Wednesday, 25 April 2018

Weapons of mass distraction in the National Health System

Salvador Casado




When we go to a health professional's office there are recurring constants, white coats, stretchers, blood pressure monitors and a computer on the table. The medical record is no longer a folder full of paperwork, but an electronic form on which health professionals work. There is no doubt that it has many advantages over the previous format but it has not yet been able to correct its major flaw: its great power of distraction of the professional who uses it.

The limitations of design and usability mean that at each clinical meeting a considerable amount of time has to be devoted to registering, filling in numerous protocols and making requests for analyses, consultations to other professionals or issuing prescription, bureaucracy  or reports of any kind.  The perception of many patients is that health professionals look at their screens more than they do at themselves, and that's usually not cool.  Nor is it a dish  for nurses and doctors who see how their limited time is spent on tasks that prevent them from devoting dignified attention to the people they attend.

At a time when speed and efficiency are becoming more and more important, it is also becoming increasingly difficult to listen properly. This is a multilevel  challenge, in the world of health care, even more as it is necessary to try to translate the symptoms and signs presented by the patient into accurate diagnoses and appropriate treatments. If listening is not correct when taking a medical history and performing a physical examination it will be impossible to understand what is happening to the patient and to propose appropriate courses of action.  This is sadly evident in the pediatric care  with children who consume more and more antibiotics and medicines and in the elderly who, suffering from loneliness and hopelessness,  every time they come to the health system for help they are burdened with more diagnostic labels and pills that solve them little. In general, we sink into overdiagnosis and overtreatment, the health system is becoming increasingly used as a sink for many situations of difficulty and suffering derived from ordinary life, which in the strict sense should not be labelled as illness as it ends up being.

On the other hand, the fashion of biometrics encourages citizens to use applications and devices that record their steps, heart rate, blood pressure and other constants. This calms anxiety with a certain sense of control over the body and one's own health, which is nothing more than a mirage. Measurement does not transform habits of life on its own. We end up distracted and everything stays the same.

One of the main courses of action of medicine of all time is to wait and see. Most minor situations end up resolving spontaneously in a few days without the need to apply any external remedies. However, it is becoming increasingly difficult to appeal to this possibility in the face of the demands of modern life for speed and efficiency. "Give me something to get rid of this cold now", "I need an urgent remedy to get rid of this discomfort", "I started with this symptom a few hours ago and came to the doctor for a quick solution"...

If the professional who receives us is overloaded, has little time to devote to us, or works with an information system that requires a great deal of attention and concentration, the result is that the quality and quantity of listening that can be devoted to us will be questionable at least.

If we add to this the fact that this professional does not know us because we are in an emergency department or in a hospital or primary care clinic where we go for the first time, we will have the perfect storm to leave the office with more diagnostic tests or treatments tan necessary and probably  less quality hearing from the health profesional.

At present, the quality of the listening that professionals provide to their patients is not evaluated, in spite of being one of the most valuable resources of the entire health system. Instead of protecting this input, it is sad to see how from the political and management spheres are increasingly contaminating it with infinite distractions in the form of new protocols, screens, clicks and other registration and bureaucratic demands.

In several regional health systems the computer system requires 40 to 60 seconds to authorize the signing of prescriptions.... They are not isolated cases, the punishment and hardship to which professionals are subjected ends up resenting a quality of care that is increasingly compromised by cuts, harmful health policies and other threats.

We are therefore trapped in a complex situation that does not allow for easy alternatives as it is not possible to stop using the computer completely in consultation. Awareness of the enemies of good clinical listening is perhaps a first step in rethinking the management of distractions targeting information and recording systems as leadings roles.

@doctorCasado



Monday, 23 April 2018

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  

Monday, 16 April 2018

To optimise the expense, the cost must be reduced

Josep Mª Monguet




It’s well known that the budget allocated to health services has endured brutal cumulative reductions over recent years. This is a detrimental fact, but one can not deny the merit of having suffered and then having survived the cut, the professionals - in the first instance and the users alike. It’s sad but praiseworthy.

The health budget is unlikely to improve in the short to medium term because the situation is what it is and by definition the public deficit has a ceiling. Lamenting that resources were not well managed during the "good times" doesn’t change anything. Although it seems a contradiction, the financial management cannot be improved if the health system and its users, collaboratively, are incapable of reducing the avoidable costs that weigh us down. Only thus we can free up resources and allocate them to make the system more efficient.

Monday, 9 April 2018

Home sweet home and some other lessons

David Font




An article in the New England Journal of Medicine explains that the Department of Health in Victoria, Australia in 2010, announced the construction of a 500-bed hospital without using bricks. This virtual hospital currently receives 33,000 patients per year. And the introductory paragraph of the article ends by asking: What was the incredible technological progress that made it possible? Caring for the patient at home!

Let's continue without leaving the house. I remember post by Jordi Varela introducing the experience of Buurtzorg Netherlands, the Dutch home care company, described as a success story by King's Fund. During a Congress in Barcelona, I heard Jos de Blok, the leader of the project, explaining the experience as a paradigm of innovation success. Let's see why.

Monday, 2 April 2018

Plea for the end of clinical practice guidelines








James McCormack, a professor of pharmacy at British Columbia University, posted on his YouTube channel, a video clip that adapts the song of the Traveling Wilburys group, "End of the Line", to become "End of the Guidelines". The video begins with a scene from “Life of Brian" where the actor Graham Chapman as a fake Jesus Christ, addresses his followers from the window of his house and says: "You are wrong; you have no need to follow me. Follow no one; be yourselves, each of you is a different person."




Monday, 26 March 2018

Inappropriate use of large healthcare structures








The healthcare system has many resources that can be used appropriately, or not. Think of the child with fever who leaves the paediatrician’s office with a prescription of antibiotics, the elderly lady who ends her days in an intensive bed, when, in their case, a palliative action would have been more appropriate or the person with a moderate headache, without other neurological manifestations, which, by insistence, ends up undergoing a tomography. George Halvorson, in "Health care will not reform itself", echoes an investigation that, after reviewing 5 million medical records, concluded that waste due to clinical practices that don’t add value could be considered to reach at least 25% of the total health expenditure.

This waste affects practically all areas of healthcare, but now I would like to focus on what happens with the inadequacy of the use of large health structures: operating theaters, emergencies units, intensive care units, wards and primary care.

Monday, 19 March 2018

Experience versus evidence, regarding Ian Harris








Professor Ian Harris, author of the book, "Surgery, the ultimate placebo", is a traumatologist who directs a research unit focused on the results of surgical practice in Sydney. Harris says in the book's introduction: "Lack of evidence allows surgeons to practice techniques for the simple reason that they have always been done, because they learned them from their mentors, because they are convinced that it works or simply because it does everybody. It's easier to have no problems if you behave like most colleagues, my argument, says the author, is that trusting tradition and perceptions often leads, in terms of clinical effectiveness, to unconvincing results."