Monday, 21 May 2018

The English surgeon, talking about Henry Marsh

Not too long ago, after having read his book "Surgery, the ultimate placebo", I wrote about Ian Harris, an Australian traumatologist. I remember that Harris defends the rigor in the surgical indications after having observed that more than half of the surgery that is practiced does not have enough support of consistent scientific evidence. Now I have finished the book "Do no harm", by Henry Marsh, an English neurosurgeon at the lintel of retirement, and I am inevitably immersed in the comparison between the two texts: first, Harris's, is written by someone who loves surgery and believes that too often is practiced with little rigor, while the second, Marsh’s, is a biography of great literary level, elaborated from the notes that the surgeon has been taking throughout his career, not in vain has he received several recognitions. Marsh, like Harris, is passionate about his work, but his literary contribution comes not from scientific exaltation but from the knowledge he has accumulated from his own mistakes. The veteran English neurosurgeon has not published any revealing research nor has he led any innovative discovery. His honesty and his hands are his strength.

According to Marsh, each surgeon has his own skeleton in the cupboard, and this is where he looks for the lessons to keep improving: What happened? Why did I bite off more than I could chew if I felt too tired? The neurosurgeon, after having intervened on more than 15,000 people, now demands more humility from his colleagues. In the book he takes the first step, recalling one by one, all the cases that did not go well, analyzing the reasons and drawing lessons, but what makes the reading more endearing is when the author goes beyond professional rhetoric and also remembers those people’s names, what they were like and how those disastrous clinical processes affected their lives and the lives of their families.

Shared clinical decisions

Marsh reflects on the relationships he maintains with patients. He believes that the emotional bond is necessary, in fact he would not know how to do it in any other way, he is a temperamental man, but -according to him- we have to know how to find a balance, which he has never stopped looking for. Patients must be treated with frankness, although - he admits - the difficulty appears when there is no hope and the patient wants to cling on to the last straw. According to Marsh, knowing how to convey the deep sadness intrinsic in not being able to help enough is one of the biggest difficulties that any doctor faces.

Quantity or Quality of life

When the prognosis is bad, many people feel disconcerted. Sometimes operating, despite the obvious risks, opens up excessive expectations and most believe that the worst that can happen is for others; while the decision not to operate is a less attractive option, although, they imagine, it is objectively the most advisable, because everyone, including the surgeon, if nothing is done, have the feeling that they have thrown in the towel too early. In an interview with Carles Capdevila, Henry Marsh says that at this point people should consider why it’s worth living, but that many don’t want, or can not do so, they just want to listen to therapeutic options that promise them more life, despite the inherent risks of such treatments. These are situations of great uncertainty in which, often, the surgeon finds himself facing the unbearable pressure of having to decide on how the last days of the patients should be spent.

"The English surgeon"

Henry Marsh, during the Communist dictatorship, was invited to Kiev to give lectures. He was impressed by the sordidness of the Ukrainian hospitals and met Igor Kurilets, a young neurosurgeon who was repressed by the regime for his too-bold proposals about the practice of medicine. Igor and Henry became friends and, since then, the British surgeon has established a London-Kiev bridge, which gave way to an intense professional relationship, including donations of surgical equipment, so that, at least once a year, Marsh stays in the hospital of his Ukrainian friend where he visits the most serious cases, operates on some and, above all, teaches an honest and endearing way to practice medicine.

In 2007 the Odyssey channel recorded "The English surgeon“. This multi-award winning documentary is based on the activities of Henry Marsh in the Ukraine.

The documentary is sensational, it could not be otherwise in the case of Henry Marsh, and in it I have seen two things that could have been impossible to capture in a book. The first is to see Marsh visiting the hospital in Kiev, where I was struck by his genuine emotions when faced with cases where there was nothing to be done and second, is to see how he treats the case of Tania, a girl with a cerebral tumour that he operated on in London in a clinical process that went wrong. Well, in the documentary we can see Henry and Igor going to visit Katia, Tania’s mother, they went to the girl’s grave and then they accept the invitation to lunch with the family. Moving!

Jordi Varela

Monday, 14 May 2018

Self-management: Buurtzorg Identity

Frederic Laloux in "Reinventing organizations" describes the teal-evolutionary companies as those based on the personal growth of their employees and chooses Buurtzorg Netherland as an organization to which we should be paying attention to if we are among those who believe that the time to do things differently has arrived.

What is Buurtzorg Netherland?

Buurtzorg Netherland is a non-profit company, which was founded in 2007 in the Netherlands, when a group of community nurses rethought their work and came to believe that, instead of only going to homes and exercising the functions of their profession, they should advance to becoming the patients’ referee and take charge of attending to their global needs.

Ten years later, Buurtzog Netherland is a company that has already more than 70% of the market share. It has hired 10,000 nurses and 4,000 family employees, organized into 850 self-managed teams, each comprising of a maximum of 12 professionals who serve 40-50 home patients. In a study by Ernst & Young and collected in Lalouxs’ book, the results of Buurtzorg compared to the other companies are spectacularly good: 40% fewer hours are spent per patient, this despite the fact that the Buurtzorg nurses take time to chat and have coffees with the people they attend to, the health care plans last half the usual time and patients recover their autonomy earlier, a third of the hospitalizations are avoided, and when people do have to be admitted to hospital, the stays are shorter. The consultant estimated that if the Buurtzorg model were to be implemented in the US, the health system would save 49 billion dollars.

Inside Buurtzorg Netherland

The work teams don’t have a boss, and to make self-management viable, everyone, when joining the company, must attend a course: "Interaction methods oriented to find solutions", where they learn to listen, communicate, drive meetings and help each other (coaching). Team meetings should ensure that all voices are heard, but no one has the right to veto a proposal. They avoid, as much as possible, conceptual discussions and consensus and instead, there is a tendency to say: "if you have it clear, try it, and we will value the goodness of what you say with the facts". The test-error system is the preferred one. If a team gets stuck, it asks for the help of an external coach, usually a veteran nurse with prestige, who has no executive capacity and is only a facilitator for the resolution of conflicts. As there is never any decision made by an outside official, there is never a manager to blame. According to Laloux, learning to live with this degree of freedom and responsibility can generate confusion and frustration, but this is a journey of personal development from which mature professionals emerge.

Are there general rules?

There are very few, of which Frederic Laloux, in his analysis of the organization highlights the following:

- The teams must know how to distribute tasks in a way that is adjusted to the capacities of each of their members and they must be alert not to concentrate too much on one person, since this could be the seed of a traditional hierarchical form.

- The coaching should be used on a regular basis not only in the resolution of conflicts but in order to encourage the team's ongoing learning.

- Once a year team members should evaluate each other according to the competencies they had defined.

- The teams must prepare annual plans with the initiatives they want to implement, mainly in the areas of patient care, quality, training and organization.

- It’s a sign of maturity that the teams manage to allocate 60-65% of the time for direct care work which means that they have enough time for community work, internal teamwork, training, personal growth, etc.

- The hiring of new professionals, personnel management, task planning, administrative work and investments are the responsibility of each of the 850 work teams. There is no central staff for any of these issues. Laloux admits that with this decentralized model economies of scale are lost, but he says that this is compensated for in sufficient quantity by the enthusiasm that professionals feel for a job well done.

- BuurtzorgWeb, more than an intranet, is a Facebook where all professionals put questions, answers and feelings. This network has the utility of being a substitute for traditional planning. When someone has a proposal that affects the organization as a whole, the debate is generated on the internal website and, if there is sufficient support, a specific work group is created to study its opportunity and viability from a more technical perspective. 

- Each month, the compared productivity data of all the teams is openly posted on the intranet. 

The video includes a lecture by Jos de Blok at King's Fund in London, in which he asks if the Burtzoorg model would work in England.

The spectacular growth of Buurtzorg, the results it credits, and the fact that, right now, the Dutch government encourages competing companies to adopt its model, suggests that self-management, difficult as it may seem, should be the answer to the burnout of professionals. 

Frederic Laloux states that when people have the power to make decisions and the resources to work for a meaningful goal, they don’t need motivational speeches and challenging targets.

Jordi Varela

Monday, 7 May 2018

I don’t know ... but it seems to me that times are changing

Joan Escarrabill

Health care’s future is an issue that is debated multiple times. The most academic visions or those that start from the observation of reality have common elements. Increasing the number of professionals (more doctors and nurses are needed, is strongly agreed), to the extent that the weight of the hospital will be reduced and interventions in the community will gain prominence, health education of the population is very important or in what way are we going to create sustainability in a system that has contributed significant improvements during the last years, can be just a few examples of these common places of all the debates.

Monday, 30 April 2018

Could we organize ourselves in a different way?

Frederic Laloux, in "Reinventing Organizations", a revealing book, at least for me, invites us to rethink the way we manage companies. The age of the internet, he says, has precipitated a new vision of the world that contemplates the possibility of a distributed intelligence instead of a vertical hierarchy. According to Laloux we should be able to invent a more powerful and meaningful way of working together if we would change our belief system.

In the first part of the book, the author makes an evolutionary analysis of the way in which humans organize companies, which I found colourful and insightful, and that is why I have prepared a summary (for more details I recommend going to the tables that are at the end of chapters 1.1 and 2.3):

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.

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.

  • 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  
  • 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.