaesthesia and, thereafter, the development of the nursing profession has focused on what has been renamed Advanced Nursing Practice (ANP). It’s a graduate training that provides an overview for the care of complex patients, for the involvement of people in managing their own diseases and, in short, for everything that regards innovation, evidence and research aimed at improving the care offered to people.

Family doctors: it’s time to strongly support

The number of places for family doctors at the last resident doctors (MIR) call from the Spanish government is of 1,671, only 25% of all specialties convened. The question is: Will this annual promotion of family doctors cover the future needs of an increasingly aging population? If we’d pay attention to a report from British experts, "Securing the future GP workforce" the answer would be clearly negative. This document ensures that to meet the challenges in chronic disease from primary care, half of medical students who now graduate would need to become family doctors. But how to make the profession more attractive if its disrepute is so big that each year, at the MIR call, there are many vacancies left and the dropouts during training reach 15%?

In a survey (“Why doctors flee and shun the family medicine?” by Gonzalez B, Barber P and Ortún V) undertaken with students from the sixth grade of the medical course, a surprising finding stands out: students prefer generalist specialties, including family medicine. The surprise, however, doesn’t last long, because after strenuous preparation for the MIR test, most of, by now graduated doctors, shift in preference and opt for more technical specialties. The same survey warns that, this in this shift, we can detect not only the influence of MIR but also other relevant issues such as working conditions, pay and prestige.

How to involve doctors in transforming the health system

All health systems need to streamline costs while solving a lot of complex problems and  improving health outcomes. We’re dealing then with difficult challenges that are almost impossible without the doctors’ involvement, and for this reason I found this article to be very relevant: "Engaging Doctors in the Health Care Revolution" by Thomas Lee and Toby Cosgrove, from Harvard Business Review, as they are seeking solutions from Max Weber and his 4 fundamental motivations for social actions.

Motivation 1. Look for noble targets

When managers and doctors meet up, they ought to discuss patients, quality and results, and if they really want to change the status quo, they should not wonder away from this script. The conversation, therefore, should never start with contracts and compensations, this topic ought to be reserved, if at all, for the end of the meeting, after the main topics. Managers ought to listen, assess the views and know how to create a process in which all parties should have the opportunity to add their personal touches to the final process. A basic script of 3 points that the authors extracted from Mayo Clinic should be kept in mind: a) at the time of sitting down for the discussion, everyone should be very clear that things can not continue as they are; change is needed, b) the transformative project that arises must be clearly focused on the patient, and c) this is a path on which all involved actors will walk together.

Hospitals and frail elderly patients

Health Service Journal published a report from a committee of experts based on several previous publications, including the British Geriatric Society, Future Hospital Report and King's Fund. From the conclusions of the report I want to highlight some ideas that in my opinion are important:

a) Age should never be a barrier to receiving appropriate, coordinated, safe, efficient and effective care.

b) Integration of social and health services within the community framework is the best approach that can be offered to the group of frail elderly people, although this does not prevent the occurrence of circumstances that may require hospitalization.

c) The emergency departments of hospitals should have the geriatric culture well established in order to make appropriate choices and avoid unnecessary admissions.

d) If the frail person qualifies for hospitalization, the practice of geriatric assessment is imperative as is the practice of developing an individualized treatment plan, because it has been shown that if this methodology is followed through, patients are 30% more likely to survive and go home.