Monday, 4 December 2017

We need a fish tank

Pere Vivó

The American psychologist Barry Schwartz, who can be read frequently in The New York Times or listened to in TED (Technology, Entertainment, Design) conferences, invites us to reflect on the paradox of choice. His talk begins with what he calls the "official dogma" of all Western industrial societies, which states: "If we are interested in maximizing the welfare of our citizens, the way to do so is to maximize individual freedom." The reason for this is that freedom itself is good, valuable, praiseworthy and essential for human beings: "If people have freedom, each of us can act on their own to do things that will maximize our well-being and no one will have to make decisions for us. The way to maximize freedom is to maximize choice: the more possibilities people have, the more freedom and greater well-being they will have."

This concept also applies to health services with the transfer of responsibility to the patient when choosing therapeutic alternatives, both in free market environments such as the American, as in national health systems such as English or Spanish.

The good thing about having maximized the ability to choose is known by all, but what about the bad news? Schwartz highlights the following negative effects:
  1. Paralysis. With so many options to choose from, people find it difficult to make the choice and often a paralysis occurs as a result of having too many alternatives.
  2. Reduction of satisfaction. The wide range of possibilities that we have, makes the opportunity cost of each decision very high, that is, the act of choosing involves not choosing other options and that makes us always ask ourselves if we really made the right decision.
  3. Increased expectations and disappointment. Our expectations about the result increase with the number of alternatives, since the logic tells us that if we can choose between several options some has to conform to us to perfection and the problem emerges when this expectation does not occur.

Schwartz, showing a fish bowl, asks: "What does this fish know? Nothing is possible in this fish bowl... Poor imagination and myopic vision of the world: that's the way I read it the first time... But the more I think, the more I come to the opinion that this fish knows something... because if you break the fishbowl so that everything is possible, you don’t have freedom, you increase the paralysis and you diminish the satisfaction. We all need a fishbowl although certainly this is very limited, perhaps even for the fish... but the absence of the fish tank is a recipe for misery, and perhaps for disaster."

Monday, 27 November 2017

Let patients help!

Dave deBronkart, better known as "e-Patient Dave", is a marketing expert who on January 3, 2007, at 09:02, received a call from his doctor: "We have found something in your lung." DeBronkart remembers that moment with precision because that news changed his life. From that moment he abandoned his normal citizen status to become a metastatic patient of a tumour of renal origin and, given his clinical condition, in an advanced cancer patient. DeBronkart received a treatment that normally does not work, but luckily it worked for him.

So far a story with a happy ending, but Dave's story highlights his attitude (just look at the cover of the book with a picture of him with his doctor, Dr. Danny Sands). With the sentence above, far from adopting a fearful and docile attitude, searched Google, went to find other patients with the same diagnosis, and sat down to talk to his doctors using his own criteria, sharing with them each of the decisions that he was taking. Now e-Patient Dave has become a leader in what we call patient empowerment.

Monday, 20 November 2017

The fallibility of scientists

Nature has echoed the professional debate about the intrinsic quality of scientists’ work, in a dynamics of self-criticism comparable to what is taking place, in similar terms, in the clinical world. Scientists are also fallible, says the article writer and therefore, should enhance the mechanisms of self-criticism, rather than enrol in self-deception.

John Ioannidis, Meta-Research Innovation Center at Stanford, says scientists should work harder to understand the biases of their human fallibility if they want to overcome the crisis of confidence generated by the poor reproducibility of research results. And to illustrate his words, Ioannidis offers three examples: a) from a selection of one hundred psychology studies, only the results of just over a third of the work could be replicated, b) a group of Amgen researchers only succeeded in reproducing 6 of the results of 53 reference studies in the field of oncology and haematology, and c) the Ioannidis team itself was able to replicate completely only 2 of the 18 gene expression studies based on microarrays (DNA chips).

Monday, 13 November 2017

Measuring the value of anti-cancer drugs

Cristina Roure

Anti-cancer drugs, especially palliative drugs, are toxic, costly and sometimes of little benefit, as a result their value to the patient and society are often questionable. It’s also true that significant improvements in the survival rates are threatened by the difficulty in accessing them, due to their unsustainable cost.

Monday, 6 November 2017

Precision medicine in the elderly care

Marco Inzitari

One of the challenges launched by President Barack Obama ($215 million for 2016) is the "Precision Medicine Initiative" a concept that goes against the treatment focused on the "average-patient". According to this initiative, as a first step, cancer treatments should be oriented to the specific genetics of the patient. For this reason, we often refer to the future of oncology as a "precision medicine". As another example, to continue with oncology, the Watson Intelligent System (IBM) will provide support to oncologists for informed and well fitted decision-making, analyzing patients' medical records and looking for possible evidence-based options.

Monday, 30 October 2017

Prediabetes epidemic in sight

Prediabetes is a terminology that, recently, is used when a person is detected with higher than normal levels of blood glucose, but there is no pathology. Prediabetes could be understood as a disposition to develop diabetes in the future, a disease that, in turn, represents a condition that puts one at risk of serious affections such as nephropathy, retinopathy or cardiovascular disorders, among others. Due to this chain of risks, and with a healthy intention to reduce morbidity and mortality, the American Diabetes Association (ADA) led a study to consider that glycosylated haemoglobin (HbA1c) is a test that can be done without any preparation or need for fasting and see if it can become a new criterion for detecting prediabetes. The concern arises when, according to this diagnostic extension, it’s estimated that in millions of pre-diabetics would show up: in China 493, in the US 86 and in Spain 6, to cite three countries from which I have data.

Monday, 23 October 2017

The Patient Revolution according to Victor Montori

In 2016, Victor Montori, a professor of medicine and diabetes doctor at the Mayo Clinic, launched The Patient Revolution, a foundation whose mission is to help make truly patient-centred treatment a reality. In his new book, Why We Revolt, Montori argues that “industrial medicine” has corrupted the mission of medicine to the point where doctors are now incapable of caring for the people who place their trust in them (for further information about the author in this same blog, search for “Montori, V." entries in the tags [top-right-hand column].