Monday, 22 May 2017

Beyond the reforms (on the subject of Franco Basaglia)








What can we do when reforms are in short supply? This is a question that many of us ask ourselves when rigidities and bureaucracies show us their sordid face. Without going any further, the integration of services and community work is the only way (I think there are no dissenters in this) to adequately care for complex chronic patients, but when it comes to the truth, it turns out that the levels of care, professionals’ abilities and the fragmentation of medical specialties are a drag on the progress of the necessary reforms.

I’ve pondered on this when I read that The Guardian had just published a book by John Foot, "The man who closed the asylum" that tells the life of Franco Basaglia, a psychiatrist with an exceptional entrepreneurial force. During the war, according to the author, Basaglia was imprisoned as an antifascist and this experience was key to the fact that when he was appointed director of an asylum in the early 1960s, he realized that the psychiatry practiced in that establishment was inspired by and took the shape of prisons.

Franco Basaglia embraced the ideas of anti-psychiatry and by his first day as director of the Gorizia asylum, he already refused to sign repressive orders, beginning to work for the democratization of the internal life of the institution from the outset. His biographer says that the transformative enthusiasm of Basaglia and his collaborators (including his wife) was overwhelming. The reactionary forces stood up to him, but he was determined: the asylums could not be reformed; they had to be abolished. In 1978, shortly before dying at the age of only 56, he managed to convince the Italian parliament to approve the law that takes his name and which meant the dismantling of all Italian mental hospitals and adopt the European model (see post: Mental health, the most forceful transformation).

If you have six minutes do not hesitate to click on this video, narrated by John Foot the author of the book on Basaglia, about the closure of asylums for the insane in Italy.




Going back to where we started, to the need to go beyond the reforms for complex chronic patients, I think it would be good to recover the Basaglia spirit, in the sense that what we ought to abolish what we do know, just as the anti-psychiatry did in their moment, to realize that if we don’t understand how people are and how they live, it will be impossible for us to offer them adequate services. For this reason, it will be necessary to eliminate levels and specialties in order to integrate services from community leadership.


Jordi Varela
Editor

Monday, 15 May 2017

The controversy of health checks








The National Health Service announces health checks by making use of the mood of the "Full Monty" or "The Calendar Girls." Let yourself be undressed for a good cause - they say - your body deserves it. In Spain, on the other hand, this approach is more typical to the private offer. "The best way to take care of your health is to open your eyes to possible diseases and not hesitate to undergo periodic tests to prevent them," says "10 Minutos" magazine in an article on the subject. Many private centres have "Medical check-ups" and most insurers and clinics offer health check-ups, as can be seen in an announcement from the Quirón Teknon Hospital: "basic preventive check-up: previously € 820 - now € 690; advanced preventive check: was € 1,800 - now € 1,520". The Sanitas proposal that offers the possibility of choosing between "checks: classic, integral and complete" is also interesting just as the National Conference of Marketing and Sales Management of the Health Sector that says "the most demanded from the iGlobalMed platform are the health checks for managers who are going to work abroad". To end this journey through the world of health reviews, see the clip below from the University Hospital of Navarre website:

Monday, 8 May 2017

What if I decide to do nothing?








TIME magazine has surprised us with a question on its front page: "What would happen if I decided to do nothing?" Desiree Basila, a 60-year-old teacher, had just been diagnosed with ductal carcinoma in situ (DCIS) and, overwhelmed by the aggressiveness of the treatment proposals offered to her, began to investigate on her own and realized that there were many unknown elements about the progression of this type of injury and also saw that there was no agreement in the scientific community on what should be the most appropriate therapy for her case. For this reason she made a bold decision and asked her oncologist to do nothing, which resulted in two checks a year and a treatment with Tamoxifen, a drug that blocks estrogens that could cause the tumour to grow.

The case of Desiree Basila is quite valuable because when she made this decision, 8 years ago, it was not yet known that the mortality of women with DCIS, regardless of the type of treatment they adopt, is 3.3%, a figure comparable to that of the general population, and it was also not known that chemotherapy has no effect on tumours in initial staging. But to better understand the pressure that Desiree had to endure, it should be added that the attitude of most oncologists, even in the case of DCIS, was, and remains, "the sooner the better and the more the better."

Monday, 1 May 2017

Primary care: segment to reform?







In a paper published in Health Affairs, Redesigning Primary Care: A strategic vision to improve value by organizing around patients' needs (see commented post) Michael Porter invited us to rethink the organizational model of primary care in accordance with the real needs of the population.

Following the Porterian advice, and just to think a little, it’s worth the excellent Memory of the Catalan Institute of Health (ICS) of 2013, with data from 288 primary health care teams spread throughout the territory, from small local clinics to metropolitan centres with several basic health areas under their care. On page 7 of the document you will see a table elaborated with the attendance of more than 4 million people (who have been visited at least once during the year). The segmentation of this population, grouped with Clinical Risk Group, shows that segments 5, 6 and 7 (different intensities of chronicity) have represented 64.5% of the people who have visited, a group that has consumed 88.8% of the pharmacy and generated 74.7% of urgent hospitalizations (among patients who have been hospitalized two or more times in a year).

Monday, 24 April 2017

The value of clinical practice in chronic complex patients









Lost in the country of the pink bibs

To illustrate what kind of patients Dr. Meier is talking about, I found an article in The New York Times, where the writer Marcy Cottrell House explains the case of her father, who at age seventy, developed dementia and also broke his femur. Cottrell says that during the long postoperative period, the father got much worse and often found him in a room with other insane patients, all of them with a pink bib around their necks. The quiet of the place was impressive and the old man's gaze no longer recognized anyone. The nurse told them not to worry, it was normal to be more disconnected because of the tranquilizers they gave him to avoid the aggressiveness that he displayed during his stay. The writer ended up going in the office of a good geriatrician, who told him that the postoperative pain or that of poly-arthritis was likely to be torturing his father. He clarified that cognitive problems don’t stop him feeling the pain of bones and joints. The fact - explains the author - is that with a gram of Tylenol three times a day (a painkiller), his father revived and returned to smile when he heard his music and, better still, managed to escape the country the pink bibs.

Monday, 17 April 2017

The attitude of the doctor when faced with the biological opportunity of death


Gustavo Tolchinsky


During one of my postings in a small county hospital I found myself in the resuscitation room. A colleague had been trying for some time to understand how to tackle the cascade of problems harbored by an elderly patient: the monitor roars at 150 beats per minute, the pulse-oximeter shows 78%, despite the FiO2 1 of the high concentration mask; the patient, with a blank stare, the breathing strongly audible and the arterial tensions hardly captured. While the nurses are desperate to find a vein, to probe, to administer the prescribed corticosteroids and digoxin, to perform the electrocardiogram and to anticipate the next steps that the emergency doctor will order. Around her, another nurse points out, with great conscientiousness, what time it is and what procedure has been performed.

Faced with this situation it is reasonable to act by instinct driven by our eagerness to ‘solve’ the problem. I had already framed a first diagnosis. The patient presents a fall in rapid atrial fibrillation in the context of acute respiratory failure due to a respiratory infection, perhaps caused by bronchoaspiration. The hypotension is secondary to the haemodynamically poorly tolerated tachyarrhythmia. At this moment, knowledge put into practice demands that you slow down the heart rate, indicates serum therapy to overcome stress and starting treatment with antibiotics, relieving symptoms, etc.

Monday, 10 April 2017

Strategies for the integration of services








King's Fund has published a timely and in depth document "Acute Hospitals and Integrated Care" where they question what role should hospitals play in the integration of services. Given the approach, one could ask: What role should primary care play? How about community services? And the social health services? However it may be best, King's Fund has focused on it in this way and I believe it has its reasons for doing so because, right now, the organizational model that everyone tends to is that of territorial management or that of integrated health organizations, all of which are intended to integrate services from a hospital-centred position.

Who should lead the integration of services?

According to the document, it’s fundamental to generate the network of services on a territorial basis and the question of leadership should depend on the nature of each clinical process. Let's take a few examples: a) A remote dermatology project should be led by specialized care, b) An infarct ought to be led by cardiologists, intensive carers and emergency specialists, c) Care for type 2 diabetes mellitus, should be led by the primary care, d) Individualized therapeutic plans of complex chronic patients, should be led by primary care with the community nurse and the social worker taking a high profile role, e) Complex end-of-life processes should be led by community-based multidisciplinary palliative teams.